Memo: Geriatric Inpatient Service Adjustments during COVID-19 Pandemic
Re: Inpatient Consultation Services at HHS and SJHH
From: Brian Misiaszek, Head of Service, Geriatric Medicine, HHS
Joye St. Onge, Head of Service, Geriatric Medicine, SJHH
Date: March 30, 2020
Background:
A thoughtful and consistent collective response is needed for the next phase of this pandemic, where we can expect markedly increased numbers of confirmed and occult COVID positive patients and staff. The value of comprehensive multidisciplinary assessment is indisputable in normal times, however we must rigorously reconsider all of our habits and traditions through the lens of public health and resource planning. A key philosophical shift is to recognize that some aspects of what we normally consider high quality care, can be counterproductive to community health in the setting of a pandemic.
The 3 new duties that are of paramount importance at this time are to:
1. Practice and promote social distancing
2. Preserve PPE
3. Preserve healthcare capacity
We are asking that the following questions be asked for every consult.
1. Can I answer the question of the referring provider based on chart review and functional history alone?
2. If direct entry into the patients room is necessary for physical exam, or patient interview, then how can I organize our workflow so that the fewest possible team members go into the room? (the goal would be only one)
3. If direct entry into the patients room is necessary and there is a need for PPE use,
a) Am I really, really sure entering the room is necessary?
b) Do I know the proper technique? https://www.youtube.com/watch?v=syh5UnC6G2k
4. Is this consult necessary at all? Use Table below for reference.
(1) GRU criteria may be fluid and any changes will be communicated by Service Head or designate.
(2) Guiding principles for appropriateness:
· Is there significant risk of clinical deterioration without the geriatric assessment?
· Does the benefit to patient outweigh the public health risk?
(3) Recommended modifications:
· Timeliness of direct assessment is less important than judiciousness about whether it needs to be done or can be deferred.
· Use functional and nonspecific markers to guide need for detailed physical exam (e.g. alert, eating well, mobilizing independently, normal vitals – exam will probably not change much)
· Use exam findings reported by a trustworthy colleague/resident where possible
· Use technology where possible
· Limit exam to the RFR or clinical concerns identified on chart review/collateral
· Defer standardized cognitive testing
· Negotiate sequential rather than simultaneous assessments with other services and work collaboratively to gather pertinent information for best patient care.
· Allow flexibility in ‘comprehensiveness’ particularly if the service is busy. We do not want system stressed so much that staff and residents, either deliberately or by accident, practice social distancing ‘shortcuts’
We are also asking for the following changes immediately:
1. There should be no routine face to face consult team meetings with more than 3 people. Though less efficient, new routines should be developed to facilitate team communication by phone, through documentation/EMR, or in 1:1 conversations.
2. There should be no face to face group teaching sessions, if physical distancing of at least 2m between participants cannot be achieved. Though less efficient, new routines should be developed to facilitate teaching and supervision though 1:1 interactions, and alternative delivery models.
3. Team members should use available spaces with infrequently shared computers and personal phones to carry out indirect work wherever possible.
4. Geriatricians should track all “encounters” to the best of their ability, including those that involve substantive chart review/interview without direct patient assessment. Division leadership, in consultation with division members and others will develop billing guidelines for this new type of geriatric care.
~~~
If you have any questions or concerns, please contact your respective Head of Service.