XI. Co-Management and Consultation Services

A. PROVIDING CO-MANAGEMENT TO SURGICAL SERVICE PATIENTS

Note: Patients co-managed with Surgical Services count as primary patients and not as consults. Please follow the admissions algorithm for these patients.

• The Geriatrics Service provides co-management on surgical patients who belong to the Geriatrics Practice, if requested by the outpatient Geriatrics Practice provider or Surgery Service, or other older patients with non-Geriatrics PCP if requested by the Surgery Service, unless the Geriatrics Teaching Service is capped for primary patients. If the Geriatrics Service is capped or if it is after 4:00 PM, co-management requests from the surgical services are forwarded to the Hospitalist Consult Service and are not to be deferred to the following morning to avoid care delay.
• For co-managed patients with Surgery Service serving as the primary team, the Geriatrics resident is not responsible for the admission orders, discharge orders, or discharge summary. The Geriatrics service will continue to follow the co-managed surgical patient and write daily progress notes until the patient is discharged.
• The Geriatrics resident should write orders for any recommendations (see exceptions below) and inform the Surgery team. This includes ordering labs, additional studies, medications, and consults you recommend, studies you recommend, and consults you recommend (e.g., Infectious Disease, Cardiology etc.). The Geriatrics resident should touch bases with Surgery resident or NP on a daily basis to review recommendations.
• The Geriatrics resident should write orders and answer pages from nurses about non-surgical issues (exceptions below).
• Please do NOT write orders for anticoagulation, antibiotics, ambulation, fluid management, Foley catheter removal, or feeding, without first discussing with surgery team and receiving their OK.
• Medical issues should be signed out to the Night Float resident, as if these co-managed patients are primarily on the Geriatric Service.
• As a rule, the Surgery service will continue to serve as the primary team for surgical patients being co-managed by Geriatrics throughout their hospital stay. There are exceptional circumstances when a co-managed patient's surgical problems and related complications have completely resolved, and the patient requires ongoing hospitalization due to the development of complex medical conditions that would be more appropriately managed by a primary medical team. In these exceptionally rare occasions, the Surgery Service may request the transfer of such patient to the co-managing Geriatrics service, even if the patient has a non-geriatrician PMD. All transfer requests must first be discussed with the Geriatrics Attending before accepting to determine the appropriateness of the transfer. Transfer requests for discharge purposes will be declined. The Geriatrics attending will make the final decision to accept or decline the request for transfer. Once accepted, the Geriatrics Service will assume the primary team role for the patient. There are also very rare instances when it is deemed that the patient may no longer require ongoing Geriatrics co-management; signing off must be discussed with the Geriatrics Attending, discussed with and agreed by the surgical team, and documented clearly in the last Geriatrics consult progress note.
• If a Surgery service patient that Geriatrics was co-managing is rehospitalized at SMH for a medical condition within 14 days of discharge and is requiring a primary medical team, the patient will be re-admitted to the Geriatrics service if the Geriatrics resident who cared for the patient is still on service or not on last day of service.

B. PROVIDING GERIATRIC CONSULTATION TO OTHER SERVICES

Note: When performing Geriatrics consultation, please indicate in the electronic chart that you are the Geriatrics resident and include your pager number. May use the SmartPhrase template .GERIATRICSCONSULTINPATIENT (under User Garcia, Maristela) for your consult note. Please assign yourself to the care team on Care Connect. Click here for the Department of Medicine Inpatient Consultation Guidelines.

1. Intensive Care Unit (ICU) Consults
   • For Geriatrics Practice patients admitted directly to the ICU, the ICU team will inform the on call Geriatrics resident if a consultation is requested. The resident will provide Geriatrics consultation if requested, follow the patient and write progress notes daily, until it is deemed appropriate for the Geriatrics service to sign off. Signing off must be discussed with the Geriatrics Attending, conveyed to the ICU team, and documented clearly in writing.
   • For patients transferred to the ICU from the Geriatrics service, the Geriatrics service may follow in a consulting role and write daily notes only if specifically requested by the ICU team. If requested to follow the patient, the resident will write daily progress notes and continue to see the patient until it is deemed appropriate for the Geriatrics service to sign off. Signing off must be discussed with the Geriatrics Attending and conveyed to the ICU team.
   • When Geriatrics Consultation is requested, the Geriatrics team assists in in goals of care discussion and the management of geriatrics syndromes including but not limited to delirium and polypharmacy.
   • The Geriatrics Service does not serve as primary in the ICU.
   • Geriatric residents and attendings do not write orders on ICU patients once they are in the ICU.
   • The Geriatrics resident may write transfer orders in order to admit them to the ICU (for example, transferring them from the Geriatrics Unit or admitting from the ED).
   • When ICU patients are transferred out of the ICU, the Geriatrics service will serve as the primary team for Geriatrics Practice patients and patients who were transferred to the ICU by the Geriatrics Inpatient Service during their current hospitalization, except in cases when the Geriatrics service has permanently signed off. Appropriate transfers from the ICU to the Geri Service will count as admissions and be triaged per admissions algorithm, even if the Geriatrics attending has followed the ICU patient independently as consult. If the Geriatrics Service permanently signs off, the Geriatrics team notifies and discusses this with the ICU team. Panel patients from the ICU who were not ICU transfers from the Geri service do not qualify as panel admissions for Geriatrics. Panel admissions for Geri must come from the SMH-ER.
   • For mechanically ventilated patients who have been downgraded to Intermediate Care, the Pulmonary Service will continue to have primary responsibility for ventilator management, and will continue to see the patient daily and write daily consult notes.
      
2. Oncology Consults
   • If requested by the Oncology team, the Geriatrics resident will provide Geriatrics consultation and follow the patient and write daily notes until it is deemed appropriate for the Geriatrics service to sign off. Signing off must be discussed with the Geriatrics Attending and conveyed to the Oncology team. Please note that if requested by the Geriatrics Practice outpatient PCP, Geriatrics service will continue to follow their patients admitted in the Oncology Service until it is deemed appropriate for the Geriatrics service to sign off; however please discuss with the Geriatrics Practice outpatient PCP before signing off to address any concerns, including adequate plan upon discharge.
      
3. Other Consults
   • ​​​​​​​​​​​​​​Any primary team may request a Geriatrics consult. The Geriatrics resident will see the consult and provide recommendations at the time of consult after staffing with the Geriatrics Attending.
   • Non-urgent, non-comanagement Geriatrics Consult after 4:00 PM may be seen the following morning at the discretion of the Geriatrics attending.
   • Geriatrics Service will provide consultation for patients whose PMD is a UCLA Geriatrics faculty or fellow and who are being admitted electively for lumbar drain trial (NPH program) in 4NW. The Hospitalist Team will serve as the primary for these patients during the hospital stay, with co-management by the Neurology Service. The expectation is for Geriatrics to be called for consult when these admissions come in. The initial consultation is to address relevant geriatric issues including, but not limited to: functional status assessment, falls assessment, medication safety review, presence of delirium, mood assessment, skin evaluation, and social support.
   • The Geriatrics service will follow the consults and write daily notes until it is deemed appropriate for the Geriatrics service to sign off. Signing off must be discussed with the Geriatrics Attending and conveyed to the primary team.
      
4. OBTAINING CONSULTATION FROM OTHER SERVICES
   • ​​​​​​​Every effort should be made to call consultations before noon, if possible.
   • Contact information for consult services is posted in the IDR room, and is also available through the page operator.
   • Because SMH is a community hospital, some services do not have housestaff or fellows.
   • It is critical to contact consultants early during the hospital course, rather than waiting until the consultant is needed urgently.
   • If you cannot determine who is on-call for a Consult Service, the page operator or the emergency department as they may have a list.