TISS28 collection & scanning Survey April 16, 2013

Hi everyone. The new TISS28 has now been in place for 3.5 month. We would like feedback once again from data collectors and from data processing in regards to these forms. Feedback from the data collection & processing front lines is helpful for continued bedside nursing education and also for the main database office to assess for applicable QA checks that could be automated in data processing (see: TISS28 Scanning quality checks), where possible. Beside commenting on compliance in your unit here, I need specific details in regards to items you observe done well or not on new forms.

The last survey done: January 7.13 was very helpful and the information went back to QA officer, nursing education, ICU TASK team and managers. Also provided main office with important observation when interpreting TISS data and also some tweaking of wording on form.

Dats, thank you in advance for taking the time to comment here.

NOTE; when referring to any items on the TISS28 form, please indicate the TISS28 item number you are referring to. For example, if Hourly vital sign is missed or done well, refer to TISS #2. Thanks again.

Site

HSC

MICU/CCU

Same issues as STB MICU plus:

• #2-Vital signs are occasionally counted for OH1 when all elements of monitoring are not met
• #9-CAM positive is not accurate on the TISS form
• #17 & #46-vascaths that dialysis patients have even prior to admission are not counted occasional as central lines
• LAST DAY - not done most of the time but the form is never missing.That I'm very grateful for!
• Compliance at filling in the form except for the last day is very good.
• Accuracy is improved since form has been changed to better language and it's easy to check
• line through bubble rather than filling in dot (HSC_MICU). Can't ID individual doing this.

HSC_SICU & IICU

We have an unique problem because the unit now has SDU (stepdown unit) overflow beds and transferring into them from the actual SICU beds is messed up by many staff members. It is not documented properly anywhere in the charting either by doctors or nurses, so I often have to guess at time and date. As patients go back and forth between the 2 parts of the unit, the sheets may be missing, certain days may be missing or non-ICU days may be counted. All these require recopying or total form completion by me.

• Even where the above is not an issue, the start date is often wrong on the TISS's.
• Completion of the last day in the unit is OFTEN not done (as was a problem with the old sheets).
• Using blue pens. Instruction at the top of the form says use dark pencil or black pen.
• #8 Drains - foley is still missed as a drainage tube even though I try to communicate as often as possible to get the staff to do this.
• #9 Cam - My issue with #9 is the wording. A blank may indicate no CAM +ve that day, or just an incomplete. How do we know the difference? Should we then do the CAM assessment of the patient to see if it is in fact +ve and has been left incomplete by the nurse? Could the wording just be changed?
  • Anyone.... suggestion for wording re above issues with CAM on TISS28?Trish Ostryzniuk 19:00, 2013 April 30 (EDT)
    • Not sure about the wording, it really is a training issue. As for distinguishing between legitimate and forgotten blanks, we should not have to pursue it. If you see from the chart that they were CAM positive, add it, but that's it. Ttenbergen 15:56, 2013 May 1 (EDT)
• #39 - Staff are not aware of the condition of E1 needed to qualify as emergency surgery.
• #46 to 49-Frequent errors in the 2300hr section.
• Short stay patients, especially if they die within a few hours of admission, regularly have no TISS completed.--Jpeterson 09:39, 2013 April 23 (EDT)

STB

MICU

I find that there is more overall compliance with completing the new form. The problem spots are as follows:

• #9-CAM+ is sometimes marked when it is not documented on the flow sheet and sometimes it is missing when it is documented.
• #12-more than 5L per day IV fluids is usually missed as people are not going back to check if this amount of volume was given
• #24-chest physio is often missed. Need to remember that even encouraging DB&C can be counted.
• #26-inhalation therapy is often missed I fix this section when I review the MAR.
• #28 & #29-I always ensure when the extubations are marked as this is sometimes missed
• #40 to #44 -I always ensure when the specific interventions are done as this is sometimes missed. (bronchs, intubations and cardioversions most common)
• #45-trips out of the ICU-sometimes this is missed when pt goes to CT scans, etc.
• #46-49-Need to also check the 2300 hr items as these are sometimes done wrong
• Sometimes the last day is missed (transfer out day) and sometimes the first day is missed especially if the pt arrives late in the day like after 2330 hrs.

Overall, I find this tiss much easier to trouble shoot and check and compliance is much better. --LKolesar 10:17, 2013 April 16 (EDT)

CCU

In CCU,compliance with the new TISS is much improved since the last "audit". Problematic for my unit remain:

• #8 Drains - Foleys are seldom documented
• #20 O2 nasal prongs...Frequently missed
• #26 Puffers, nebulizers....Frequently missed
• #31 IV Lasix more than 30mg/day....Frequently missed
• #39 Emergency surgery E1 - Code "Stemi" Angiocath intervention certainly qualify as "EMERGENCY" surgery and yet this is frequently missed as well
• (Note to Marla: code stemi angios are not E1 surgery and should not be included in the tiss item # 39 Emergency Surgery. This was previously clarified.) --LKolesar 15:48, 2013 April 16 (EDT)

I have mentioned these "omissions" and compliance has much improved but not yet "stellar". Marla Penner

CICU

• I find the same problem areas as Laura noted above
• compliance is still only fair
• worst compliance is during weekends
• they often do not get another TISS sheet when the first one is full. Lois

CON

• Overall compliance has improved but with the following issues persist:
• Short stays of 1-2 days are on occasion left blank.
• The last day frequently not completed.
• Some forms appear to be "ripped" out of the chart so that all punch-holes have to be re-inforced.

• #3 Lab spec: miss when sending labs such as urine, ETT, etc.
• #5 Two IV meds or more: like the OAKS-not counting PRNs
• #6 Dressings: Counting the total sites not dressing changes/complexity
• #9 CAM+ve: Entered incorrectly-pt comatose, RASS -4/-5, confused only and not documented on flowsheets

• #12 >5L missed or entered incorrectly by including pre-ICU volumes
• #20 Supplemental Oxygen-missed on the day of extubation
• #25 Incentive spirometry: PRN puffers missed, incentive spirometry not charted
• #27 Intratracheal suctioning--missed on pts who are orally suctioned
• #46-#49 2300 hour items: entered on day of D/C and pt not in ICU at 2300 hr

OAK

I find compliance rates with filling out the form to be similar to the old form.

• #2 hourly VS- not always documented properly eg) not a full set of VS done ( missing RR ) and this will still be blacked out
• #4 IV meds - 2 or more - nurse does not think to include prns
• #8 drainage tubes- an issue initially but was mentioned to staff and compliance has improved greatly
• #9 CAM+- poor documentation on flow sheet therefore rarely blacked out
• #5 Chest physio- I have to read PT charting to know if it was done, or notice them doing it- rare to have this filled out by nurse

• 46-49 - 2300 hr section is frequently not accurate. It seems as if the blacking out just continues, even if device is not longer in use.

• ADMIT DATE: Another occasional concern is that the admission date is not always accurate on the TISS, the first nurse to notice it then starts with the date that he/she is working with the patient and I have to backtrack the form.

GRA

I am impressed with the compliance in filling out the form. There just seems to be a rare occasion when one or two days are totally not filled in. ?one individual

• #2 Vital signs not done hourly yet filled in as such
• #3 specimen collection by RN missed on rare occasion
• #5 Two or more IV meds - missed frequently takes time to go through all med sheets to check
• 6&7 Dressing, sometimes confused
• #8 Drains - missed for foleys hopefully revised form will correct this
• #9 CAM+ is seldom marked. Also marked incorrectly when a pt is sedated
• #12 > 5L fluids - missed on couple occasions
• #24 Chest physio - rarely documented as ever being done
• #31 substantial IV diuries - missed frequently
• LAST DAY is occasionally missed
• One TISS form totally missing

What are your obervations with item 46-49 at your site? Other sites have reported in about this section. Thank you.Trish Ostryzniuk 19:26, 2013 April 23 (EDT)

VIC

There is better compliance with the new TISS .I found like Laura, the following get missed:

• #9 CAM+
• #12 more than 5L IV fluid in ICU
• #24 Chest Physio
• #26 Inhalation therapy
• #45 RN accompanied trips - will be filled out yet the transport team goes only not the ICU nurse this depends if the test/procedure is done in the hospital or out of the hospital so you have to check whether the transport team went or the nurse.

April 17/13 {{The following seem to get missed frequently:

• #3 Lab specimen collection
• #4 Drainage tubes
• #9 -CAM+ - discrepancy in having heavily sedated pts (rass -4 to -5) as CAM positive, and not marking it when the nurses notes indicate that there was cam + activity later in the day
• #24 - db&c is rarely if ever marked
• #26 and #31 (#35 -not used often here)- meds are almost always missed)
• #45 RN trips out of icu - people will mark when pt is accompanied by wrha transport team and not the nurse
• 46-49 Compliance is generally very good with the exception of: the day before discharge item 46 (central venous catheter) might be missed.

Main office - Data Processing observations

• missing last day TISS - very common. (not marked with no Treatment or acutal last day in ICU NOT DONE).
• missing first day on form (example, patient admitted at 2330 hrs).
• incorrect first date on form (admission date different than registry date)
• dates not sequential. Example: March 1, 3, 4 5. Second column should be Mar 2. Missing day.
• VERY faint (anemic) pencil marks to fill in bubbles on form. Top of form states using black pen or dark pencil.
• bubble not clearly filled in (half filled in, one stroke through bubble or bubble is circled outside)
• BLUE pen used to fill out form
• incorrect unit location recorded on form (example CCU instead of MICU).

ICU Education RE: above

Information from survey above, forwarded to Basil Evan ICU QA officer. He will review with p:Jodi Walker Tweed, Regional ICU Educators and manager. Feedback will go back to staff at sites via nursing education..Trish Ostryzniuk 15:42, 2013 April 23 (EDT)