Transcript MSH Orientation Slides

MSH Orientation
Geriatric Medicine
Dr. Shabbir Alibhai | Dr. Arielle Berger | Dr. Vicky Chau
Dr. Barry Goldlist | Dr. Dan Liberman | Dr. Karen Ng | Dr. Samir Sinha
Mount Sinai Hospital
Suite 475, 600 University Avenue
Toronto, Ontario, M5G 1X5
(416) 586-4800 x 7859
Outline
• Why Geriatrics?
• Continuum of Geriatric Models of Care
• Geriatric Medicine Consultation Service & Clinics
• Orientation Package
• Orthopedic & Physiatry Residents
WHY GERIATRICS?
Ageing and Hospital Utilization
in Central Toronto LHIN, 2005
Number
Age <65
Seniors 65 +
% Seniors 75+
1,142,469
87%
13%
49%
Emergency Room Visits
321,044
79%
21%
62%
Acute Hospitalizations
78,025
63%
37%
64%
w/ Alternate Level of Care Days
4,263
17%
83%
76%
w/ Circulatory Diseases
10,361
32%
68%
65%
w/ Respiratory Diseases
5,928
43%
57%
73%
w/ Cancer
6,743
53%
47%
54%
w/ Injuries
5,809
58%
42%
71%
w/ Mental Health
6,161
87%
13%
59%
Inpatient Rehabilitation
3,368
25%
75%
66%
2005 Population
Toronto Central LHIN, 2006
The Hazards of Hospitalization
• Older people are particularly vulnerable to the risks of
iatrogenic illness and functional decline
• The pathogenesis of functional and cognitive decline is
complex and involves an interaction amongst:
– The ageing process
– Comorbid and acute illnesses
– The hospitalization process
Conceptualizing Functional Decline
The Hazards of
Hospitalization
Functional
Older
Person
Acute Illness +
Possible
Impairment
Hostile Environment
Depersonalization
Bedrest / Immobility
Malnutrition / Dehydration
Cognitive Dysfunction
Medicines / Polypharmacy
Procedures
Depressed Mood
Negative Expectations
Physical Impairment
and Deconditioning
Dysfunctional
Older
Person
Palmer et al., 1998 (Modified)
Trajectories of Functional Decline
Baseline
70+ Pts
Admission
57% Stable
Discharge
45% Stable
N=2293
20% Recovery
65% Discharged
with Baseline
Function
12% Hospital Decline
43% Decline
18% Fail to Recover
Pre-Hospital Decline
5% Pre-Hospital and
Hospital Decline
Covinksy et al., J Am Geriatr Soc 2003
35% Discharged
with Worse than
Baseline Function
Costs of Functional Decline
• The loss of independent functioning during hospitalization
has been associated with:
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Prolonged lengths of hospital stay
Increased readmission
A greater risk of institutionalization
Higher mortality rates
Palmer et al., 1998
Comprehensive Geriatrics
Assessment (CGA)
“ … 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
Components of a CGA
ID/RFR
Labs &
Investigations
PMHx
Confusion Assessment Method (CAM)
Mini Mental Status Exam (MMSE)
Montreal Cognitive Assessment
(MoCA)
Physical
HPI
Examination
S hopping
Activities of Daily
Living (ADLs)
Rowland Universal Dementia
Assessment
D ressing
H ousekeeping
Scale (RUDAS)
Mood &
Weight loss
CGA
E ating
A ccounting
Geriatric Depression Scale (GDS)
cognition
Bladder & bowel
A mbulating
F ood Prep/Meds
• Current living
situation
Vision & hearing incontinence
Cognitive
Tcommunity
oileting/transfer
T
Medications
Assessment
•
Family
&
supports
Falls
Pain
ygiene
• AdvanceHcare
directives ransportation/Tele
Dysphagia
Sleep
phone
• Powers of attorney
Geriatric
• GeneralFunctional
financial situation
Review of
History
Systems
Social History
MSH & UHN
GERIATRIC CARE CONTINUUM
AMBULATORY
INPATIENT
MSH/UHN Geri Med Consults
MSH Geri Psych Consults
MSH/TWH Orthogeriatrics
MSH ACE Unit
TRI Geriatric Rehabilitation Unit
MSH/TRI Geri Med Clinics
MSH Geri Psych Clinic
TWH Memory Clinic
TRI Falls Prevention Program
TRI Geriatric Day Hospital
Mount Sinai / UHN
Geriatrics Continuum
COMMUNITY
ER
MSH/UHN GEM Nurses
MSH ER Geri Mental Health Prog
Home Based Primary/Geri Care
MSH Reitman Centre
Temmy Latner Home Palliative Care
CCAC ICCP Partnership
GERIATRIC CONSULTATION SERVICE
Inpatient Geriatric Medicine
• Interprofessional team
– Carm Marziliano, SW
– Natasha Bhesania, PT
– Chris Fan-Lun, Pharm
• Common Referrals from MSH, TGH, & PMH
Delirium & dementia
Functional decline, falls
Diagnostic/treatment challenge
Transition to outpatient & home-based services (House
Calls)
– Goals of care & disposition
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Other Common Referrals
• Automatic consultations
– Orthogeriatrics hip fracture patients
– House Calls
– ICCP
• GEM Flags
• Geriatric Psychiatry
Orthogeriatrics
Automatic geriatric consultation for
ALL fractured hip patients ≥65 years old *
* Orthopedic residents focus on low trauma (fragility) hip fractures (NOT high
trauma, periprosthestic, or pathological) but can be involved in medical & surgical
cases for further learning
• Orthopedic, Hospitalist, & Geriatric Medicine Co-Management
Model
• Referrals
– Staff automatic e-mail notification
– Jeanette Villapando/Tammy Mok, x8419
– 11S, x4580
A Reactive Proactive Strategy
• Delirium prevention & management
• Functional recovery
• Pain management
• Falls prevention & bone health
• Disposition planning
Marcantonio et al, 2001; Siddiqi et al., 2009
n=126 admitted hip# patients ≥65 yo
Geri Consult pre-op or <24h post-op
Daily visits to follow 10 parameters
Incident delirium
50 vs. 32% (ARR 18% NNT~6)
Fractured Hip Patients
Geriatrics
• Mental status
– Delirium
– Pre-admission cognition
– Mood
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Falls
Bone Health
Pain and nausea
Constipation
Medication rationalization
Disposition planning
Hospitalist & Med Consults
• Perioperative risk assessment
• Respiratory issues requiring
close frequent monitoring
• Management of
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Anticoagulation
Blood glucose
Electrolyte abnormalities
Acute kidney injury
House Calls (HC)
• Home based primary care for homebound seniors living
within the central LHIN catchment area
• Types of consultations:
– New Patient Referral to HC
• Complete & fax HC’s referral form (including geriatrics consultation
note & discharge summary)
– Existing HC patients who are admitted to MSH
• Staff e-mail notification when HC patient arrives to ER
• Automatic but limited consultation for MRP co-management and
support
• Upon discharge, fax discharge summary and geriatric notes to HC
http://www.seniorshousecalls.ca
Integrated Client Care Project (ICCP)
• Intensive CCAC case management for the most
complicated patients living in the community
• Close collaboration with Primary Care, Psychiatry,
Geriatrics
• Referrals
– Staff e-mail notification when ICCP patient arrives in ER
– Automatic consultation for MRP co-management and
support
http://www.ccac-ont.ca/icc
GEM Flags
• Check GEM flags daily
• Review GEM nursing notes in Powerchart for GEM flagged patients
– Open patient chart  Clinical Notes  GEM Nursing notes
• Liaise with admitting team and offer geriatric support if needed
Geriatric Psychiatry Consult Service
• Shared care for complicated:
– Mental health illnesses
– Delirium management
– Behavioural & psychological symptoms of dementia
Consultations
E-mail new referrals to the interprofessional geriatric
medicine team at MSH & TGH respectively
Consultations
• Always record consult date, start, and stop time on
your consult note
• Store carbon copy of completed consults in the
filing cabinet (middle drawer) in alphabetical order
Consult Recommendations
• AVOID consult SUGGEST orders
– Miscommunication
– Delays in patient care
• Always best to communicate recommendations
directly to referring team
• Direct order entry for geriatric related issues on
fractured hip patients
Sign-out Lists
“geriatrics”
*** ALWAYS UPDATE THE SIGN-OUT LIST ***
OUTPATIENT GERIATRIC &
SPECIALTY CLINICS
Clinic
• Please check your schedules & be on time for your
clinic, as patients have been scheduled for you in
advance
Geriatric Medicine Clinics
TRI Outpatient Clinics Ground Floor (Elm Street Entrance)
Drs. Alibhai, Berger, Chau, Liberman
Ramona Gheorghe, NP, & Katie Stock, SW
UC Outpatient Physician Clinics Admin (416) 597-3422 x 4200
MSH AIMGP Area 4th floor
Drs. Goldlist, Ng, Sinha
Chris Fan-Lun, Pharmacist
Stephanie (416) 586-4800 x 8563
* Please ensure you obtain an MSH and/or UHN dictation code at the
beginning of your rotation *
TWH Memory Clinic
• Collaborative multidisciplinary assessment of memory
disorders beyond the MMSE/MoCA
Collaborative Multidisciplinary Clinic
Neuropyschologist/OT/SW
Geriatrician
Behavioural Neurologist
Geriatric Psychiatrist
One of the above
Cognitive testing
Medical history, Rx,
non-neuro physical exam
Neuro exam
Psychiatric history
Family gives collateral
Multidisciplinary Team Meeting
• Arrive at 1:00 pm sharp in the West Wing on the 5th
Floor
TRI Falls Prevention Clinic
• Focused assessment of falls in older adults
– Multidisciplinary intake assessment for consideration of
a 12 Week Falls Prevention Program
• Arrive at 1:00pm sharp for clinic orientation
• Located in the outpatient clinic area on the
ground floor (Elm Street entrance)
ORIENTATION PACKAGE
Orientation Package
• Personalized schedule (review daily)
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Clinical activity (e.g. clinics)
Weekly Rounds
Education & Teaching opportunities
End of Rotation Debrief & Feedback
• On Call Schedules
* Reminder: new consult e-mail notifications
• Orientation manual
– Includes Falls & Memory Clinic orientation materials
• References & Resources
Weekly Rounds
Attended by:
• House Calls (Emma)
• ICCP (Debbie)
• ACE (Rebecca)
Attended by:
• Hospitalist
Educational Opportunities
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Informal/bedside teaching
Geriatric giant seminars, Geriatric Psychiatry, Journal club
Specialty seminars
Allied health professional teaching
General medicine, grand, & osteoporosis rounds
Resident Geriatric Office
• Office workspace for you and others during your
rotation, so please keep it clean and tidy
• Obtain an office key from Phoebe Tian
– $20 deposit - - returned at the end of rotation
• Always lock the door and turn off the lights if you
are the last one in the office
http://www.mountsinai.on.ca/education/
geriatrics/resident-resources-andschedules/
ADDITIONAL NOTES FOR ORTHOPEDIC &
PHYSIATRY RESIDENTS
Orthogeriatric Resident Schedule
• 2 weeks hospitalist then 2 weeks geriatric medicine
• Mandatory clinics & programs during your rotation
– Falls Prevention Clinic
– Geriatric Day Hospital
• Additional medical consults teaching
• 1 Weekend Home Call shift (see next slides)
Physiatry Resident Schedule
• 8 Week block
– 2 Weeks acute care geriatrics at MSH/UHN
– 3 Weeks rehabilitation at TRI
• Separate TRI Orientation upon start at TRI
– 3 Weeks outpatient clinics & community experiences
• 1 Weekend Home Call shift
Weekend Home Call
• Geriatric medicine staff receives e-mail notification
of new orthogeriatrics (and surgical) referrals and
will divvy consults to the orthopedic resident on call
• Contact your on-call staff prior to the weekend to
exchange contacts
Thank You & Enjoy Your Rotation!
• Questions?