Geriatric Medicine

VIII. The Call Cycle: Admissions & Geriatrics Consults

  • Daytime (7:00 AM-4:00 PM): Geriatrics residents alternate Short Call days and Long Call days.

  • Overnight (4:00 PM-7:00 AM): NAR will assign Geriatrics Practice patients alternately between the following day's Short Call resident and Long Call resident, starting with the Short Call resident (sequence: Short Call, Long Call, Short Call, Long Call). If one team does not have space for their full complement of overnight admissions, admissions will be distributed to the team that does have space, up to a total of 4 holdovers for the Geriatrics Service or the Geriatrics Service cap of 16 total primary patients, whichever comes first.

 

A. ADMISSIONS

(Click here to access admission algorithms)

  1. Daytime Admissions (7AM-4PM)
    Geriatrics Practice patients as well as SM-ED Panel patients are accepted during these hours.
     
    • Short Call

      • Accepts overnight Geriatrics Practice admissions from NAR and NF

      • Admits up to 2 de novo patients until 2:00PM; if an overnight holdover patient has an MRAN only  (i.e., pt was paged out between 5-7AM and the overnight resident essentially eyeballed the patient and put in holding orders and a brief MRAN), this patient counts towards the daytime resident's 2 de novo patients. These patients almost always don't have much in the way of full history/workup, so it is essentially a brand new patient for the day Geri resident.

      • Signs onto the Geriatrics virtual pager (p91907) at 7:00 AM

      • When capped:
        When the hard cap for total number of primary patients (8) or cap for maximum number of 2 de novo admissions is reached before 2:00 PM, the Geriatrics admitting pager 91907 is to be forwarded to the Long Call resident who will begin taking admissions. Co-managed patients count as primary patients.

    • Long Call

      • Accepts overnight Geriatrics Practice admissions from NAR and NF

      • Admits up to 2 de novo Geriatrics Practice and Panel patients from 2:00 PM - 4:00 PM; if an overnight holdover patient has an MRAN only  (i.e., pt was paged out between 5-7AM and the overnight resident essentially eyeballed the patient and put in holding orders and a brief MRAN), this patient counts towards the daytime resident's 2 de novo patients. These patients almost always don't have much in the way of full history/workup, so it is essentially a brand new patient for the day Geri resident.

      • Signs onto the Geriatrics virtual pager (pager 91907) at 2:00 PM (sooner if Short Call resident caps sooner)

      • On weekends, when short call resident is off, Long Call resident signs onto Geriatrics admitting pager (p91907) and admits up to 2 de novo admissions from 7:00AM-4:00 PM

      • When capped:
        When the hard cap for total number of primary patients (8) or cap for maximum number of de novo admissions is reached before 4:00 PM, a notification via page should be sent to the Hospitalist Admitting Pager p30060 that Geriatrics has capped and the Geriatrics admitting pager p91907 is to be forwarded to the Hospitalist Admitting Pager p30060. Any Geriatrics     Practice patients admitted by the direct care hospitalists (day or night) will be kept by the direct care hospitalist teams.

  2. Overnight Admissions
    Only Geriatrics Practice patients are admitted overnight. The NAR and NF will assign the overnight Geriatrics Practice admissions alternately between the Short Call and Long Call residents (on Saturdays and Sundays, between the Covering NP for the Off-Day resident and the Long Call). If one team does not have space for their full complement of overnight admissions, admissions will be distributed to the team that does have space, up to a total of 4 holdovers for the Geriatrics Service or the Geriatrics Service cap of 16 total primary patients, whichever comes first.
    • Night Admitting Resident (NAR) admits up to 2 Geriatrics Practice patients
      • When the Geriatrics Service cap is reached (total of 16 primary Geriatrics Service patients, including co-managed patients):
        The NAR sends a notification via page to the Hospitalist Admitting Pager p30060 that Geriatrics has capped and the Geriatrics admitting pager p91907 is to be forwarded to the Hospitalist Admitting Pager p30060. Any Geriatrics Practice patients admitted by the direct care hospitalists (day or night) will be kept by the direct care hospitalist teams.
      • When the NAR cap is reached and the Geriatrics Service has capacity to accept Geriatrics Practice patients:
        The NAR sends a notification via page to the Night Float p 90016 that Geriatrics has capped and the Geriatrics admitting pager p91907 is to be forwarded to the Night Float p 90016.
    • Night Float (NF) may admit up to 2 additional Geriatrics Practice patients, depending on the capacity of the Geriatrics Service.
      • When the Geriatrics Service cap is reached (total of 16 primary Geriatrics Service patients, including co-managed patients):
        The NF sends a notification via page to the Hospitalist Admitting Pager p30060 that Geriatrics has capped and the Geriatrics admitting pager p91907 is to be forwarded to the Hospitalist Admitting Pager p30060. Any Geriatrics Practice patients admitted by the direct care hospitalists (day or night) will be kept by the direct care hospitalist teams.
      • When the NF cap is reached and the Geriatrics Service has capacity to accept Geriatrics Practice patients:
        The NF sends a notification via page to the Hospitalist Admitting Pager p30060 that Geriatrics has capped and the Geriatrics admitting pager p91907 is to be forwarded to the Hospitalist Admitting Pager p30060. Any Geriatrics Practice patients admitted by the direct care hospitalists (day or night) will be kept by the direct care hospitalist teams.

 

 

B. GERIATRICS CONSULTS

(Click here to access consult algorithm)

Each Geriatric resident can only take or have 1 Geriatrics consultation (new or existing) at any given time. This is independent of caps for admissions and total number of primary patients. Please note that co-managed patients (with surgical services) count as primary patients; please use admissions algorithm for these patients, not the consult algorithm. 

  1. Short Call

    • ​​​​​​​Can take up to 1 consult generally from 7:00 AM – 2:00 PM with exception below:

      • When capped for new consult: When the hard cap for total number of consult (1 consult), new or existing is reached before 2:00 PM, any new consult will be forwarded to the Long Call resident.

      • When not capped but it is a re-consult of a previously signed off consult, the original resident will take the re-consult regardless of the call cycle/time of day, for continuity of care. If short call resident is capped, the re-consult will be staffed by the original attending if still on service, for continuity of care; if original attending is no longer on service, such re-consult will be triaged per Geri residents’ capacity (follow Consult algorithm above).

      • When both Short Call and Long Call are capped for consults, the Geriatrics Attending will provide the consult without the resident and will be keep the consult until signed off.

  2. ​​​​​​​​​​​​​​Long Call

    • Can take up to 1 consult from 2:00 PM – 4:00 PM (on weekends, from 7:00AM-4:00PM)

      • When capped for new consult: When the hard cap for total number of consult (1 consult) is reached before 4:00 PM, the Geriatrics Attending see the new consult and will be keep the consult until signed off.

      • When not capped but it is a re-consult of a previously signed off consult, the original resident will take the re-consult regardless of the call cycle/time of day, for continuity of care. If short call resident is capped, the re-consult will be staffed by the original attending if still on service, for continuity of care; if original attending is no longer on service, such re-consult will be triaged per Geri residents’ capacity (follow Consult algorithm above).

 

C. BOUNCEBACKS

(Click here to access bounceback algorithm)​​​​​​​

General Rule

  1. If the original resident has rotated off on last day of service:
    The patient who is a bounceback will be triaged per general admission guidelines.
  2. If the original resident is still on the Geriatrics rotation:
    ​​​​​​​The patient who is a bounceback to Geriatrics is to be reassigned back to the Geriatrics. The bounceback will be assigned to the Geriatrics resident with capacity to accept admission (may not be the original resident, if the original resident is capped). Overnight bounceback  admission on weekends may be assigned to covering NP for Off-day original resident, or to the Geriatrics resident with capacity to accept admission if the original resident is capped, with the goal of repatriating back to the original resident if not discharging. (Daytime bounceback admissions on weekends cannot be given to Covering NP). The admission will count as a de novo admission to Geriatrics resident if the resident completes the full H&P. If the resident did not complete the full H&P, the patient will count towards the resident’s total cap and not towards the de novo admission cap. 

 

D. ICU DOWNGRADES

  1. ICU BACK TO GERI DOWNGRADES (2 scenarios)
    • ​​​​​​​Patient originally admitted to Geri Teaching Service, then was upgraded to ICU and is now ready to bounce back to Geri.
      • BEFORE 4PM
        1. ​​​​​​​​​​​​​​​​​​​​​If original Geri resident is hard-capped, but co-resident is not capped, we would have the co-resident accept the patient and, if not DCing, repatriate back to the primary resident when space opens (i.e. optimizing for the benefit of continuity with the Geri service for patient, even if not original resident). This patient would count as towards their admissions cap.
        2. If original Geri resident is soft-capped (but not hard-capped), they should accept this patient, as following our RR Bounceback Rules.
        3. If both Geri residents are hard capped, the patient is triaged to the Hospitalist service &  follow the bounceback rules.
      • AFTER 4PM
        1. Only in extenuating circumstances (i.e. if ICU needs to free up a bed in the unit for unstable admit). If there is room on overall Geri census and NAR/NF have not reached their Geri admissions cap, NAR/NF will admit the pt as a bounceback following above bounceback rules.
    • ​​​​​​​​​​​​​​Patient is a Geri Practice pt who was admitted directly to ICU.
      • ​​​​​​​BEFORE 4PM
        1. ​​​​​​​​​​​​​​If Geri Teaching service is not capped we:
          • ​​​​​​​​​​​​​​Have the Geriatrics Practice patient downgrade be treated in the same way as a Geri direct admit from clinic/office/home, i.e., Geri resident with space will take the patient regardless of call cycle as along as within total cap (8).
      • ​​​​​​​​​​​​​​AFTER 4PM
        1. ​​​​​​​​​​​​​​Only in extenuating circumstances (i.e. if ICU needs to free up a bed in the unit for unstable admit). If there is room on overall Geri census and NAR/NF have not reached their Geri admissions cap, NAR/NF will admit the pt to Geri. If there is no room on Geri census or if NAR/NF have reached Geri adm cap, pt will go to direct care hospitalist team.​​​​​​​