Inpatient Acute Care for the Elderly (ACE) Unit

 

Welcome to the Christus Santa Rosa ACE rotations!

 

The ACE training experience includes two (2) family medicine resident experiences: 1) a four-week second year rotation and 2) a two-week third year rotation.

 

Policies are outlined below and should be reviewed prior to the rotation, as you will be responsible for following these policies during your rotation.

OBJECTIVES

At the end of the rotation the resident physician will be able to:

• diagnose and manage common inpatient medical problems common to the elder population, including critically-ill patients requiring critical care unit management.
• provide medical care for the older surgical patient, including pre-operative evaluation and post-operative management.
• complete a comprehensive assessment of functional status and appropriate levels of care, e.g., "can this patient go home rather than to a nursing home, or to some other less restrictive environment?"
• participate in geriatrics consultations to physicians in the inpatient hospital environment with specific emphasis on geriatric psychiatry and surgical care.
• participate in discharge planning to optimize use of community and outpatient services available for the elderly, including follow-up with Senior Health Care Center, if desired.
• provide care for older adults using an ACE model.
• work as part of an interdisciplinary team.
• provide successful transitions of care for older adults

We hope you enjoy the time that you spend with us. We love and respect our patients and take pride in being able to improve the quality of life for each of them. We have gathered information, instructions and tips we hope will help you succeed in this challenging rotation. Please familiarize yourself with the contents before your rotation begins. We are constantly attempting to improve it, so if you have any questions, concerns, or suggestions, please contact Dr. David Espino (358-3888, espino@uthsca.edu) or Dr. Oakes (oakes@uthscsa.edu).

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Before You Start:

1. Make sure that you have completed training and have a current username/password for 1) the Christus Meditec EMR and 2) the UT medicine EPICcare EMR. Contact Janie Trevino (trevinoj@uthscsa.edu) PRIOR to starting the rotation for assistance.
   

   
   

2. Review presentation over ACE Unit. We use an Acute Care of the Elderly approach on this service.

• CLICK HERE to download.
  
  

3. Review the Curriculum for the Aging Hospitalized Medical Patient (CHAMPS).

• CLICK HERE to download.
  
  

4. Review the geriatric assessment tools on this web site. You will use them daily.
   
   

5. Mandatory Resources:

   1. Palm Pilot or equivalent with ePocrates or equivalent medical database.

   2. Copy of Reuben's Geriatrics at Your Fingertips, available from attending.

   3. Review Merck Manual of Geriatrics (http://www.merck.com/mkgr/mmg/home.jsp).
      
      

6. Read articles available in the Assessment Tools & Readings section of this web site. You will use this information daily.

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More about the: ACUTE CARE OF THE ELDERLY (ACE) UNIT

The ACE inpatient unit and consult service will offer you the opportunity to learn patient care skills unique to older, frail patients, to practice systems based care, and to experience working as part of an interdisciplinary team (IDT).

 

The Vision:

We utilize an Acute Care of the Elderly (ACE) model of care, an evidence based approach shown to improve outcomes for elders. The ACE approach strives to maintain function, independence, and quality of life for elders and to prevent iatrogenic illness (illness caused by medical care). CLICK HERE to view ACE presentation.

 

The goal of the ACE approach is to avoid the cycle of complications and extended hospital stays common to older patients illustrated below.

 

Risks of Hospitalization of Elders

 

 

 

 

The ACE Unit is located on the 10th floor of the Christus Santa Rosa City Centre adult hospital wing.

The majority of the patients admitted to the ACE unit are ambulatory or long term care patients of the UT Medicine Senior Health family medicine group. You also may be asked to provide consultations on patients on other services such as the hospitalist service. Common consultation requests include evaluation and management of delirium and other cognitive impairments, weight loss and medication review. Please review these topics prior to the start of the rotation.

 

*Please note: Because Christus Santa Rosa is a private community hospital, in some ways this inpatient service differs from that at university hospital. For example, specialists welcome your referrals and will respond immediately. They will advise you, but generally you will continue to manage the patient.

 

Finally, because this is a geriatric service, many of the patients are extremely frail and have complex, multi system medical problems. As always in geriatrics, maintaining function and independence for our patients is a primary goal. Social support and placement become critical issues.

 

Residents participate in the clinical teaching that occurs during inpatient rounds which start between 9-9:30 am each week day. Rounds are led by the community geriatrics division attendings.

 

A key learning activity is the residents' participation in the daily 30-minute geriatrics interdisciplinary team meeting, held at noon each week day. The team consists of the primary nurses, rehabilitation staff, a dietician, a discharge planner, and other health care providers. The nursing staff led by the ACE geriatric nurse practitioner leads the meetings. These meetings provide unique opportunities for communication which has been demonstrated to improve patient care quality. The IDT team also reviews individual patient progress and discharge planning.

 

Ambulatory Experience (PGY2 residents)

Second year residents will be required to participate in an ambulatory component. The ambulatory experience takes place at the UT Medicine Senior Health office across the street from the main Santa Rosa Hospital. Each half day experience starts promptly at 8am or 1pm, so please be on time.

 

The teaching emphasis will be on the resident being able to comprehensively evaluate a frail elder in the outpatient setting. This includes resident competency in basic geriatric mental status evaluation. Information on administration of the instruments are included on this web site. and must be reviewed prior to the rotation.

 

Elements of the Geriatric Assessment:

• Physical Health - Medical Problems
• Mental Health - Cognitive, behavioral, and emotional
• Social and Economic status - Support network, Caregivers
• Functional Status - ADLs, IADLs
• Environmental Characteristics - Home safety services
• Medication Review
• Development and Implementation of a Care Plan
• Palliative Care - Pain Management, End of Life issues, Non-pain symptoms at end of life

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CONFERENCES

Geriatrics Division Grand Rounds
Attendance is required. Geriatric Grand Rounds are held the first and third Monday, 12:30pm-1:30pm, in the Center for Children's and Families building. These conferences cover a variety of geriatric topics and are led by the UT Medicine Senior Health provider team. Check with the attending on Mondays for more information. Lunch is provided.

 

Absences - other than illness must be cleared with your attending at least 24 hours prior to the event as a professional courtesy. All absences or changes in schedule should be brought to the attention of your attending and Tisha Rodriguez (rodriguezl11@uthscsa.edu).

 

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ROTATION OVERVIEW

CLINICAL RESPONSIBILITIES

Residents are primarily responsible for caring for inpatients under the direct supervision of the attending physician. There is always a geriatric attending on call 24x7. The attending call schedule changes every Monday at 12 noon. A copy of the call schedule will be sent you one day prior to the start of the month. If you do not receive one, please contact Tisha Rodriguez (rodriguezl11@uthscsa.edu) or get one from the ACE unit clerk. Attending beepers and cell phones are available on the schedule. Please ask your individual attending how they prefer to be contacted.

 

ADMISSIONS

You are required to discuss all admissions with the attending and/or the Inpatient Geriatric Nurse Practitioner.

• Admission order form are available under Commonly Used Forms on the left side of the web page. Admission orders which are called in should follow this format.
• Include your beeper number in the orders, along with the hours of your availability (6am-6pm, M-F). This especially important for patients admitted to other floors.
• Patients may be admitted directly to the ACE unit (10th floor). These patients must be seen by a resident upon arrival.
• Admissions arriving on the floor after 5pm will be admitted by the Nurse Practitioner and/or the attending.
• Monitored telemetry patients must be seen and admitted by residents within two (2) hours.
• Non-monitored patients must be seen within twelve (12) hours or before AM attending rounds, whichever comes first.
• We avoid nigh transfers if at all possible. There are no intrahospital (i.e. ICU to floor) transfers allowed after 12 noon.
• You should be out of the hospital by 7:30pm at the latest. If you don't feel that you will have your work completed by this time, please contact the attending PRIOR to exceeding this time in order to work out rounds the following day. As duty hours are a serious issue, we will reflect any violation of this specific policy in the professionalism section of your evaluation.

ACE Unit Rounds

• Occur daily at 9:15am, unless told differently by an attending.
• Residents are responsible for being familiar with the ongoing medical situations of all inpatients and consultation patients at the start of rounds.
• Check the MARS (medication sheet) at least every day.
• After the first hospital day, determine the patients discharge level of care (nursing home, home, home health).
• Do not discharge patients to long term care institutions after 1pm.

AFTER HOURS CALL

• Call is primarily beeper (home) call shared with other resident physicians and nurse practitioners during weeknights and on alternate weekends.
• You are responsible for verifying your own call responsibilities on receipt of the monthly call schedule.
• All call trades must be communicated to both Tisha Rodriguez (rodriguezl11@uthscsa.edu) and Dr. Espino (espino@uthscsa.edu).
• If a call trade occurs after the schedule is published, the resident arranging the trade is required to call the UT Medicine Call Center (450-9100) after 5pm to confirm that the proper resident is on call.
• You are required to report expected 80-hour overages to your inpatient attending BEFORE you reach an overage.
• Most overnight issues can be addressed by telephone conversation with the floor nursing staff. However, if patients require more intensive evaluation, then the resident physician is expected to go to the hospital. Compensatory time off will be given the following morning.
• You are required to contact the attending at ANY hour for ANY questions or concerns.
• Residents are to track all received calls on the NH/Facility Call Tracking form.  Download the form.  The completed form is to be emailed to TK Efeovbokhan,  EFEOVBOKHAN@uthscsa.edu the next day following call.

ER ADMISSIONS

• Contact will be from the ER doctor to the on-call resident.
• The resident will call the attending per prior arrangement by cell or page to 235-0556.
• After discussion, the resident physician will call the ACE unit at 704-2832 and give the initial orders.
• If the on-call resident is at the hospital, they need to d a quick initial evaluation in the ER.
• If the resident is out of the house, they need to sign the patient out to the on-service resident or the next on-call resident at the end of their shift.

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DOCUMENTATION REQUIREMENTS

Admission Orders - Review the format on the printed form with the ACE unit nurse practitioner on the first day of your rotation.

 

Progress Notes - Residents are expected to write daily progress for all inpatients. You cannot refer to a students note for information but must write a stand alone note, with the exception of the day of discharge where your dictated Discharge Summary will serve as your note and the student note will serve as the chart note.

• All notes should refer to the past family/social history from the H&P. The H&P date must be in your note.
• All daily notes must have a review of systems documented.
• JAHCO requires all notes and orders to be timed and dated. They also must have either a legible signature or a signature stamp.
• All orders and notes should have countersignatures by the attending prior to discharge.
• Information on the Santa Rosa dictation system is found both in the left hand column of this web page.

Charts & Medical Records - Charts are hard copy. Medical records are on the 1st floor. Please before you finish the rotation go and complete any pending medical records work. You are responsible for initial H&Ps and all Discharge Summaries.

• If you have more than two (2) dictations pending after you finish your rotation, your evaluation may be held until they are completed. Your final evaluation will reflect this.
• Dictation instructions are available under Commonly Used Forms on the left side of this page.
• Our discharge summary dictation format is available under Commonly Used Forms on the left side of this page.

 

CHECK OUT PROCEDURES

All patients must be checked out to the cross covering provider to ensure good patient care. A written handoff is required. Cross coverage starts at 6pm and ends at 6am.

 

Check out calls are the responsibility of the third year (PGY3) ACE resident. The IPS resident must call the night call provider (either the covering resident or the Geriatric Nurse Practitioner) to check out the patients on the service prior to being relieved of their responsibilities. The third year (PGY3) ACE resident is also required to call back in the AM to receive the service back.

 

A verbal check out must occur each time coverage changes, even if the patient status does not. If the PGY3 ACE resident is unable to make contact with the night cover, inform the IPS attending that AM. The PGY3 ACE resident should also give a brief call to faculty attending before going off call each day at 6pm.

The third year (PGY3) ACE resident must never leave the hospital, for whatever reason, without checking out the service to either the night call, fellow, or attending. Violation of this policy may result in an automatic failure for lack of professionalism.

 

Guidelines for check out include:

Name/age dx on admission Short summary of hospital course PMH Allergies

Code Status Pending labs and films that must be reviewed overnight Other important medications that should be started or stopped Incoming patients or discharges

 

CONSULTATIONS

• The third year (PGY3) resident has primary responsibility for consultations.
• Consultation recommendations are to be patterned after the information found on the ACE unit cards.
• All consultation recommendations must be reviewed with the attending prior to dictation.

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Third Year Medical Students

• You will have one or two third year medical students working a two week rotation with you Monday-Friday. On the final week of their rotation, they will the last Thursday afternoon and all day Friday off to study and take their final exam.
• When the students first arrive, you will be responsible for orienting them to the service, teaching them everything you want them to know about how things work so they can be helpful to you.
• They are responsible for rounding on the patients you have assigned to them, presenting their patients to the attending and writing a note on each patient.
• Students should be encouraged to do new admission workups.
• The student's note does not substitute for the resident note except on the patient's day of discharge, as noted below.
• The students are also to assist the resident with getting labs, running down radiographs and helping the patient care activities run smoothly.
• Students should almost never leave the hosptial before the residents.

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HELPFUL HINTS

Parking - Residents are permitted to park on the 2nd floor and up in the parking garage located off San Saba. Residents receive a CSR parking permit and ID badge at the beginning of the PGY2 year. If you do not have either of these items, please contact Janie Trevino (trevinoj@uthscsa.edu) PRIOR to starting the rotation.

 

Cafeteria - 12th Floor. There is a FREE physician's cafeteria, which is open during lunch on weekdays. It is not open on holidays.

 

Key Phone Numbers:

ACE Unit: 704-2832

Direct ACE Unit Admissions: 704-3292

ER Doctor Number: 704-2125

UT Medicine Senior Health Center: 450-9890

UT Medicine After Hours Call Center: 450-9100

Further Information - For more information, you can visit our clinical services web site.

 

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