Geriatrics

Geriatric Service Policy and Procedure

HOUSE OFFICER: Eligibility and Staffing

The geriatric rotation would consist of one resident. During the first six months of the year, this would be an upper level resident (HO II or HO III). The second six months of the year interns would be allowed to take this rotation as well. This plan would allow for interns to have 6 months of experience before they admit patients on this service unsupervised.

STUDENTS

Medical, Nurse Practitioner, and PA students at times will be on service. They will be under the immediate supervision of the HO and the ultimate supervision of the attending. They would perform duties as on any other inpatient service

ADMISSIONS

Weekdays: Geriatric service resident admits patients to the inpatient Geriatrics service on M-F from 8:00 am until 5:00 pm. From 5:00 pm (or the designated time) until the following morning, the inpatient ward team on call would admit the geriatric patients and transfer their care to the Geriatrics' resident the following morning.

For admits when the geriatric service resident is in clinic, or if unavailable during the day for educational activities; the patient would be cared for by the following in this sequence: 1st choice: the geriatric fellow (if they are on Acute care rotation), 2nd choice: the geriatric medicine attending. The fellow or attending will care for patient and then be responsible for alerting the geriatric medicine H.O. of admission. The geriatric service H.O. would then be expected to see the patient after clinic to complete any part of the admission.

Weekends: The weekends would be treated like a weekday, (i.e., whoever is on call for the weekend would admit patients from 8:00 am until 5:00 pm). The nights would be covered by the inpatient ward team.

NIGHT COVERAGE

Overnight, the geriatric inpatients would be "checked out" to the intern on ward call for the night.

WHEN STAFF HOSPITALIST  ADMITS A PATIENT

When a staff (attending-level) hospitalist admits one of our patients overnight, we assume care of the patient the next morning, but our first encounter and documentation is in the form of a Geriatrics Consultation.  (See the earlier section, "Hospital Geriatrics Consultation", for format and suggested content.)

CALL RESPONSIBILITIES

When on call the resident covers: outpatient calls and nursing home calls. For times (See schedule). Call follows RRC guidelines. The call schedule is sent directly to the resident. If you did not receive a call schedule, please contact Travis Weyant via email at tweyant@unmc.edu or via phone at 402-559-3964.  Please note, due to variations in a number of factors (weekends per month, availability of fellows, etc.) there may be some inconsistency in the call obligations for residents from month to month.

When on call, if you decide to send a nursing home patient to the Emergency Department, be sure to (a) call the triage nurse in the Emergency Department to provide information about the patient and the reason for transfer, and (b) give an order to the nursing home staff to notify the patient's primary doctor in the morning about the transfer.

The primary provider for patient you were called about overnight will generally need to know about the calls and any new orders you gave. You can pass along these messages via the message function on LastWord, or by dropping notices in the providers' mailboxes.

CONSULTATION

Presently we are unable to do inpatient consultations, except for patients whose primary providers practice in the Geriatrics Clinic. Other consult requests should be referred to the general medicine services.

COMMUNICATION

This system of cross cover will require careful and deliberate communication between house officers and at times between house officers and fellows before each transition in care. It must be the responsibility of the HO or fellow "going off" to contact the person "coming on".

The transfer of information is suggest to occur in the following manner;

Check out: The daytime HO or fellow calls the night call HO and provides some written information ( ie patient's names, MR number, room, code status and important medical issues).

Check in: The day HO or fellow should call the overnight Supervisor for any admissions overnight. Although this does complicate care, it will also be an opportunity for trainees to refine this skill for "real world" practice later on.

GERIATRICS FELLOWS

During some months of the year, the inpatient Geriatrics service operates with the addition of a Geriatrics fellow. Although fellows will assume primary care of some inpatients, their role is not to serve as a "co-resident" on the team. Rather, the fellows are expected to provide exemplary acute care of their assigned few patients, to teach at the bedside and in short didactic sessions, and to role model the three critical domains of inpatient geriatric medicine:

  1. Systematic care targeted at minimizing iatrogenic injury and in-hospital functional decline;
  2. Managing care transitions seamlessly as patients move between venues;
    and
  3. Using prognostic information and goals-and-priorities discussions to collaborate with patients/families in making decisions near the end of life.

VACATION

Vacation would be allowed as it is on most rotations: two weekdays and the associated weekend. Again, coverage for rounds, admissions would need to be provided by the geriatrics fellows or staff. Vacation time is to be requested per the Internal Medicine Education Office Residency Program Vacation Policy. Notice of the resident's vacation request will be sent to Geriatrics by the Education Office for signature.

ROUNDS

Daily rounds would be implemented with one staff for all patients at a specified time.

CLINIC

The resident would attend GAC (Geriatric Assessment Clinic) at least once in the month. Specific time should be determined in consultation with the attending.

TEACHING ROUNDS/DIDACTICS

The geriatrics lecture schedule would remain in place as is with the addition of a PT/OT and nursing home lecture. Didactic instruction may also be provided by the attending geriatrician on the inpatient service. This would be a time that the staff would be allowed to explore geriatric specific issues and questions with the residents.

If the census is low, the resident is welcome to attend University Morning Report as is done on other ward services. This would be optional and based on time constraints.

RESEARCH

Individuals interested in research opportunities are encouraged to inquire.

EVALUATION

Written and oral feedback to residents by the attending on the service will be done at the end of the rotation using the standard departmental forms.

ELECTIVES

A separate elective, one month for upper level residents that are interested in geriatrics, is available. This could potentially include more GAC, nursing home issues, hospice care, other outpatient clinics, etc. Please contact a geriatric faculty member for assistance in scheduling and custom-designing this elective.

SICK DAYS

Contact attending as soon as aware you will be unable to perform duties.

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