E mergency nurses, a long wi th all of nursing, face the cha l lenge of adop t ing a common l anguage

to documen t the contr ibut ions of nurs ing pract ice to pa t i en t outcomes. As we move toward the imple- men ta t ion of computer ized pa t ien t records, and communi ty hea l th information ne tworks for the electronic cap ture and transfer of medica l informa- tion, it is impera t ive tha t we document nurs ing care in the same language . Same l anguage in computer te rms means us ing a common set of da t a e lements and e s t ab l i sh ing a specific mean ing for each da ta e l emen t so tha t the same information is col lected regard less of the prac t i t ioner or the pa t i en t care set- t ings. It also means the da t a are col lected in a com-

Table 1 E l e m e n t s of t h e E m e r g e n c y N u r s i n g U n i f o r m D a t a S e t

Nurs ing Care Elements Triage classification Nurs ing diagnosis Nurs ing intervention Nursing outcome Intensi ty of nurs ing care

Patient or Client Demographic Elements Personal identification* Date of birth* Sex* Race and ethnicity* Residence*

Service Elements Unique facility or service agency number* Unique heal th record number of patient or c l ient Unique number of principal registered nurse provider Episode a d m i s s i o n or encounter date and time* Discharge or terminat ion date and time* Disposi t ion of pat ient or client* Expected payer for most of this bill (anticipated finan-

cial guarantor for services)*

The NMDS was modified to reflect emergency nursing practice. Items in italics reflect the recommendations of the ENUDS task force. Adapted from Werley H et al. Am J Public Health 1991;81:421~6. Used with permission. *Elements included in the Uniform Hospital Discharge Data Set.

mon format to facil i tate electronic l inkage be t w een sys tems and ins t i tu t ions to form community, re- gional, and nat ional da ta repositories. To prepare emergency nurses to mee t this chal lenge, ENA cre- a ted a task force to explore the deve lopment of an Emergency Nurs ing Uniform Data Set (ENUDS).*

Nursing Minimum Data Set The ENUDS task force eva lua ted the Nursing Min- imum Data Set (NMDS) to de te rmine whether the da t a e l emen t s wi th in the NMDS are re levant and essent ia l to emergency nurs ing practice. The NMDS

was original ly deve loped to s tandard ize the collec- tion of essen t ia l nurs ing data. The NMDS is def ined as a min imum set of i tems of information with uni- form def ini t ions and ca tegor ies concerning the spe- cific d imens ion of nursing, which meets the infor- mat ion needs of mul t ip le da ta users in the heal th care system. 1 The ENUDS task force agreed tha t the NMDS would mee t the needs for da ta collection in the emergency depa r tmen t wi th the addi t ion of t ime to admiss ion and d ischarge date, and the inclusion of t r iage classif icat ion (Table 1).

Data collection Some nurses and ins t i tu t ions may not currently use or accept the e lements def ined in the ENUDS. For example , nurses may resist accep t ing the classifi- cation sys tem by the North Amer ica Nursing Diag- nosis Associa t ion for nurs ing d iagnoses as the bes t sys tem for desc r ib ing the pa t i en t condit ions t rea ted

*Members of the ENA task force on Emergency Nursing Uniform Data Sets are Pare Kidd, RN, PhD, CEN, Chairperson; Joan Sny- der, RN, MS, CEN; Vicky Bradley, RN, MS, CEN; Lisa Marie Ber- nardo, RN, PhD; Amy Coenen, RN, PhD, CS; Sue Hoyt, RN, MN, CEN; and Susan MacLean, RN, PhD, ENA Director of Research and staff liaison to the task force. Please communicate any thoughts and suggest ions to Dr. MacLean at ENA.

For reprints, write Vicky Bradley, RN, MS, CEN, 4017 Palomar Blvd., Lexington, KY 40513.

J EMERG NURS 1995;21:248-50

Copyright �9 1995 by the Emergency Nurses Association.

0099-1767/95 $3.00 + 0 18 /62 /64009

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by nurses. However, unti l a be t te r sys tem is forth- coming, the t ask force asks all emergency nurses to agree to use the North Amer ica Nursing Diagnoses Associa t ion nurs ing d iagnoses . If da t a repor t ing and collection me thods are not consistent , the da ta can- not be col la ted or compared. If nurses do not docu- men t their pa t i en t s ' problems, adminis t ra tors and the publ ic will have val id reasons to ques t ion the value of an emergency nurse versus a mul t i sk i l led worker as the provider of care for emergency pa- t ients.

To promote the use of nurs ing diagnosis , the Nurs ing In tervent ions Classif icat ion system, 2 out- comes, and other aspec ts of the NMDS, the informa- tion mus t be incorpora ted into ED computer infor- mat ion systems. It is much eas ier to select a nurs ing d iagnos i s from a list than to recall it wi thout prompts. It is even eas ier if the computer sys tem uses decis ion suppor t to p resen t a list of l ikely nurs- ing d i agnoses b a s e d on the pa t i en t assessment , and then sugges t s in te rvent ions for select nurs ing diag- noses. These sys tems could also facil i tate capture of pa t i en t outcomes for each nurs ing d iagnos is by in- c lud ing reminders ("f lags") to h igh l igh t an undoc- u m e n t e d outcome before the pa t i en t ' s disposi t ion.

Computer information sys tems also al low in- c reased f lexibi l i ty in the a r r angemen t of the fields for da t a collection. Given our desire to f requent ly revise the ED record and the thousands of var ia t ions of the ED record current ly in use, f lexibil i ty will ob- viously be an essent ia l feature in any ED computer system. Genera l ly sys t ems can be personal ized; if you wan t the pa t i en t ' s p r imary symptom to be the first ques t ion and another facili ty prefers to list sex or age first, bo th reques t s can be met. An emergency d e p a r t m e n t can a lways add addi t iona l da t a ele- men t s for collection at its par t icular facility, bu t first a g r e e m e n t on the uniform da ta to be col lected is necessary. The order in which the da ta e l emen t s of the ENUDS are en te red may vary, but the essent ia l da t a e l ements tha t are col lected should not vary.

Triage classification Triage classif icat ion is a da t a e lement that is not in- c luded in NMDS. Triage classif icat ion is an area in which d ivers i ty and creat iv i ty have flourished, bu t now a uniform t r iage classif icat ion sys tem is n e e d e d for consis tency. Current t r iage sys tems range from three- t ier to seven- t ier acui ty levels with inconsis- ten t def ini t ions for each acuity. For example , in some ins t i tu t ions a level 1 case is very minor and in other emergency d e p a r t m e n t s a level 1 case is emergent . If we compare the volume of level 1 cases in the first ED facil i ty wi th those in the second, we

are compar ing nonurgen t wi th emergen t c a s e s - - apples to oranges. Even if level 1 cases ind ica ted nonurgen t s i tua t ions at both inst i tut ions, wi thout clearly def ined character is t ics for des igna t ion of a level 1 (nonurgent) si tuation, the t r iage class and pa t i en t outcomes be t w e e n these two emergency depa r tmen t s still would not be comparable . The task force r ecommends the use of nonurgent, urgent, and emergent acui t ies as the t r iage classif icat ion system, real izing we must suppor t the deve lopment and acceptance of a r e sea rch-based s t andard ized t r iage classif icat ion sys tem wi th defini t ions for inclusion in the ENUDS.

It is e s s e n t i a l that e m e r g e n c y n u r s e s qu ick ly def ine the a s p e c t s of ED nurs ing care to be i n c l u d e d in ED d a t a b a s e s .

ED data elements Defining the da ta e l ements to be inc luded in the ED record is a topic of great interest . The Centers for Disease Control and Prevention (CDC) first collected da ta on emergency and ambu la to ry visits in 1992. 3 The Amer ican College of Emergency Physicians de- ve loped an information pape~ on "Emergency De- pa r tmen t Medical Record E lements" in 1993. 4 The Amer ican Society for Test ing Mater ia ls has re leased numerous versions of the "S t anda rd View of Emer- gency Medical Care in the Computer ized Pat ient Record. 5 The Amer ican College of Surgeons defines da ta e lements for t r auma in "Nat ional Tracs, ''6 and Emergency Medical Services for Chi ldren has pro- posed a set of essent ia l e l emen t s wi th a special focus on children.7Nursing diagnosis , nurs ing inter- ventions, nurs ing outcomes, and in tens i ty of nurs- ing care are not inc luded in any of these l is t ings of da t a e lements . It is essent ia l tha t emergency nurses quickly define the aspec t s of ED nurs ing care to be inc luded in ED da tabases . This task mus t be com- p le ted before the 1996 mul t id i sc ip l inary National Workshop on Emergency Depar tmen t Data by the Centers for Disease Control and Prevention. At this workshop ENA will p resen t essen t ia l nurs ing da ta e l ements tha t should be inc luded as part of every emergency care visit. If we do not reach consensus, not only will nurs ing da ta be omi t t ed from these

June 1995 ~49

JOURNAL OF EMERGENCY NURSING/Bradley

na t iona l d a t a se ts for e m e r g e n c y visi ts , b u t t he

v a l u e of n u r s i n g care wi l l be un iden t i f i ab le .

Summary T h e c o n v e r s i o n from h a n d w r i t t e n to e l ec t ron ic

r ecords is an o p p o r t u n e t i m e to s t r ive t o w a r d s tan-

d a r d i z a t i o n of t he da t a w e collect . E m e r g e n c y nurses

m u s t a c t i ve ly lobby hosp i t a l a d m i n i s t r a t o r s to con-

ve r t f rom p a p e r - a n d - p e n c i l d o c u m e n t a t i o n to a com-

p u t e r i z e d p a t i e n t record. To improve c l in ica l care

a n d the h e a l t h care de l i ve ry sys tem, w e m u s t h a v e

the ab i l i ty to e l ec t ron ica l ly ana lyze l a rge se ts of da t a

to e v a l u a t e old a n d n e w p rac t i ce s to d e t e r m i n e the

b e s t p r ac t i ce s and de l i ve ry sys tems . If e m e r g e n c y

n u r s i n g d a t a are to be i n c l u d e d and accu ra t e ly rep-

r e s e n t e d , our first s t eps are to r each c o n s e n s u s on

t h e e l e m e n t s a n d de f in i t ions of an ENUDS, a n d to

vo lun ta r i l y incorpora te co l lec t ion a n d r epo r t i ng of

t h e s e d a t a e l e m e n t s into our pract ice . T h e s e s teps

are n e c e s s a r y to e n s u r e t he fu ture of ED n u r s i n g

prac t ice .

References

1. Werley H, Devine E, Zorn C, Ryan P, Westra B. The nursing minimum data set: abstraction tool for standard-

ized, comparable, essential data. Am J Public Health 1991;81:421-6. 2. McCloskey J, Bulechek G, eds. Nursing interventions classification (NIC): Iowa intervention project. St. Louis: Mosby, 1992. 3~ McCaig L. National hospital ambulatory medical care survey: 1992 emergency department summary. Hyatts- ville, Maryland: National Center for Health Statistics. Ad- vance data, 245, Vital and health statistics of the Centers for Disease Control and Prevention. DHHS Publication No. (PHS) 94-1250. 4. American College of Emergency Physicians, Practice Management Subcommittee on Essential Medical Record Elements. Emergency Department Medical Record Ele- ments. Dallas, Texas: American College of Emergency Physicians, May 1993. 5. American Society for Testing Materials. Standard guide for a view of emergency medical care in the computerized patient record, seventeenth version (draft). Philadelphia, Pennsylvania. 6. American College of Surgeons. National Tracs, Data elements. Chicago: American College of Surgeons, Feb- ruary 1994. 7. Dutch J, Lohr K, eds. Emergency medical services for children proposed national uniform data elements (Ap- pendix 7B). In: Institute of Medicine Report on Emergency Medical Services for Children. Washington, DC: National Academy Press, 1993.

p r e v e n t i n g v io l ence t o w a r d h e a l t h care worke r s

is an i s sue of g r ea t impor t ance . In one as ton i sh -

i ng case, p a r a m e d i c s w e r e t r an spo r t i ng a p a t i e n t

w h o h a d b e e n s t a b b e d in t he an te r ior a s p e c t of the

left c h e s t wall . On arr ival at the s cene of t he injury,

t he knife w a s found i m p a l e d in t he pa t ien t . The

Dr. George is editor of Emergency Nurse Legal Bulletin, Med Law Publishers, Inc., P.O. Box 293, Westville, NJ 08093. Ms. Quattrone is associate editor Both are partners in the law firm of George, Korin, Quattrone, and Blumberg, Woodbury, New Jersey. Mr. Goldstone is consulting editor of Emergency Nurse Legal Bulle- tin, MedLaw Publishers.

p a r a m e d i c s s e c u r e d the knife to t he ches t wal l and

t r a n s p o r t e d the pa t ien t . Whi le en route to the hos-

pital , t he p a t i e n t ac tua l ly p u l l e d the knife from his

o w n ches t and t h r e a t e n e d the p a r a m e d i c s w i t h it.

In r e s p o n s e to i n c r e a s i n g ED violence , s o m e

e m e r g e n c y d e p a r t m e n t s h a v e re so r t ed to me ta l de-

For reprints, write Madelyn S. Quattrone, JD, Suite 101, Box 319, 307 S. Evergreen, Weodbury, NJ 08096. J EMERG NURS 1995;21:250-1 Copyright �9 1995 by the Emergency Nurses Association. 0099-1767/95 $3.00 + 0 18/62/64494

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