XII. Providing Geriatric Consultation To Other Services

A. Patients In The Intensive Care Unit (ICU)

1. For non-Covid Geriatrics patients admitted directly to the ICU, the ICU team or the Geriatrics NP will inform the on call Geriatrics resident. The resident will provide Geriatrics auto-consultation and write daily notes. For patients transferred to the ICU from the Geriatrics service, the Geriatrics service will continue to automatically follow in a consulting role and write daily notes until the patient is discharged from the ICU, except in cases when the Geriatrics service has permanently signed off, and in cases when the patient has Covid (in order to limit the number of teams) unless the ICU team specifically requests the Geriatrics service to consult and assist in goals of care discussion and the management of geriatrics syndromes. The Geriatrics service does not serve as primary in the ICU.
2. 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).
3. In addition to assisting the ICU team with the management of geriatric issues, the Geriatrics service helps provide continuity of care between the ICU team, family, and outpatient geriatrician.
4. The Geriatrics service should collaborate with the ICU team in facilitating goals of care discussions with patient/surrogates, and where appropriate, assist in end-of-life care conversations.
5. When ICU patients are transferred out of the ICU, the Geriatrics service will assume primary care for patient, except in cases when the Geriatrics service has permanently signed off. For mechanically ventilated patients, the pulmonary team will continue to have primary responsibility for ventilator management, and will continue to see the patient daily and write daily consult notes.

B. Surgery Co-Management

1. The Geriatrics service consults and provides co-management on General Surgery patients whose PMD is a UCLA Faculty or Fellow.
2. The Geriatrics service consults and provides co-management on General Surgery patients 80 years or older with non-Geriatrics PMD.
3. The Geriatrics NP or the Surgery team informs the Geriatrics admitting resident of these consults. These consults are not to be "shunted" to the following day and are to count as an admission.
4. Because these patients are on the Surgery team, the Geriatrics resident is not responsible for the admission orders, discharge orders, or discharge summary.
5. The Geriatrics resident should write orders for any recommendations (see exceptions below) and inform the General Surgery team. This includes ordering labs you recommend, new medications 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.
6. The Geriatrics resident should write orders and answer pages from nurses about non-surgical issues (exceptions below).
7. 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.
8. Medical issues should be signed out to the Long Call and cross-cover residents, as if these co-managed patients are primarily on the Geriatric Service.
9. As a general 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 the purpose of disposition 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.
10. If a Surgery service patient that Geriatrics was co-managing is readmitted to the hospital within 14 days of discharge for a medical condition requiring a primary medical team, the patient will be admitted to the Geriatrics service. This applies to patients with non-Geriatrics PMDs, including those subsequently transferred from the Surgery Service to the Geriatrics Service.
11. The Geriatrics service will continue to follow the co-managed surgical patient and write daily notes until the patient is discharged.

C. Orthopedics and Neurosurgery Co-Management

1. For Orthopedics patients, please Click link for Inpatient Orthopedics Workflow
2. The Geriatrics service autoconsults and provides co-management on neurosurgery patients whose PMD is a UCLA Geriatrics Faculty or Fellow, and who are admitted for surgery, except:
3. Medical issues on consult patients should be managed as if they were on the Geriatrics Service. The Geriatrics service follows a co-management model for the consult service.
4. When performing Geriatrics consultation, please indicate in the electronic chart that you are the Geriatrics resident and include your pager number. Please assign yourself to the care team on Care Connect.
5. The Geriatrics resident is not responsible for the admission orders, discharge orders, or discharge summary. The admitting team will handle these.
6. The Geriatrics resident should write orders and answer pages from nurses about non-surgical issues. The Geriatrics resident does not generally write orders for pain management and pharmacologic DVT prophylaxis, as the surgical services prefer to do this.
7. Medical issues should be signed out to the Long Call and cross cover residents, as if these co-managed patients are primarily on the Geriatric service.
8. The Geriatrics service will continue to follow the patient and write daily notes until the patient is discharged.

D. All Other Consults

1. Any primary team may request a Geriatrics consult at any time of day. The Geriatrics admitting resident will see the consult and provide recommendations at the time of consult. This will count as an "admission" even though Geriatrics is not the primary team.
2. When performing Geriatrics consultation on these patients, please indicate in the electronic chart that you are the Geriatrics resident and include your pager number. Please assign yourself to the care team on Care Connect.
3. 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. Geriatrics practice patients are to be followed by Geriatrics Service on a consultative basis until they are discharged from the hospital. The expectation is for Geriatrics will 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.
4. Medical issues should be signed out to the Long Call and cross cover residents, as if these co-managed patients are primarily on the Geriatric service.
5. The Geriatrics service will continue to follow consults from the Hospitalist, Family Medicine, and Oncology teams 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 physician and conveyed to the primary team. Please note that Geriatrics service will continue to follow all Oncology consult patients whose PMD is a UCLA Geriatrician, until discharge.