Perioperative Nursing Data Set, 2nd Edition Revised
A new eraWith the Syntegrity™ Standardized Perioperative Framework, AORN brings a new kind of standardized documentation to the perioperative profession
By Carina Stanton
Senior News Editor
It happens every day. A perioperative nurse prepares a patient for surgery by conducting a preoperative assessment to determine many factors, such as the patient's skin integrity. Depending on the facility, the nurse may document this information on paper or electronically, but the specific language used to describe the patient is likely tailored to that facility, so the same skin color may be described differently depending on the facility or even the nurse, and any regulatory or accreditation codes required mean taking an additional step.
With AORN's Syntegrity™ Standardized Perioperative Framework, this variability and extra time taken for additional steps is eliminated, because this new IT tool automatically uses a standardized nursing language for all data elements, so values for things such as skin integrity are standardized.
"Now 'red skin' is 'red skin,' across the board, not 'pink' or 'light pink,' depending on where you are employed. That standardized language goes for every step of the perioperative process that is documented with Syntegrity," said Janie Bowman-Hayes, RN, MSN, MBA, AORN clinical informatics specialist. "When you have to choose extra variables and take additional steps for things like CMS-required elements, that is time taken away from the patient."
AORN's Syntegrity Standardized Perioperative Framework includes
current nursing language (PNDS), AORN's standards and recommended practices,
regulatory and accreditation requirements and work flow processes in a standardized
language. Source: Computer Sciences Corporation.
Bowman-Hayes is part of a team of nurses and informatics specialists from AORN, Computer Sciences Corporation (CSC) and a number of other collaborators who have worked over the past year to shape a standardized perioperative language into a tangible framework that perioperative professionals can use with existing electronic health record systems to record and report perioperative nursing practice. The project, initially called the standardized perioperative record and direct repository system initiative, began last year following its announcement at AORN's 2008 Congress in Anaheim, Calif.
Today, the tool called the Syntegrity Standardized Perioperative Framework is a reality. Using AORN's Perioperative Nursing Data Set (PNDS) language within an XML overlay, Syntegrity can be mapped into a software vendor's electronic health record system to give facilities a standardized language with which to record perioperative care.
Responding to a need
Healthcare organizations, facilities and regulatory bodies are working to meet the federal mandate to create an interoperable electronic health record by 2014. Recent developments, such as the new agreement to establish a joint health record for the Department of Defense and the Department of Veterans Affairs, point to an increasing push toward widespread standardization for electronic health records.
This focus toward standardization is the driving force behind the development of Syntegrity, explained AORN's CEO Linda Groah, RN, MSN, CNOR, FAAN."Patient safety can be improved through standardization and streamlined workflow processes available through electronic documentation, but it can also be hindered if this information is not created in a language nurses speak," Groah said. "Syntegrity uses AORN's established PNDS nursing language to enable any nurse in any facility to record and report their practice in a standardized, evidence-based way."
Syntegrity breaks down the PNDS language to make clear connections between nursing diagnoses, care implementation and assessment, to get to a measurable outcome that is standardized and meets with AORN's standards of practice, as well as those of The Joint Commission, the Centers for Medicare and Medicaid Services and other regulatory and accreditation organizations.
To aid nurses at the bedside, Syntegrity also includes an electronic companion guide so a nurse can do a quick search on a term he or she may have a question about, while charting, to understand more about what he or she is charting, where it is referenced and why it is needed. "This takes the guess work out of charting and provides, in real time, rationales and explanations for charting data elements, rather than having to go to an educator or clinical informatics specialist to ask why a particular element needs to be charted," Bowman-Hayes added.
She is one of a team of AORN staff nurses who have worked closely with perioperative staff nurses, educators, managers, and informatics specialists from around the country, including members of AORN's PNDS task force, to verify Syntegrity's nursing language is accurate and relevant in daily practice.
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Janie Bowman-Hayes (center) helps Congress attendees in Chicago
explore the Syntegrity Standardized Perioperative Framework,
a new standardized framework recently released by AORN.
"This verification aspect of developing the Syntegrity language was critical because the tool had to augment patient care, include referenced data elements and be a practical benefit to the perioperative nurses who will use Syntegrity," Bowman-Hayes said.
How it works
"It's all about standardization," stressed Robert Tran, MS, senior consultant with the CSC Healthcare Group and a member of CSC's Health Delivery Team working with AORN to develop Syntegrity. "Facilities document perioperative information in many ways-using an electronic vendor system, a home grown electronic system, and paper charting. No matter what approach they take, or what data elements they lack, Syntegrity can help them standardize their nursing language and streamline their work flow processes by following a standardized nursing pathway," he explained.
For example, if the facility's electronic health record system does not include a variable to chart the latest National Patient Safety Goals from The Joint Commission, Syntegrity will carry this information to the existing system. With the release of updates, Syntegrity provides a standardized, low-maintenance way for facilities to continually update their existing systems," Tran added.
AORN's Standardized Perioperative Framework also will include a data recording method that will give facilities a means to compare themselves with others across the country. The result is a direct, "apples-to-apples" comparison of data such as turnover time, surgical outcomes and other surgical factors. This data repository tied to Syntegrity will provide users with an automatic tool to compare performance against other facilities in a way that does not compromise patient information. All data in the system will be stripped of patient identification and will be coded in Health Level 7 (HL7) guidelines, a standards-based language for communicating healthcare data.
"Today, benchmarking and quality improvement are the tools practitioners use to advance patient safety. Syntegrity will provide the nursing profession with standardized data that can be used to advance practice and improve perioperative care," said Cathy Kleiner, PhD, RN, AORN vice president of research and nursing resources. "When we utilize standardized data for research, we can more easily attain quality research results that can be utilized for evidence-based practice."
Exploring Syntegrity
Members attending AORN's 56th Congress in Chicago this March were able to get a sneak peak at Syntegrity, to see how the standardized perioperative framework tool can be used with an electronic health record system.
Karen Gray, RN, BSN, CNOR, perioperative education/staff developer at the U.S. Naval Hospital in Naples, Italy, was relieved to see that a tool like Syntegrity exists, especially as leaders in the armed services she works with are moving toward greater standardization among the branches of military service.
"We are trying to standardize every aspect of our practice, and we are discussing right now how to establish standardized electronic recording and reporting for perioperative practice," Gray said. "It's a huge undertaking to think about creating something like this, so I am encouraged to see AORN coming out with this."
LEARN MORE
Syntegrity continuing education webinar, May 13
CSC and AORN will host a webinar on May 13 to address the need for a Standardized Perioperative Framework, to communicate the national need for a perioperative electronic health record and to discuss the deficits in the current state of many perioperative records and plans of care.
The course will be held on May 13 at 4 p.m. Eastern Standard Time for 1.0 continuing education contact hours. Based on interest, a second webinar may also be held.
Register for the webinar here.
Read more news in AORN Connections.