TISS

Therapeutic Intervention Scoring System

General Points

• 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).

• Modified in 1983. (TISS with 76 therapeutic variables).
• Modified version in 1994 for use for intermediate and floor care nursing units (iTISS).
• Modified version in 1996. (TISS with 28 therapeutic variables).

*ICU in the City of Winnipeg uses a locally modified version of the 1983 TISS-76 and has a list of 83 therapeutic variables.

• TISS is a method of quantifying nursing and medical care required by critically ill 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 being given to a patient.

• TISS has become a widely accepted and validated method of classifying critically ill patients.

• TISS is utilized in the USA, Canada and abroad for many purposes:
  1. Determining severity of illness (NOTE: this capability of TISS has lost its application with the appearance of more specific scoring systems in the 1980).
  2. Establishing nurse’patient ratios in the ICU
  3. Assessing current utilization of ICU beds
  4. Establishing future needs and numbers of ICU beds
  5. Expresses work activities in statistical terms.

• TISS has been incorporated as an intergral part of the Acute Physiologic and Chronic Health Evaluation APACHE II

• 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.

• 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.

• Each of the most common ICU nursing activities is weighted from 1 to 4 point. More points indicate that greater nursing management is required.

• A high daily TISS score indicates an increase in nursing workload.

Template:Discussion Need to put a comparative table here of the various version of TISS. TOstryzniuk 17:32, 14 July 2008 (CDT)

Collection Guidelines

Fill the circles on the TISS form completely

All TISS forms should have their filled circles “black blobbed” fully with a marker prior to handing in for scanning. The scanning program will not detect circles that are not filled completely with a sufficiently dark marker.

Who fills out the TISS

• TISS is done retrospectively for the previous 24 hours of care in ICU.
  • In some centers it is done ongoing as care is given.--LKolesar 11:29, 21 May 2008 (CDT)

• TISS is generally done by Night staff.
  • In some centers it is done on all shifts as an ongoing tool.--LKolesar 11:29, 21 May 2008 (CDT)

• 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.

Discussion

• As LKolesar points out, there is variation in how the TISS is collected in different centers. Is this something we should look at? Ttenbergen 00:04, 27 May 2008 (CDT)

When and for how long is a TISS required

• If a patient is in the ICU a very short time, a TISS score is required to reflect nursing efforts during this time.

• 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.

• Once the first 5 days of TISS are cmpleted, 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.

• TISS is to be done for a patients entire length of stay in ICU.

• If a patient is transfered to another ICU, do not sent the form to the other center.

• If a patient is transfered 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.

• See The two hour rule for TISS for patients admitted after 2200 or discharged before 0200

Mutually Exclusive Items

• Shaded items on TISS are mutually exclusive. You can only select one item in that group for a 24 hour day.

Quality Control

• Data collectors are required to do qualilty control for the first 10 days of TISS.
• 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 checks, see TISS Data Consistency Checks.

TISS Item Rules

Hourly rule

Item 2 Hourly Neuro checks Item 10 Hourly Vital signs Minimum 6 hrs consecutively in the first 24 hrs in ICU to get points

Blood Products

• 23 - Infusion of blood ≤5/24 hrs.
• 24 - Infusion of blood ≥5/24 hrs.

E.G.

• 1u FFP=350 mls
• 1u PC,HSA 5%, Pentaspan = 250 mls
• 1u HSA 25% = 100 mls

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: E.g. FFP 350 + 150+175 =675 Divide by 350 (base amt.) = 1.9. Amount given ROUND OFF to = 2u. 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.

Does not include platelets. Platelets have own slot. This total includes Pentaspan (not a blood product but a volume expander) since we are looking at workload.

48 Hour Rule

• 5 - RX of seizures, metabolic encephalopathy
• 17 - Post arrest cardiac or respiratory
• 34 - Fresh Tracheostomy
• 73 - Acute digitilization

Any activity marked with 48 hrs on form, should have TISS days marked for 2 days.

Cardiovascular

• 15 - Temporary Pacemaker-Standby (includes external) - wires hooked up but pace not turned on.
• 16 - Temporary Pacemaker-Active (includes external) - turned on but may not be pacing all the time.

Testing not included. Permanent pacer not included.

• 18 - Cardioversion/Defibrillation - While in ICU only
• 19 - IABP
• 20 - Pressurized blood transfusion
• 21 - Mast Trouser discontinued practice in ICU - 1998-99

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.

Respiratory

29-32 are mutually exclusive. Select only ONE item per day that will give you the most points. Points in this group are in descending order, i.e 29 gives the most.

• 26, 27, 28 - Two issues:
  • ventilator groupings "compacted to items 29 & 30 by Dr. Carla Chrusch, Roberts and Light. May 2000.
  • There was a discrepancy on the original collection form. The person who created form for TELEFORM and PROGRAMMER had different Row numbers and labels.

**OLD LABELS on FORM:

• • • 27 - Controlled ventilation:
    • 28 - with or without PEEP
    • 29 - with intermittent continuous muscle relaxant/sedation
    • 30 - IMV or assisted respirations (with/without PEEP)

CURRENT LABELS on FORM:(correct)

• • • 27 - blank
    • 28 - blank
    • 29 - A/C, SIMV, PSV with muscle relaxant
    • 30 - A/C, SIMV, PSV without muscle relaxant
    • 31 - CPAP or BIPAP
    • 32 - Spontaneous Resp per E-T tube or Trach

• • • 36 - Chest Physio - check only if done by ICU nurse or assisting Physio staff. Active in the processing.
    • 37 - Incentive spirometry Inhalation therapy - Don’t forget Ventolin per mask.

Gastrointestinal

• 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.
• 86 Drainage tube(s) Hemovac/ any type of tube. Note: foley is #50, Chest tube is #40, Ostomy is # 85
• 45 Oral / NG replacement of fluid above maintainence - Forced fluids per NG.

Genitourinary

53-55 are mutually exclusive - Select one per day only

• 53 Hemodialysis: Stable client
• 54 Hemodialysis: Unstable client
• CVVHD - added Sept 23, 1998

Metabolic/blood work

58, 59 Count includes EACH TUBE, Bottle or SYRINGE of blood sent. E.g. CBC x2+ABG x3+ cultures x2 = 7

• 58 Blood samples ≤12/24 hrs
• 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

• 60 - (see 61)
• 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.

• 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

Medications / IV’s

• 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.

• 67+68 Vasoactive drugs - Dopamine, Dobutamine, Epinephrine, Phenelyphrine, Nitroglycerine, Nipride, Amrinone, Norepinephrine, Milrinone, Labetalol, Nitroprussde, Esmolol.
• 69 Antiarrhythmic Infusion - Lidocaine, Amiodarone, Ca channel block, Verapamil drip, Cardiazipine, MG
• 72+73 Anticoagulation - TPA, STK or heparin infusion, ReApro,RHAPC, Anti Prot C. Continuous IV. Infusion. Sub Q not included
• 76+77 IV Antibiotics - Also assign point in slot 79 or if PRN, Stat use slot 78 also.

General Care

• 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.
• 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 postops or medical pts, traumas or postops 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.

• 83 Extensive wound care - Burns 30% 3rd degree or bleeding required packing more than once per shift.
• 87 Orthopedic Traction-standard -Single weight
• 88 Orthopedic Traction-complex - 2 or more weights, C-Spine, Halo

Procedures and Interventions

• 91 Diagnostic Procedure Outside of ICU - Points if accompanied by ICU nurse for test, procedure outside of ICU. If by transport team, no points
• 96 Operative Procedure - day of surgery only; Angioplasty also gets point.

Angio / Angioplasty

see... Angio / Angioplasty

Legacy Data

• 72 & 72 - (Jan 1.02 Heparin sq & coumadin po DC’d from this list)
• 26, 27, 28 Two issues:

1. There was a discrepancy on the original collection form. The person who created form for TELEFORM and PROGRAMMER had different Row numbers and labels.
2. ventilator groupings "compacted to items 29 & 30 by Dr. Carla Chrusch, Roberts and Light. May 2000.TOstryzniuk 18:53, 14 July 2008 (CDT)

**OLD LABELS on TISS FORM:

• • • 27 - Controlled ventilation:
    • 28 - with or without PEEP
    • 29 - with intermittent continuous muscle relaxant/sedation
    • 30 - IMV or assisted respirations (with/without PEEP)

CURRENT LABELS on TISS FORM:(correct)

• • • 27 - blank
    • 28 - blank
    • 29 - A/C, SIMV, PSV with muscle relaxant
    • 30 - A/C, SIMV, PSV without muscle relaxant
    • 31 - CPAP or BIPAP
    • 32 - Spontaneous Resp per E-T tube or Trach

CURRENT LABELS in MAIN DATABASE for TISS:

• • • 27 - Controlled Ventilation (with/without PEEP)
    • 28 - blank
    • 29 - C.V. continuous muscle relaxant/sedation
    • 30 - IMV or assisted respirations (with/without PEEP).

TOstryzniuk 19:14, 14 July 2008 (CDT)

• 21 - Mast Trouser - discontinued practice in ICU - 1998-99. Taken off ICU TISS form but label is still in main database.TOstryzniuk 18:53, 14 July 2008 (CDT)

• 55 - CVVHD added September 23, 1998 TOstryzniuk 19:14, 14 July 2008 (CDT)

Template:Discussion

Discussion

• The 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.Ttenbergen 09:04, 21 May 2008 (CDT)
  • It is possible that Julie uses this information for other reasons (not nursing workload)--LKolesar 11:06, 22 May 2008 (CDT)
• Under Cardiovascular pacemaker 16 states that testing is not included. Where is testing included, then? Ttenbergen 09:04, 21 May 2008 (CDT)
  • I think this means you can't count that the pacemaker was actively pacing if you just turn it on to test it and then turn it off again. --LKolesar 11:06, 22 May 2008 (CDT)
    • Are we not tracking such testing then? Or are we tracking it under a different code? Ttenbergen 10:22, 26 May 2008 (CDT)
      • We don't track pacemaker testing (usually done by doctor)--LKolesar 13:20, 26 May 2008 (CDT)
        • Then we should say it like that. However, does that mean a pacemaker ready for testing should be marked as stand-by, or not marked at all? Ttenbergen 13:29, 26 May 2008 (CDT)
          • The pacemaker that is still attached to the patient, but not turned on, is considered on standby. If turned on and actively pacing and/or sensing should be considered active. I personally wouldn't even mention the testing at all in this criteria as it is not really relevant in my opinion.--LKolesar 10:48, 27 May 2008 (CDT)
            • Interesting point. Does mentioning it serve only to cause confusion? I wonder if this would be listed if no one had ever asked the question. If so, it should be listed to ensure consistent answers in the future. Ttenbergen 12:28, 27 May 2008 (CDT)
            • It is not in there to created confusion. It is included in the guideline because people were marking "ACTIVE PACING" when all that was done was testing pacer for capture.TOstryzniuk 18:25, 14 July 2008 (CDT)

• Missing info for TISS 19-28, does anyone have it? Ttenbergen 08:31, 27 May 2008 (CDT)
  • Tina, not sure what you are looking for:  ?? criteria for this range of TISS numbers?--LKolesar 10:48, 27 May 2008 (CDT)
    • The manual I was copying from had no info for those entries. It just seemed odd to not have them listed at all. If they are not listed at all, and one does a search on them, nothing will show up. So, maybe even if there is little to say about them, they should at least be noted here. That would also result in a place to discuss the items if the need arises. Ttenbergen 12:25, 27 May 2008 (CDT)