IV. The Interdisciplinary Team Rounds

The Interdisciplinary Rounds (IDR) is a structured session intended to facilitate efficient and closer collaboration among the various disciplines involved in the patient's care. Participants of the IDR include attending physicians, residents, nursing staff, clinical case manager, pharmacist, rehabilitation therapist representing PT/OT, social worker, dietician, and chaplain. During this session, members of the care team review the progress of each patient in the Geriatrics Service, share information relevant to the provision of care, and identify barriers to progress and discharge. The IDR is facilitated on weekdays by the clinical case manager of the day or SW (when CM is off), and on weekends by the NP.

 

The Geriatric Nursing Unit Nurse:

Each patient is first presented briefly by the nursing staff caring for the patient in the Geriatrics Unit (or by the resident if the patient is off floor). The Geriatric Unit nurse is expected to touch upon the following elements:

  1. the presence of delirium
  2. the presence of oxygen and telemetry needs
  3. the presence of diarrhea or constipation
  4. oral intake, if <50%
  5. ongoing indication for Foley catheters, if present
  6. ongoing indication for central lines, if present
  7. level of pain control if applicable
  8. ability to transfer out of bed, amount of assistance needed
  9. pressure ulcers, if present
  10. DVT prophylaxis, if in place
  11. MD orders to update

During this time, the nurse may ask for orders to discontinue telemetry, catheters and lines if they are no longer indicated, or the resident may ask for a discontinuation (resident must enter the dc order on Care Connect) if appropriate.

 

The Geriatrics Resident:

The Geriatrics resident is expected to provide the team with the following information (generally a one-liner “Pt admitted for.... Plan is for... We're anticipating discharge in ... days to home/SNF/ALF etc….& Will need the following: Home Health, these DMEs, etc…”)   :

  1. why the patient is in the hospital and a brief update of the patient's major clinical issues
  2. plans for the day
  3. needs/goals to be met before the patient can be discharged
  4. anticipated discharge date
  5. anticipated discharge location, level of care needed for discharge (e.g., home, SNF, ALF, etc.)
  6. anticipated home health, equipment (e.g. home O2), and caregiver needs, if any

During this time, the resident may request other members of the team for their input or follow-up of action items including assessment and equipment recommendation (e.g., front wheeled walker) by PT or OT, medication review by the Geriatric Pharmacist, psychosocial assessment by the Social Worker, or updates on placement & orders for home health and DMEs by  the Case Manager. The resident may request the nursing staff to perform specific geriatric assessments such as the PHQ 9 with the patient. (In addition to the verbal request, an order must be entered by the resident on Care Connect, under Nursing Communication to complete the specific assessment tool such as the PHQ-9).

 

The Geriatrics Clinical Case Manager:

The Geriatrics Clinical Case Manager notes the medical team's recommendation regarding the appropriate level of care (SNF, home with help, ALF, etc.) and anticipated discharge needs of the patient including DMEs (e.g., O2, tubefeeding supplies, equipment recommended by PT or OT, etc.), updates the team regarding SNF bed availability if applicable, and identifies barriers to achieving recommended discharge location. 

 

Note: The attending physician will provide additional guidance to the team, as needed. In order for the IDR to run efficiently and finish on time, presentations are expected to be succinct.