Download ORIENTATION TO GERIATRICS ROTATION

MSH/UHN GERIATRICS ROTATION GUIDE
WELCOME TO OUR GERIATRICS ROTATION
Dear Residents,
We would like to take this opportunity to welcome you to the Geriatric Medicine rotation at Mount
Sinai and the University Health Network Hospitals. We hope you enjoy your time with us.
This detailed orientation document has been prepared to help you understand how the rotation and
our clinical services are structured and how to get the most out of this overall learning experience.
This guide starts by outlining the philosophy and components of geriatric assessments. It then
provides a detailed orientation to the various elements of our multi-site and multi-component
rotation that you will be exposed to including the Interprofessional Inpatient Consult Services at
Mount Sinai and the UHN Hospitals and our Outpatient Clinics (MSH, TRI and St. Joseph’s
Geriatrics Clinics, TRI Falls Clinic, TWH Memory Clinic, and TGH Osteoporosis Clinic).
Accompanying this document are your detailed rotation schedules that have been personalized for
each of you. If you see any conflicts or need to make any changes – please let Libby Mendonca at
17-6641 now so that the necessary changes can be made. Family Medicine residents will have
received their schedule from Paula Da Rocha.
Furthermore, we have also enclosed some essential articles and other documents in your orientation
packs that should help facilitate your learning on this rotation.
We are always looking to find ways to improve this rotation and so we always welcome any
comments or feedback you could provide us to improve things further.
Welcome once again and enjoy your rotation.
Yours Sincerely,
Dr. Barry Goldlist
Director of Geriatrics Education
Mount Sinai and the University Network Hospitals
And
Dr. Samir K. Sinha
Director of Geriatrics
Mount Sinai and the University Network Hospitals
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FACULTY AND RESIDENT CONTACT INFORMATION
Faculty Contacts:
Dr. Shabbir Alibhai
Dr. Barry Goldlist
Dr. Samir Sinha
Dr. Karen Ng
Dr. Vicky Chau
Dr. Dan Liberman
Dr. Arielle Berger
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
PHILOSOPHY OF GERIATRICS ASSESSMENTS
Although there is a list of learning objectives for this rotation, our ultimate goal is to provide you
with an opportunity to learn how to perform Comprehensive Geriatric Assessments (CGAs). CGA
can be defined as “a multidisciplinary diagnostic process intended to determine a frail elderly
person’s medical, psychosocial, and functional capabilities and limitations in order to develop an
overall plan for treatment and long-term follow-up” (Rubenstein, 1982).
In other words, one of the most important goals of a Geriatrician is to identify a frail older person’s
abilities and those diseases/illnesses that limit their abilities. We then make recommendations
related to the delivery of a person’s health and social care and identify any rehabilitation goals that
might minimize limitations and maximize a person’s abilities and quality of life.
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COMPONENTS OF A COMPREHENSIVE GERIATRICS ASSESSMENT
When requested to see an older patient in Consultation – Geriatricians always look beyond the
admitting diagnosis to complete a broader assessment that also encompasses the full medical,
psychosocial, and functional capabilities and limitations in order to develop an overall plan for
treatment and long-term follow-up that supports the work of their primary care providers during a
hospital admission or within the context of their community living situations.
While an inpatient medical team may be focused rightfully around the main admitting diagnosis – ie
pneumonia – the Geriatrician looks to address other potential geriatric syndromes that may
complicate an admission or preclude a durable return to the community. The issues we often focus
on in our assessments include amongst other things:
1. Diagnostic/Treatment Challenges
2. A recent Decline in Functional Abilities or Mobility Issues
3. Problems Common to Older Adults – (Falls; Polypharmacy; Incontinence; Weight Loss,
Acute/Chronic Pain, Failure to Thrive etc.)
4. Complex Social Issues – (Caregiver Burnout, Elder Abuse etc.)
5. Goals of Care and/or Disposition Planning Issues - including assessment and referrals to
our Outpatient Clinics and Home Based Services (House Calls Program).
There are many ways to organize a Comprehensive Geriatrics Assessment.
framework is one way to organize the way you document your assessments.
The following
1.
2.
3.
4.
5.
Patient Identification and Reason for Consultation
Chief Complaint and Related History
Past Medical History
Relevant Family History
Medication and Allergy History (including prescription, non prescription, vitamins and other
supplements – don’t forget to enquire about sleeping aids, alcohol and other addictive
agents)
6. Functional History (including activities of daily living, falls, memory complaints, bowel and
bladder function)
7. Social History (including current living situation, family and community supports, advance
care directives, powers of attorney, and general financial situation)
8. Physical Exam (including gait assessment along with orthostatic vitals when necessary)
9. Cognitive and Mood Exams (includes screen for Dementia e.g. Folstein Mini-Mental State
exam; Depression e.g, Geriatric Depression Scale; Delirium eg Confusion Assessment
Method etc)
10. Review of Relevant Diagnostic Information
11. Assessment and Plan (including brief summary and impression and then usually no more
than 5 recommendations)
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ROTATION LOGISITICS
MSH Geriatrics Residents’ Office
While we are a multi-site rotation – our residents are always based out of Mount Sinai Hospital
which is our busiest site. The main office for our residents is located in the main tower of Mount
Sinai Hospital in Suite 475. This space has two networked computers and a phone as well. You will
each be given keys to the area (with a $20 Deposit) that must be returned at the end of your rotation.
Please lock the door behind you if you are the last one to leave the offices at any time.
TWH Geriatrics Residents’ Office
The Geriatrics Residents’ Office at TWH is located on 8 East Wing, Room 410 and the door lock
code is 2341. This space has one networked computer and a phone as well. This space is meant to
provide residents a touchdown area where they can work from and leave their belongings while seeing
patients at TWH.
MSH and UHN On Call Schedules
Resident Call Schedules have been developed to cover the MSH and UHN Services. Usually a
different resident is assigned to receive consults. At MSH –the Geriatrics Fellow usually takes and
assigns the consults while one of the assigned Medicine residents does the same for the UHN Consults.
Consults can be received between 8 am and 5 pm by the resident assigned to receive consults that day
whose pager number is kept with locating. The Staff Geriatricians handle consults and calls after 5pm
during weekdays and on weekends.
MSH and UHN Geriatrics Signout Lists
Please ensure that the MSH and UHN Geriatric Medicine Consult Signout Lists are always up to date.
If allied health team members at either site are working with patients after Geri-Med issues have been
addressed – you can indicate that Geri-Med has signed-off – and then delete the patient once all team
members have verified they have signed off as well.
At Mount Sinai - The list is accessible through Powerchart or via the Intranet under “Clinical Tools”.
The password remains ‘geriatrics’.
At UHN - please ensure that the UHN Geriatric Medicine Consult Signout List is always up to date.
The list is accessible through EPR.
Phone Services at MSH and UHN
It is helpful to know that MSH and UHN share a common phone system – with each hospital being
distinguished by a prefix to facilitate calling extensions at each site directly, The Prefixes are 17
(MSH), 13 (TWH), 14 (TGH) and 16 (PMH). Therefore if you need to call an extension at TGH and
you are at Mount Sinai – dial 14 and then the appropriate 4 digit extension.
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MOUNT SINAI HOSPITAL INPATIENT CONSULT SERVICES
At Mount Sinai we have established a busy service where consults arrive or can be generated through
one of three ways:
Geriatric Medicine/Psychiatry Consults Number
1. A number Geriatric Medicine and Geriatric Psychiatry consults are called into the x8419 extension
that is staffed by Jeanette Villapando. When Jeanette receives a Geriatric Medicine consult she will
call the Geriatric Medicine resident on call – to relay them the details and the contact information of
the person who called in the consult so that further information can be gathered from the referring
individual.
GEM Flag System
2. Potential Geriatric Medicine consults are also generated through the GEM Flag System that is
unique to Mount Sinai. Our ED Geriatric Emergency Management (GEM) Nurses often will flag
patients admitted with Geriatric Issues overnight that may need further inpatient support by the
Geriatric Medicine or Psychiatry services.
For those patients flagged on Powerchart – the on-call Geriatric Medicine Resident should look at
the GEM Nursing Assessment saved under the Clinical Notes Tab on the left side of the Menu List
on a patient record in Powerchart to gain more information about the patient’s Geriatric Issues that
may need follow-up and then call the relevant admitting team to see if they would like our
additional support to manage these issues with their patients.
Any consults that are generated through this method must be called in to Jeanette at 8419 – so
that she can keep track of all the patients we are seeing. If any of the new consults require
Geriatric Psychiatry – please ask the team caring for the patient to call a consult in to Jeannette at
8419.
Direct Requests
3. Finally, consults can be received directly between 8 am and 5 pm by the resident assigned to receive
consults that day whose pager number is kept with locating. Again if you are on-call for MSH and
will be away for a clinic or half-day education commitment – please notify Jeanette at 17-8419 and
MSH Locating at 17-5133 notifying them of who will cover you in your absence.
Sometimes you will find that only the expertise of one of our interprofessional team members is being
requested for their specific expertise and support – ie from our Social Worker (Carmelina Marziliano),
Physiotherapist (Natasha Bhesania), or Pharmacist (Chris Fan-Lun) who are all seen as advanced
practice leads at Mount Sinai. In these cases – the appropriate team members should be notified so
that they can pick up the consult and the follow the patient as is necessary.
When you get a general Geriatric Medicine Consult the expectation is that the patient will be seen and
assessed within 24 hours.
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Please let the Consult Staff Geriatrician and the rest of the MSH allied health team know as well of any
new MSH consults either in person or via EMAIL, and the required support they may need to give – so
that they can support your work in caring for the consult patients as well. We usually notify the
interprofessional team members using email – and highlight issues and the help we may be looking
for from our interprofessional colleagues. Getting their assistance early often helps you provide a
better overall assessment and set of recommendations to the team that has requested a consult.
If a patient needs to be seen urgently in the ED or for an urgent issue (e.g. acute delirium) but
the residents are unable to do so, the senior resident should speak directly with the Attending
Geriatrician to determine the appropriate next step.
Residents should write a note every time they assess the patient. Progress notes should be written
following consult rounds on all patients by either the resident or another team member. Patients
should be seen a minimum of twice a week (usually before consult rounds) or more frequently as
the situation requires.
Inpatient Geriatric Psychiatry Services at MSH
We work in partnership with a very responsive Geriatric Psychiatry Service as well. Consults that
typically should go to Geriatric Psychiatry can be for older patients: requiring an evaluation for a
possible diagnosis of depression, dementia, delirium, personality disorder or other psychiatric illness,
with active psychiatric diagnoses needing further management, and hard to manage delirium. Delirium
work-ups usually stay with Geriatric Medicine. In many cases our services often work together on a
number of consults and both should be involved. If we feel a patient we are seeing needs a Geriatric
Psychiatry consult – we ask the managing team to consult Geriatric Psychiatry directly. If there are
any questions about the appropriateness of the consult, or around which service should handle a
consult, please speak with the consult staff geriatrician before communicating further with the referring
service.
Inpatient Geriatrics Consults Rounds at MSH
All consults are reviewed at least twice weekly on Mondays at 11:00am and Thursdays at 9:00am with
the entire team.
On Tuesdays and Fridays – we do a quick 20 minute huddle with the entire team at 9:00am to quickly
review new patients being consulted upon and to update each other about other patients that are being
followed as well. We do the same at 11:30am on Wednesdays.
Shared Geriatric Medicine and Geriatric Psychiatry patients are reviewed every Wednesday from 9:009:30am.
UHN INPATIENT CONSULT SERVICES
The assigned “UHN Geriatrics Consult Resident” will also be based at TWH and responsible for
attending the consult rounds that are held at TWH three times a week.
At the Toronto Western Hospital, Geriatrics Consults are handled by an interprofessional team that
comprises our Mobile Acute Care for Elders (ACE) Service. Consults are generally received directly
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between 8 am and 5 pm by the “UHN Consults Resident” assigned to receive consults that day.
Sometimes an interprofessional team member may be notified of a possible Consult and request the
“UHN Consults Resident” to verify if the medical team involved would like the help of the Mobile
ACE Service.
Every patient seen by the Mobile ACE Service receives a geriatrics consult and is at least screened by
the rest of the team. The allied health members can further support their colleagues by becoming the
main social worker, or therapist working with their patient during an admission. This allows the older
patient to receive the specialized care that they may require.
Currently our Mobile ACE Team includes a Social Worker (Helen Levin), Nurse Practitioner (Sandra
Tully), Clinical Nurse Specialist (Naudea Mair) PT (Nadia Iannetta) and OT (Oriana Medeiros). If
there are any questions about the appropriateness of the consult, please speak with the consult staff
geriatrician before communicating further with the referring service.
Please let the Consult Staff Geriatrician and the rest of the TWH allied health team know as well of any
new TWH consults either in person or via EMAIL, and the required support they may need to give – so
that they can support your work in caring for the consult patients as well. We usually notify the
interprofessional team members using email – and highlight issues and the help we may be looking
for from our interprofessional colleagues. Getting their assistance early often helps you provide a
better overall assessment and set of recommendations to the team that has requested a consult.
It is extremely important that the carbon copy of the consult note be placed in the geriatric consult files
– on the table in the RGP office on 8 East Wing at TWH. This carbon copy becomes our record that
we have seen the patient and provides information about the patient for the other consult team
members.
At the Toronto General and Princess Margaret Hospitals, consults are will be also be handled by
the assigned “UHN Geriatrics Consults Resident” and reviewed directly with the Staff Geriatrician at a
mutually convenient time. There is usually no allied health support to currently help with consults at
these two sites – but you can certainly call them for advice around specific issues.
Again, if a patient needs to be seen urgently in the ED or for an urgent issue (e.g. acute
delirium) but the residents are unable to do so, the senior resident should speak directly with
the Attending Geriatrician to determine the appropriate next step.
Again, Residents should write a note every time they assess the patient. Progress notes should be
written following consult rounds on all patients by either the resident or another team member.
Patients should be seen a minimum of twice a week (usually before consult rounds) or more
frequently as the situation requires.
Inpatient Geriatrics Consults Rounds at TWH
All TWH consults are reviewed three times a week on Mondays at 1:00pm and Wednesdays and
Fridays at 10:00am with the entire Interprofessional Team.
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Inpatient Geriatric Psychiatry Services at UHN
At TWH - From July 1, 2013 onwards, the Psychiatry CL service will be the point of first contact
for inpatient referrals from the RGP. Dr Monica Scalco, who is currently first contact, will be
available to consult on cases when requested by the Psychiatry CL service. Thus, there will still be
input from a geriatric psychiatrist when needed. Referrals to the Psychiatry CL service should be
phoned to 416-603-5847 with the following information: patient’s name and MRN, ward, referring
MD, reason for referral and brief history, and the urgency of the consultation (‘urgent’, ‘today’, ‘can
wait until tomorrow’).
At PMH and TGH – there is no specific inpatient geriatric psychiatry consultation service.
Therefore, psychiatry consultation requests at these sites should be directed to the general
Psychiatry Consultation-Liaison (C-L) Service on call at TGH and PMH. Locating – 14-3155 will
provide the best number to make contact with the CL Psychiatry Team.
GERIATRICS ROTATION CLINICS
Several clinics take place each week and include general Geriatric Medicine Clinics at MSH, TRI
and St. Joseph’s, a multi-disciplinary Memory Clinic, a multi-disciplinary Falls Clinic and an
Osteoporosis Clinic. We strive to ensure each of our residents receives as many clinic training
experiences as is possible.
If you are scheduled to be in clinic, please arrive on time. You will see one or two new patients and
possibly one or more follow-up patients. Specific details about both the general geriatric clinic and
memory clinic will be provided to you. The clinics are summarized below.
Mount Sinai Geriatric Medicine Clinic - This clinic is held at Mount Sinai and is supervised by
Drs. Samir Sinha and Barry Goldlist. They see patients on Wednesday afternoons. One or two new
patients will be specifically booked for you to see. New patients are often seen by our Geriatrics
Pharmacist (Chris Fan-Lun) first to review a patient’s medications and to help prepare a medication
list that the patient can take home with them at the end of a visit. During this time – the resident can
look over the new patient assessment and other records that the patients were asked to supply in
advance. The residents will then see the patient and perform a comprehensive geriatric assessment
in 75-90 minutes, after which the patient is reviewed with staff. You may also see one or more
follow-up patients and spend 30-45 minutes with each one. Patients are usually seen in clinic for
reasons similar to the consult service, although patient acuity is usually less intense in clinics. If
you could use the advice of our Geriatrics Social Worker (Carmelina Marziliano) or our Geriatrics
Occupational Therapists (Jennifer Carr) please page them to assist you during the visit if they are
available. Otherwise if they are not available they can follow-up with your patients after their
appointment. Please report to Cathy Boyce in room 457 at the designated time for your clinic. Also
please confirm your attendance with Cathy Boyce at (416) 586-4800 x8563 one day ahead of
your scheduled clinic visit, and let us know as soon as possible if you cannot be there for
whatever reason.
TRI Geriatric Medicine Clinic - This clinic is held at the Toronto Rehab Institute (building south of
MSH) and is supervised by Dr. Shabbir Alibhai. He sees patients on Wednesday afternoons. One
or two new patients will be specifically booked for you to see. The resident will see the patient and
perform a comprehensive geriatric assessment in 75-90 minutes, after which the patient is reviewed
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with staff. You may also see one or more follow-up patients and spend 30-45 minutes with each
one. Patients are usually seen in clinic for reasons similar to the consult service, although patient
acuity is usually less intense in clinics. Clinics are held at the TRI in the outpatient clinic area. It is
located on the 1st floor, at the Elm Street entrance to TRI. Please report to Angela at the designated
time (see above). Please confirm your attendance with Angela at (416) 597-3422 x3047 one day
ahead of your scheduled clinic visit, and let us know as soon as possible if you cannot be there
for whatever reason.
St. Joseph’s Geriatric Medicine Clinic – Located at St. Joseph’s Hospital, this general geriatric
clinic provide exposure to outpatient geriatrics in a busy community hospital. Clinics are often held
from 9:00 a.m. to 4:00 p.m. Trainees are often assigned to work with Dr. Varga based on her
availability. Specific details regarding location and contact person will be put on your schedule.
Geriatric Osteoporosis Clinic – This clinic is located at Toronto General Hospital, 7th Floor, North
Wing with Dr. Shabbir Alibhai on Thursdays from 1:00 to 5:00 p.m. This clinic provides a good
opportunity to assess and manage osteoporosis in an outpatient setting.
Memory Clinic – The UHN Memory Clinic at Toronto Western Hospital is a collaborative, multidisciplinary clinic where patients with memory disorders are assessed by geriatric medicine,
geriatric psychiatry, neurology, and social work. You will see one or two new patients each week in
clinic and observe a detailed mental status, neurological examination and work-up of a patient with
memory loss. Further details will be provided on the first day of memory clinic. Please report at 1
pm sharp on the scheduled day to 5 West Wing, Toronto Western Hospital. A more detailed
introduction to the Memory Clinic is included in your package.
Falls Clinic – The UHN Falls Clinic at Toronto Rehab Institute is a collaborative, multidisciplinary clinic where patients with memory disorders are assessed is an evidence-based,
collaborative, multi-disciplinary clinic where older patients with one or more falls in the past year
(or who are at high risk of falling) are assessed by geriatric medicine, nursing, physiotherapy,
pharmacy, and another allied health team member. You will see two new patients each week in
clinic and learn how to take a focused falls history and relevant physical examination. Further
details will be provided on the first clinic day. Please report at 1:30 pm sharp on the scheduled
Monday to the Outpatient Clinics, 1st Floor – South Wing, Elm Street Entrance. A more detailed
introduction to the Falls Clinic is included in your package.
EDUCATIONAL OPPORTUNITIES
There are many opportunities for formal education while on this rotation. These are listed on your
schedule. There are weekly seminars (Geriatric Giants Seminar Series) for residents. Our allied
health colleagues often provide specific sessions to allow the residents to learn about their areas of
expertise further as it relates to the care of geriatric patients. Residents also get to partake in the
monthly Geriatric Psychiatry Teaching at Mount Sinai. Ward rounds, consult rounds and clinics
have patient-centred teaching as well. GIM Noon Rounds occur almost every day at noon as well
as the usual Medical Grand Rounds on Wednesdays at noon. Your package also includes a
selection of review articles on the common topics in geriatric medicine. If you are interested in
additional formal teaching, please speak with your attending.
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A PRIMER FOR HIP FRACTURE CONSULTS
At. MSH we have an agreement with the Orthopedics Group where we will see all of the Geriatric
Hip Fracture Patients – essentially to provide these patients with optimal Geriatrics Support
throughout their stay. It is not uncommon for the Orthopedics group to consult on other fracture or
elective orthopedic patients that need Geriatrics support as well.
We will often manage these patients in partnership with the Orthopedics Hospitalist – Dr. Christine
Soong on weekdays - as well as Med Consults – who can provide after hours support and often do
pre-op clearances and manage more medical specific issues like hyponatremia, hypertension etc.
These patients are some of the most vulnerable for issues like delirium, and often have other issues
that have gone undiagnosed or untreated ie. osteoporosis, dementia etc.
Usually the Orthopedics CNS will call in the consults in the morning to Jeannette at 8419 – who
then lets the resident-on-call know about the consults. Depending on when the consult is called in
we may see the patient pre-op or post-op.
We also have the permission of the Orthopedics Service to directly order the following
investigations and medication regimens that we both feel will best optimize a patient’s care.
Currently as Dr. Soong, the Hospitalist, is the Most Responsible Physician (FOR HIP FRACTURE
PATIENTS) – so if you would like to consider other orders or want to discuss other issues related to
the care of the hip fracture patients – please speak with her directly. After hours – please speak to
the Orthopedics residents. For NON-HIP FRACTURE PATIENTS – we communicate with the
Orthopedics residents directly but have permission to enter any orders we see fit around these
patients.
In your ASSESSMENTS:
Be sure to assess and document the person’s prior functional and cognitive status, living
arrangements, need for home supports and for the presence of geriatric syndromes.
This will help you come up with your plan that should focus on amongst other things:
1. Delirium Prevention or Management
This usually emphasizes aggressive mobilization – up in chair for all meals and D/C Foley
48Hrs after Surgery. Optimizing Pain and Nausea Management that emphasizes less
deliriumgenic medications and screening for B12 and Thyroid Issues helps as well.
2. Pain and Nausea Medication Optimization.
Pain Management - D/C PAIN Meds Ordered and Reorder the Following Regimen:
1. Tylenol 1g PO TID and
2. Hydromorphone 1mg PO Q2H PRN and 0.5mg IV Q1H PRN (PRE-OP) and
Hydromorphone 1mg PO and 0.5mg IV Q4H PRN (POST-OP)
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The thinking here is to reduce the use of opiates with round the clock Tylenol which
is underutilized in these patients. When using Opiates in these patients – the goal is
to use the best metabolized and most effective narcotics. T3s, Percocets, and
Morphine are not as good as the regimen that we are standardizing above.
Nausea Management – D/C the GRAVOL that is often Ordered and Reorder the Following
Regimen:
1. Zofran 4mg PO or IV Q8H PRN for Nausea/Vomiting or
2. Maxeran 5mg PO or IV QID PRN for Nausea/Vomiting
The thinking here is to reduce the patient’s exposure to high anti-cholinergic (and
this deliriumgenic) and less effective nausea medications like Gravol. If the patient
has Parkinson’s or is antipsychotic medications – then best to use Zofran instead of
Maxeran which can cause some EPS Symptoms in high doses.
3. Constipation Prevention or Management
If patients are getting a narcotic – they should be on something for constipation.
4. Osteoporosis W/U or Management and
5. Geriatric Screening – for B12 Deficiency and Thyroid Issues
Every patient should get a B12, 25-Hydroxy Vitamin D and a TSH Level Done.
All patients can be started Pre-Op on Calcium Carbonate 1250mg bid and Vitamin D
1000 iu Daily.
When their Vitamin D Level Comes back at less than 30 nmol/L we usually replete
the patient with Vitamin D 50,000 units daily x 2 weeks, then maintain on 1,000
units daily.
Chris our Geriatrics Pharmacist helps to follow-up on these results and will work
with you to advise on how we can initiate further treatment based on the results that
are generated.
6. Disposition Planning
The key here is to indicate the best plan of post-op care. Patients who had a good
level of function and are not severely cognitively limited should be recommended a
Rehab Stay. Even patients with mild-moderate dementia should be considered for a
Rehab Stay as they can often benefit from therapy.
We are currently working with the Orthopedics Group to revise the Hip Fracture Order Sets to
indicate the above. While the ORTHO Group is getting better about following the above regimen they are happy to give us permission to refine their orders directly to ensure their patients get the
best care and derive the best outcomes possible.
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MOUNT SINAI ACUTE CARE FOR ELDERS (ACE) UNIT PRIMER
What is an ACE Unit?
An Acute Care for Elders (ACE) Unit is a specialized general internal medicine unit that focuses on the
unique needs of older adults.
ACE units have been shown to reduce lengths of stay, functional decline and institutionalization (Landefeld,
1995; Palmer, 1994; Wong, 2006) by employing unit-based interprofessional teams, daily rounding,
expanded nursing roles, and a proactive approach to care with a focus on managing geriatric syndromes and
maintaining physical function.
An ACE Unit emphasizes two key goals:
1. Provide appropriate, knowledgeable and effective care for older patients experiencing an
acute medical episode and subsequent changes in physical, cognitive or functional abilities.
2. Assist older adults in maintaining or improving their functional, physical and social abilities,
enabling them to continue to live independently and prevent or delay institutionalization.
MSH ACE Unit Location
17 South will serve as the new GIM ACE Unit. Months of planning have gone into the planning for
the launch of this unit. We are launched the unit with a soft start on April 18th when patients were
first being admitted to the new unit. We anticipate that the by the time the new GIM residents start
on May 2nd the ACE Unit will be fully operational.
ACE Unit Operational Logistics (What YOU Need to Know)
1. ACE Unit Beds remain GIM Beds, GIM Attendings remaining the MRPs for ACE Unit
Patients.
2. GIM Teams will determine which of their patients will be admitted to an ACE Bed vs.
a standard GIM Bed. Pocket Cards and newly revised Powerchart GIM/ACE
Admission Order Sets that went live on April 18th, 2011 will help GIM Teams
determine which of their patients should be admitted to ACE.
Admission Criteria for the ACE Unit
Older Adults 65 and older with an acute medical illness and any THREE or more of
the following:
1. A recent decline in functional abilities
2. A recent change in cognition or behaviour
3. Problems common to older adults (eg: falls, incontinence, acute and/or chronic pain,
adverse drug reactions, delirium etc)
4. Complex social issues
5. Identification of Seniors At Risk (ISAR) Score ≥ 2 on ED assessment
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Identification of Seniors at Risk (ISAR) Screening Tool for those 65+
1. Before the illness or injury that brought you to the Emergency, did you need someone
to help you on a regular basis? (Detects baseline functional impairments)
2. In the last 24 hours, have you needed more help than usual?
(Detects recent functional decline)
3. Have you been hospitalized for one or more nights during the past six months?
(Indicates a higher likelihood of bouncing back)
4. In general, do you have serious problems with your vision, that cannot be corrected
by glasses? (Detects a high risk for developing a Delirium)
5. In general, do you have serious problems with your memory? (Detects underlying
cognitive impairments which are the greatest risk factor for developing a Delirium)
6. Do you take six or more different medications every day?(Detects polypharmacy and
serves as a proxy for polymorbidity)
≥ 2 Positive Responses - Predicts Functional Decline, Recidivism, and
Institutionalization
3. All patients admitted to an ACE Bed will be medically managed by the existing GIM
Teams (A, B, C, D) with strong collaboration from the Interprofessional Geriatric
Medicine and Psychiatry Services as is necessary.
4. ACE Unit patients will be supported with dedicated (unit-based) allied health staffing
that will round daily on all patients (GIM Teams will still have a dedicated allied health
assisting with their non-ACE Patients on GIM).
a.
b.
c.
d.
e.
f.
ACE Physiotherapists - Dana Rowe and Nancy Ng
ACE Occupational Therapists - Karen Hayeems and Vivien Lam
ACE Therapy Assistants - Grace and Kevin
ACE Social Worker - Jill Pascoe
ACE Pharmacist - Heather Moon
ACE Geriatrics Nurse Practitioner – Rebecca Ramsden
5. Social work, occupational therapy and physical therapy will be automatically consulted
for all ACE patients through automatic physician orders embedded into the revised
admission order sets. These professionals will conduct early screening on all patients
and determine the need for their more full involvement.
6. The ACE Unit will have daily (including weekends) Physiotherapy and Therapy
Assistant services available as of Mid-May, 2011 as well as the support of a Geriatrics
Nurse Practitioner on weekdays. The CCAC will also be hiring a new Coordinator as
of June 1, 2011 to work exclusive with ACE Unit and Geriatrics Service patients at
Mount Sinai.
7. Patients admitted to the ACE Unit but not given a bed on the actual unit – will still
receive the ACE Unit Standard of Care as outlined above.
Revised: 11 June 2013
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THE MSH CCAC ICCP PROJECT
Starting April 1st MSH launched a 1 Year Intensive Case Management Pilot for up to 40 of its most
complicated elders.
Through this program - 1 CCAC Care Coordinator will be assigned to manage the care of these
patients throughout the continuum in close collaboration with Geriatric Medicine, Psychiatry and
Primary Care Support.
The goal of this initiative is to ensure these patients access and receive appropriate and integrated
care, experience smooth transitions, and are supported to remain at home for as long as possible.
Geriatrics Program Staff will be notified when ICCP Patients arrive at MSH – it is generally expected
that the Geriatrics Service will help manage the care of these patients while they are in hospital in
conjunction with the admitting team.
Jennifer Thomas is the name of the CCAC Coordinator that will be working closely with the MSH
Clients.
Revised: 11 June 2013
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