EP - Exemplary Professional Practice

EP16:  Interdisciplinary Care-Describe and demonstrate interdisciplinary collaboration across multiple settings to ensure the continuum of care. 

Interdisciplinary collaboration is essential to the daily practice of the nursing staff at the Medical Center.  Our patients and families often have complex needs that require services from multiple members of the care team.  Our nurses frequently serve as care coordinators as they navigate patients through the continuum of care.  Interdisciplinary care and teamwork are core measures of our nursing philosophy and Patient Centered Family Focused Professional Practice Model. 

Continuum of care in Psychiatry 

Jersey City Medical Center is Hudson County’s designated Psychiatric screening center.  The Behavioral Health Services include:  Inpatient detoxification, Psychiatric Emergency Screening, Acute Psychiatric Inpatient Care, Partial Hospitalization programs and Outpatient programs, and Residential services.  Many patients are seen on a daily basis in this setting.  Review the following statistics: 

Volume Statistics-Psychiatric Emergency Department



Volume Statistics-Psychiatric Emergency Department



Year-to-date we have seen 136 more patients in the Psychiatric Emergency Department than in the previous year.  Marcello Matutino BSN, RN is a nurse in the Psychiatric Emergency Department and performs a brief medical assessment on each patient who presents in the ED.  The screener, who may be a Master’s prepared Social Worker, a Certified Counselor or a Psychologist, meets with the patient and the family.  The screeners also review prior records and perform a biopsychosocial assessment.   The screeners then present the case to the Psychiatrist.  Approximately 45% of the patients seen are admitted; the rest are discharged to community services.  Patients are referred to regular outpatient facilities, or if a higher level of care is needed, to the Intensive Day Treatment and/or Intensive Case Management, which is home services.

Clinician’s follow-up with patients to ensure a seamless transition to the next level of care.  They meet or talk to the patient until they are connected to the next service.  The Psychiatric Emergency Department patients (25%) are observed for up to 24 hours for stabilization purposes.  The Medical Center has state designated beds (Extended Crisis Evaluation Beds, ECEB) and we are expected to stabilize patients if possible. 

The continuum of care does not stop with just inpatient services.  The Psychiatric Unit is the Hudson County Mobile Crisis Unit and patients are seen at home.   The idea is to provide a continuum of care in the least restrictive environment because that usually works better for the patients and helps keep Emergency Departments from overcrowding.  

A 34 year old male presented in the Psychiatric Emergency Department with a diagnosis of Bipolar disorder and alcohol dependence.  He has had a long history of noncompliance with outpatient treatment, as he usually does not believe he has a mental illness and that he can control the alcohol dependence on his own.  This has led to multiple psychiatric admissions, detoxification admissions, incarcerations, and failed attempts at inpatient rehabilitation.  In order to try to intervene and interrupt this pattern, he was assigned to the Navigator Program.  This program was funded to provide outreach and case management to the hardest to link individuals with co-occurring mental health and substance abuse disorders.  The Navigator met with the individual in the psychiatric emergency department and walked him over to the outpatient clinic.  At the clinic he met with a program director that was able to engage him in the idea of attending an Intensive Outpatient Program.  This all happened within 2 hours.  He met later that week with a Psychiatrist and was prescribed a medication by injection that would hopefully decrease his craving for alcohol.  He was also given a medication for his mood disorder.  He was able to achieve two weeks alcohol free and was able to see that treatment might be helpful in dealing with his mental health symptoms which subsequently lead him to self-medicate with alcohol.  The ability of our specialized outreach and treatment programs to meet individuals where they are has led to many other similar success stories for individuals who were unable on their own to make the transition from emergency and/or inpatient care to outpatient treatment in the community 


Total Joint Replacement 

Elenita Ajose BSN, RN

Patients undergoing elective total joint replacement are encouraged to select a rehabilitation facility prior to the surgery.  Our physicians provide the unit (6 West) with information regarding the patients they have scheduled.  Many total joint patients reserve two (2) units of their own blood to transfuse to themselves in the event of excessive bleeding.  The patients have their preadmission testing performed in the PAT unit.  Once this process is completed the patients are invited onto the units to tour.  Elenita Ajose BSN, RN, Nurse Manager will take the patients through the process, the room equipped with a trapeze that they will be in and the physical therapy area.  The physical therapy employees will walk them through the therapy process.  They can ask the nurses and the therapists questions if need be.  During surgery sequential compression devices are placed on the unaffected limb.  Following surgery a continuous passive motion (CPM) is utilized to stimulate circulation.  An epidural or neural blockade is placed in the operating room by the anesthesia department in order to alleviate the pain.  This epidural usually stays in place for 24 hours, after which, patients migrate to Patient Controlled Analgesia (PCA) device to control the pain.  (Please see References EP16-A and B for total knee and hip plans of care).  

A 54 year old female was recently admitted to Jersey City Medical Center with a several year history of worsening right knee pain.  The patient had, previous to admission, undergone physical therapy and injections to the knee which did not resolve her symptoms and therefore a decision was made to replace her knee joint. The patient underwent a Right Total Knee Replacement in September, 2012.  She was placed on a CPM machine and medicated for pain via a PCA/Epidural.  Lady Mendez BSN, RN was her primary nurse immediately postoperatively and for the next few days following surgery.  Respiratory Therapy, under the guidance of Omyra Sanabria, Manager, insured that incentive spirometer, coughing and deep breathing occurred throughout the patient’s stay.  Physical Therapy, under the expert guidance of Erika Kane, Manager, immediately began treatment by performing ankle pumps every hour and quadriceps/gluteus exercises.  The Case Manager, Susan Murphy BSN, RN, immediately began arrangements for the patient to receive follow-up rehabilitative care at the center of their choice.  The patient had chosen CARE at Wellington, a facility close to where she lived.  Her rehabilitation care would require a minimum of ten days of therapy for several hours daily.  Plans had been made for this transition prior to admission and the Case Manager insured that the application and arrangements were made in a timely manner. 

Continuum of care for stroke patients 

The stroke department incorporates interdisciplinary collaboration across multiple settings to insure the continuum of care of the patient diagnosed with stroke and TIA.  Social Services and Case Management work closely with Dan Murray MPA, RN, Stroke Program Coordinator and Kelly Sietsma BSN, RN, Stroke Program Manager and rehabilitation facilities to help with a smooth transition to the tertiary care setting.  Ms. Sietsma frequently receives calls from patient family members once patients are transferred to a Rehabilitation Center.  These calls provide for a continuity of care between the patients and the Stroke Manager as issues are discussed.

Recently, a patient presented to the Emergency Department with complaints of weakness in bilateral lower extremities, causing a fall to the ground.  His past medical history included Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Hypertension, Diabetes and Coronary Artery Disease.  The ED workup included a CT to the head, two-dimensional echocardiogram, CBC, PTT and Troponin levels were tested.  The patient was admitted to the Telemetry Unit with a diagnosis of weakness. Thelma Campbell RN, staff nurse on 6 East was his primary nurse during the patient’s course of care.  Cardiology and neurology consults were ordered on the day of admission.  Physical and Occupational therapy evaluations were ordered as was an MRI of the brain.  This was positive for an acute lacuna infarct.  The patient was started on Aspirin, Coumadin, Crestor and a lipid panel was ordered.  During the course of the patients stay he was followed by his primary physician, cardiologist, neurologist, physical and occupational therapist, social worker, case manager and Stroke Program Director.

Initial assessment in discharge planning revealed that the patient lived alone in senior housing and had a prior history of rehabilitation at Kessler and was receiving home services at the time of this admission.  It was determined that the patient needed CHF reinstruction and that was instituted as an ongoing stroke education.

Dietra Irving MSW, Social Worker for 6 East, met with the patient and his family to discuss the appropriate level of post acute care.  The family was advised that the physical therapist evaluation recommended in-patient rehabilitation.  The family indicated that they would like the patient to receive post-hospital treatment at a facility in Paramus, New Jersey.  This request was discussed by the Case Manager and the Primary Physician

who approved the plan.  Ms. Irving contacted the requested facility to advise of the request and initiate the application process.  Janet Serylo BSN, RN, Case Manager, then contacted the insurance carrier and forwarded the required medical documentation, similar records were also faxed to the selected facility.  The patient and his family were continually updated as to the patient’s condition and the progress of the discharge plan.  The patient was medically cleared for discharge to the receiving facility, authorization was obtained from the insurance carrier and transportation was arranged for by Ms. Serylo.

For future growth, Ms. Sietsma intends to connect with all rehabilitation centers in our area to provide even more continuity of care across settings and even extended into home care, if need be.  Ms. Sietsma has developed a patient monitoring tool which captures all the data of the patient beginning with arrival in the Emergency Department (Appendix EP16-A).