Glossary
EP - Exemplary Professional Practice

EP4: Care Delivery System(s)-Describe and demonstrate the structure(s) and process(es) of the Care Delivery System that involve the patient and/or his or her support system in the planning and delivery of care. Provide at least two (2) examples of a plan of care that included patient and/or family member involvement.

Our Professional Practice Model, Patient Centered Family Focused Care includes the patient’s families in collaborative care plan development. Family members are encouraged to participate during interdisciplinary rounds and during nursing handoff. Hand-off is performed at the patient’s bedside with family involvement when they are present. Important information is written on white boards in the patient’s room, for example, a schedule of tests to be performed or when the next pain medication is due. The names of all care givers and the goal for the day are also noted on the white board. This process assists in maintaining patients and family members involved and updated regarding their care.

Hourly rounds, as described in EP35, are performed by nurses and Patient Care Technicians in order to continuously observe the patients condition and address any concerns or problems they might have, or any change in status that may have occurred. These rounds also improve communication with the care team and reveal any adaptations needed for the care delivery plan. For patients with complex care planning needs; family conferences are conducted so that the patient and his/her support team can discuss care plan decisions. Other specialty team members may also be invited to participate. 

Modular Care on 6 East

The 6 East nursing unit consists of a ten-bed Pulmonary Unit and a Telemetry Unit that consists of 39 beds. They use a modular form of care delivery system which is dependant on geographic location for staff assignments. The registered nurse is the team leader which increases the involvement of the nurse in planning and coordinating care.

A patient was recently admitted to the 6 east Pulmonary Unit diagnosed with hypertension and amyotrophic lateral sclerosis (ALS) for five years. The patient presented with shortness of breath and respiratory failure. The patient was intubated and placed on ventilator support. The patient could not be weaned off the ventilator, even though several attempts had been made. The initial plan of care, following a team consultation which included Marilyn Sarnatora MS, RN, BC, Nurse Manager of 6 East, Janet Serylo RN, Case Manager, Rodoro Iglesias RN, Case Manager, Detra Irving LCSW, Social Worker and Luz DeLeon BSN, RN, RNC, and Fely Macato BSN, RN both Staff Nurse on 6 east and Team Leaders on the day shift and Vicky Devera BSN, RN and Maluz Coropuz BSN, RN, RNC Staff Nurses and Team Leaders on the evening and night shifts, was to transfer the patient to a Long Term Care Facility. Since the patient could not be weaned from the ventilator the team needed to reformulate the plan. The patient went to the operating room for a tracheotomy and a PEG feeding tube in order to support him nutritionally. At this point, ancillary services were engaged to help support the care of this patient. Omayra Sanabria, Respiratory Therapist was engaged to continue to work with the patient in an attempt to wean him. The Physical Therapy Department was also engaged in his care and provided passive range of motion exercises. The wife and the patient’s two sons were active participants in this process. They had watched their husband /father deteriorate over the past several months and did not want him to go to another facility; they wanted to bring him home. The nursing staff mobilized into action and began intensive training sessions with the family. They taught the family how to suction and take care of the tracheotomy and change the dressing, how to manage medication administration through the PEG tube, and how to manage feedings through the PEG tube as well. Extensive follow-up care was arranged by the Case Managers and they also arranged for daily visiting nurses. The patient seemed content to be at home with his family, and the family was happy to be able to provide end-of-life care for their father.

Plan of Care

Care Coordination on Behavioral Health

Care Coordination requires teamwork and an integration of efforts across the organization(s) and departments in a concentrated effort to achieve a high level of contiguous care for the patient. Teamwork is very evident on the Behavioral Health unit. They have “team meetings” daily to talk about each patient and the plan of care necessary immediately, and in the future. These team meetings include Therapists, Nursing Staff, Psychiatrists, Social Workers and Case Managers.

Selena Bray BSN, RN, Nurse Manager in Behavioral Health states:

“The opportunity to make decisions is essential to the well-being of our patients. It is our responsibility to maximize patients’ opportunities for choices and to respect those choices. In Behavioral health each of our patients develops their own WRAP (Wellness Recovery Action Plan). This self-designed plan teaches people to identify and monitor symptoms and to use simple, safe, personal skills, supports and strategies to reduce or eliminate symptoms. WRAPs do not replace professional health support and medication, but rather supports it. Our patients and their families are our partners and have knowledge that is essential to their care. We take the information that our patients provide in their WRAP and try and develop a plan of care, based on the information they provide us. The opportunity to make decisions is essential to the well-being of our patients. It is our responsibility to maximize patients’ opportunities for choices and to respect those choices.

Our patients family and significant others are also our partners in our patients well-being and we welcome their involvement. Nursing staff are always available to speak with family and friends about their loved one’s treatment. Family support groups are held on Wednesday evening by a Social Worker.”

A young Hispanic male, well known to the Behavioral health area, with a diagnosis of schizophrenia, has cycled through the behavioral health inpatient unit numerous times. One of his main issues was that he was always non-compliant with his medication regimen. When admitted to the unit, he is disorganized, psychotic and was becoming increasingly violent. Initially it was extremely difficult to get him to engage and participate in the development of his WRAP. His mother has always been involved in his care, but often times would sabotage the treatment teams plan for her own various reasons.

During his last admission, the team was able to encourage him and his mother to allow us to try a new medication regimen with him. It included a long-acting injection which helped him with his issue of non-compliance. He received his first dose here on the unit. We were then able to sit down with him and his mother and start to revise his WRAP with the input of the both of them.

Once discharged, he attended our outpatient program. One of the things he identified in his WRAP (which followed him to the outpatient setting) is that he wanted to work with a female therapist in the outpatient program as opposed to a male. The team was able to arrange that for him. He has continues to keep his appointment in the outpatient setting and takes his injections as scheduled. As a result of all of this, he has not been readmitted to the inpatient unit for over 6 months. Getting him to baseline and having his input to his care has thus far been a great success.

Plan of Care

Synergy on Critical Care

The Synergy model of care links certified practice to patients’ outcomes in the acute care setting. This model describes nursing practice based on the needs and characteristics of patients and the demands of the healthcare environment. The goal is to match the patient’s characteristics to the nurses’ competencies in order to optimize the patient’s outcomes. Nicole Sardinas MSN, RN, CCRN, Critical Care Educator, uses the Synergy Model combined with Benner’s “Novice to Expert” to match the patient characteristic and registered nurse competency ratings which are shown below:

Patient Characteristic Rating

Registered Nurse Competency Rating

In this way, nursing assignments can match the correct nurse with the patients needs.

Recently a 35 year old female was admitted to Jersey City Medical Center under Obstetrical Services for an elevated blood pressure and to rule out pre-eclampsia. She was 35 weeks pregnant. Her previous history indicated that she had had a previous Cesarean Section and had stillborn twins at 28 weeks. Past history determined that she had surgery for Ventricular-Septal Defect at the age of 3 years. History and Physical determine that her lower extremities have been edematous for a one month period and she has an elevated blood pressure. She was admitted to L&D and a C-Section was performed. She had a critical event while recovering from the C-Section. Her temperature became elevated, she c/o shortness of breath and wheezing followed by projectile vomiting. A Rapid Response was called and a Code Blue was called shortly afterward. She was intubated by Anesthesia and transferred to the Medical ICU in critical condition. She was placed on a ventilator and a Pulmonary Artery Catheter was inserted. She was diagnosed with Adult Respiratory Distress (ARDS) and seizures. A continuous video EEG was started. The patients’ family members who were naturally distraught by the situation required extensive support through this process. The patient’s mother, brother, sister, and partner were actively involved in the plan of care during the patients stay in critical care. Family members discussed the patients care with the interdisciplinary team during rounds, family meetings were arranged as needed to update the family on the patient’s progress and establish daily goals.

Using the synergy model the patient’s and nurse’s characteristics were assessed and paired to ensure best patient outcomes.

Cynthia Clougher RN, CCRN was the primary nurse for this patient. She has 30 years of critical care clinical experience, is nationally certified in critical care nursing, and is active in AACN where she functions as an Ambassador. She is also a member of the End of Life/Organ Sharing Committee. She functions as a teacher/preceptor to new staff when necessary. Ongoing treatment continues in the critical care area and she was placed on a percussion bed for secretion management.

Cynthia Clougher’s plan of care consisted of the following: