MSH/UHN GERIATRICS ROTATION GUIDE
WELCOME TO OUR GERIATRICS ROTATION
We would like to take this opportunity to welcome you to the Geriatric Medicine rotation at Mount Sinai and the University Health Network Hospitals. We hope you enjoy your time with us.
This detailed orientation document has been prepared to help you understand how the rotation and our clinical services are structured and how to get the most out of this overall learning experience.
This guide starts by outlining the philosophy and components of geriatric assessments. It then provides a detailed orientation to the various elements of our multi-site and multi-component rotation that you will be exposed to including the Interprofessional Inpatient Consult Services at Mount Sinai and the UHN Hospitals and our Outpatient Clinics (MSH, TRI and St. Joseph’s Geriatrics Clinics, TRI Falls Clinic, TWH Memory Clinic, and TGH Osteoporosis Clinic).
Accompanying this document are your detailed rotation schedules that have been personalized for each of you. If you see any conflicts or need to make any changes – please let Libby Mendonca at 17-6641 now so that the necessary changes can be made. Family Medicine residents will have received their schedule from Paula Da Rocha.
Furthermore, we have also enclosed some essential articles and other documents in your orientation packs that should help facilitate your learning on this rotation.
We are always looking to find ways to improve this rotation and so we always welcome any comments or feedback you could provide us to improve things further.
Welcome once again and enjoy your rotation.
Dr. Barry Goldlist
Director of Geriatrics Education
Mount Sinai and the University Network Hospitals
Dr. Samir K. Sinha
Director of Geriatrics
Mount Sinai and the University Network Hospitals
FACULTY AND RESIDENT CONTACT INFORMATION
PHILOSOPHY OF GERIATRICS ASSESSMENTS
Although there is a list of learning objectives for this rotation, our ultimate goal is to provide you with an opportunity to learn how to perform Comprehensive Geriatric Assessments (CGAs). CGA can be defined as “a multidisciplinary diagnostic process intended to determine a frail elderly person’s medical, psychosocial, and functional capabilities and limitations in order to develop an overall plan for treatment and long-term follow-up” (Rubenstein, 1982).
In other words, one of the most important goals of a Geriatrician is to identify a frail older person’s abilities and those diseases/illnesses that limit their abilities. We then make recommendations related to the delivery of a person’s health and social care and identify any rehabilitation goals that might minimize limitations and maximize a person’s abilities and quality of life.
COMPONENTS OF A COMPREHENSIVE GERIATRICS ASSESSMENT
When requested to see an older patient in Consultation – Geriatricians always look beyond the admitting diagnosis to complete a broader assessment that also encompasses the full medical, psychosocial, and functional capabilities and limitations in order to develop an overall plan for treatment and long-term follow-up that supports the work of their primary care providers during a hospital admission or within the context of their community living situations.
While an inpatient medical team may be focused rightfully around the main admitting diagnosis – ie pneumonia – the Geriatrician looks to address other potential geriatric syndromes that may complicate an admission or preclude a durable return to the community. The issues we often focus on in our assessments include amongst other things:
- Diagnostic/Treatment Challenges
- A recent Decline in Functional Abilities or Mobility Issues
- Problems Common to Older Adults – (Falls; Polypharmacy; Incontinence; Weight Loss, Acute/Chronic Pain, Failure to Thrive etc.)
- Complex Social Issues – (Caregiver Burnout, Elder Abuse etc.)
- Goals of Care and/or Disposition Planning Issues - including assessment and referrals to our Outpatient Clinics and Home Based Services (House Calls Program).
There are many ways to organize a Comprehensive Geriatrics Assessment. The following framework is one way to organize the way you document your assessments.
- Patient Identification and Reason for Consultation
- Chief Complaint and Related History
- Past Medical History
- Relevant Family History
- Medication and Allergy History (including prescription, non prescription, vitamins and other supplements – don’t forget to enquire about sleeping aids, alcohol and other addictive agents)
- Functional History (including activities of daily living, falls, memory complaints, bowel and bladder function)
- Social History (including current living situation, family and community supports, advance care directives, powers of attorney, and general financial situation)
- Physical Exam (including gait assessment along with orthostatic vitals when necessary)
- Cognitive and Mood Exams (includes screen for Dementia e.g. Folstein Mini-Mental State exam; Depression e.g, Geriatric Depression Scale; Delirium eg Confusion Assessment Method etc)
- Review of Relevant Diagnostic Information
- Assessment and Plan (including brief summary and impression and then usually no more than 5 recommendations)
MSH Geriatrics Residents’ Office
While we are a multi-site rotation – our residents are always based out of Mount Sinai Hospital which is our busiest site. The main office for our residents is located in the main tower of Mount Sinai Hospital in Suite 475. This space has two networked computers and a phone as well. You will each be given keys to the area (with a $20 Deposit) that must be returned at the end of your rotation. Please lock the door behind you if you are the last one to leave the offices at any time.
TWH Geriatrics Residents’ Office
The Geriatrics Residents’ Office at TWH is located on 8 East Wing, Room 410 and the door lock code is 2341. This space has one networked computer and a phone as well. This space is meant to provide residents a touchdown area where they can work from and leave their belongings while seeing patients at TWH.
MSH and UHN On Call Schedules
Resident Call Schedules have been developed to cover the MSH and UHN Services. Usually a different resident is assigned to receive consults. At MSH –the Geriatrics Fellow usually takes and assigns the consults while one of the assigned Medicine residents does the same for the UHN Consults. Consults can be received between 8 am and 5 pm by the resident assigned to receive consults that day whose pager number is kept with locating. The Staff Geriatricians handle consults and calls after 5pm during weekdays and on weekends.
MSH and UHN Geriatrics Signout Lists
Please ensure that the MSH and UHN Geriatric Medicine Consult Signout Lists are always up to date. If allied health team members at either site are working with patients after Geri-Med issues have been addressed – you can indicate that Geri-Med has signed-off – and then delete the patient once all team members have verified they have signed off as well.
At Mount Sinai - The list is accessible through Powerchart or via the Intranet under “Clinical Tools”. The password remains ‘geriatrics’.
At UHN - please ensure that the UHN Geriatric Medicine Consult Signout List is always up to date. The list is accessible through EPR.
Phone Services at MSH and UHN
It is helpful to know that MSH and UHN share a common phone system – with each hospital being distinguished by a prefix to facilitate calling extensions at each site directly, The Prefixes are 17 (MSH), 13 (TWH), 14 (TGH) and 16 (PMH). Therefore if you need to call an extension at TGH and you are at Mount Sinai – dial 14 and then the appropriate 4 digit extension.
MOUNT SINAI HOSPITAL INPATIENT CONSULT SERVICES
At Mount Sinai we have established a busy service where consults arrive or can be generated through one of three ways:
Geriatric Medicine/Psychiatry Consults Number
1. A number Geriatric Medicine and Geriatric Psychiatry consults are called into the x8419 extension that is staffed by Jeanette Villapando. When Jeanette receives a Geriatric Medicine consult she will call the Geriatric Medicine resident on call – to relay them the details and the contact information of the person who called in the consult so that further information can be gathered from the referring individual.
GEM Flag System
2. Potential Geriatric Medicine consults are also generated through the GEM Flag System that is unique to Mount Sinai. Our ED Geriatric Emergency Management (GEM) Nurses often will flag patients admitted with Geriatric Issues overnight that may need further inpatient support by the Geriatric Medicine or Psychiatry services.
For those patients flagged on Powerchart – the on-call Geriatric Medicine Resident should look at the GEM Nursing Assessment saved under the Clinical Notes Tab on the left side of the Menu List on a patient record in Powerchart to gain more information about the patient’s Geriatric Issues that may need follow-up and then call the relevant admitting team to see if they would like our additional support to manage these issues with their patients.
Any consults that are generated through this method must be called in to Jeanette at 8419 – so that she can keep track of all the patients we are seeing. If any of the new consults require Geriatric Psychiatry – please ask the team caring for the patient to call a consult in to Jeannette at 8419.
3. Finally, consults can be received directly between 8 am and 5 pm by the resident assigned to receive consults that day whose pager number is kept with locating. Again if you are on-call for MSH and will be away for a clinic or half-day education commitment – please notify Jeanette at 17-8419 and MSH Locating at 17-5133 notifying them of who will cover you in your absence.
Sometimes you will find that only the expertise of one of our interprofessional team members is being requested for their specific expertise and support – ie from our Social Worker (Carmelina Marziliano), Physiotherapist (Natasha Bhesania), or Pharmacist (Chris Fan-Lun) who are all seen as advanced practice leads at Mount Sinai. In these cases – the appropriate team members should be notified so that they can pick up the consult and the follow the patient as is necessary.
When you get a general Geriatric Medicine Consult the expectation is that the patient will be seen and assessed within 24 hours.
Please let the Consult Staff Geriatrician and the rest of the MSH allied health team know as well of any new MSH consults either in person or via EMAIL, and the required support they may need to give – so that they can support your work in caring for the consult patients as well. We usually notify the interprofessional team members using email – and highlight issues and the help we may be looking for from our interprofessional colleagues. Getting their assistance early often helps you provide a better overall assessment and set of recommendations to the team that has requested a consult.
If a patient needs to be seen urgently in the ED or for an urgent issue (e.g. acute delirium) but the residents are unable to do so, the senior resident should speak directly with the Attending Geriatrician to determine the appropriate next step.
Residents should write a note every time they assess the patient. Progress notes should be written following consult rounds on all patients by either the resident or another team member. Patients should be seen a minimum of twice a week (usually before consult rounds) or more frequently as the situation requires.
Inpatient Geriatric Psychiatry Services at MSH
We work in partnership with a very responsive Geriatric Psychiatry Service as well. Consults that typically should go to Geriatric Psychiatry can be for older patients: requiring an evaluation for a possible diagnosis of depression, dementia, delirium, personality disorder or other psychiatric illness, with active psychiatric diagnoses needing further management, and hard to manage delirium. Delirium work-ups usually stay with Geriatric Medicine. In many cases our services often work together on a number of consults and both should be involved. If we feel a patient we are seeing needs a Geriatric Psychiatry consult – we ask the managing team to consult Geriatric Psychiatry directly. If there are any questions about the appropriateness of the consult, or around which service should handle a consult, please speak with the consult staff geriatrician before communicating further with the referring service.
Inpatient Geriatrics Consults Rounds at MSH
All consults are reviewed at least twice weekly on Mondays at 11:00am and Thursdays at 9:00am with the entire team.
On Tuesdays and Fridays – we do a quick 20 minute huddle with the entire team at 9:00am to quickly review new patients being consulted upon and to update each other about other patients that are being followed as well. We do the same at 11:30am on Wednesdays.
Shared Geriatric Medicine and Geriatric Psychiatry patients are reviewed every Wednesday from 9:00-9:30am.
UHN INPATIENT CONSULT SERVICES
The assigned “UHN Geriatrics Consult Resident” will also be based at TWH and responsible for attending the consult rounds that are held at TWH three times a week.
At the Toronto Western Hospital, Geriatrics Consults are handled by an interprofessional team that comprises our Mobile Acute Care for Elders (ACE) Service. Consults are generally received directly between 8 am and 5 pm by the “UHN Consults Resident” assigned to receive consults that day. Sometimes an interprofessional team member may be notified of a possible Consult and request the “UHN Consults Resident” to verify if the medical team involved would like the help of the Mobile ACE Service.
Every patient seen by the Mobile ACE Service receives a geriatrics consult and is at least screened by the rest of the team. The allied health members can further support their colleagues by becoming the main social worker, or therapist working with their patient during an admission. This allows the older patient to receive the specialized care that they may require.
Currently our Mobile ACE Team includes a Social Worker (Helen Levin), Nurse Practitioner (Sandra Tully), Clinical Nurse Specialist (Naudea Mair) PT (Nadia Iannetta) and OT (Oriana Medeiros). If there are any questions about the appropriateness of the consult, please speak with the consult staff geriatrician before communicating further with the referring service.
Please let the Consult Staff Geriatrician and the rest of the TWH allied health team know as well of any new TWH consults either in person or via EMAIL, and the required support they may need to give – so that they can support your work in caring for the consult patients as well. We usually notify the interprofessional team members using email – and highlight issues and the help we may be looking for from our interprofessional colleagues. Getting their assistance early often helps you provide a better overall assessment and set of recommendations to the team that has requested a consult.
It is extremely important that the carbon copy of the consult note be placed in the geriatric consult files – on the table in the RGP office on 8 East Wing at TWH. This carbon copy becomes our record that we have seen the patient and provides information about the patient for the other consult team members.
At the Toronto General and Princess Margaret Hospitals, consults are will be also be handled by the assigned “UHN Geriatrics Consults Resident” and reviewed directly with the Staff Geriatrician at a mutually convenient time. There is usually no allied health support to currently help with consults at these two sites – but you can certainly call them for advice around specific issues.
Again, if a patient needs to be seen urgently in the ED or for an urgent issue (e.g. acute delirium) but the residents are unable to do so, the senior resident should speak directly with the Attending Geriatrician to determine the appropriate next step.
Again, Residents should write a note every time they assess the patient. Progress notes should be written following consult rounds on all patients by either the resident or another team member. Patients should be seen a minimum of twice a week (usually before consult rounds) or more frequently as the situation requires.
Inpatient Geriatrics Consults Rounds at TWH
All TWH consults are reviewed three times a week on Mondays at 1:00pm and Wednesdays and Fridays at 10:00am with the entire Interprofessional Team.
Inpatient Geriatric Psychiatry Services at UHN
At TWH - From July 1, 2013 onwards, the Psychiatry CL service will be the point of first contact for inpatient referrals from the RGP. Dr Monica Scalco, who is currently first contact, will be available to consult on cases when requested by the Psychiatry CL service. Thus, there will still be input from a geriatric psychiatrist when needed. Referrals to the Psychiatry CL service should be phoned to 416-603-5847 with the following information: patient’s name and MRN, ward, referring MD, reason for referral and brief history, and the urgency of the consultation (‘urgent’, ‘today’, ‘can wait until tomorrow’).