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)

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 (7) 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.

   • 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 (7) 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).
   • Night Admitting Resident (NAR) admits up to 2 Geriatrics Practice patients
     • When the Geriatrics Service cap is reached (total of 14 non-consult Geriatrics Service 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 14 non-consult Geriatrics Service 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 alternately accepts up to 2 Geriatrics Consultations. This is independent of caps for admissions and total number of primary patients.                

1. Short Call

   • ​​​​​​​​​​​​​​Accepts up to 2 consults from 7:00 AM – 2:00 PM, unless cap of 2 total number of consult patients is reached

     • ​​​​​​​When capped:
       When the hard cap for total number of consult patients (2) or cap of up to 2 new consults is       reached before 2:00 PM, additional consults will be forwarded to the Long Call resident

2. ​​​​​​​​​​​​​​Long Call

   • ​​​​​​​Accepts up to 2 consults from 2:00 PM – 4:00 PM (on weekends, from 7:00AM-4:00PM), unless cap of 2 total number of consult patients is reached

     • ​​​​​​​When capped:
       When the hard cap for total number of consult patients (2) or cap of up to 2 new consult is reached before 4:00 PM, Geriatrics resident apprises the Geriatrics attending of consult: If co- management is requested (from surgical teams), all co-management consults will be deferred to the Hospitalist Consult Service; non-comanagement Geriatrics consults will be provided by the Geriatrics Attending. After 4PM, the Geriatrics attending to decide if non-comanagement Geriatrics consult be seen the same day or defer to the next morning.

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 cap for admits (2) and within total cap (7).
     • ​​​​​​​​​​​​​​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.​​​​​​​