THERAPEUTIC INTERVENTION SCORING SYSTEMSYSTEM-28 TISSTISS-28

UBAIDUR RAHAMAN SENIOR RESIDENT, CCM, SGPGIMS,

COST RESOURCE UTILIZATION SEVERITY OF ILLNESS

RESOURCE UTILIZATION MANPOWER MACHINE POWER = Interventions, gadgets,

CARE OF PATIENT MANPOWER

Nursing activities in ICU

Activities directly related to patient activities included in TISS-28 Activities not included in TISS-28
1. Communication with patient 2. Ensuring safety of patient- restraining 3. Ensuring physical and rest of patient 4. Ensuring general hygiene of patient 5. Encouraging passive movement, changing position, mobilization 6. Assisting in procedure and radiological investigation

Activities not directly related to patient

but necessary for continuity of personal care of patient Communication with family Communication with other disciplines- physiotherapist, radiology, lab, technical service Coordination task- reporting and consultation with doctor Paperwork- reporting, registration and other administrative works Equipment care Other activities not routinely performed- looking for property of patient

Nursing activities in ICU

Activities not related to patient administrative making duty roster Dealing with organization issues Trainee supervision Research activities

Personal care For nursing staff himself/herself- taking a break, refreshment, washroom

Other activities Not fitting in above categories

RESOURCE UTILIZATION

Justified utilization of resources Care of patient should not suffer Nursing staff should not overworked Cost should not increase

Optimal nurse: patient ratio

But, how to decide?

THERAPEUTIC INTERVENTION SCORING SYSTEM ( TISS)

Originally developed as severity of illness score in 1974 Consisted of 76 interventions With development of more sophisticated severity illness scores its use for this purpose was abandoned Mainly used as assessment of nursing manpower and cost

Modified in 1983

Further modified in 1996 by Miranda et al: simplified TISS or TISS-28 as number of intervention reduced to 28 from 76

TISS-28
points

Basic activities
Standard monitoring: hourly vital signs, regular registration and calculation of fluid balance Laboratory : biochemical and microbiological investigations Single medication: IV, IM, SC and or PO/NG/NJ/FJ Multiple intravenous medication: more than one drug, single shot or continuously Routine dressing changes: care and prevention of decubitus and daily dressing change Frequent dressing changes: at least one time per each nursing shift and or extensive wound care Care of drains: all except gastric tube 5 1 2 3 1 1 3

Ventilatory support
Mechanical ventilation: any form of mechanical ventilation/ assisted ventilation with or without PEEP, with or without muscle relaxant, spontaneous breathing with PEEP Supplementary ventilatory support: breathing spontaneously through ET tube without PEEP T piece breathing, supplementary O2 by any method Care of artificial airways: ET tube or Tracheostomy tube Treatment for improving lung function: chest physiotherapy, incentive spirometry, inhalational therapy, ET/TT suctioning 5 2 1 1

TISSTISS-28
Cardiovascular support
Single vasoactive medication: any vasoactive drug Multiple vasoactive medications: more than one, regardless of type and dose IV replacement of large fluid boluses: > 3 L/m2/d, regardless of type Peripheral arterial catheter Left atrial monitoring: PAC with or without cardiac output monitoring Central venous line Cardiopulmonary resuscitation after arrest: in past 24 hours 3 4 4 5 8 2 3

Renal support
Hemofiltration or dialytic technique Quantitative urine output measurement Active diuresis : eg. Frusemide >0.5 mg/kg/d for fluid overload 3 2 3

Neurological support
Measurement of intracranial pressure 4

TISSTISS-28

Metabolic support
Treatment of complicated metabolic acidosis/ alkalosis Intravenous hyperalimentation Enteral feeding: through NG/NJ/FJ 4 3 2

Specific intervention
single specific intervention in ICU: ET intubation, Pacemaker implant, Cardioversion, Endoscopy, Emergency surgery in past 24 hours, Gastric lavage Multiple specific intervention in ICU: more than one, as described above Specific interventions outside ICU: surgery or diagnostic procedures Total score

3 5 5

The Therapeutic Intervention Scoring System: one single tool for the evaluation of workload, the work process and management? Miranda R. Intensive Care Med 1997;23: 615-617. 615-

During 8 hours work shift An average nurse is capable of giving care equal to 46.35 TISS-28 points One TISS-28 points = 10.6min

In evening shift time spent on patient care is higher compared to other 2 shifts Time spent on personal care vary between 70-100 min during each nurses 8 hour shift

More TISS-28 point more time for patient related activities- more workload More TISS-28 point - less time left for personal activities- increased stress level

Nursing workload in intensive care units: A study using the Therapeutic Intervention Scoring System-28 (TISS-28).
Padilha KG, Sousa RM, Kimura M, et al. Intensive Crit Care Nurs 2007; 23(3) 162-169.

.Nurse to patient ratio TISS-28 point >22------ Nurse: Patient= 1:1 TISS-28 point <22------Nurse: Patient= 1:2

THAN K