TISS General Info

The Therapeutic Intervention Scoring System (TISS) is a method of quantifying, over a 24 hour period, the intensity of nursing and medical care required by ICU patients.

On January 1, 2013 @ 0001 hours, the WRHA, Critical Care Program will change to a locally modified version of TISS28 which includes "49" therapeutic variables. In addition to the "28" TISS therapeutic variables, our version contains an additional 21 items that our Regional Critical Care Program have included to monitor for QI purposes.

The WRHA Critical Care Program is changing to TISS28 because it takes less effort to collect, compared to the original TISS76 and provides the same level of information required for purposes listed below. Like the original TISS76, TISS28 also does not even come close to including all of the things done by ICU nurses. 76 items is a considerable number, and efforts were made to try and reduce the number of individual items without reducing the validity of the TISS score. In 1996 a careful analysis was done by ( TISS 28 R.Miranda CritCareMed_1996) to reduce the original 76 items to 28 items (TISS-28) Instead, the snapshot of nursing workload represented by the TISS28 score has been demonstrated to correlate with total nursing workload, and with the severity of illness. Since the TISS items are things done by bedside ICU nurses, they are in the best position to accurately identify them.

The wording of the specific items on the TISS28 scoring sheet comes directly from those who developed it. It is purposely simplified and repetitive to ensure clear understanding by all.

The completion of TISS scoring benefits both the nurses and the patients in our ICUs.

We will scan all pages for entire LOS in ICU. New form will have 7 days per form. TISS28 data will no longer be uploaded to master TMSX database. It will be stored in an alternate repository.

Regional ICU Bedside Education Script

see Bedside nurse education for TISS28

I have a few TISS 28 questions:

1. TISS item #3: I am having difficulty determining if the bedside nurse drew the lab samples from art. line, PICC, etc. Does this item give points only if RN drew/obtained the sample? (which would differ from previous TISS)
   • TISS has alway been a NURSE workload measure therefore, should only be marked if RN drew sample. This is not different than previous TISS just more clear on the new form.
2. Do accuchecks count as "lab specimen"?
3. TISS item #6: Would removing dressing, pulling an IV and applying dressing count?
   • If your pulling any type of lines, you are pulling off and applying dressing so YES.
4. TISS item #7: Does wrapping a body for morgue still count as a "dressing"?
   • I don't think we should mix morgue wrapping in with general wound/line care dressings.
5. TISS item #8: Are foley catheters given points under #8 AND #30?
   • Yes, this is caring for any type of drainage tube other than NG or OG. #30 is measuring output with or without a foley. If a foley is in and nursing in NOT measuring urine (not likely) them 30 is not marked.
6. TISS item #13 and 14--is there a list of drugs: ie.excludes anti-arrhythmics?
7. TISS item #24: Are there guidelines re if assisting physiotherapist or points if done by physio alone? I am finding all pts have documentation that they have been encouraged to DB & C but does this really count??Mlaporte 13:30, 2013 January 9 (EST)
   • if someone else is doing the work other than the RN, then it is not a workload for the nurse so it should not be marked. If only physio doing the work, no points. If RN is assisting physio, then points. The key here is NURSES workload. Verbally encouraging DB+C is really not a major burden of workload for a bedside nurse but actively coaching and working with a patient while doing the process is. Telling a patient to do it is not the same workload as actually helping a patient while they are trying to do it. I can see by having DB & C included here, nurse sees it and marks it because she may have told patient once. Not sure how we can have staff diffentiate between degree of work for this one.

Purpose/Use of TISS

TISS is the only tool we have at present to quantify objectively, the nursing care that is done in ICU's. It is a widely accepted and validated method of classifying critically ill patients which is used for a number of purposes:

1. Expresses nursing work activities in statistical terms (nursing workload).
2. Establishing nurse-patient ratios in the ICU (matching ICU nurse staffing to ICU needs)
   • As the nursing staff are the largest economic investment in an ICU, measuring nursing workload in different ICUs from different centres can contribute to the estimation of nursing staff required according to the specific demands of the units.
3. Assessing current utilization of ICU beds
4. Establishing future needs and numbers of ICU beds
5. Determining severity of illness
   • Since the intensity of ICU interventions is related to severity of illness, the TISS score is related to outcomes such as length-of-stay and mortality
     • NOTE: the capability with determining severity of illness with TISS has lost its application with the appearance of more specific scoring systems in the 1980 namely APACHE.
6. our TISS also contains elements that assist with quality reviews and provide information about resource utilization which is used by: WRHA Nursing & Medical Administrators, CCVSM & ICU QI Team & Researchers.

TISS has been incorporated as an integral 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.

History of TISS

• 1974 first introduced 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. Included 70 therapeutic variables. TISS70.
• 1983 modified: with 76 therapeutic variables. TISS76
  • Keene AR, Cullen DJ. Therapeutic Intervention Scoring System: update 1983. Crit Care Med. 1983 Jan;11(1):1-3.
    • A "locally modified" version of the 1983 TISS76 with a list of 83 therapeutic variables has been used at Health Sciences Center (HSC) since July, 1988 & in other ICU's in the Winnipeg Region since 1998 & 1999.
• 1994 modified: for use for intermediate and floor care nursing units iTISS.
• 1996 modified: to reduce and included 28 therapeutic variables. TISS28.

Original article, go to: TISS 28 R.Miranda CritCareMed_1996

• Miranda article on Web] Lippincott William _not all tables in article.
• Miranda abstract only - Pubmed
• Rolkf Lefering evaluating ITSS28 in an SICU-abstract only - Pubmed]
• UofM Library: J Graf, C Graf, KC Koch, P Hanrath and U Janssens. Cost analysis and outcome prediction with the Therapeutic Intervention Scoring System (TISS and TISS-28). [German]. Medizinische Klinik 98(3):123-132, 2003. ---- this good paper compares TISS76 with TISS28, and showed use of TISS to track ICU costs
• UofM Library: KB Laupland, R Shahpori, AW Kirkpatrick and HT Stelfox

Legacy Information

Critical Care

A "locally modified" version of the 1983 TISS76 with a list of 83 therapeutic variables has been used at Health Sciences Center (HSC) since July, 1988.

• From about June 1988 to mid September 1998, only one page (pts first 5 ICU days) of TISS76 was scanned and uploaded to master ICU TMSX database. Mid Sept 1998, we started to scan and upload two pages (pts first 10 ICU days) in master ICU TMSX database.
• Our version of TISS76 was as also implemented in all other ICU's within the Winnipeg Regional Health Authority (WRHA) in 1999. Stop date of this version will be December 31, 2012, midnight.

January, 1, 2013 - New TISS28 we will scan all pages for entire LOS in ICU. New form will have 7 days per form. TISS28 data will not be uploaded to master TMSX database. It will be stored in an alternate repository

Medicine

iTISS piloted for Medicine wards. For start and stop dates go to iTISS article.