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. The WRHA Critical Care Program uses 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 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

Some questions/clarifications about TISS 28

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)

1. • 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. We have to assume if bedside marked it they drew it. We don't expect collectors to interview staff. Reminders to staff via unit manager if noted staff are misinterpreting.

Do accuchecks count as "lab specimen"?

1. • Accuchecks have always counted as lab specimens and this should continue.--LKolesar 13:00, 2013 January 10 (EST).Trish Ostryzniuk 14:05, 2013 January 10 (EST)

TISS item #6

Would removing dressing, pulling an IV and applying dressing count?

1. • If your pulling any type of lines, you are pulling off and applying dressing so YES.

TISS item #7

Does wrapping a body for morgue still count as a "dressing"?

1. • We won't mix morgue wrapping in with general wound/line care dressings.

TISS item #8

Are foley catheters given points under #8 AND #30?

1. • 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) then 30 is not marked.

For Tiss #11

re "CPR in the past 24 hours": Only fill in one bubble for each CPR event (ie count for only one day).

TISS item #13 and 14

1. • This does not include antiarrythmics
   • It is only norepinephrine, epinephrine, dopamine, dobutrex, milrinone, vasopressin, nitroprusside, nitroglycerine, labetolol etc. ie cont inf for BP and vascular support including inotropic support.

For Tiss #21 re

"CPAP or BiPAP": does not include opti-flow--Mlaporte 19:58, 2013 August 20 (CDT)

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)

1. • 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, which is likely, 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.
     • I do not think we need to second guess the staff on every pt. If they mark it then we need to trust that they did do it. The tiss sheet states "mark if the activity occurred any time during that calender day"--LKolesar 13:00, 2013 January 10 (EST).-Trish Ostryzniuk 14:05, 2013 January 10 (EST)

For #39 Emergency Surgery

Do not include angiograms. It is only for E1 Surgery which is indicated on the OR sheet. (This is now printed right on the tiss form)--LKolesar 15:59, 2013 April 16 (EDT)

Purpose/Use of TISS

see TISS28 data use

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.

• 5 days of TISS - from June 1988 to mid September 13, 1998, only one page (first 5 ICU days) of TISS76 was scanned and uploaded to master ICU TMSX database.
• 10 days of TISS - started: September 14, 1998 two pages (first 10 ICU days) was scanned and uploaded to master ICU TMSX database.
• Our modified version of TISS76 was as also implemented in all other ICU's within the Winnipeg Regional Health Authority (WRHA) in 1999.
• TISS76 was stopped: December 31, 2012, midnight.

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

The WRHA Critical Care Program changed 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.

Medicine

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