ITISS

iTISS was the Intermediate Therapeutic Intervention Scoring System (nursing workload trending tool). It used to be collected in the medicine DB. The following is a rough import for legacy purposes only.

Start Date

• HSC
  • A4, H4, D4, D5-May 1.2004
  • B3-March 1.2005
  • H4H-May 1.2005
• STB
  • B5 October 1.2004
  • B4 Nov 1.2004
  • E5 Dec 1.2004
• GRA
• N3, N5, W3-Feb 1.2005
• VIC
  • N5 - Aug 1. 2005
  • S5,S3, N4- Sept 1.2005

General Information & Guidelines

Oct 4.04 Revision: Minor- Nov 2, 2004

• iTISS was developed in 1994 by Dr D. Cullen for use on medical and surgical nursing wards

• iTISS provides a method of quantifying nursing care required by ward patients according to the number and type of therapeutic interventions employed.

• By quantifying nursing care, this helps reflect the amount of time as well as complexity of the care given.

• iTISS has been a widely accepted method of classifying patients. It has been utilized for many purposes such as:
  1. Determining severity of illness.
  2. Establishing nurse patient ratios.
  3. Assessment of utilization of ward beds.
  4. Establishing future needs and number of ward beds.
  5. Expresses workload in statistical terms.
  6. Along with an acuity score it enables the wards to maintain quality care

• iTISS has been incorporated as an integral part of the Acute Physiologic and Chronic Health Evaluation. A data collector does the acuity score. Using an acuity score (APACHE II and SAPS II) the data collector determines the worst deviation of vital signs and blood work. Each patient’s score reflects the worst deviation from normal of selected physiological variables, which occur in the first 24 hours after admission on to the ward.
• The iTISS SCORE is compared to an ACUITY SCORE . The comparative scores enable us to relate nursing care (iTISS) with

various acuity levels. By reviewing both scores data is collected about the workload & patient acuity of the specific ward. This data could also help determine whether certain nursing activities can be reduced or redirected without affecting patient mortality or morbidity.

• Each specifically selected criteria (i.e.) Neuro, CVS, Resp etc., is weighed from 1-4 points, 4 points indicates a higher workload.
• A high daily iTISS total indicates extensive nursing activity for an individual patient.
• Mostly night staff does iTISS. Any shift can fill in the form as patient care is administered. The items chosen reflect the previous 24 hours in the unit. (2400hr-2400hr).
• The exception is the two-hour rule:
  • If a patient is admitted to a ward on or after 22:00 hrs, then an iTISS is not required for that day.
    • Day 1 starts next day and is 26 hours long.
    • The FIRST DATE ON THIS FORM boxes need to be filled in correctly to reflect this.
    • The first DATE in the “first column” on the ITISS form needs to be filled in correctly to refect this.
• If a patient is discharged from a Medicine unit on or before 0200 hrs., then an iTISS is not required for that day. (Add the work associated within these 2 hours to the previous days iTISS. The previous day iTISS will be based on 26 hours duration)
• If a patient on the unit for a very short time (5-15min) an iTISS score needs to be done to reflect nursing activities during this time.
• If a patient is discharged on any shift an iTISS score needs to be done for the period from midnight to time of discharge.
• If a patient expires on any shift an iTISS score needs to be done for the period from midnight to time of death.
• iTISS is done for the entire length of stay in the unit. Each day reflects the previous 24 hours of care in unit. If the patient is on a pass the no treatment section may be selected to reflect that no nursing activity occurred in the time the patient was gone from the ward.
  • Fill in the bubble on the form that reflects the patient care. If a mistake is made put an X over the bubble at the end of the line in the square that corresponds to the section the error was made. Do not mark the forms in any other way as it affects the ability to scan them for data entry.
• Once the first sheet of 10 days is completed for one patient, hand in completed form to ward clerk and start a new form for the next 10 days. Please DO NOT STAPLE forms together.
• The iTISS is a reflection of the work on your ward. The quality of the data depends on the staff accurately assessing the patient care. The iTISS form does not leave your ward when the patient is discharged, transferred or expires. It does not go to medical records with the rest of the chart. Remove the form from the chart and place it in the iTISS binder at the nursing station. The data

collector will collect them from the binder and submit them for data entry.

iTISS Form Guidelines

All of the information is about care being delivered to an individual patient on your ward. The sections are usually reflective of the last 24hours unless otherwise stated. The form can be filled in by any shift as care is delivered but needs to be checked and completed by the night shift.

Boxed & grouped items on form – mutually exclusive –only select one for a minimum of 3 consecutive checks

NEUROLOGICAL

Mutually Exclusive: select 1 or 2.

1. Neuro checks q1-2 minimal 3 consecutive checks (every hour for 3 checks or every 2 hours for 3 checks during the previous 24 hours of care.)

2. Neuro checks q4h minimal 3 consecutive checks (i.e. 02:00,06:00,10:00,14:00 etc.)

Four point restraints (for any period during previous 24 hours) if a patient requires four point restraints they also require constant observation.

4. Acute seizure or encephalopathy active treatment via oral (i.e. Lactulose) or IV medications used for treatment of seizures and/or encephalopathy

5. Hypothermia or Hyperthermia blanket (any time during previous 24 hrs of care while in your unit). This is not used in a Medicine Unit (If not used on your ward LEAVE BLANK)

CARDIOVASCULAR

6. EKG monitoring or telemetry (for any length of time during previous 24 hrs of care while in your unit)

Mutually Exclusive: select 7 or 8

7. Scheduled EKG and/ or serial cardiac enzymes done any time during previous 24 hours. The bedside nurse must be present to monitor the patient during EKG or must assist EKG technician or lab technician or in some cases do the test.

8. Unscheduled12 lead EKG Done any time during previous 24 hours. The bedside nurse must be present to monitor the patient during EKG or must assist EKG technician or lab technician or in some cases do the test.

Mutually Exclusive: select 9, 10 or 11

9. Vital Signs or post procedure checks -q1h– minimum for 3 hours consecutively during previous 24 hours of care. Vitals include; blood press pulse and respirations.

10. Vital Signs or post procedure checks – q2-4 hours- minimum of q2h for 6 or more consecutive hours during previous 24 hours of care (e.g. 02:00, 04:00 & 06:00 hours)

11. Vital Signs-q shift – at least once in 24 hour period.

12. Central Lines - Care of central lines which includes; site inspection, dressing change, monitoring and maintenance of patency, e.g. heparinization. (TPN - central line EXCLUDED – see item # 33)

13. Cardiac Arrest –with or without defibrillation - points given if cardiac arrest occurred in the unit or within the previous 48 hours prior to being admitted to your unit. On the form iTISS points are marked for 2 days after recent cardiac arrest.

14. Cardioversion mechanically not pharmacologically in the previous 24 hours (does not include defibrillation)

15. Temporary Cardiac A/V pacing ACTIVE pacing (wire or external). Demand mode. Testing of pacer not included. Permanent pacemaker not included. Not used on a Medicine Unit. (If not done on your ward leave BLANK)

16. Cardiac Pacemaker implant within previous 48 hours. Points scoredfor 48 hours after recent pacemaker implant.

17. Blood Product – frequent infusion ( >3units/24 hours while on your ward) this section will include administration of volume expanders such as Pentaspan. Blood products such as packed cells, fresh frozen plasma,5% and 25% albumin, and cryoprecipitate are all in this section. Remember to accurately reflect the workload the frequency of vital signs should be filled in on the iTISS vital sign section.

18. Platelet Infusion - Any number of units in the previous 24 hours on your unit.

Respiratory

19. BIPAP or CPAP – anytime during the previous 24 hours while in your unit.

20. Spontaneous Respirations via tracheostomy -evaluation of respirations via trach tube.

21. Oxygen by any method of delivery - if required by the patient at anytime during the previous 24 hours while on your unit.

22. Intubation on ward –Fill this section in if the intubation was done on your ward and a bedside nurse was required to assist and/or monitor the patient during the procedure or post procedure.

Mutually exclusive: select either 23 or 24

23. Fresh Tracheostomy care £48 hours –tracheostomy within 2 days or less

24. Chronic Tracheostomy care >48 hours -this includes deflating the cuff, weaning, corking, cleaning and dressing changes.

Mutually exclusive: select either 25 or 26

25. Endotracheal Suctioning (with or without tube)-at least once in the previous 24 hours of care with or without a trach tube.

26.Endotracheal Suctioning (with or without tube)-two times or more in the previous 24 hours of care with or without a trach tube.

27. Pulse oximetry –The checking of the oxygen saturation at least once in the previous 24 hours of care.

28. Chest physiotherapy– formal chest physiotherapy by bedside nurse. Posturizing and pummeling by bedside nurse or assisting the physiotherapist with a procedure. The nurse must be present throughout procedure AND / OR bedside nurse must be present to teach, coach and supervise (DB+C) deep breathing and coughing exercises.

29. Chest tubes – Routine care of chest tubes.

GASTROINTESTINAL

30. Replacement of excess fluid loss (> 3 liters) this is the 24-hour total IV and/or oral intake, which are intended for replacement of excess fluid loss.

31. Nasogastric and or other gastric tubes – care of tubes used for drainage.

32. GI feedings –care of tubes used for feeding.

33. TPN by CENTRAL catheter– monitoring, titration, bag changes for central line TPN.

34. TPN by PERIPHERAL catheter– monitoring, titration, bag changesn for peripheral line TPN.

GENITOURINARY

35. Indwelling Foley Catheter – maintenance or changing of indwelling foley catheter. NOTE: intermittent catheterizations are not included here.

36. Hemodialysis – STABLE – chronic dialysis – If patient is sent out of the unit for Dialysis, no points scored. RN must be required to monitoring a patient during dialyzed. If nurse has to stay with patient in dialysis unit then points are awarded.

Mutually Exclusive: select either 37 or 38

37. Peritoneal Dialysis – INITIAL and / or UNSTABLE – bedside nurse who is actively involved in this procedure with a patient who is “first time” on peritoneal dialysis and/or is unstable

38. Peritoneal Dialysis – CHRONIC and / or STABLE – bedside nurse who is actively involved in this procedure with a patients who has had this procedure done once before and / or is stable

Mutually Exclusive – select EITHER 39 or 40

39. Intake and Output – accurate & precise measurement & calculation every 6-8 hours or more frequently

40. Intake and Output – standard monitoring with calculation once every 24 hours.

METABOLIC / SPECIMENS

41. Specimens – Multiple STAT blood samples by the bedside nurse. Stats need to be more than once in 24 hours.

42. Diabetic management – Min Q4h. (accu-checks or any type of Glucose monitoring which includes sliding scale coverage requiring insulin administration, infusion or glucose infusion).

• • Oral therapy is not included.

43. Diuresis –acute IV or initial acute ORAL diuresis or change in oral diuretic therapy administered one or more times in 24 hours

Mutually exclusive: select EITHER 44 or 45

44. Cultures: any type of culture sent for culture and sensitivity including all swabs, secretions, urine, fluid and blood sent by the bedside nurse.

45. Initial “Septic workup” - complete cultures sent by the bedside nurse. Complete group of cultures is considered to be one of the following: A.) Urine + Sputum + Blood B.) Urine + Sputum + Wound + Blood C.) Urine + Sputum + Wound + Other sites + Blood

LINES / MEDS / IV’S

Mutually Exclusive: select EITHER 46 or 47

46. Intravenous catheter-1 peripheral IV

47. Intravenous catheter-2 or more peripheral IV’s.

48. Epidural Infusion –Monitoring of pain control, catheter site, and changing of infusion bags according to hospital policy.

Mutually Exclusive: select EITHER 49 or 50

49. IV anti-infective drugs- The administration of one medication that is for an infection of any type. This would include any one of the following types of medications- antibiotics, antifungals or antiviral

50. IV anti-infective drugs- The administration of two or more medications that are for an infection of any type. This would include any one of the following types of medications- antibiotics, antifungals or antiviral.

51. Antiarrhythmic drug infusion (e.g. amiodarone)– CONTINUOUS infusion for a minimum of 2 hours NOTE: This is not a Medicine Unit intervention. Will keep on form but will block for scanning. Will be used on Medical step up unit. If not used on your unit – LEAVE BLANK

52. Anticoagulation – Acute or Chronic oral anticoagulation –Coumadin

53. Intravenous Anticoagulation- This is for IV Heparin not subcutaneous Heparin.

54. ACUTE Digitalization – IV or PO - within the FIRST 48 hours while on your unit. Mark for 2 days on iTISS.

55. Bronchodilator administration – min q4h by any method of inhalation.

56. IV sedation and / or analgesia – (continuous IV infusion) and/or (PCA) Patient controlled analgesia.

57. IV chemotherapy –administration and monitoring by the bedside nurse.

58. IV medications – Scheduled

59. IV medications – Unscheduled (PRN, STATS, BOLUS, loading doses) Please fill this section in at anytime during the day as this section is often missed when the night shift is filling in the form.

GENERAL

Mutually Exclusive – select EITHER 60 or 61

60. Routine/Simple Dressing changes – simple standard ward routine dressings including uncomplicated post-op dressings. (not central line – see item # 12 for points)

61. Multiple and/or complex Dressing changes –dressings that are beyond the ward routine. Some examples would be burn dressings, or dressings requiring packing, or dressings with a large amount of drainage and/ or bleeding.

Mutually Exclusive – select EITHER 62 or 63

62. Orthopedic therapy - simple traction or cast care

63. Orthopedic therapy – complicated traction or special care beds

64. Drainage tube(s) – Other drainage tubes; EXCLUDED; Gastric tubes, Chest Tubes, and Foley catheter tubes. (**see items # 29, 31 & 35 for points)

PROCEDURES

65. Isolation precautions-This is total isolation not universal precautions. The bedside nurse is required to mask, gown and glove. The patient is in a private room.

• DETAIL NOTE:

a. Appropriate patient placement is a significant component of isolation precautions. A private room is important to prevent direct or indirect contact transmission when the source patient has poor hygiene habits, contaminates the environment, or cannot be expected to assist in maintaining infection control precautions to limit transmission of micro-organisms (I.e., infants, children, and patients with altered mental status). When possible, a patient with highly transmissible or epidemiologically important micro-organisms is placed in a private room with hand washing & toilet facilities, to reduce opportunities for transmission of micro-organisms.

b. When a private room is not available, an infected patient is placed with an appropriate roommate. Patients infected by the same micro-organism usually can share a room, provided they are not infected with other potentially transmissible micro-organisms and the likelihood of re-infection with the same organism is minimal. Such sharing of rooms, also referred to as cohorting patients, is useful especially during outbreaks or when there is a shortage of private rooms. When a private room is NOT available and cohorting is not achievable or recommended, it is very important to consider the epidemiology and mode of transmission of the infecting pathogen and the patient population being served in determining patient placement. Under these circumstances, consultation with infection control professionals is advised before patient placement. Moreover, when and infected patient shares a room with a noninfected patient it also is important that patients, personnel, and visitors take precautions to prevent the spread of infections and that roommates are selected carefully.

66. Surgery – within 24 hours – points for “day of surgery” only.

67. Bronchoscopy or Endoscopy- “Day of” post-procedural care. If the procedure is done and you are the nurse providing the care fill in the iTISS at the time the care is given so that this is not missed on the night shift.

68. Thoracentesis, paracentsis or pericardiocentesis – “Day of” post procedural care. If the procedure is done and you are the nurse providing the care fill in the iTISS at the time the care is given so that this is not missed on the night shift.

OTHER

69. Transports – The bedside nurse must accompany the patient to tests, appointments or procedures off of the unit.

Mutually Exclusive – select EITHER 70 or 71; This section is capturing time spent that is more than expected above the ward routine.

70. Psychosocial: >1 hour spent with patient or family –during the previous 24 hours

71. Psychosocial: >3 hours spend with patient or family – during the previous 24 hours

Mutually Exclusive – select EITHER 72, 73 or 74 during Previous 24 hours of care

72. Administrative & Managerial Tasks:

• <2 hours for an individual patient during the previous 24 hours of care.
• (Admission, discharge, transfer, OR, test prep)

73. Administrative & Managerial Tasks:

• 2-3 hours for an individual patient during the previous 24 hours of care.
• (Admission, discharge, transfer, OR, test prep)

74. Administrative & Managerial Tasks:

• >3 hours for an individual patient during the previous 24 hours of care
• (Admission, discharge, transfer, OR, test prep)

GUIDELINES FOR DATA QUALITY OF THE TISS / iTISS FORMS

IMPORTANT QUALITY CHECK FOR iTISS are as following. Data collectors are responsible for these.

VARIABLES	ACTION REQUIRED
Serial
Site
Study #
Page
DATE	Must be CONSECUTIVE dates.
	IF ADMITTED between 2200 & 2400hr is Y then the first DATE should be Admit Date + 1 .
	Example. Admit date=May1 then first DATE = 2
	IF DISCHARGED between 0001 & 0200hr is Y then the last DATE should be Discharged Date - 1.
	Example. Disch Date=May8 then last DATE = 7
	IF both 'ADMITTED between'
	and 'DISCHARGED between' are Y and 1) LOS < 1day, then fill up only one DATE .
	Example. Admit=May1 Disch=May2 then first DATE=either 1 or 2 whichever has the longer time (#col= 1 )
	2) LOS >1day then fill up the first DATE as Admit date+1 and the last DATE as Discharged Date - 1
	Example1. Admit=May1 Disch=May3 then first DATE=2 (# col=1)
	Example2. Admit=May1 Disch=May4 then first DATE=2, last DATE=3 (# cols=2)
	IF both 'ADMITTED between ' and 'DISCHARGED between' are N, then the first DATE should be the Admit Date and the last DATE should be the Discharged Date
	Example1. Admit=May1 Disch=May2 then first DATE=1, last DATE=2 (# cols=2)
	Example2. Admit=May1 Disch=May3 then first DATE=1, last DATE=3 (# cols=3)
	There should be at least one circle filled-up on each DATE unless the NO TREATMENT box is marked.
No Treatment /or Day pass	Should only be shaded if there is no treatment/procedure made on that DATE.
Items 1 to 96 (TISS –ICU)	The circle(s) should be fully shaded using a black pen or marker (ie. not half or partially shaded circle) .
or item 74 (iTISS-Medicine)
	If made a mistake, cross out (X) the erroneous circle(s), shade the correct circle(s) and put an X on the square box at the end of the row where the correction was done.
	If all entries in a row are correct, do not put any mark on the square box.
The bottom right corner	Must be kept clean and unmark (ie. No lines or characters over writing the number).

Discussion

• If this is for both the TISS and the ITISS, we should pull it out of here and make it separate. Ttenbergen 00:56, 27 May 2008 (CDT)