Geriatrics & Palliative Care Inpatient & Consult Rotation - Nix Rotation

Welcome to the third year GERI-Nix rotation. We have gathered information, instructions and tips we hope will help you succeed in this challenging rotation. Please familiarize yourself with the contents before your rotation begins. If you have any questions, concerns, or suggestions, please contact Dr. Alford (358-3888, alford@uthsca.edu) or Dr. Oakes (oakes@uthscsa.edu).

Before You Start:

1. Review all information on this page AND carry a paper-based copy with you each day for reference.

• CLICK HERE to download.
  
  

2. Review presentation over ACE Unit. We use an Acute Care of the Elderly approach on this service.

• CLICK HERE to download.
  
  

3. Review the Curriculum for the Aging Hospitalized Medical Patient (CHAMPS).

• CLICK HERE to download.
  
  

4. Review the geriatric assessment tools on this website. You will use them daily.
   
   

5. Mandatory Resources:

   1. Palm Pilot or equivalent with ePocrates or equivalent medical database.

   2. Copy of Reuben's Geriatrics at Your Fingertips, available from attending.

   3. Review Merck Manual of Geriatrics (http://www.merck.com/mkgr/mmg/home.jsp).
      
      

6. Read articles available in the Assessment Tools & Readings section of this website. You will use this information daily.

Please note: Because the Nix is a private community hospital, in some ways this inpatient service differs from that at university hospital. For example, specialists welcome your referrals and will respond immediately. They will advise you, but generally you will continue to manage the patient. Secondly, the hospital does not use an EMR, so you will be using paper charts.

 

Finally, because this is a geriatric service, many of the patients are extremely frail and have complex, multi system medical problems. As always in geriatrics, maintaining function and independence for our patients is a primary goal. Social support and placement become critical issues.

 

We hope you enjoy the time that you spend with us. We love and respect our patients and take pride in being able to improve the quality of life for each of them. We are constantly attempting to improve it. If you have any further questions or comments, please let the faculty know.

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OBJECTIVES

At the end of the rotation the resident physician will be able to:

• diagnose and manage common inpatient medical problems common to the elder population, including critically-ill patients requiring critical care unit management.
• provide medical care for the older surgical patient, including pre-operative evaluation and post-operative management.
• complete a comprehensive assessment of functional status and appropriate levels of care, e.g., "can this patient go home rather than to a nursing home, or to some other less restrictive environment?"
• participate in geriatrics consultations to physicians in the inpatient hospital environment with specific emphasis on geriatric psychiatry and surgical care.
• participate in discharge planning to optimize use of community and outpatient services available for the elderly, including follow-up with Senior Health Care Center, if desired.
• provide care for older adults using an ACE model.
• work as part of an interdisciplinary team.
• provide successful transitions of care for older adults.
  
  

 

ROTATION OVERVIEW

CLINICAL RESPONSIBILITIES

Residents are primarily responsible for caring for inpatients under the direct supervision of the attending physician. There is always a geriatric attending on call 24x7. The attending call schedule changes every Friday at 12 noon. Please get a copy of the call schedule from either Tisha Rodriguez or at the Nix Senior Health Care Center (11th floor). Attending beepers and cell phones are available on the schedule or in your geriatrics resident notebook.

 

64 Hour Work Rule - We have planned our schedule to observe the 64 hour work rule and to give you sufficient rest between shifts. If you see a potential problem, please let us know ASAP so we can address the problem. You are required to report expected 64 hour overages to your inpatient attending BEFORE you reach an overage.

 

Consultations - The geriatric service provides geriatric medicine consultations for geriatric psychiatry patients 65 years of age and older within 24 hours of admission and for patients on other services by request.

 

Nix Geriatrics Office Support - If you have less than 2 patients on the inpatient service, you are required to provide outpatient support after rounds to the geriatrics outpatient attending in the Senior Health Care Center, Nix
Suite 1111.

 

Third Year Student Assistants on IPS

• You will have one or two third year medical students working a two week rotation with you Monday-Friday. Each is also required to work one weekend day on the weekend in the middle of their two weeks. (Two scheduling exceptions: In the first week of their 6 week FCM clerkship rotation, the two assigned students have a clerkship orientation on Monday and will page you when they arrive at 1pm. In the final week of their FCM clerkship rotation, the 2 students are required to have the Thursday afternoon prior to their final exam and the Friday of their final exam off).
• When the students first arrive, you will be responsible for orienting them to the service, teaching them everything you want them to know about how things work so they can be helpful to you.
• They are responsible for rounding on the patients you have assigned to them, presenting their patients to the attending and writing a note on each patient. The student's note does not substitute for the resident note except on the patient's day of discharge, as noted below. Students may not write in intensive care notes.
• The students are also to assist the resident with getting labs, running down radiographs and helping the patient care activities run smoothly. See the student part of this web site. for more information on their rotation.

Fellows

You may also be working with a geriatric fellow on the inpatient service. The fellows function at a sub attending level. If the attending is not present, the fellow functions as the leader of the service. The fellow is responsible for all clinical decisions under the supervision of the attending.

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ADMISSIONS

• Admission order form are available under Commonly Used Forms on the left side of the web page.
• Admissions are always received and authorized by the geriatric attending. The attending will then call you for instructions on evaluation and management.
• Patients may be admitted directly to the floor (19th floor). These patients must be seen by a resident upon arrival.
• Inform the nursing staff of your beeper number on all new admissions, especially on patients admitted to floors other than the 19th.
• Clinic admissions arriving on the floor after 6pm will be admitted by the on-call resident by phone and discussed with the attending.
• Monitoring telemetry patients must be seen and admitted by residents within two (2) hours during the daytime. At night, it is up to the discretion of the faculty.
• Non-monitored patients must be seen within twelve (12) hours or before AM attending rounds, whichever comes first.
• Admission orders can be called in to the inpatient nurses after sign-out is received from ER attending by geriatric attending.
• We avoid night transfers if at all possible. There are no intrahospital (i.e. ICU to floor) transfers allowed after 12 noon.

CALL

Most overnight issues can be addressed by telephone conversations with the floor nursing staff. However, if patients require more intensive evaluation, a physician is expected to go the hospital. You are required to contact the attending at any hour for any questions or concerns.

 

Medical Assessment Team (MAT Team) is a service you can use at night. The number is 579-3800. A trained RN goes to the LTC facilities (our facilities & our partners, including HIMS) and assess possible non-emergency hospital admissions. They will then call back recommending either therapy or admission. This may occur without a prior call to you as LTC facilities are initiating a protocol to call them directly. If the patient is recommended for admission, your job is to accept the patient and determine level of care. As always, ask the attending for guidance whenever needed.

 

IPS Service Check Out Procedures

All patients must be checked out to the night call provider to ensure good patient care.
Guidelines for check out include:

• Name/age dx on admission short summary of hospital course
• PMH
• Allergies
• Code Status
• Pending labs and films that must be reviewed overnight
• Other important medications that should be started or stopped
• Incoming patients or discharges

Check out calls are the responsibility of the Nix IPS resident. The IPS resident must call the night call provider (either the covering resident or the Geriatric Nurse Practitioner) to check out the patients on the service prior to being relieved of their responsibilities. The IPS resident is also required to call back in the AM to receive the service back.

 

A verbal check out must occur each time coverage changes, even if the patient status does not. If the Nix IPS resident is unable to make contact with the night cover, inform the IPS attending that AM. The Nix resident should also give a brief call to faculty attending before going off call each day at 6pm.

The Nix IPS resident may never leave the hospital, for whatever reason, without checking out the service to either the night call, fellow, or attending.

 

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DOCUMENTATION REQUIREMENTS

Initial Orders - Please use the Initial Orders form listed under Commonly Used Forms area on left side of the web page, http://geriatrics.uthscsa.edu/nixinpatient.asp. Review these with the attending prior to the start of your rotation.

 

Floor Progress Notes - Residents are expected to write daily progress for all inpatients. You cannot refer to a students note for information but must write a stand alone note, with the exception of the day of discharge where your dictated Discharge Summary will serve as your note and the student note will serve as the chart note.

• All notes should refer to the past family/social history from the H&P. The H&P date must be in your note.
• JAHCO requires all notes and orders to be timed and dated. They also must have either a legible signature or a signature stamp. Please not that we are required by the Nix to monitor this closely.
• All orders and notes should have countersignatures by the attending prior to discharge. Information on the Nix dictation system is found both in the left hand column of this web page and the notebook distributed to you prior to the start of the rotation. Attending dictation numbers are included in your notebook only.

ICU Notes - The attending writes the official ICU note. Copies of our group ICU note are found in the ICU on the website. You can prepopulate the note with clinical information such as the vitals, labs, I&O's and radiograph results but only the attending can complete the HPI, physical examination and A/P portions.

 

You are required to write a note as well to ensure that all patient care issues are adequately addressed. Students should also be encouraged to write ICU notes, but they can not substitute for your daily note.

Charts & Medical Records - Charts are hard copy. Medical records are on the 9th floor. Please before you finish the rotation go and complete any pending medical records work. You are responsible for initial H&Ps and all Discharge Summaries.

• Call dictation number: 226-1310. Attending dictation numbers are found on the back of your resident notebook only. They are not list on this web site. for obvious reasons.
• Dictation instructions are available under Commonly Used Forms on the website, http://geriatrics.uthscsa.edu/nixinpatient.asp.
• You will be asked to return to dictate any outstanding charts. If you have more than two outstanding dictations you may be evaluated as being below the standard in your final rotation evaluation.

Discharging Patients - After the first day, work with the discharge planning staff to determine the ultimate level of care (nursing home, home, home health) after the patient is discharged.

• Our dictation summary format is available under Commonly Used Forms on the website, http://geriatrics.uthscsa.edu/nixinpatient.asp. In addition, a one page transition form must be filled out for all LTC patients.
  
  A transition form that is available in Ste. 1111 or on our website should be filled out on all LTC patients and faxed. The MS3 usually is responsible for this but in case they are not present it is responsibility of the resident. Do not discharge patient to long term car institutions after 3pm.

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ACUTE CARE OF THE ELDERLY (ACE) UNIT

The ACE inpatient unit and consult service will offer you the opportunity to learn patient care skills unique to older, frail patients, to practice systems based care, and to experience working as part of an interdisciplinary team (IDT).

**Note to students: During 2 week rotation, one week you will serve as ACE tracker; one week you will assist resident on inpatient.

The Vision:

We utilize an Acute Care of the Elderly (ACE) model of care, an evidence based approach shown to improve outcomes for elders. The ACE approach strives to maintain function, independence, and quality of life for elders and to prevent iatrogenic illness (illness caused by medical care). CLICK HERE to view ACE presentation.

 

An Interdisciplinary team meeting, held at noon each day is central to the service. At these meetings each member of the team contributes to managing vulnerable elders to prevent poor outcomes common to older hospitalized patients. The resident will meet with the hosptialist, the geriatrician, case management, nutrition, PT, OT, nursing, and the chaplain. You will participate by contributing what you know about the patients in these meetings.

 

We provide care for all admissions of the Hosptial Internal Medicine Specialists (HIMS) groups's 1200 nursing home patients. We also provide medical care for patients in the Nix's geriatric psychiatry service (Heritage Unit). Additionally, we provide geriatric consultations as requested by the Apogee Hosptialist Group and other Nix physicians.

 

The goal of the ACE approach is to avoid the cycle of complications and extended hospital stays common to older patients illustrated below.

 

Risks of Hospitalization of Elders

 

 

Acute Care of the Elderly Guidelines for Residents & MS3 Students

1. PREPARE. Read about the geriatric syndromes on the website for background knowledge. Review the geriatric assessments instruments on the website. STUDY THE ACE CARDS. Learn what symptoms to look for and why. The ACE cards list points that need to be address in notes.
2. Your responsibility is to provide inpatient care, using an ACE approach. We use the ACE tracker to monitor each patient. You are also responsible for any CONSULTS requested.
3. ACE Tracker copies are found at the NIX clinic in the wall folder.
   • ACE Tracker Indicators & Where to find the information:
     • Falls Score, Braden Score : Nurse's Notes
     • Advanced Directives : Past Medical History
     • Catheter : Ask Nurse
     • Pressure Sores : Exam
     • Medications : Orders
     • Beers List : assessment tools or ACE Card
     • Physical Restraints : Nurse
     • Overnight incidents (falls, family complaints) : Nurse
4. Sitting rounds will start at approximately 9am in Ste. 1111. Review all new patients, follow ups, and consults with the geriatrician. Didactics will be taught as part of rounds for about 15 minutes. Then you will conduct walking rounds with faculty. One student will be dismissed at 11am to complete ACE tracker before noon rounds. The second student will assist the resident as needed. Students change roles after first week.
   Please see ACE care "Preparing for Rounds". Be ready to adapt and be flexible. Consult with attending and adapt as needed.
5. PREPARE FOR IDT MEETING.
   1. MS3 Students: From 11 to 11:45am, write ACE tracker data on white board in meeting room, 17th floor. Also, make approximately 6 copies of your ACE tracker for providers at the meeting. Report patient information to geriatric attending only.
6. IDT ROUNDS. Start at 12:30pm. The purpose of the IDT meeting is to discuss each & every admitted aptient with the entire care team (geriatrician, hospitalist, nutritionist, nursing, social work, PT, OT, pharmaist, chaplain). Geri team will present the testing, clarify patient's baseline, raise questions about clinical problems. We will make recommendations on patients of concern, both new admits and standing consults. Consults will be discussed.
7. DISCHARGES. A one-page Transition Form needs to be filled out for all LTC patients. MS3 student take primary responsibility for completing the form.
8. CONSULTS. As a service we are pleased to see inpatient or outpatient at the request of any Nix attending. You may be called for consultation questions after hours when on call, but will generally nto be required to come in.
   
   Our geriatric consult service offers expertise in the following areas:

   Acute mental status changes/delirium	Difficult discharges (long stay pt.)
   Adverse drug reaction and polypharmacy	Elder Abuse
   Weight loss or Failure to thrive	Urinary or Fecal Incontinence, Refractory constipation
   Behavioral disturbances in dementia, capacity evaluation, sleep disorders	Parkinson's disease
   Depression and Anxiety	Weakness/Lethargy
   Pain Management	Unsteadiness/Falls/Osteoporosis/Compression fractures
   End of life issues	Wounds

   
   On a daily basis, the resident checks charts and talks to hospitalists about any new consults. For all consult patients, talk to the nurse. Questions to ask: How is the patient doing? Stable VS? Stable O2 sats? Pain? Any prn's last 24 hours? Any incidents last 24 hours? Any unstable behaviors? How are the wounds doing? Nursing concerns? Patient eating and stooling/urinating?
   
   Review new consults at sitting rounds. You will be responsible for formally presenting the patient. Your H&P is a Consult format focusing on the question that the primary is asking you to help with, e.g. Falls, Dementia eval, delirium, etc. Give a brief synopsis of the patient's present situation & reason for hospitalizaiton, focusing on risk indicators and geriatric issues. You will then (briefly) round on all consults with faculty. This will prepare you and the faculty for the interdisciplinary (IDT) meeting at noon.
   
   OFFICIAL CONSULTS will need a FULL consult note (H&P, MMSE/CLOX, ADL/IADL, etc., which can be done in the afternoon. IF you have less than three (3) consult patients you are required to provide outpatient support to the geriatrics clinic, Ste. 1111 in the afternoons. Before going home each day, place a copy of the day's completed ACE trackers in the geriatric attending's mail box in the call room, Ste. 1111.
   
   When consult is agreed to in IDT meeting, determine whether attending needs to be involved same day. Otherwise, resident and student start consult in the afternoon.
   
   BILING CARDS - Keep a list of all consults on billing card. Note all needed follow ups on billing cards, especially pscyh. Per Medicare guidelines, sign off on consults when all f/u from initial consult is complete. We cannot get paid to provide care for a new problem without another consult request.
   
   While making rounds on patients, write on each chart: "Nix consult (date) please see dictation"
   Negotiate with individual Apogee hospitalists re: who will write orders.
   
   Dictations must be done, Phone: 226-1310. Follow up the same dictation codes from faculty on file. They should be done upon discharge. Failure to dictate patients will require you to come back.
   
   CONSULTATION DOCUMENTATION
   You must follow the consultation form on this website or in the orientation to Sevocity.
   Specifically you must include:
   1. The name of the consultant and the reason for consultation. e.g. "thanks Dr. ______ for consultation on Mr./Mrs. for "prolonged immobility", "acute mental status changes"
   
   Management - The Apogee hospitalist group may ask the medical students or resident to assist in reviewing labs and scans as well. This should be documented on daily notes. Residents are responsible for being familiar with the ongoing medical situation of all consult patients including ICU and psychiatric floor patients.

ELEMENTS OF THE GERIATRIC ASSESSMENT

• Physical Health - Medical Problems
• Mental Health - Cognitive, behavioral, and emotional
• Social and Economic status - Support network, Caregivers
• Functional Status - ADLs, IADLs
• Environmental Characteristics - Home saftety services
• Medication Review
• Development and Implementation of a Care Plan
• Palliative Care - Pain Management, End of Life issues, Non-pain symptoms at end of life
  
  

 

CONFERENCES

Geriatrics Division Grand Rounds
Attendance is required. Geriatric Grand Rounds are held most Mondays, 12:30pm-1:30pm, in either the 5th or 6th floor conference room. Check with the attending on Mondays for more information. Lunch is provided.

 

Geriatric Didactics

On Tuesdays, Wednesdays, and Thursdays, you will participate in geriatric learning sessions. See the topics and prepare them using the materials found on the CHAMPS website .

Week 1	Tue	Wed	Thurs
MS3 Teaches: topic overview   Resident Teaches: Prevention & Mngmt	Delirium	Pain	Falls & Physical Restraints
Week 2
MS3 Teaches: topic overview   Resident Teaches: Prevention & Mngmt	Pressure Sores	Foli Catheters & UTIs	Adverse Drug Reactions/Polypharmacy

 

 

SUMMARY of RESIDENT WORK SCHEDULE

64 Hour Work Rule - We have planned our schedule to observe the 64 hour work rule and to give you sufficient rest between shifts. If you see a potential problem, please let us know ASAP so we can address the problem. You are required to report expected 64 hour overages to your inpatient attending BEFORE you reach an overage.

• You should be out of the hospital by 6pm at the latest. Please contact the attending prior to exceeding this time to work out rounds the next day.
• Sitting Rounds & Didactics start at 9am daily.
• Interdisciplinary Team Rounds occur daily at 12:30pm.
• After Hours Calls - You will cover calls from nusring home patients at Air Force Village, Buenavida, Morningside Manor, and Parklane West. See schedule for specifics.
• Most overnight issues can be addressed by telephone conversations with the floor nursing staff. However, if patients require more intensive evaluation, a physician is expected to go the hospital. You are required to contact the attending at any hour for any questions or concerns.

Absences - other than illness must be cleared with your attending at least 24 hours prior to the event as a professional courtesy. All absences or changes in schedule should be brought to the attention of your attending. The attending schedule is posted on When To Work, the department's online scheduling system. More than 4 - EXCUSED or UNEXCUSED absences during both parts of the two week experience will require repeating part of the rotation.

 

HELPFUL HINTS

Parking - Park at Mid City Garage (see map). Validate your parking each day at the NIX garage (ground floor of the Nix Hospital). Identify yourself as a resident Nix Senior Health Care Center physician. We can not pay for parking if you do not follow these instructions.

 

If you drive down to the Nix after hours, park in Valet. If you happen to be in the Mid City Garage after 5pm, contact Nix security at 271-1800 to escort you to your car.

 

Call Room - Although no call rooms are available, Nix Senior Health Care outpatient office (11th floor) has computer access and a place to rest during the night. There is coded entry so please take down the code when you get there. If you need to spend the night in-house contact the nursing supervisor to arrange for a private room.

Cafeteria - 6th floor. There is a 25% physician discount with jacket and UHS id on. The cafeteria takes both cash and credit cards. Lunch is provided free during the Monday Geriatrics Grand Rounds, but not at any other time.

 

Surgeons Lounge - 23rd floor. Please wear your jacket. If anyone asks you tell them you work with the geriatrics group. Free breakfast, lunch, coffee and sodas are available while they last.

 

SACU ATM - available on the first floor in valet parking.

Further Information - For further information on the Nix Hospital, go to www.nixhealth.com .

 

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