Standardized Nursing Language - Essay Example

? Standardized Nursing Language By Candi s FACULTY OF HEALTH SCIENCES, COLLEGE OF NURSING The use of standardized nursing language for electronic documentation enhances communication between nurses and other health care professionals to present improved patient care, adherence to standards and increased visibility of treatment. Electronic patient records are now important for hospitals because these allow for ease of access to clinical information, easy transfer of information to various hospital departments and other care providers with enhanced reporting. Because of the significance of electronic patient records, by the year 2014, hospitals in the United States will have to meet meaningful criteria for electronic health records to qualify for financial incentives. Thus, it makes strategic sense for all hospital departments, including the Accident and Emergency (A&E) unit within a hospital, to maintain electronic patient record systems, which present clinical and nursing notes, patient data, treatment history, etc. to assist with care. Life and death decisions in the A&E unit within a hospital are quick and clear and legible information is essential to administer proper treatment. This project report presents a discussion about electronic patient record systems that incorporate standardized nursing language for the A&E unit within a hospital. Consideration of the Keogh Medical Systems Electronic Patient Record System, the Ascribe Symphony system and the Siren ePCR that enables information collection in ambulances concludes that the ideal electronic patient record system for an A&E unit within a hospital combines the Ascribe Symphony system and the Siren ePCR system. This combination presents a capacity for timely information flow right from first contact with a patient. (This page intentionally left blank) Introduction McGonigle and Mastrian (2011) suggest that the use of informatics in healthcare is increasing because a need exists for adequate knowledge about the progression of various ailments for application of the right therapy. Thus, nursing professionals are now information dependent knowledge workers who must maintain accurate nursing records in information systems for accurate depiction of the care process and the results presented by this. However, it is impossible for medicine, nursing or any other healthcare related discipline to present accurate electronic records without resorting to a standardized language or vocabulary that accurately depicts the real-life condition of a patient at any point in time. According to Rutherford (2008), doctors, nurses and other health professionals should be able to read a record for a patient, maintained as an electronic document, to seek an accurate assessment of the situation without getting confused about what really transpired. Knowledge imparted by accurate records benefits care because everyone knows what happened without ambiguity to decide about what needs doing. However, any inaccuracies result in confusion that presents an adverse impact on the delivery of appropriate care for a patient. Thus, nursing information systems that maintain computerized electronic records based on the standardized nursing language are now essential for hospitals in which a wide variety of health professionals must make the right decisions at all times based on these records to deliver the most appropriate care for a large number of patients. According to McGonigle and Mastrian (2011), nursing informatics systems should permit for accurate knowledge acquisition for the health situation for patients, precise knowledge processing, knowledge dissemination without any adulteration and accurate knowledge generation. However, if depiction of information in a nursing informatics system presents flaws, the nursing informatics system is likely to present errors. This adds to the impetuous for ensuring accurate transcription of electronic records into the system, and the standardized language ensures that this is possible. Rutherford (2008) states that because the standardized nursing language is a common language readily understood by all trained nurses, a common terminology exists to describe the same conditions and the same care. However, Lundberg (2008) states that the Committee for Nursing Practice Information Infrastructure (CNPII) of the American Nurses Association (ANA) has recognized thirteen standardized nursing languages with their own terminologies and data element sets. These standardized nursing languages emphasize aspects of diagnosis, interventions, outcomes, outcome indicators, assessment concepts, etc. that lend their use to various nursing situations that may include perioperative care, practice documentation, diagnosis, and other care settings. NANDA International, Nursing Intervention Classification (NIC), Nursing Outcome Classification (NOC), Omaha System, Perioperative Nursing Data Set (PNDS), and Systematized Nomenclature of Medicine (SNOMED CT), etc. are examples of standardized nursing languages suited to various care situations. It makes sense to select the right language for maintaining electronic records for the right care setting. However, it is important to note that according to Paganin et al (2008), institutional factors, including busy nursing shifts, high patient to nurse ratios, lack of practice in implementation, administrative tasks imposed on nurses, etc. may interfere with the proper use of nursing languages. Because of a variation in effectiveness of various standardized nursing languages for different care settings, the nature of the most effective nursing record tools for various settings, such as primary care or accident and emergency setting may differ. Thus, it makes sense to consider carefully the healthcare setting for deciding about the record tool that is suitable for a situation, and this report presents a brief discussion about what is best for a specific situation based on a number of alternatives available as a solution. Medico – legal considerations emphasize maintaining the use of the right record tools for the right situation. Healthcare Situation This project report considers the Accident and Emergency (A&E) healthcare setting in which a need exists for urgent medical attention. Van Eeden (2009) suggests that critically ill or injured patients that exhibit altered vital signs and a decreased level of consciousness with signs of respiratory, cardiovascular or neurological compromise may seek urgent attention to stabilize their condition for further care in an A&E unit. The patients may be walking, on stretcher, or they may be in the process of transportation to a hospital, between hospitals or between a hospital and a specialist healthcare institution. A suspected stroke, heavy blood loss due to an accident, suspected broken bones, deep wounds such as a stab or gunshot wound, a suspected heart attack, difficulty in breathing or severe wounds are examples of conditions that need urgent attention in an A&E unit at a hospital. A&E units in a hospital are not alternatives to a GP clinic, and it is not appropriate for a patient to go to an accident and emergency department as an alternative to a clinic because this may present an excessive load at a time when it is proper to attend to serious cases. Often, accident and emergency care delivers pre-hospital care that leads to stabilization of a patient for further treatment in a hospital setting, and this means that accurate nursing records for a patient are important because a need exists for referring to these records to decide about further treatment options. Thus, other doctors and nurses decide about further treatment options after stabilization of a patient in a A&E unit and a need exists for trying to convey nursing observations on a patient as accurately as possible to others health professionals. Van Eeden (2009) goes further to suggest that A&E healthcare professionals may include doctors, paramedics or nursing practitioners with training in advanced nursing practice involving trauma or emergency nursing, critical care, midwifery, anesthetics or other specialties. Thus, a multi-disciplinary team provides treatment to the critically ill or injured patients in an A&E unit, which may present a chaotic situation if overloaded due to the arrival of many cases after an accident, a disaster or other catastrophic occurrence. The A&E unit remains attached to a hospital, and it is probably right to consider the A&E unit as the front door of a hospital for the critically ill or injured patients. Detailed Analysis of the Problem Although the A&E environment presents a rapidly changing and evolving environment that presents a quick pace in which what transpires within minutes decides about life or death, it is important to maintain patient nursing records for the A&E unit because these present legal requirements with medico-legal implications. In addition, as mentioned previously, nursing records are vital for further treatment. However, it is important to understand that electronic records are preferred because digital documents boost efficiency and according to Computer Weekly (2012), a large hospital may present a requirement for maintaining 500,000 electronic document records for up to eight years, which could occupy 400 meters of shelf space if these were paper documents. Thus, electronic records present a great convenience that not only enables access of documents for individual patients within minutes, but also a capacity for accessing these records across vast spatial distances due to the development of Internet technology. Electronic records do not go missing readily, and these records are more accessible to more health professionals. Searching for electronic records takes microseconds, and it is possible to enhance security of data by duplicating storage at a number of locations. Scanning and conversion of paper documents into electronic documents using scanners is a relatively straightforward exercise, and it is possible to integrate the record system for a hospital with the national record system. It is possible to update constantly electronic records relatively easily, and this means that various health professionals and departments in a hospital may readily add their own data to such records. Mantas (2001) states that ordered sets of descriptors with a nomenclature for indexing objects associated with descriptors are important for electronic records. However, it makes sense to use a standardized nursing language, such as the SNOMED, for nomenclature because of a need for maintaining standardization in syntax and meaning. For an A&E unit in a hospital, a need exists for recording various nursing observations to decide about prioritization of attention for treatment, a process known as ‘triage’. Triage involves a formal assessment for a patient by a professional nurse to decide about the level of urgency associated with a patient with a life-threatening condition. Usually, a specially designed triage form is available based on various instruments for triage that consider specific injury types, assumed diagnosis based upon an injury / diagnostic approach, Medical Early Warning Scores that include measures for mobility, respiratory rate, pulse rate, systolic blood pressure, temperature, AVPU (Alert, Verbal, Pain, Unresponsiveness) responses, etc. According to Ruthven (2007) physical assessment usually follows the triage that decides about prioritization for treatment, and it is necessary to record nursing observations related to visual examination, palpitations for assessing various parts of a patient’s body, percussion that records results of tapping of a patient’s body to decide about abnormal sounds. Auscultation involving listening to sounds produced by body, including heartbeat and breathing to decide about abnormalities is also relevant. A nursing diagnosis is available after initial observations, and this diagnosis assists doctors to decide about a medical diagnosis. Ruthven (2007) suggests that the triage process separate patients into the following types: Level 1: Immediate Resuscitation Level 2: Emergency Level 3: Urgent Level 4: Semi-Urgent Level 5: Non-Urgent Ruthven (2007) goes further to state that apart from deciding about the urgency of care needed by a patient, the triage staff also decides about the area of the A&E unit that is most appropriate for a patient. The following are the departments in an A&E unit into which a patient may shift after triage: Trauma (high acuity patients with severe, life-threatening conditions) Psychological (mentally unstable patients) Women’s (care specifically related to female conditions) Heart (care geared towards the heart, arteries) Pediatrics (children’s care) Orthopedics (focus on bone-related illnesses) General Care (typical patient with mid-range acuity level) Urgent Care (lower acuity patients, also referred to as ‘fast track’) According to Ruthven (2007), after a patient is in an appropriate section of an A&E unit, a doctor examines them and makes an important decision about delivering care involving whether to continue treatment with or without further tests. If a decision exists for further tests, the patient moves to imaging, (including MRI or X-ray) and laboratory, otherwise the patient will continue to receive treatment. The diagnosis presented by the doctor results in treatment and further nursing evaluation / monitoring until a decision to discharge the patient from the A&E unit results in the discharge of the patient to go home or a transfer to a ward or another specialist care unit of the hospital. A&E records present decisions made by doctors, treatment details and nursing observation together with discharge / transfer decisions and any other observations pertaining to the patient, including details of any attempted self-harm or perspectives on criminal nature of harm inflicted upon the patient. Medusa (2012) and ASCRIBE Consulting (2012) suggests that the electronic record system in an A&E unit should allow for quick and rapid recording of nursing observations to allow for the fact that activity in an A&E unit is often hectic, with limited time for recording of detailed observations. Thus, many electronic recording systems present an assistive interface for data inputs that prompts users for information based on likely possibilities for rapid data entry. This means that although nurses must still type in their observations related to a patient using standardized nursing language when this is required, most of the information input is through selection of alternatives presented with a tablet computer for electronic data entry. Van Eeden (2009) suggests that it is important to remember that A&E department records are often relatively simple compared to the detailed and extensive records maintained by other care units in hospitals because time is of essence in delivering care in the A&E unit. However, space is always available for notes presented by clinicians and nurses. It is important to present timing associated with various events pertaining to treatment because the timing of events is important from a medico-legal perspective for deciding about presentation of the right treatment in a timely manner. It is desirable for the A&E electronic record systems to present a capacity for connecting with a central server for exchanging health record information and other personal details for a patient and to send automatic referrals to ancillary departments that assist with the welfare for a patient, such as social services, case management, dietary, physical therapy, etc. Computing.co.uk (2012) states that ambulances in many developed nations now have electronic care reporting software that transmits patient records, including records pertaining to any treatments administered by paramedics in an ambulance, to the A&E unit within a hospital. Further medical history of patients is available from a centralized medical records repository that maintains results of past treatments, any allergies or other problems, etc. when queried. Thus, those attending an A&E unit in a hospital now present vastly improved chances of receiving optimal treatment that assists with their quick recovery. Paperless technology enables quick and accurate capture of far more information than was possible using paper records, and all information is available to present a complete medical history for a patient to clinicians. Healthcare Application Systems Solutions Van Ginneken (2002) suggests that although quick and relatively hassle-free data entry is the most important consideration for a computerized patient record system containing nursing notes in addition to other relevant pieces of information about a patient, a requirement also exists for integration with other available systems, flexibility in operation, interconnection and report generation. In addition, the system should make financial sense because patient record systems do not present a direct return on investment and present accessibility, completeness, decision and diagnostic support if possible. Thus, it makes sense for the system to minimize typing, time consumption, limited coverage and the impact on the patient encounter. A superior portable tablet interface ideally anticipates user needs for entering information, and it should offer helpful choices based on standardized nursing language to ease the burden of data input into the system. Depending on what specialty for emergency medicine is most relevant, the system should be able to present anticipated choices for data entry for a specific stage of data entry. Availability of menus, set of templates, descriptors, assistance with recognition of words, assistance with correctness of narratives based on nursing language, data views, report generation capabilities, etc. differentiate between good and poor computerized recording tools for patient records for A&E departments. Acumen Insights (2009) suggests further that if a need exists for an IT system to act as a support, then it is possible to emphasize ad hoc planning using eclectic technology based on controls that are similar to those used for project implementations with a backroom organization. However, if the IT system in an organization presents strategic implications, a need exists for strategic planning with a more complex organization that presents mixed controls with a technology architecture that will present possibilities for growth. The management approach to IT varies depending on whether an IT system is one of the most important responsibilities within an organization or whether a need exists to merely deliver and operate IT systems in a reliable manner and a McFarlan strategic grid presented in attachment A of the Appendices illustrates this. DHHS (2012) suggests that for the hospital A&E units, a patient record tool has become a legal essential because by the year 2014, hospitals in the United States will have to meet meaningful criteria for electronic health records to qualify for financial incentives. Thus, it is best that a solution for A&E patient records remain in tune with the strategic information management emphasis of the hospital organization. The following three systems are worth considering: Keogh Medical Systems Electronic Patient Record System described in KS Medical (2008) with an Accident and Emergency Room Module. However, the Keogh Medic Systems Electronic Patient Record System does not present a Clinical Decision Support or Diagnostic module and although this system can interface with other systems, it is inferior to the Ascribe Symphony system, which is the system described next. Ascribe Symphony - Emergency Departments and Minor Injuries Electronic Patient Record System is described in ASCRIBE Consulting (2012). This solution presents connectivity with many other hospital management modules developed by the Ascribe Symphony, and the Ascribe Symphony Data Acquisition and Dispersal Module (DAD) presents a capability of wide interconnectivity with many other systems. The DAD may use TCPIP, Socket or shared file, set up HL7, ASCII or XML for connecting to other packages. Diagnostic, Clinical Decision Support, automated Triage, e-Notes, tracking system for information access at point of care, together with medical document imaging, major incident management support, etc. make the Ascribe Symphony system a very attractive choice, and the technology is tried and tested technology with application in many hospitals around the world. The Ascribe Symphony system provides for clinical documentation and nursing notes, order management and electronic prescribing, conditional data collection, electronic discharge summary and patient advice letters, document scanning and imaging with a capacity for generating various management reports. The Ascribe Symphony system is highly expandable and integrates with the pharmacy system, the endoscopy system, the acute pharmacy system, etc. Prompts, and suggestions make it easy to enter data into the Ascribe Symphony system, and nurses may enter their observations using standardized nursing language. The Medusa Medical Technologies Inc. Siren ePCR is an ambulance / emergency EMS electronic patient-care reporting solution that presents a unique capability of providing a remote data entry solution using portable tablets. Medusa Medical Technologies Inc. (2012) depicts this system. Data entry commences when the paramedics reach the patient and may continue right to the A&E unit within a hospital. Thus, although the Siren ePCR may replace the Ascribe Symphony system, it, in fact, works best as an add-on to the Ascribe Symphony system by presenting the data entry at the earliest for an incident while presenting a capacity for using the more advanced features for the Ascribe Symphony system. The interface provided by Siren ePCR is a big-button interface that enables effortless capture of clinically rich information from remote sites where ambulance or disaster crews are attending for electronic transmission to the patient record system within the hospital in real time. Thus, hospital staff remains aware of the situation developing with patients and they remain prepared for the arrival of a patient even before the ambulance arrives. Doctors at an A&E unit know about the treatment administered by paramedics in an ambulance while a patient is on the way to the A&E unit, and they may present inputs. If the Siren ePCR system interfaces to an Ascribe Symphony system within the hospital, it is possible for triage to take place to prioritize treatment to a patient even before the patient arrives at the A&E unit within a hospital. Thus, it is possible to use synergistically the complementary strengths of the Siren ePCR system and the Ascribe Symphony system to present a combined system that presents the best possible system for A&E units within a hospital at the time of writing. It is important to note that the Siren ePCR will interface with the Keogh Medical Systems Electronic Patient Record System, but the Keogh system lacks the sophistication presented by the Ascribe Symphony system. DHHS (2012) suggests that for hospitals and A&E units in the United States of America and in other developed nations around the world, regulatory requirements are now emphasizing a move towards electronic patient records. Thus, electronic patient record systems are now a strategic necessity for all A&E units and hospitals and attachment A, in the Appendices, illustrates this. A need now exists for hospital managers to provide judicious deployment of patient record systems for all A&E units with a capability for data inputs from remote ambulance and attended emergencies. Recommended Solution and Implementation A recommended solution for an electronic patient record system for the A&E unit within a hospital is a combination of the Ascribe Symphony system, described in ASCRIBE Consulting (2012), and the Siren ePCR, which is depicted in Medusa Medical Technologies Inc. (2012). The Ascribe Symphony system focuses on the hospital end with electronic patient record terminals located in the A&E unit and other hospital departments, but the Siren ePCR focuses on the ambulance and paramedic end to provide data capture from ambulances and casualty incident locations. The Siren ePCR links within the Ascribe Symphony system through cellular wireless data links to permit transmission of patient data to the hospital electronic record system, which is the Ascribe Symphony system. Thus, up-to-the-minute information about an emergency patient is available to the A&E unit within a hospital transmitted by the Siren ePCR into the Ascribe Symphony system, which then takes over the total management of a patient until discharge from the hospital. The Ascribe Symphony system provides automated triage, allocation of a patient to a department of the A&E unit, storage and retrieval of any laboratory tests or imaging, clinical and nursing records and observations, discharge / transfer to another hospital ward, link to pharmacy and prescription, etc. For tight hospital IT budgets that require a gradual implementation of the electronic patient record system for a hospital A&E unit, it is possible to save by commencing only with Ascribe Symphony and to add the Siren ePCR module for ambulance and offsite logging of patient data at a later stage. Apart from budget, other implementation issues relate to training of A&E unit staff on the new patient record system and changeover from old procedures involving casualty cards and paper records to the new electronic patient record system. A short-duration training session for off-duty A&E staff for about three days should be sufficient to get the staff using the electronic record system and conversion of paper records based on casualty records for the past few years should present a fully converted new electronic system. It is important for representatives from hospital IT department, hospital administration, and nursing as well as clinical staff to oversee implementation of the system contracted out for delivery as a functional system to avoid undue problems or distractions for a hospital with a primary mission of providing care. Conclusion The discussion presented throughout this project report illustrates the value of standardized nursing language for electronic patient records for the A&E unit within a hospital. It is clear that technology now makes it possible to capture patient data right from the moment of first contact with paramedics or emergency healthcare staff, and it is now possible to access rapidly the complete medical history for a patient with accurate depictions based on the standardized nursing language that every nurse and health professional should understand. Thus, technology is now a valuable partner in offering superior care in the A&E unit. Appendices The two attachments presented below illustrate the discussion presented in this project report. Attachment A presents the McFarlan Strategic Grid for the A&E electronic patient record system. The subsequent attachment presents a comparison of the electronic patient record system solutions discussed in this report. Attachment A: Strategic information Systems The McFarlan Strategic Grid depicted below illustrates the strategic nature of electronic patient record systems for hospitals in the USA. After the year 2014, in the USA, only those hospitals with installed electronic patient record systems will receive full reimbursements, and this makes electronic patient record systems a strategic investment. High Strategic Importance of Planned Information Systems Low Low High Strategic Importance of Current Information Systems McFarlan Strategic Grid Depicting Patient Record Systems for A&E Unit Strategic Information Systems Grid BUSINESS CHALLENGES: Efficient and timely care in A&E unit Efficient storage and dissemination of information across patient caregivers MANAGEMENT ISSUES: Costs of traditional record keeping Electronic records essential for full reimbursement INFORMATION SYSTEMS SOLUTIONS: Keogh Medical Systems Electronic Patient Record System Ascribe Symphony system Siren ePCR TECHNOLOGY ISSUES: Lack of expertise in IT system integration Need for reliability BUSINESS BENEFITS: Rapid flow of information for care Easy Access to Information Delivery of superior care ORGANIZATION ISSUES: Staff training and acculturation Privacy Concerns Attachment B: Comparison of Solutions Comparison of Solutions Objectives Option 1 Keogh Medical Systems Option 2 Ascribe Symphony System Option 3 Siren ePCR Ease of Data Entry Low Medium High Full Automation Medium High Medium Ease of Implementation High Medium Medium Ease of Use Low Medium High Cost Low High Medium Time to Implementation Low High Medium A comparison of solutions suggests that the Ascribe Symphony system presents best functionality with diagnostic and clinical support systems that are lacking in the Keogh Medical Record System. 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