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| Therapeutic Intervention Scoring System
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| ==TISS Collection Guidelines==
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| === "Black Blobbing" - Fill the circles on the TISS form completely ===
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| The scanning program will not detect circles that are not filled completely with a sufficiently dark marker. Since it is impossible to control how bedside staff fill out the form, or for data collectors to gauge accurately what the scanner will be able to recognize, the [[Category:Steering Committee| Steering Committee]] has mandated that all TISS forms must have their filled circles “black blobbed” fully with a marker prior to handing in for scanning.
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| *this is part of the quality assurance that the collectors must do on the first 10 days of TISS only.
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| [[User:TOstryzniuk|TOstryzniuk]] 15:20, 3 December 2008 (CST)
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| === Who fills out the TISS===
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| * TISS is done retrospectively for the previous 24 hours of care in ICU.
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| ** In some centers it is done ongoing as care is given.--[[User:LKolesar|LKolesar]] 11:29, 21 May 2008 (CDT)
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| * TISS is generally done by Night staff.
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| ** In some centers it is done on all shifts as an ongoing tool.--[[User:LKolesar|LKolesar]] 11:29, 21 May 2008 (CDT)
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| * Day and Evening staff are also required to fill out a TISS if a patient is discharged or passes away on their shift. TISS done on Day or Evening shift reflects the workload from midnight to time of discharge or death.
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| ===When and for how long is a TISS required===
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| * If a patient is in the ICU a very short time, a TISS score is required to reflect nursing efforts during this time.
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| * Do not sent TISS form to the ward with the chart. Please hand it in to the Unit Clerk who will file it in the Research Forms binder.
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| * Once the first 5 days of TISS are completed, please '''do not staple''' together. Hand in the completed form to the Unit Clerk and start a new form. Scanning of forms is affected if stapled.
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| * TISS is to be done for a patients entire length of stay in ICU.
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| * If a patient is transferred to another ICU, do not sent the form to the other center.
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| * If a patient is transferred to another ICU in your center and the Service looking after the patient changes, then a '''new''' TISS form is required. E.G., a patient who goes from MICU under Medical Service and is transferred to SICU under Surgical service.
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| * See '''[[TISS - General Information#The 2 Hour rule for TISS |2 Hour rule]]''' for patients admitted after 2200 or discharged before 0200
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| === Quality Control===
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| * Data collectors are required to do '''quality control for the first 10 days''' of TISS.
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| <dig up quality control guide an insert here>
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| [[User:TOstryzniuk|TOstryzniuk]] 15:23, 3 December 2008 (CST)
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| * the [[data processor]] runs internal consistency checks on the TISS data and will flag patients whose TISS information is inconsistent with their collected information. For a list of data consistency checks and rules, see the [[:Category:Data Integrity Rules | Data Integrity Rules Category]].
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| == TISS Item Guideline ==
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| ===Mutually Exclusive Items===
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| * Shaded items on TISS are '''mutually exclusive'''. You can only select '''one''' item in that group for a 24 hour day.
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| === '''The 2 Hour rule for TISS''' ===
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| Special instruction regarding collection of TISS apply for '''two hours on either side of midnight'''.
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| # If a patient is '''admitted to ICU at or after 2200''', nursing activities for the time before midnight are included on the '''next''' day's TISS score.
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| # If a patient passed away or is '''discharged from ICU at or before 0200''' hours, nursing activities for the time after midnight are included on the '''previous''' day's TISS score.
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| # If a patient's time of admission and discharge falls within the above 2 periods, i.e. [[LOS]] ≤ 4 hours, '''one TISS''' score must be done using the '''admit date'''.
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| Examples
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| * If a patient is admitted at 2200 hours on November 2.01 then the Day 1 TISS will start on November 3.01 and will be done done retrospectively by the night staff on November 3.01 looking back the previous 26 hrs of care.
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| * If a patient is discharged at 0200 hours on December 10.01 then the last day TISS score will be on December 09.01 which will be 26 hours long to include these 2 hours.
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| === '''The 48 Hour Rule for TISS''' ===
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| * 5 - RX of seizures, metabolic encephalopathy
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| * 17 - Post arrest cardiac or respiratory
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| * 34 - Fresh Tracheostomy
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| * 73 - Acute digitilization
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| Any activity marked with 48 hrs on form, should have TISS days marked for 2 days.
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| === Neurological ===
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| Tiss therapeutic variables: 2 to 7
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| *2 - Hourly Neuro checks
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| *3 - Intracranial pressure montoring
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| *4 - Mannitol infusion for cerebral edema
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| *5 - RX (treatment) of seizures, metabolic encephalopathy (1st 48 hrs)
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| *6 - Hypo/hyperthermia blanket (induced hypothermia including cardiac arrests)
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| *7 - patient restraint (to prevent harm)
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| === Cardiovascular ===
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| TISS therapeutic variables: 9 to 25
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| * 9 - ECG monitoring
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| * 10 - Hourly Vital signs -Minimum 6 hrs consecutively in the first 24 hrs in ICU to get points
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| * 11 - Peripheral arterial line
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| * 12 - Pulmonary arterial line
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| * 13 - Measurement of CVP (any method)
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| * 14 - Measurement of Cardiac Output
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| * 15 - Temporary Pacemaker-'''Standby''' (includes external) - wires hooked up but pace not turned on.
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| * 16 - Temporary Pacemaker-'''Active''' (includes external) - turned on but may not be pacing all the time.
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| ** The testing for "capture" not counted as active pacing.
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| **Permanent pacer not included.
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| * 17 - Post Cardiac Arrest - (first 48 hours) mark for 2 days
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| * 18 - Cardioversion/Defibrillation - While in ICU only
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| * 19 - IABP
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| **NOTE: Community hospitals (Oaks, Grace, Concordia, Victoria). If a patient goes from your center to STB or HSC for an angiogram/plasty, has an IABP inserted in the angio department and is either admitted for HSC or STB ICU/CCU or goes directly to the OR from there, please do not put on your TISS item # 19 -IABP.Discharge to should be coded using the codes for HSC or STB for OR , CCU , SICU or MICU.
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| * 20 - Pressurized blood transfusion
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| * 21 - Mast Trouser '''discontinued practice in ICU - 1998-99'''
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| * 22 - Platelet Infusion (scored separately from 23 & 24 below.
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| * 23 - Infusion of blood ≤5/24 hrs.
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| * 24 - Infusion of blood ≥5/24 hrs.
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| **Do not include blood products given in the OR in your lab tally or TISS. Add up volume given and divide by the BASE amount that is indicated on the TISS form.
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| **For the lab data collection of blood products, since the amount in a bag now varies in terms of volume, please record totals as follows:EXAMPLE: FFP 350 + 150+175 =675 Divide by 350 (base amt.) = 1.9. Amount given ROUND OFF to = 2u.
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| **We are looking at the number of bags hung not the exact volumes infused. If a person gets only half a bag of blood or only 2 mls for that matter, the cost is associated with hanging the product regardless of whether the volume is totally infused or not.
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| **This total includes Pentaspan (not a blood product but a volume expander) since we are looking at workload.
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| **If Voluven is given as a volume expander add this number to the Pentaspan. (In the lab section it is counted separately).
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| **Does not include platelets. Platelets have own slot.
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| ** ''Example:''
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| *** 1u FFP=350 mls
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| *** 1u PC,HSA 5%, Pentaspan = 250 mls
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| *** 1u HSA 25% = 100 mls
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| *** 1u Voluven = 500 mls
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| * 25 - IV replacement of excess fluid loss (>6L/24 hrs).
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| ==== Discussion ====
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| * what is meant by:
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| "if Voluven is given as a volume expander add this number to the Pentaspan. (In the lab section it is counted separately)."
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| Wouldn't you be adding it to the number of blood products hung, not to the Pentaspan? [[User:Ttenbergen|Ttenbergen]] 15:21, 16 October 2008 (CDT)
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| ===Respiratory===
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| TISS therapeutic variables: 26-40
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| *29-32 are mutually exclusive. Select only ONE item per day that will give you the most points.
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| *Points in this group are in descending order, i.e 29 gives the most.
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| * 26, 27, 28 - (see... [[TISS - General Information#Legacy Data|Legacy Data]] for more information).
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| '''CURRENT LABELS on TISS FORM:''' (correct)
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| ***26 - ''header row label so not on form''
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| ***27 -'' blank''
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| ***28 -'' blank''
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| *** 29 - A/C, SIMV, PSV with muscle relaxant
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| *** 30 - A/C, SIMV, PSV without muscle relaxant
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| *** 31 - CPAP or BIPAP
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| *** 32 - Spontaneous Resp per E-T tube or Trach
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| * 33 - Intubation - nasal or tracheal (perform in the ICU)
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| * 34 - Fresh tracheostomy (first 48 hours)
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| * 35 - Tracheostomy care (over 48 hours)
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| * 36 - Chest Physio - check only if done by ICU nurse or assisting Physio staff. Active in the processing.
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| * 37 - Incentive spirometry Inhalation therapy - Don’t forget Ventolin per mask.
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| * 38 - Tracheal suctioning of non-intubated patients
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| * 39 - Oxygen by mask or nasal prongs
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| * 40 - Chest tubes
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| {{Discussion}}
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| ==Discussion==
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| * I just want to clarify what other facilities consider "ventilation with sedation" is. That is, do they have to be on a continuous infusion of versed or fentanyl to be considered sedated. Or is PRN versed etc. count as well. What if they only get a few doses in a 24 hr period? Does that still count?
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| --[[User:MWaschuk|MWaschuk]] 16:41, 24 November 2008 (CST)
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| ** I mark sedation even when it is given only prn...it still keeps them adequately ventilated and from fighting the machine. Every pt is different in their sedation needs...so even if it is given only once in 24 hours, I will code it. [[User:BDeVlaming|BDeVlaming]] 09:16, 26 November 2008 (CST)
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| ***I have been following what Betty is doing too. It seems that there are very few instances when a pt does not receive some type of sedation while they are being ventilated. It seems though that there are levels of sedation. There are those who are on versed and fentanyl infusions and those who get the odd PRN yet both score the same points. If other centres are giving points in this manner then at least we are all consistent. Any comments?--[[User:MWaschuk|MWaschuk]] 09:56, 3 December 2008 (CST)
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| ***Betty is correct.[[User:TOstryzniuk|TOstryzniuk]] 12:19, 3 December 2008 (CST)
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| ===Gastrointestinal===
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| TISS therapeutic variables: 42 to 48
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| * 42 - Tube feeding - If client is being tube fed then there should not be any points for item # 86, unless there is another type of drain tube.
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| * 43 - Central IV hyperalimentation
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| * 44 - Peripheral IV hyperalimentation
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| * 45 - Oral / NG replacement of fluid above maintainence - Forced fluids per NG.
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| * 46 - Balloon tamponade of varices (Blakemore)
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| * 47 - Gastric lavage for active bleeding
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| * 48 - Kayexalate/colonic enema
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| ===Genitourinary===
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| TISS therapeutic variables: 50 to 55
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| ***50-55 are '''mutually exclusive''' - Select one per 24 hours period
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| * 50 - Urinary - Foley catheter
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| * 51 - Dipstick urine testing (S&K)
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| * 52 - Peritoneal dialysis
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| * 53 - Hemodialysis: Stable client
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| * 54 - Hemodialysis: Unstable client
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| * 55 - CVVHD - added '''Sept 23, 1998'''
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| ===Metabolic/Fluid and Electrolytes/blood work===
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| TISS therapeutic variables 57 to 62
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| *58, 59 The Count includes EACH tube, bottle or syringe of blood sent. **EXAMPLE: CBCx2 + ABGx3 + culturesx2 = 7
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| * 58 - Blood samples ≤12/24 hrs
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| * 59 - Blood samples ≥12/24 hrs (E.G. FFP 187 ml + 158 ÷ 350, 1 unit FFP = 350, 1 unit of HSA 25 = 100mls, 1 P.cell, HSA 5% or Pentasapn = 250mls
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| * 60 - (see 61) (see... [[TISS - General Information#Legacy Data|Legacy Data]] for more information).
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| * 61 - Treatment of metabolic acidoisis or alkalosis. (TX with NAHCO# or Diamox etc.) In the main database this item was listed inadvertently in 2 rows, items 60 & 61. The TISS collection form is correctly labeled. There is no item 60 and the form, only items 61.
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| * 62 - Active diuresis - (IV or PO) - Lasix etc. if stat or PRN also fill in TISS '''78'''; If by pump also fill in TISS '''66''' and '''79'''
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| ===Medications / IV’s===
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| TISS therapeutic variable 64 to 79
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| * 66 - Pump Regulated infusions - Points given when a pump is FIRST initiated for a specific drug. Does include bag or syringe change of same substance.
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| * 67+68 - Vasoactive drugs - Dopamine, Dobutamine, Epinephrine, Phenelyphrine, Nitroglycerine, Nipride, Amrinone, Norepinephrine, Milrinone, Labetalol, Nitroprussde, Esmolol.
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| * 69 - Antiarrhythmic Infusion - Lidocaine, Amiodarone, Ca channel block, Verapamil drip, Cardiazipine, MG.
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| * 72+73 - Anticoagulation - TPA, STK or heparin infusion, ReApro,RHAPC, Anti Prot C. Continuous IV. Infusion. Sub Q not included.
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| * 76+77 - IV Antibiotics - Also assign point in slot 79 or if PRN, Stat use slot 78 also.
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| ===General Care===
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| TISS therapeutic variables 81 to 89
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| * 81 - Dressing Routine - Simple dressings-routine practice per 24 hr. period. Arterial line, Swan ganz,trach care, NG dressing change. Each site or a specific site has 1 or 2 dressing changes per 24 hr period at the most.
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| * 82 - Dressing Multiple - Any dressings that are above & beyond what I considered routine in your ICU. E.g. numerous bedsores, excessive bleeding from any site for post-ops or medical patients, traumas or post-ops with an open abdomen. DEATH-morgue prep (if done by bedside nurse. Each dressing site, or a particular site requiring 3 or more dressings per 24 hr. period.
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| * 83 - Extensive wound care - Burns 30% 3rd degree or bleeding required packing more than once per shift.
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| ==Discussion==
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| * Do other centers find that routine dressing changes are being marked for everyday that a pt is in ICU? It is hard to quality check because every little dressing change is not always charted. I have been leaving it if it marked. Any comments?--[[User:MWaschuk|MWaschuk]] 09:48, 3 December 2008 (CST)
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| * 86 - Drainage tube(s) Hemovac/ any type of tube.
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| **EXCEPT THE FOLLOWING which are found elsewhere on the TISS form:
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| ***foley is #50
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| ***Chest tube is #40
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| ***Ostomy is # 85
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| * 87 - Orthopedic Traction-standard -Single weight
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| * 88 - Orthopedic Traction-complex - 2 or more weights, C-Spine, Halo
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| {{Discussion}}
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| ===Procedures and Interventions===
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| TISS therapeutic variables 91 to 96
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| * 91 - Diagnostic Procedure Outside of ICU - Points if accompanied by ICU nurse for test, procedure outside of ICU. If by transport team, no points
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| * 96 - Operative Procedure - '''day of surgery only'''; Angioplasty also gets point.
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| ====Discussion====
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| Pt's who go for procedures like IVC filter, cystoscopy, radiologist guided pigtail insertion,CT guided drainage of abscess, do they get points for operative procedure on the TISS? I know angioplasty does. There are some things we mark on our PDA that fall under OR but do they all count as OR on the TISS. --[[User:MWaschuk|MWaschuk]] 20:14, 29 September 2008 (CDT)
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| **The PDA only allowed a limited number of grouping for the diagnostic codes. There are a number of "diagnostic" procedure scattered amongst the surgical codes. A diagnostic procedure is not a surgery, therefore TISS item 96 should not be marked.
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| ** I don't put operative procedure on the TISS (T96) for these items but you bring up a good question, why do we count angioplasties as an operative procedure and not other invasive procedures? Maybe Trish could comment on this? --[[User:LKolesar|LKolesar]] 09:50, 2 October 2008 (CDT)
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| **We have include patients that go for angioplasty as a surgical procedure because when we started data collection in ICU, plasty's/stent were always sent to CCU and required alot of post care. We have kept that process going in order to try a be consistent. Things change over time.... Will put this on the list to discuss this at ICU TASK group. [[User:TOstryzniuk|TOstryzniuk]] 18:13, 3 October 2008 (CDT)
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| ==== Angio / Angioplasty ====
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| see... [[Angio / Angioplasty]]
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| == Background ==
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| * First introduced in 1974 by Cullen DJ, Civetta JM, Briggs BA, et al: Therapeutic scoring systems: A method of quantitative comparison of patient care. ''Crit Care Med'' 2:57-60, 1974) at the Massachusetts General Hospital. (TISS with 70 therapeutic variables).
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| *Modified in 1983. (TISS with 76 therapeutic variables).
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| *Modified version in 1994 for use for intermediate and floor care nursing units (iTISS).
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| *Modified version in 1996. (TISS with 28 therapeutic variables).
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| *'''ICU in the City of Winnipeg uses a locally modified version of the 1983 TISS-76 and has a list of 83 therapeutic variables.'''
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| * TISS is a method of quantifying nursing and medical care required by
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| * TISS has become a widely accepted and validated method of classifying critically ill patients.
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| * TISS is utilized in the USA, Canada and abroad for many purposes:
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| *# Determining severity of illness (NOTE: this capability of TISS has lost its application with the appearance of more specific scoring systems in the 1980).
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| *# Establishing nurse-patient ratios in the ICU
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| *# Assessing current utilization of ICU beds
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| *# Establishing future needs and numbers of ICU beds
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| *# Expresses work activities in statistical terms.
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| * TISS has been incorporated as an integral part of the Acute Physiologic and Chronic Health Evaluation [[:Category:APACHE II|APACHE II]]
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| * The comparative scores of TISS and APACHE enables us to see trends in the type of nursing care (TISS) provided for certain acuity levels (APACHE), for a specific type of diagnosis.
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| * Reviewing both scores can help determine whether certain nursing activities can be redirected or standardized in certain types of critically ill patients without affecting patient mortality or morbidity.
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| * Each of the most common ICU nursing activities is weighted from 1 to 4 point. More points indicate that greater nursing management is required.
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| * A high daily TISS score indicates an increase in nursing workload.
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| == Legacy Data ==
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| * 72 & 72 - (Jan 1.02 Heparin sq & coumadin po DC’d from this list)
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| * 26, 27, 28 '''Two issues''':
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| # There was a discrepancy on the original collection form. The person who created form for TELEFORM and PROGRAMMER had different Row numbers and labels.
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| # ventilator groupings "compacted to items 29 & 30 by Dr. Carla Chrusch, Roberts and Light. May 2000.[[User:TOstryzniuk|TOstryzniuk]] 18:53, 14 July 2008 (CDT)
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| *'''OLD LABELS on TISS FORM:'''
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| **27 - Controlled ventilation:
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| **28 - with or without PEEP
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| **29 - with intermittent continuous muscle relaxant/sedation
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| **30 - IMV or assisted respirations (with/without PEEP)
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| *'''CURRENT LABELS on TISS FORM:'''(correct)
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| **27 - ''blank''
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| **28 -'' blank''
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| ** 29 - A/C, SIMV, PSV with muscle relaxant
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| ** 30 - A/C, SIMV, PSV without muscle relaxant
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| ** 31 - CPAP or BIPAP
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| ** 32 - Spontaneous Resp per E-T tube or Trach
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| *'''CURRENT LABELS in MAIN DATABASE for TISS:'''
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| **27 - Controlled Ventilation (with/without PEEP)
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| **28 - ''blank''
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| **29 - C.V. continuous muscle relaxant/sedation
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| **30 - IMV or assisted respirations (with/without PEEP).
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| * 21 - Mast Trouser - '''discontinued practice in ICU - 1998-99'''. Taken off ICU TISS form but label is still in main database.
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| * 55 - CVVHD added September 23, 1998
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| {{discussion}}
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| == Discussion ==
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| * The [[TISS - General Information#TISS 23 & 24 & Lab data collection of blood products|TISS 23/24]] section states that we want to know the number of bags since we are looking at work load, not product used. It also says to calcualte the total amount of product and round up. The two seem inconsistent.[[User:Ttenbergen|Ttenbergen]] 09:04, 21 May 2008 (CDT)
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| ** It is possible that Julie uses this information for other reasons (not nursing workload)--[[User:LKolesar|LKolesar]] 11:06, 22 May 2008 (CDT)
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| [[Category:TISS]]
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| * As [[:User:LKolesar|LKolesar]] points out, there is variation in how the TISS is collected in different centers. Is this something we should look at? [[User:Ttenbergen|Ttenbergen]] 00:04, 27 May 2008 (CDT)
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| *Do other centres mark hourly vital signs on the TISS if only the screen pulse is marked every hour on the nurses' flow sheet and BP recorded every 4 hours?--[[User:MWaschuk|MWaschuk]] 20:18, 29 September 2008 (CDT)
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| *MaryLou, I think as long as some vital signs are done hourly it should still count as the nurse must still document this. --[[User:LKolesar|LKolesar]] 07:21, 30 September 2008 (CDT)
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| *I agree. I always mark hourly vitals if the pulse has been documented hourly. I don't worry so much about the other vitals. My thinking is that the nurse is monitoring for arrythmias as well, and dealing with whatever alarms may be generated. That all takes time as well. [[User:BDeVlaming|BDeVlaming]] 11:45, 30 September 2008 (CDT)
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