Care of the Elderly and Stroke Department

Welcome to the department for Care of the Elderly, we hope that you have an enjoyable and educational experience whilst working with us.

This booklet has been written for medical students and junior doctors and is intended to orientate you to your role, the team and educational opportunities available to you whilst you are with us. If you have any questions please ask a member of the team.

Care of the Elderly Department Personnel

Consultants

Dr William Wareing - Consultant in Elderly Medicine (with special interests in Front Door Geriatrics and Movement Disorders) – also Clinical Lead for Care of the Elderly Department

Dr Saurabh Shandilya - Consultant in Elderly Medicine (with special interest in Orthogeriatrics & Falls) - also Joint Divisional Medical Director for Urgent Care and SAS Tutor)

Dr Tim Webster - Consultant Stroke & Elderly (with special interest in Movement Disorders) - also Joint Divisional Medical Director for Urgent Care and Department Lead for Mortality and Morbidity

Professor Kausik Chatterjee - Consultant Stroke & Elderly Medicine (Lead Clinician Research)

Professor Anand Prakash - Consultant in Elderly Medicine (with special interest in Orthogeriatrics, Falls and Bone Health)

Dr Arumugam Nallasivan - Consultant Stroke & Elderly Medicine (Department Audit Lead)

Dr Syed Haider - Consultant Stroke & Elderly Medicine and Trust Guardian of Safe Working Hours

Dr David Scholes - Consultant in Elderly Medicine (with special interest in Surgical Liaison Geriatrics)

Dr Lisa Hill - Consultant Community Geriatrician (Community Geriatrics Lead)

Dr Ei Thant Zin - Consultant in Elderly Medicine (including Community Geriatrics) Lead for Emergency Health Care Planning.

Dr David Curran - Consultant in Stroke and Elderly Medicine (Stroke Medicine Lead)

Dr Michelle McCarthy – Consultant Community Geriatrician (Educational Lead for COTE department)

Specialty Doctors (Middle Grade)

Dr Josh Deb-Barman – (Department staffing and rota lead)

Dr Pramodh Hettiarachchi - (Assistant Mortality and Morbidity Lead)

Dr Loredana Mihalca-Mason

Dr Hussam Shabbir

Dr Yumiko Doi

Secretaries

Jennifer White (Lead) (ext. 2168) – for Professor Chatterjee and Drs Curran, Haider, Nallasivan and Webster

Shelagh Andrews (ext. 6294) – for Professor Prakash and Drs Shandilya, Qaffaf, Zin and McCarthy

Samantha Williams (ext. 2155) – for Drs Hill, Scholes, McCarthy and Wareing

Val Walker (ext. 4527) – Support Secretary

Stroke Coordinators (VOIP 2358, bleep 2348, ext. 5509)

Tom Taylor (Lead)

Sue Cotgreave

Karen Roberts

Stroke Research Nurse

Sandra Leason (ext. 2385)

Care of the Elderly Wards

We currently have four wards on the COCH site, and also have links to Bluebell Unit (rehabilitation ward at Ellesmere Port Hospital) - although its team is somewhat separate.

Ward 42 - Stroke Unit (Hyperacute Stroke Unit (HASU))

Doctors: -

One Consultant Stroke Physician of the Week (SPOW) – usually in 3 week rotations

Two Middle Grades (SpR / Specialty Doctors), one of whom is purely for the Stroke Unit, the other is for the Stroke Unit but also covers Acute Stroke Thrombolysis

One Thrombolysis / Orthogeriatrics Specialty Doctor (Registrar) nominally attached to the ward, but mostly not needed on the ward

Three SHOs (GPSTs / IMTs / Trust SHOs)

One F1

Other Key Staff: -

Ward Manager: Sister Stephanie Williams

Ward Clerks: Sue Nolan and Jacqui Williams

Notes for Stroke Unit: -

There are five Stroke Consultants in total. Each rotates as the Stroke Physician of the Week (SPOW) in 3 week blocks. The SPOW conducts a daily morning ward round on Ward 42 as well as providing Stroke Thrombolysis cover and providing senior cover for the High Risk TIA Clinic if the daily non-SPOW Stroke Consultant in clinic is away.

Ward 42 is a Hyperacute Stroke Unit (HASU) with a 16 bedded area. It can be found on the Countess of Chester Hospital NHS Foundation Trust main site within the Main Building (1st floor) next to CCU and it should be considered a Level 2 area like CCU / RSU / HDU.

It is a true multidisciplinary unit with its own team of highly skilled Neuro-Physiotherapists and Neuro-Occupational therapists and links to Speech & Language, Dieticians, PEG specialists and the Stroke Association. There is a dedicated team of Stroke Coordinators led by Tom Taylor (who is also a trained ANP and the designated Stroke Champion) and a Stroke Research Nurse, Sandra Leason.

The Unit has cardiac telemetry facilities and two bedded bays and four side rooms dedicated to Acute Stroke patients. The two bays are mostly single-gender, but there may need to be temporary breaches of this due to imbalance in the number of male/female stroke patients. Each patient (including any non-stroke medical patients) will be reviewed on a daily basis, and once they are identified as being medically optimised, they will either be discharged or if further rehabilitation is needed, they will be transferred to the Stroke Rehabilitation Unit at Ellesmere Port Hospital. There is a general target of 2 discharges/transfers per day in order to maintain adeqate flow on the Unit and to create beds for new stroke admissions.

During the working day, there can be direct admissions to the Stroke Unit (including of thrombolysis patients) – these may be clerked in by the ward team (if there is enough staffing), but may already have briefly been seen in the ED by the SPOW or a Middle Grade for a focused Hyperacute Stroke review. After 5pm it is the on-call medical team who do this as usual or if there is not enough ward staffing, the on-call team may have to come up to clerk them.

Note: New stroke patients are not initially put on prophylactic low molecular weight heparin (LMWH), due to the risk of haemorrhagic transformation. Instead they get prescribed on EPR+ “Intermittent Pneumatic Compression Sleeves” (IPCs) for one month, after which LMWH can be used as usual. If IPCs are not possible to use (e.g. in peripheral vascular disease, if the patient is a falls risk, bruising or skin breaks, or if they cannot tolerate them), prophylactic LMWH can be given for ischaemic stroke patients (not haemorrhagic stroke patients) two weeks after the stroke.

Ward 34 - General COTE ward (mixed gender patients)

Doctors: -

Two Consultant COTE Consultants cover at a time

Two Specialty Doctors/SpRs

Three SHOs (GPSTs / IMTs / Trust SHOs)

One F1

Other Key Staff: -

Ward Manager: Rachel Powell

Ward Clerk: Eileen Chute

Notes: -

Two COTE Consultants are based on the General Care of the Elderly Wards (34, 50 and 51). On two days of the week, there is a Consultant led comprehensive ward round in which every patient on the ward is seen; this is a great opportunity for teaching.

On other days, the Consultants will visit the ward for a business round of any new patients or anyone unwell/potential discharges.

MDT occurs every morning following ward round.

There is weekend consultant cover.

Ward 50 - General COTE ward (female patients)

Doctors:

Two Consultant COTE Consultants cover at a time

One Specialty Doctor/SpR

Three SHOs (GPSTs / IMTs / Trust SHOs)

One F1

Other Key Staff

Ward Manager: Beverley Roberts

Ward Clerk: Maria Thomas

Ward 51 - General COTE ward (male patients)

Doctors: -

Two Consultant COTE Consultants cover at a time

One Specialty Doctor/SpR

Three SHOs (GPSTs / IMTs / Trust SHOs)

One F1

Other Key Staff: -

Ward Manager: Anna Jones

Ward Clerks: Patricia Littler and Eileen Pollock

Bluebell Unit, Ellesmere Port Hospital - around 40 medical/stroke rehabilitation and Discharge-to-Assess (D2A) patients.

Professors Chatterjee and Prakash provide Consultant cover and visits once weekly

Two Advanced Nurse Practitioners (ANPs) – Jan Powell and Vicki Dowdeswell

Emergency Multi-Disciplinary Unit (EMU) Frailty Unit.

The EMU unit currently operates within the Trust ED. It is staffed Monday-Friday by a Geriatrics consultant, trainee, nurse and pharmacist alongside the rapid response therapy team.

The EMU team review older people presenting to ED with frailty syndromes between 9-5pm. COTE trainees will have timetabled sessions on EMU during their COTE rotation to provide experience of front door/acute geriatrics and management of frailty syndromes. It is a good opportunity for eportfolio assessments to be completed and can be counted as clinic time for IMT trainees.

Consultant Timetables

All of the consultants rotate through various wards; there is consultant presence (either a full ward round or a short business round of selected patients) every morning on each of the four wards. All clinics are held in the afternoons.

Outpatient Clinics

There is an opportunity to gain outpatient clinic experience. A dedicated SHO stream has been created in Dr Scholes' Care of the Elderly clinic on Thursday afternoons in OPD1. There is also a High Risk TIA clinic every afternoon between in the Doctors' Office on Ward 33 - discuss with the SPOW or Stroke Coordinator if you wish to attend. Finally, there may be opportunities to attend other clinics, e.g. Falls Clinic, Movement Disorders and other General COTE clinics; discuss with the Junior Doctors' Rota Coordinator and the Consultant concerned, if you wish to attend these.

Community Facing Experience

F1 Doctors get ten sessions (equivalent to five days) for the community-facing requirement of your portfolio. This will be largely with the Community Geriatricians (Dr Hill and Dr McCarthy) either at COCH, and partly with the Falls Clinic. If any sessions are left over, they will be allocated to the GPSTs as this may be useful for them too. This will be allocated on the rota.

The community geriatrics team do a range of domiciliary visits, care home visits and intermediate care reviews for patients with frailty syndromes and at risk of hospital attendance.

Education in the Department

Educational Objectives

Please plan your educational objectives around the core geriatric problems listed below. Your Personal Development Plan, Work-Based Assessments, presentations and reflective writings should incorporate these educational objectives.

Presentations

You will be required to do at least one presentation at the weekly teaching session during your time with us; we will email you your topic at the beginning of your rotation with us.

Dr Michelle McCarthy is responsible for coordinating the teaching rota; if you are unable to give your presentation on your allotted day, please swap with a colleague (much as you would with an on-call) and email her (michelle.mccarthy7@nhs.net) to inform them of the swap.

You will need to collect teaching feedback forms and send them to your Clinical Supervisors for a formal feedback. Your Clinical Supervisor collects your feedback forms and will provide you with a summary report for your appraisal.

Educational Meetings

During COVID we had to switch to virtual meetings, mixed between Zoom and MS Teams but we hope to return to our usual process of face to face meetings asap.

Most of our Monday COTE lunch time meetings (Ophthalmology Seminar Room from 1-2pm) and Thursday Radiology MDTs (Radiology Seminar Room from 1-2pm) are Drug Company sponsored and you will be provided with food. Food will be available from 12:30 pm for Friday Grand Rounds.

Please make sure you attend these meetings unless you are on-call or on leave.

Clinical Audits

Speak to your clinical supervisors during early part of your attachment, if you intend to do any clinical audits. There may be an opportunity to do some re-audits to complete the loop or if you have new Quality Improvement Projects, please speak to Dr Nallasivan during earlier part of your attachment so that you will have time to complete it. You can also discuss any potential Audits or QIPs with Dr Nallasivan, who is the department’s Audit Lead.

Postgraduate Exams

Please discuss with your Educational Supervisor and plan ahead any private study leave in discussion with the Junior Doctor Rota Coordinator. We have regular MRCP PACES teaching in this hospital.

Educational & Clinical Supervisors

Please feel free to discuss with Dr McCarthy individually or with your Educational Supervisors if you have any personal educational objectives. Please arrange initial meeting with your Clinical Supervisor as soon as possible and complete the forms in e-portfolio.

It is your responsibility to complete Work-Based Assessments and update your e-portfolio. Use WPBAs as a prospective learning tool rather than a retrospective tick box exercise. Please inform the doctor who is going to complete your WPBA before the ward rounds and complete it at the end of ward rounds.

Annual and Study Leave, Swaps, etc

Dr Josh Deb-Barman (Specialty Doctor) is the COTE Junior Doctor Rota Coordinator and can be contacted at coch.coterota@nhs.net or bleep 2972

He signs off the annual leave and swap of on-call forms (no Consultant authorisation is required)

He will however only authorise the Rota Coordinator part of study leave requests to confirm that the dates are acceptable. Drs Shandilya or Webster will sign off the Clinical Director section.

It's generally possible to get your leave allocation on this block, especially as we are a big department where we cross-cover each other. However, please try to organise your leave relatively early on, as it will progressively become much harder the later you leave it.

Generally speaking, we require ten junior doctors across the four COCH wards as a minimum each day (plus a minimum of one staff member at Bluebell Unit), and this is the rule that will be used to judge whether a request is possible to grant or not. Anything less than nine is potentially not safe for the four COCH wards.

Sickness and absence

In the case of sickness, in the first instance juniors should inform Medical Staffing at COCH.medstaff@nhs.net or extensions 2417, 3749 or 2567, and the COTE Junior Doctors Rota Coordinator, to inform them you will not be coming in and expected duration of absence. It would also be helpful to inform your ward team.

Please also remember to inform Medical Staffing and the COTE Junior Doctors Rota Coordinator upon your return to work.

For Medical Students

Whilst you are attached to us we would expect that you gain a wide exposure to the many facets of Elderly Medicine. This not only includes the inpatients but the many activities that are delivered in an outpatient setting. Hopefully this booklet will have informed you of who and where you can get further training from.

Educational aims could include the topics listed below: -

Delirium / Dementia
Falls / Immobility
Incontinence
Syncope / Dizziness
Frailty
Polypharmacy / Pharmacokinetics / Drug Interactions
Subspecialties: Stroke & TIA / Parkinson’s Disease / Orthogeriatrics / Osteoporosis
Rehabilitation and discharge planning
Ethical and legal issues – need for artificial feeds, complications and ethical issues
Acute medical illness in elderly – nonspecific presentations, difficulty in applying guidelines and protocols, comorbidities and difficulty in drug therapy
Palliative care