Structural Data Elements — Standardized Terms and Definitions

AORN Journal, March, 2000 by Suzanne C. Beyea

* Supply costs per case. Total direct billable supplies divided by total actual cases.

* Revenue per case. Total actual revenue divided by total actual cases.

* Total expense budget. Total costs including staff, overhead, and supplies.

* Percent supply costs of total expenses. Total direct billable supply costs divided by total expenses.

* Percent staff costs of total expenses. Total paid staff divided by total expenses.

Environmental monitoring

* Room temperature Ambient air temperature in the operating room.

* Room humidity, Relative humidity in the operating room.

* Air exchange. Total air exchange per hour per operating room.

(*) Other structural elements to be included are the American Society of Anesthesiologists Classification and wound classification (Centers for Disease Control and Prevention).

Although development and validation of the structural elements was part of the original charge of the group working on data elements, it was not submitted to the ANA for recognition as part of the data set. Before submitting the final products of the various subcommittees of DECC to the ANA, DECC members decided to limit the submitted materials to nursing diagnoses, interventions, and outcomes that together formed the PNDS. The rationale for this decision was based largely on the fact that the AACD lexicon is copyrighted by that organization and that clinical testing of this type of terminology would be best conducted from a multidisciplinary perspective.

FUTURE DIRECTIONS

Major efforts continue from the organizational perspective to refine this perioperative nursing data set, disseminate information to AORN members, and create a national perioperative database. In our current health care environment, perioperative nurses must have an organized approach to collect, organize, classify, and capture clinical nursing data to communicate nursing practice. The PNDS is a specialty nursing language that provides a systematic method of collecting the basic elements of perioperative nursing care. These data will allow nurses to predict costs, determine necessary resources, and validate nursing practice in perioperative settings.

The PNDS reflects the expertise of many AORN members. As a clinically relevant and empirically validated standardized language, it is a beginning point to help perioperative RNs document the care they provide and evaluate their contributions. The data set relates to the delivery of care in the perioperative setting during any time frame of the surgical experience and is appropriate for use in any perioperative setting. Clinical validation and further empirical testing of this standardized data set are essential for its further development and refinement.

Editor's note: This article is an excerpt from Perioperative Nursing Beta Set, which is available by calling AORN customer service at (800) 755-2676 x 1. The book also will be available at the 2000 Congress in New Orleans.

NOTES

(1.) H H Werley, C R Zorn, "The nursing minimum data set and its relationship to classifications for nursing practice," in Classification Systems for Describing Nursing Practice: Working Papers (Kansas City, Mo: American Nurses Association, 1989) 50-54.