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Clinicians Corner Teamwork



Dear Colleagues, here is the next issue of A4 News. We have many relevant articles in this issue. The theme is teamwork, which is reflected in the picture below.  As we grow, we will need to find innovative ways to come together even more. This newsletter is one such attempt at building  teamwork.  Harvard Business Review recently publishes an excellent article on this topic. The authors are Martine Hass and Mark Mortensen and the title is “The Secrets of Great Teamwork”. The link to the article is below.


  • Today’s teams are different from the teams of the past: They’re far more diverse, dispersed, digital, and dynamic (with frequent changes in membership).
  • What matters most to collaboration is not the personalities, attitudes, or behavioral styles of team members. Instead, what teams need to thrive are certain “enabling conditions.
  • The Enabling Conditions
  • Compelling direction
  • Strong structure
  • Supportive context
  • Shared mindset

Among all the a compelling direction, a strong structure, and a supportive context—continue to be particularly critical to team success in today’s world.

Modern teams are vulnerable to two corrosive problems—“us versus them” thinking and incomplete information.

Larger teams are more vulnerable to poor communication, fragmentation, and free riding (due to a lack of accountability).

There are many ways team leaders can actively foster a shared identity and shared understanding and break down the barriers to cooperation and information exchange. One powerful approach is to ensure that each subgroup feels valued for its contributions toward the team’s overall goals.

For ongoing monitoring, we recommend a simple and quick temperature check: Every few months, rate your team on each of the four enabling conditions and also on the three criteria of team effectiveness. Look in particular at the lowest-scored condition and lowest-scored effectiveness criteria, and consider how they’re connected. The results will show where your team is on track as well as where problems may be brewing.

Dr. Zulfi Ahmed


Postoperative Delirium (POD) and Cognitive Dysfunction (POCD)

Postoperative Delirium (POD) and Cognitive Dysfunction (POCD)

SJMH Clinical Conference 7/12

Ryan Pirooz, M.D.



 POCD – a drop in cognitive performance on a set of neuropsychological tests taken before and after surgery, typically can span in range of weeks to years. POD – characterized by acute onset + fluctuating course + inattention + (either disorganized thinking – or – altered level of consciousness); requires increased vigilance because it can present as both hyperactive and hypo-active; typically ranges over hospital course.  Associated complications: POD associated with increased mortality, ventilator/hospital/ICU days, and health-care cost;also associated with increased rate of POCD. POCD associated with increased risk of leaving workforce, disability/unemployment, and mortality.

Prevalence: Across all adult age ranges, 30-40% of surgical patients demonstrate POCD in the first week.  Only older adults (age > 60) demonstrate persistent POCD after months/years.

Persistent POCD is associated with increased mortality.

Risk factors:

Many suspected risk factors including: multiple comorbidities, more severe illness, HTN,

Abnormally high or low BMI, hypoalbuminemia, EtOH abuse, respiratory failure, but…

…Only advanced age (>60-75 depending on study) and poor preoperative cognitive status

(E.g. lower educational level, dementia, prior CVA) show consistent predictive capability

Perioperative strategy:

 Target high-risk patients (elderly, cognitively-impaired)

  1. Limit or avoid antidopaminergic antiemetics (e.g. metoclopramide, ondansetron), antihistamines (e.g. diphenhydramine), benzodiazapines, opioids
  2. Consider regional anesthesia when possible, though evidence does not yet support it’s superiority over GA
  3. Monitor and limit depth of anesthesia; studies demonstrate less POCD (and less mortality) with use of BIS and cerebral oximeter, even in regional cases
  4. Treatment in recovery area should begin with correcting underlying problems (e.g. hypotension, hypoxia, hypercapnia, etc.) and attempting to orient patient (return eyeglasses and hearing aids, bring family back, use of a sitter) before medical intervention.

Medical intervention in recovery area begins with antipsychotics (haloperidol most readily-available, dose 0.5-1 mg repeated q5-10mins). Benzos are theoretically second-line but should only be used when patient is a threat to themselves or others, because they are associated with increased confusion, sedation, rebound delirium, paradoxical rxn.

Future considerations:

¨ Better and more consistent testing for POCD and POD?

¨ Truly significant difference between regional and GA?

¨ Prehab? Rehab?

¨ Role of perioperative surgical home? Continuity of care?


Ballard C, Jones E, Gauge N, et al. Optimised Anaesthesia to Reduce Post Operative Cognitive Decline (POCD) in Older Patients Undergoing Elective Surgery, a Randomised Controlled Trial. Xie Z, ed. PLoS ONE. 2012; 7(6):e37410.

Berger M et al. Postoperative Cognitive Dysfunction. Anesthesiology Clin. 2015; 33(3):517-550.

Davis N et al. Postoperative Cognitive Function Following General versus Regional Anesthesia: A Systematic Review. J Neurosurg Anesthesiology. 2014; 26(4):369-76.

Deiner S et al. Postoperative Delirium and Cognitive Dysfunction. Br. J. Anaesth. 2009; 103:41-46.

Gleason LJ et al. Effect of Delirium and Other Major Complications on Outcomes After Elective Surgery in Older Adults. JAMA Surg. 2015; 150(12) 1134-40.

Inouye SK et al. Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. J. of Amer College of Surg. 2015; 220(2):136-148.

Monk T et al. Predictors of Cognitive Dysfunction after Major Noncardiac Surgery. Anesthesiology. 2008; 108:18-30

Saczynski JS et al. Cognitive Trajectories after Postoperative Delirium. The New England Journal of Medicine. 2012; 367(1)30-39.

Steinmetz J et al. Long-term Consequences of Postoperative Cognitive Dysfuntion. Anesthesiology. 2009; 110:548-55.

NYSORA Conference, October 8 2016

On October 8 2016, Anesthesia Associates of Ann Arbor sponsored a one day seminar in the latest regional anesthesia techniques, technologies and applications. The faculty of the New York School of Regional Anesthesia led by Dr. Amir Hadzic and Dr. Jeff Gadsden designed the course specifically for integration into A4’s busy regional anesthesia practice.

Professors from Duke University, University of North Carolina, and Rush Presbyterian St. Luke’s, were also on the faculty staff.

Over 40 attendees from all A4 practice locations, Henry Ford Allegiance, St. Joseph Mercy, Beaumont Health, and Mercy Health
St. Mary’s-Grand Rapids engaged in the multi-disciplinary program.Teaching consisted of live model scanning with the latest ultrasound equipment, 3D imagery of anatomic fields and small group sessions reviewing all the latest techniques.

The meeting was coordinated by Dr. Tom Bonifer MD, Brandy Horton MBA RN, Syreeta Ivory and the staff of the SJMH Women’s Health Center. Thank you to all who attended as well as industry representatives who helped sponsor the day.