EP - Exemplary Professional Practice

EP7: Care Delivery System(s)-Describe and demonstrate the structure(s) and process(es) used to engage internal experts and external consultants to improve care in the practice setting.

Rita Smith DNP, RN, NEA-BC, Chief Nursing Officer has a long tradition of developing and retaining the best people. This commitment has produced an environment rich with internal consultants. These individuals, each with specialized knowledge and expertise, are an important internal resource for our direct care nurses. The internal consultants most often used to support our nurses in advancing care in the practice setting include advanced practice nurses, wound and falls program coordinator, clinical nurse leaders, pain and palliative care nurse, and lactation specialist. Other available consultants include interfaith chaplain, social workers and case management. Our nurses also receive consultation during participation in conferences, in-services, DMAIC projects and committees.

Internal Consultants

Peggy Petrucelli BSN, RN is the Wound and Falls Program Coordinator at the MedicalCenter.
Peggy Petrucelli BSN, RN, Wound and Falls Program Coordinator
 Peggy Petrucelli BSN, RN, Wound and Falls Program Coordinator  

(See Reference OO17-N for Wound Coordinator job description). Ms. Petrucelli can be reached by nursing staff via her cell phone number and/or her pager number. She also receives referrals for wounds from the nursing staff through the computer system. Nurses consult with Ms. Petrucelli on a daily basis. Peggy continuously looks for trends to identify problem areas and visits the patient and talks directly to the nurses on that unit and provides education if needed. An example of this was shown recently when the critical care area was having an increase in skin tears. She feared further skin breakdown and went to the unit to speak to the nurses. She discovered that the nurses were reluctant to use the barrier cream because it does not “wipe-off.” She changed the process by making sure that mineral oil was readily accessible to the nurses on the unit which resolved the problem.

Another example with Ms. Petrucelli was a patient on the medical-surgical unit who had an unusually difficult abdominal illeostomy fistula which was constantly draining and causing skin breakdown to the area. Ms. Petrucelli, in collaboration with Elizabeth Vocaturo MSN, RN, CNL Staff Nurse on 7 East, and the primary care physician Dr. Brambatt M.D., sent a molding of the site to a company in California, and an individualized ostomy wafer with a formed ridge was created. This allowed direct adherence to the patient so that the surrounding skin could heal. Ms. Petrucelli visited this patient at the rehabilitation center where he was recuperating to insure continuity of care with the established plan.

Ms. Petrucelli is also the Program Coordinator for Falls hospital-wide. The falls are reported via incident report from direct care nurses in rL solutions (Appendix EP7-A). Peggy gathers details from this report and collects data that is presented in a once per month interdisciplinary meeting (Appendix EP7-B) with RNs, Pharmacists and Patient Care Technicians. The committee members evaluate and strategize on how to eliminate and/or decrease falls. She worked on a reduction in the falls rate with 5 west, the Pschyciatric Unit and has partnered with the nurses on 6 West and their TCAB project.

The Clinical Nurse Leaders are utilized as a resource in critical care and hospital-wide particularly with quality, safety and evidence-based practice and research. (See Reference OO17-E for CNL job description). There are two CNLs in critical care, Mabel LaForgia MSN, RN, CNL, CCRN and Claudia Garzon-Rivera MSN, RN, CNL, CCRN. These valuable resources are available through their wireless cellular telephones, hospital e-mail or directly through their office telephones. They are frequently on the unit and are therefore very accessible to the nursing staff. They perform interdisciplinary clinical rounds on a daily basis on the critical care units which include: intensivists, primary nursing staff, respiratory, palliative care team, pharmacy and the
Mabel LaForgia MSN, RN, CNL, CCRN and Claudia Garzon-Rivera MSN, RN, CNL, CCRN-Clinical Nurse Leaders
 Mabel LaForgia MSN, RN, CNL, CCRN and Claudia Garzon-Rivera MSN, RN, CNL, CCRN-Clinical Nurse Leaders  

charge nurse. During these rounds the nursing staff has the opportunity to interact and ask questions. They provide evidence-based practice for the nursing staff as needed, for example, advocating that the Sepsis Protocol be initiated. Another issue that they help staff and physicians with is the insulin drip protocol. This protocol states that when a patient spikes a 180 glucose level twice within a specified period of time, and meets other criteria, the protocol must be initiated. They frequently respond to Code Blue announcements throughout the house, and recently, one was initiated in the Endoscopy suite. The patient was having a severe gastrointestinal bleed and Ms. Garzon-Rivera initiated the Mass Transfusion Protocol.

The CNLs are advocates and frequently teach nurses on the use of the EBSCO system for patient education materials and best practice. They also assist in the development of policies and procedures, the most recent one being a policy on the admission and discharge criteria for critical care Reference EP7-A. An entire team participated on the development of this policy: representatives from cardiology, medicine, surgery and critical care. The latest protocol that both CNLs developed was on Pulmonary Embolism Treatment (Appendix EP7-C). A recent issue came up in the Newborn Nursery about the advantages of Co-bedding for twins, and Ms. Garzon and Ms. LaForgia searched the literature to find educational articles for the nursing staff to read. Hypothermia is another protocol they are involved with in critical care patients reaching target temperatures Reference EP7-B. They also consult with the Emergency Department to assist with initiating the code sepsis on newly arrived patients if appropriate. They have recently established a webinar series for staff nurses in critical care on the Prevention of Delirium in the Intensive Care Unit. See Delirium webinar series below:

Delirium/Sedation Webinars

Both Ms. LaForgia and Ms. Garzon sit on the Adverse Event Team because of their clinical expertise. The members of this team are required to attend and participate on the Root Cause Analysis hospital-wide. Ms. Garzon is the Facilitator of the nursing Quality and Safety Council and is in a position to make clinical changes if necessary. A recent RCA occurred when a patient was injured following a fall. During the RCA it was noted that there was no documentation of the patient having received education regarding falls. One of the recommendations was to insure that nurses complete the falls education form. Ms. Garzon was instrumental in insuring that the staff nurses implement this process. One RCA involved the use of vasopressin and another 3% Sodium Chloride. Ms. Garzon and Ms. LaForgia insured that these two drugs be added to the high-alert, double-check medications. Ms. Garzon referred these issues to the Quality and Safety Council, the Professional Practice Council, the Pharmacy and Therapeutics Committee and finally to the Policy Committee.

Shani Newell BS, JD, Director of Risk and Corporate Compliance, manages risk organization-wide as well as corporate compliance. She functions as a consultant with staff nurses as she advises them relating to issues with informed consents, legal guardianship, adverse events, incident reports and trends. She is easily reached via her cell phone, her office phone and e-mail by staff nurses. In her role as corporate compliance officer, she must deal with HIPPA (Health Insurance Portability Accountability Act) issues, EMTALA (Emergency Medical Treatment and Active Labor Act) issues, whistle blower protection and investigation of Hotline telephone calls.

Infection Control Team

Vicki DeChirico MSN, RN, CIC, Director of Infection and Mary Plaskon BSN, RN, CIC, Infection Preventionist comprise the Infection Control Team in Jersey CityMedicalCenter. They are responsible for the development and implementation of techniques in conjunction with other departments, as needed, which will improve patient care and protect the staff and patients from infection. They educate as well as consult for staff personnel, visitors and other community affiliates. Infection Control services extend to all areas including those involved with maintenance and physical plant. Ms. DeChirico performs Environmental Rounds (Appendix EP7-D) on selected units in conjunction with Karen Caldas MSN-BC, Clinical Risk Manager, Wayne Griffith, Manger of Environmental Services, and Bill Cook, Director of Facilities. During these rounds they identify infection control, safety and environmental issues and can be utilized to answer questions from staff. They frequently request that the Charge Nurse and/or the Nurse Manager make rounds with them. A report is generated following these rounds outlining issues for the benefit of the Management Team. Ms. Plaskon performs surveillance rounds on the units and insures hand washing compliance and insures that personal protective equipment (PPE) is being used. She frequently conducts educational focus groups for the staff particularly if there is an issue that pertains to a specific unit. One problem which recently occurred on a unit was that all levels of staff were not using PPE appropriately. Ms. Plaskon counseled them on the importance of using this protective equipment. Both Infection Control individuals can be reached via office telephone, beeper or cell phone/blackberry usage.

Advanced Practice Nurses

The hospital is fortunate to have forty-one (41) Advanced Practice Nurses in its employment. Please see the table listed below for the names of Advanced Practice Nurses.

EB7-Table 1

These nurses range from Nurse Practitioners to Certified Registered Nurse Anesthetists. Most of our APNs work collaboratively with physicians to provide advanced care within a certain specialty. These nurses consult frequently with our nurses as well as educating and mentoring.

APNs are actively engaged as consultants by both direct care nurses and the organization at large. Direct care nurses often contact APNs with specific concerns about the patients in their care. For example, Nancy Pain APN-C Palliative Care and Pain Nurse frequently provides advice to nurses particularly on end of life care. (See Reference OO17-K for Palliative Care NP job description). One recent incidence involved a 90 year old woman who lived alone nearby in an apartment. The women’s daughter, although she was not the primary care giver, did see her mother on a daily basis. One day while at home, the mother fell and suffered a subdural hematoma and was rushed to the hospital. The daughter had been away for the day and did not find out until the next day that the mother was hospitalized. The woman was not responding and required complete nursing care. The daughter became obstructive and questioned every aspect of care that was being given. The nurses were very distressed by this behavior and tended to avoid the daughter when present. Thalia Nieves BSN, RN, staff nurse in the ICU consulted with Ms. Pain on this issue. Ms. Pain worked with the staff to help them understand what the family member was feeling. She further helped them to understand that whatever we do going forward with this patient, it is for the family members as much as it is for the patient. The nursing staff was able to cope better with this family member and incorporate her into the mothers care.

Mary Lou Almanzor APN-C
 Mary Lou Almanzor APN-C  

Mary Lou Almanzor APN-C, a Nurse Practitioner that works primarily in Medicine, was consulted by a staff nurse, Sherlaine Bass BSN, RN, on 6 East, Telemetry Unit. The patient had a diagnosis of Congestive Heart Failure and was experiencing an altered mental status. The nurse was concerned that the patient may be hyponatremic or may be experiencing a stroke, and requested that Ms. Almanzor assess the patient. The patient also had an Automatic Internal Cardiac Defibrillator (AICD) implanted. Ms. Almanzor telephoned the company that implants these devices to have a technician come and insure that the device was working properly. She also performed a neurological exam on the patient and sent the patient for a CAT scan. She then assisted the nurse with a plan of care going forward.

Jessica Babich APN-C, Nurse Practitioner in Employee Health advises and counsels nurses while performing their physical examinations. She may frequently detect an abnormality during the exam that needs a physician’s attention and follow-up and she will advise the nurse accordingly. Ms. Babich also counsels nurses on infectious diseases and exposure to blood borne pathogens via needle sticks.

External Consultants

External consultants are contracted by Rita Smith DNP, RN, NEO-BC, Chief Nursing Officer and are part of the budgetary planning process. Processes are in place to provide external consultants support for direct care nurses using specialized equipment. An example of this is the nurse consultants from Prevent, Inc., who do periodic in-services and Tracers hospital-wide in order to assess integration of the Safe Patient Handling Program. These consultants review our documentation, communication processes, equipment application and training and documentation. They also perform observations to assess caregiver proficiency. Support for direct care nurses, by an external consultant, is also provided by our Research Consultant, Sue Salmond EdD, RN, Dean of UMDNJ School of Nursing. Ms. Salmond has provided her research expertise to assist bedside nurses, as well Clinical Leadership, in conducting well designed research projects. Her support has been instrumental in increasing the interest of staff nurses, as well as the number of research projects developed. (See NK4 for further information on the Research Consultant).

FTI is an outside consultant company was retained to help insure that the organization was fiscally secure operationally. The organization wanted all services benchmarked for labor and supplies. The three major goals that the hospital wanted reviewed included:

  • Labor Resources-compare last review of this issue (2009) with current review (2011)
  • Insure that the organization is meeting the needs of a changing environment and operating at maximum effectiveness and efficiency.
  • Insure that the organization is getting the right pricing from the GPOs (Group Purchasing Organizations)
  • Analyze supplies/equipment in high cost areas, for example, operating room, cardiac catheterization laboratory as well as new programs

They were able to identify and correct many processes, such as, improvement in case cart flow between the Sterile Processing Department and the Operating Room and were instrumental in consolidating supplies and obtaining best pricing.

Please review graph below for a summary listing of savings:

Graph-Summary Lising of Savings

Sterilmed is an outside consultant company that worked with the organization to establish a single-use reprocessing program. Jersey CityMedicalCenter has been in this program for a two year period and we have generated savings related to this initiative. For a full accounting of the financial and environmental benefits to this program see EP7EO.