Intermediate TISS for Non-ICU Patients

Description

A modification of the original TISS was developed for patients in non-ICU settings such as intermediate ("step-down") and regular nursing units. This can be used both to quantitate the severity of patient illness and to measure the nursing workload.

Items relative to original TISS:

(1) retained, with same point score (49)

(2) retained, but reweighted (10)

(3) new (26)

(4) deleted (18)

Scoring: Points are scored if the modality was used within the previous 24 hours, except for a new tracheostomy or acute digitalization (48 hours).

Patient Care and Monitoring

Intervention	Type	Points
vital signs every shift [1]	new	1
vital signs every 2-4 hours [1]	new	2
vital signs hourly or procedure checks [1]	reweighted	3
intake and output every 24 hours [2]	retained	1
intake and output every 6-8 hours [2]	retained	3
pulse volume recorder, Doppler	new	2
pulse oximetry	new	2
Glasgow Coma Scale every 4 hours [3]	new	2
Glasgow Coma Scale every 1-2 hours [3]	new	4
central venous pressure	retained	2
EKG monitoring or telemetry	reweighted	2
unscheduled 12 lead EKG	new	2
serial EKG or isoenzymes	new	3
multiple STAT specimens (more than 1 per shift)	retained	3
sputum, wound or other cultures [6]	new	1
initial "PAN" cultures, including blood [6]	new	4

Procedures

Intervention	Type	Points
simple dressing changes [4]	retained	1
multiple dressing changes [4]	retained	2
simple orthopedic therapy or cast care [5]	retained	1
complicated orthopedic therapy or special care beds [5]	retained	3
Foley catheter	retained	1
drainage tube(s)	new	1
nasogastric and/or gastric tubes	retained	1
hemodialysis [7]	retained	2
hemodialysis, initial [7]	retained	4
peritoneal dialysis chronic [7]	new	3
peritoneal dialysis, initial [7]	retained	4
chest tubes	reweighted	2
arterial catheter	retained	3
hypo or hyperthermia blanket	retained	3
emergency bronchoscopy or endoscopy	retained	4
emergency surgery within 24 hours	retained	4
lavage for acute GI bleed	retained	4
isolation	new	4
4 point restraints	new	4
emergency thora, para, peri or cardiocentesis	reweighted	4
arterial sheath	new	4

Infusions and Medications

Intervention	Type	Points
one IV catheter [8]	retained	1
2 IV catheters [8]	retained	2
anticoagulation, oral	retained	1
anticoagulation, IV (heparin, etc.)	retained	3
IV medications, scheduled	retained	1
IV medications, unscheduled	retained	3
IV antibiotic, 1 [9]	retained	1
IV antibiotic, > 1 [9]	reweighted	2
intralipid/peripheral hyperalimentation [10]	retained	1
GI feedings [10]	retained	2
hyperalimentation by central catheter [10]	retained	3
epidural infusion	new	2
continuous IV sedation, patient controlled anesthesia	new	2
IV aminophylline/theophylline	new	2
IV chemotherapy	retained	2
IV diuresis [11]	retained	3
oral diuresis or change in oral diuretic therapy [11]	retained	3
replacement of excess fluid loss	retained	2
diabetic management (glucose monitoring with sliding scale insulin administration)	new	3
acute treatment of seizures or encephalopathy	retained	3
digitalization within 48 hours	retained	3
continuous antiarrhythmia infusion	retained	3
vasoactive drug infusion, 1 [12]	retained	3
vasoactive drug infusion, > 1 [12]	retained	4
blood products, frequent infusion (3 units within 24 hours)	retained	3
pressure activated blood infusion	retained	4
platelet infusion	retained	4
tissue plasminogen activation streptokinase/urokinase infusion	retained	4
concentrated potassium chloride infusion (40 mEq/dL)	retained	3

Cardiac Support

Intervention	Type	Points
pneumatic boots	new	1
chronic implanted pacemaker [13]	reweighted	2
temporary A/V pacing [13]	retained	4
cardiac pacer implanted within 24 hours [13]	new	4
chronic implanted automatic internal cardiac defibrillator [14]	new	3
automatic internal cardiac defibrillator [14]	new	4
cardioversion	reweighted	4
cardiac arrest within 24 hours	retained	4

Respiratory Support

Intervention	Type	Points
tracheostomy care [15]	retained	1
fresh tracheostomy within 48 hours [15]	reweighted	3
minitracheostomy [15]	new	2
intubation [15]	retained	3
incentive spirometry	new	1
formal chest physiology	reweighted	2
endotracheal suctioning more than 2 times every 6-8 hours [16]	new	1
blind endotracheal suctioning [16]	retained	3
oxygen by mask or cannula [17]	reweighted	2
spontaneous respiration via tracheostomy mask or T-piece [17]	retained	2
continuous positive airway pressure (CPAP) [17]	retained	3
mechanical ventilation [17]	retained	4

where:

• separation into subgroups is not in the original table, which merely separated interventions by point scores (Table 2, page 1409, Cullen et al, 1994)

• items in brackets "[ ]" appear to be mutually exclusive (my choice)

• I am not sure what an "arterial sheath" refers to

• formal chest "physiology" may refer to physiotherapy (as in original TISS)

Deleted items from original TISS (18):

• controlled ventilation with intermittent or continuous muscle relaxants

• balloon tamponade of varices

• pulmonary artery catheter

• induced hypothermia

• G suit

• intracranial pressure monitoring

• intra-aortic balloon assist

• intermittent mandatory ventilation or assisted ventilation

• measurement of cardiac output by any means

• active therapy of metabolic alkalosis

• active therapy of metabolic acidosis

• phlebotomy for volume overload

• coverage with > 2 IV antibiotics

• hourly neuro vital signs

• vasopressin infusion

• decubitus ulcer

• STAT blood tests (weighted 1 point; 3 point intervention retained)

• extensive irrigation, packings or debridement of wounds, fistula or colostomy

intermediate TISS =

= SUM [ therapeutic interventions being used]

The intermediate TISS results in the test patients showed good correlation with the original TISS results, with a linear relation.

intermediate TISS =

= 4.4 + (1.4 * (original TISS))

This can be rearranged:

original TISS =

= ((intermediate TISS) - 4.4) / 1.4

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Description

Specialty

ICD-10