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The d e t e c t i v e r epo r t ed the s i tua t ion in t he home w a s "no t r ight . " The pol ice we re familiar w i th the home, hav ing b e e n cal led the re n u m e r o u s t i m e s on violent d o m e s t i c d i spu tes . As expec t ed , the h u s b a n d empha t i c a l l y d e n i e d any respons ib i l i ty for his wi fe ' s dea th . The h o m i c i d e d e t e c t i v e exp la ined to us tha t t he med i ca l examine r would have to prove foul p lay to c h a r g e the husband .

I w a s g iven the m e d i c a l e x a m i n e r ' s ini t ial repor t w i th in hours. The w o m a n ' s liver, heart , and k idneys were all in end s t a g e s of failure. Her organs we re not ab le to me tabo l i ze the ami t r ip ty l ine , w h i c h could have c a u s e d the h igh d rug levels. If t he med ica l e x a m i n e r could have e x a m i n e d the gas t r i c contents , he would have k n o w n h o w m a n y pills h a d b e e n i n g e s t e d at

once. But t he e v i d e n c e w a s gone. No legal ac t ion w a s ever pursued . All t ha t r e m a i n e d were t he a c c u s a t i o n s from the family and m y own feel ing of frustrat ion. I still have the n a g g i n g s ensa t i on tha t if any of us h a d fol- lowed our ins t inc t s more aggress ive ly , w e m i g h t know w h a t really h a p p e n e d . This c a se e m p h a s i z e d the im- po r t ance of fulfilling the role of forensic nurse and m a i n t a i n i n g ev idence .

Cont r ibu t ions to th is co lumn should be sen t to Gaff P isarc ik Lenehan , RN, EdD(c), CS, c /o M a n a g i n g Editor, ENA, 216 Higg ins Rd., Park Ridge, IL 60068-5736; p h o n e (847) 698-9400.

A l though a large a m o u n t of d a t a is col lec ted dur- ing an ED encounte r , t he re a re no nat ional ly ac-

c e p t e d s t a n d a r d s for t he col lect ion and d o c u m e n t a - t ion of t h e s e data . Even for f requent ly col lec ted data , the re are different def ini t ions. A major ob jec t ive of de f in ing an ED d a t a se t is the abi l i ty to analyze d a t a to d e t e r m i n e p a t t e r n s a n d re la t ionships . De te rmin ing w h a t to inc lude and def in ing each d a t a e l emen t for c o m p a r i s o n b e t w e e n e m e r g e n c y d e p a r t m e n t s is a major chal lenge. For example , mos t e m e r g e n c y de- p a r t m e n t s d o c u m e n t the p a t i e n t arrival t ime; how- ever, the def in i t ion of arrival t i m e s var ies widely. It m a y b e r eco rded in one e m e r g e n c y d e p a r t m e n t as the

Vicky Bradley is systems coordinator, Emergency Department and Operating Room Services, University of Kentucky Hospital, Lexing- ton, Kentucky. Reprints not available from author. J Emerg Nurs 1996;22:238-40. Copyright �9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + 0 18/62/73367

t ime the pa t i en t en t e r ed the e m e r g e n c y d e p a r t m e n t , in ano the r e m e r g e n c y d e p a r t m e n t as the t ime t r iage began , or in a th i rd e m e r g e n c y d e p a r t m e n t as t he t ime reg i s t ra t ion occurred. If e m e r g e n c y d e p a r t m e n t s are u s i n g l eng th of s tay as a benchmark , a c o m m o n def- in i t ion of arrival t ime n e e d s to be a c c e p t e d to p r o d u c e rel iable l eng th of s t ay t i m e s for compar i son a m o n g e m e r g e n c y depa r tmen t s . A l though the re are benef i t s to col lect ion and d a t a ana lys i s wi th in t he ind iv idua l facility, t he sha r ing of d a t a b e t w e e n faci l i t ies and a g e n c i e s will p romote g rea te r benef i t s in the effort to improve the e m e r g e n c y ca re de l ivery s y s t e m and the pub l i c ' s health.

ENA's role in data set development The d e v e l o p m e n t of a d a t a se t is an a rduous and complex process . ENA is s u p p o r t i n g efforts to deve lop a uniform ED d a t a se t t h rough the ac t iv i t ies of the E m e r g e n c y Nurs ing Uniform Data Set (ENUDS) t a sk force and b y pa r t i c ipa t i ng in the d e v e l o p m e n t of the p r o p o s e d Uniform E m e r g e n c y D e p a r t m e n t Data Set

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(UEDDS) c o o r d i n a t e d by the Nat ional Center for Injury Preven t ion a n d Control, Cen te r s for Di sease Control and Preven t ion (CDC). The ENUDS ta sk force has spec i f ica l ly d i r e c t e d its ini t ial ac t iv i t ies t o w a r d defin- i ng e m e r g e n c y nu r s ing d a t a e lements . 1 The first pri- or i ty w a s to iden t i fy and def ine the e s sen t i a l e l e m e n t s of e m e r g e n c y nurs ing . As our cur rent hea l th care de - l ivery s y s t e m con t inues to be sc ru t in ized by all par t ies , it is e s sen t i a l t ha t a m e c h a n i s m for d e m o n s t r a t i n g e m e r g e n c y n u r s i n g ' s con t r ibu t ion to e m e r g e n c y care is e s t ab l i shed . To he lp e m e r g e n c y nurses collect t he ENUDS, a m a n u a l exp la in ing the e lements , thei r def- init ion, w h a t factors were cons ide r ed in the i r devel - opment , and s u g g e s t i o n s for col lect ion in a pape r - b a s e d or c o m p u t e r i z e d s y s t e m will be avai lable from ENA. 2

ENUDS ta sk force m e m b e r s * have b e e n ac t ive in the CDC-coord ina t ed in i t ia t ive to deve lop the pro- p o s e d UEDDS. Jo in ing CDC and ENA in sponso r ing this in i t ia t ive are t he U.S. A g e n c y for Heal th Care Pol- icy and Research , A m e r i c a n College of E m e r g e n c y Phys ic ians , A m e r i c a n Heal th Informat ion M a n a g e - m e n t Assoc ia t ion , A m e r i c a n Hospi ta l Assoc ia t ion , U.S. Heal th Resources and Serv ices Admin i s t r a t ion , U.S. Nat iona l H i g h w a y Traffic Safety Admin i s t r a t ion , and Soc ie ty for A c a d e m i c E m e r g e n c y Medic ine . Rep- r e s en t a t i ve s of t h e s e o rgan iza t ions p l a n n e d the 1996 Nat iona l Workshop on E m e r g e n c y D e p a r t m e n t Data he ld in J anua ry in A t l an t a and are coord ina t ing p rep- a ra t ion of the p r o p o s e d UEDDS. ENUDS ta sk force m e m b e r s r e v i e w e d a n d c o m m e n t e d on each draft of t he UEDDS and s e r v e d as concur ren t s e s s ion facil i ta- tors a t the Workshop. The Workshop w a s the pr inci - pa l na t iona l forum for the r ev iew and revis ion of the p r o p o s e d d a t a set. A p p r o x i m a t e l y 160 individuals , in- c lud ing r e p r e s e n t a t i v e s of 36 na t iona l profess ional as- soc i a t ions and 13 federa l agenc ie s , p rov ided inpu t on w a y s to improve the d a t a set. The Workshop del iber- a t ions and add i t iona l r e c o m m e n d a t i o n s so l ic i ted after t he m e e t i n g have b e e n inco rpora t ed into s u b s e q u e n t vers ions of the p r o p o s e d UEDDS. Plans call for com- p le t ion and pub l i ca t i on of the d a t a se t in the s u m m e r of 1996.

Why is adoption of these data sets important? There is li t t le l ikel ihood tha t c o n s e n s u s on w h a t to in- c lude in t h e s e ini t ial d a t a se t s will be ach ieved . How- ever, c rea t ion of a d a t a se t m u s t s ta r t somewhere ; the col lec ted d a t a and resul ts of future r e sea rch can then

*ENUDS Task Force Members: Pamela Kidd, RN, PhD, CEN, chair- person; Lisa Marie Bernardo, RN, PhD, CEN; Vicky Bradley, RN, MS; Amy Coenen, RN, PhD, CS; Sue Hoyt, RN, MN, CEN; Anne Man- ton, RN, PhD, CEN; Joan Snyder, RN, MS, CEN; Susan MacLean, RN, PhD, ENA director of research and staff liaison.

b e u s e d to ref ine the d a t a set. If you have ever par t ic - i p a t e d in the rev is ion of an ED record or c rea t ion of a t r a u m a flow sheet , you have p robab ly e x p e r i e n c e d the lively d i s c us s ion of w h a t should b e d o c u m e n t e d on the form. As you d i s c u s s adop t ion of ENUDS, UEDDS, or bo th in your e m e r g e n c y d e p a r t m e n t , cons ider the fol- lowing as in f luenc ing factors on h o w the da t a se t w a s c r e a t e d and as a jus t i f ica t ion for conv inc ing o thers to a s s i s t you in t he adop t ion of t h e s e da t a sets . The benef i t s of s a v i n g da t a in a s t a n d a r d i z e d format will no t b e real ized, un less t he d a t a se t is a d o p t e d and used .

1. Rationale for collecting the data element As d a t a e l e m e n t s were r e v i e w e d for inc lus ion in a d a t a set , a ra t ionale for the d a t a e l e m e n t was ident i f ied. Current research , whe re avai lable , was u sed to help d e t e r m i n e w h a t d a t a should b e collected. Be c ause the re is little r e sea rch va l ida t ing the collection of in- format ion in e m e r g e n c y prac t ice , expe r t opin ions de- t e r m i n e d m a n y of the d a t a e lements . The d a t a col- l ec ted should be eva lua t ed in t he future to d e t e r m i n e w h e t h e r the d a t a e l emen t is va luab le or should be e l imina ted . For example , do p a t i e n t s need a full se t of vi tal s igns a t t r i age? Be c a use the collection of vi tal s i gns is rout ine ly performed, should they be inc luded in the da t a se t? Resea rch can b e u s e d to c ompa re vi- tal s ign da t a w i th pa t i en t o u t c o m e s to d e t e r m i n e if t hey are n e c e s s a r y for all p a t i e n t popula t ions at t r iage. Thus th rough survei l lance and r e s e a r c h act ivi t ies , the p u r p o s e of co l lec t ing the d a t a e l emen t s can be va l ida ted . 3

In add i t i on to d a t a e l emen t s tha t cap ture the care del ivered, e l e m e n t s are i nc luded tha t provide infor- ma t ion for eva lua t ion of t he e m e r g e n c y hea l th care de l ivery s y s t e m a n d publ ic health. The scope of the d a t a se t is b road so tha t mul t ip le use r s can use the d a t a se t to bene f i t pa t i en t care in a var ie ty of ways . The ED prac t i t i one r m a y a c c e s s t he d a t a ba se in real t ime to v i ew p a s t visi t informat ion on this pa t i en t or f ind other p a t i e n t s wi th s imilar ini t ial symptoms . The ca se m a n a g e r m a y use the da t a se t to develop pa th - w a y s for de l ivery of care to g roups of pa t i en t s wi th c ompa ra b l e ch ie f s y m p t o m s , or iden t i fy the i l lnesses and injuries tha t are the mos t expens ive to treat . M a n a g e r s will u se the d a t a se t to i nves t i ga t e the t ypes of p a t i e n t s s e e k i n g care in thei r e m e r g e n c y depar t - m e n t (e.g., age groups, mos t c o m m o n initial symp- toms and d iagnos i s , and f inancia l class). Other uses of the d a t a se t i nc lude the following: �9 Eva lua t ing the benef i t of spec i f ic t r e a t m e n t s or in-

t e rven t ions �9 C o m p a r i n g ca re de l ivered by nurse pract i t ioners ,

p h y s i c i a n s a s s i s t an t s , and e m e r g e n c y phys i c i ans

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�9 Iden t i fy ing r e source ut i l izat ion for m a n a g e m e n t �9 Eva lua t ing c o m m u n i t y wel lness �9 D e t e r m i n i n g the n e e d for c o n s u m e r e d u c a t i o n �9 De t e rmin ing the e f fec t iveness of c o m m u n i t y edu-

ca t ion p r o g r a m s �9 Suppor t i ng the n e e d for n e w legis la t ion to d e c r e a s e

injur ies (e.g., gun control, he lme t laws, je t ski reg- ulat ions)

�9 Suppo r t i ng fund ing of spec i f ic se rv ices such as im- m u n i z a t i o n s and d o m e s t i c v io lence she l te rs

Given the na tu r e of the se t t ing , d o c u m e n t a t i o n of d a t a is f requent ly not a h igh pr ior i ty for front-l ine m e m b e r s of the ED team. Subsequen t ly , w h e n d a t a a re not col lected, t hey are not r eco rded or avai lable for future dec i s ion making . Cri t ical ana lys is of t he value and i m p a c t of the col lect ion of t h e s e da t a e l e m e n t s on e m e r g e n c y pa t i en t c a r e - - a n d our f u t u r e - - i s e s sen - tial. The cha l l enge is to d e t e r m i n e w h i c h d a t a ele- m e n t s have the g r e a t e s t value and should be col- lec ted .

2. Opportunities provided by computerization of the ED record

As the ED record b e c o m e s inc reas ing ly compute r i zed , d a t a will b e eas ie r to collect. Ideal ly the da t a e l e m e n t s would b e en t e r ed by the ED prac t i t ioner in t he com- pu t e r i zed pa t i en t record as care is provided. The d a t a se t would be au tomat i ca l ly cop ied to a d a t a b a s e , e l imina t ing the n e e d for r e t rospec t ive aud i t s and d a t a entry. 4 The n e e d to a c c e s s informat ion for cl inical and m a n a g e m e n t decis ion, m a k i n g war ran t s the c rea t ion of a more ex t ens ive d a t a set. A d a t a se t i nc lud ing el- e m e n t s tha t d e s c r i b e the major i ty of the d a t a co l lec ted in the e m e r g e n c y d e p a r t m e n t ac t s as a b luepr in t or t e m p l a t e for c o m p u t e r s y s t e m vendors to a d o p t and bui ld into the i r sys tems . A d i l e m m a in the deve lop- m e n t of d a t a se t s is w h e t h e r to c rea t e a se t for t o d a y ' s level of compu te r i za t i on or lack thereof, or d e s i g n a se t of more ex tens ive e l ements tha t will be easi ly cap tu red via compute r i zed documen ta t i on 5 to 10 years from now. If w e do not develop the more comprehens ive da t a se t today, w e miss the opportunity to set s t anda rds for h o w the da t a e l ements will b e def ined as compute r sy s t ems are deve loped and pu t into pract ice .

3. Cost of collecting and' reporting each data element Does the p u r p o s e of the d a t a e l emen t just i fy the cos t to col lect and record the d a t a e l emen t? Initially, b e c a u s e m o s t e m e r g e n c y d e p a r t m e n t s have paper sys t ems , re t r i ev ing and repor t ing on the d a t a ele- m e n t s is an add i t iona l cost. E m e r g e n c y d e p a r t m e n t s tha t u se t he p a p e r record and have l imi ted r e sou rces for d a t a col lect ion and r epor t ing m a y collect a smal ler

s u b s e t of the da t a e l emen t s initially. E m e r g e n c y d e p a r t m e n t s wi th c o m p u t e r i z e d p a t i e n t records will find i t eas ie r and c h e a p e r to collect and re t r ieve more of the d a t a e lements . There will also b e an init ial cos t in conver t ing from h o w your e m e r g e n c y d e p a r t m e n t or hosp i ta l cur rent ly def ines the d a t a to h o w the d a t a e l e me n t is de f ined in t he ED d a t a set. Thus a l though the cos t m a y s e e m h igh to e m e r g e n c y de pa r tme n t s , the cos t to soc ie ty is higher . If the d a t a are not col lected, w e will m i s s an oppor tun i ty to d e t e r m i n e wh ich c h a n g e s are n e e d e d to improve the e m e r g e n c y p a t i e n t care s y s t e m a n d the hea l th of t he public.

Crea t ion of d a t a se t s for e m e r g e n c y nurs ing and the e m e r g e n c y d e p a r t m e n t is jus t beg inn ing . The use and ana lys i s of the p r o p o s e d da t a se t s will p rovide in- pu t for future r e f i nemen t s of the d a t a set . As compu te r s y s t e m s b e c o m e more commonplace , d a t a retr ieval will b e c o m e faster and easier. The informat ion pro- v ided b y the adop t ion of t he se d a t a se t s is useful for all e m e r g e n c y prac t i t ioners . The c l in ic ian will have a c c e s s to da t a to faci l i ta te c rea t ion and evalua t ion of cl inical p r ac t i ce guidel ines . A d m i n i s t r a t o r s can use the d a t a for r e source al locat ion and benchmark ing . The r e sea rche r can c o n d u c t mul t i s i te s tud i e s on an end less supp ly of topics . E d u c a t o r s can be t t e r ident i fy con t inu ing educa t i on needs , and hea l th care policy- make r s can deve lop a n d coord ina te local, regional, nat ional , and in te rna t iona l d a t a b a s e s as a repos i tory of da t a for pol icy deve lopmen t . The long- te rm benef i t s of adop t ion and use of the da t a se t s far ou twe igh the s t rugg les e x p e r i e n c e d dur ing the c rea t ion and imple- m e n t a t i o n phase .

References

1. Bradley V. Toward a common language: emergency nursing uniform data set (ENUDS). J Emetg Nurs 1995; 21:248-50. 2. Emergency Nurses Association, Emergency Nurses Uni- form Data Set Task Force. Emergency nursing uniform data set manual. Park Ridge, Illinois: Emergency Nurses Associ- ation. In press. 3. Garrison HG, Runyan CW, Tintinalli JE, et al. Emergency department surveillance: an examination of issues and a proposal for a national strategy. Ann Emerg Med 1994;24:849- 56. 4. Simpson RL. Ammunition in the boardroom: the clinical nursing data set. Nurs Manage 1995;26:16-7.

Cont r ibu t ions to th is co lumn should b e s en t to Vicky Bradley, RN, MS, CEN, 4017 Pa lomar Blvd., Lexington , KY 40513; p h o n e (606) 257-2350 (E-mail address : vmbrad l e %taonode .mvs .hosp .uky . edu)

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