Miranda D R, de Rijk A, Schaufeli W
Department of Surgery, University Hospital of Groningen, The Netherlands.
Crit Care Med. 1996 Jan;24(1):64-73. doi: 10.1097/00003246-199601000-00012.
To validate a simplified version of the Therapeutic Intervention Scoring System, the TISS-28, and to determine the association of TISS-28 with the time spent on scored and nonscored nursing activities.
Prospective, multicenter study.
Twenty-two adult medical, surgical, and general Dutch intensive care units (ICUs).
A total of 903 patients consecutively admitted to the ICUs.
TISS-28 was constructed from a random sample of 10,000 records of TISS-76 items. The respective weights were calculated using multivariable regression analysis through the origin; TISS-76 scores were used as predicted values. Cross validation was performed in another random sample of 10,000 records and the scores of TISS-76 were compared with those scores obtained with TISS-28 (r = .96, r2 = .93). Nursing activities in the ICU were inventoried and divided into six categories: a) activities in TISS-28; b) patient care activities not in TISS-28; c) indirect patient care (activities related to but not in direct contact with the patient, such as contact with family, maintaining supplies); d) organizational activities (e.g., meetings, trainee supervision, research); e) personal activities (for the nurse him/herself, such as taking a break, going to the bathroom); f) other. During a 1-month period, TISS-76 and TISS-28 scores were determined daily from the patient's records by independent raters. During a 1-wk period, all of the nurses on duty scored their activities using a method called "work sampling."
The analysis of validation included 1,820 valid pairs of TISS-76 and TISS-28 records. The mean value of TISS-28 (28.8 +/- 11.1) was higher (p < .00) than that value of TISS-76 (24.2 +/- 10.2). TISS-28 explained 86% of the variation in TISS-76 (r = .93, r2 = .86). "Work sampling" generated 10,079 registrations of nursing activities, of which 5,530 could be matched with TISS-28 records. Samples were taken from medical (19.3%), surgical (19.1%), and general (61.6%) ICUs. Of these samples, 51.1% originated from university hospitals, 35.8% from hospitals with > 500 beds, 7.1% from hospitals with 300 to 500 beds, and 5.8% from hospitals with < 300 beds. Samples were scored in the morning (43.0%), evening (32.9%), and night shifts (24.1%). This sample of work activities was divided into four groups, according to their matched TISS scores (0 to 20, 20 to 35, 35 to 60, and > 60 points). In the successive groups of TISS scores, there was a significant increase in the proportion of time spent on the activities scored with TISS-28. In the lower TISS score group (0 to 20 points), there was a significantly larger proportion of time allocated to patient care activities not in TISS-28. There was no significant difference in the proportion of the time spent when associating indirect patient care and organizational activities with the level of TISS score. There was a significant decrease in the proportion of time spent on personal activities in the successive groups of TISS scores. The mean time spent per shift with personal activities varied between 1 hr and 40 mins (group 0 to 20 points TISS), and 1 hr and 16 mins (group > 60 points TISS). Significantly more time was used for patient care activities during the evening shift than during the day or the night shift. Conversely, nurses spent significantly less time on activities regarding their personal care during the evening shift. The time consumed for the activities of indirect patient care did not differ significantly among the three shifts. A typical nurse was capable of delivering work equal to 46.35 TISS-28 points per shift (one TISS-28 point equals 10.6 mins of each nurse's shift).
The simplified TISS-28 explains 86% of the variation in TISS-76 and can therefore replace the original version in the clinical practice in the ICU. Per shift, a typical nurse is capable of delivering nursing activities equal to 46 TISS-28 points.
验证简化版的治疗干预评分系统（TISS-28），并确定TISS-28与有评分和无评分护理活动所花费时间之间的关联。
前瞻性多中心研究。
荷兰22个成人医学、外科及综合重症监护病房（ICU）。
共有903例患者连续入住ICU。
TISS-28由10000条TISS-76项目记录的随机样本构建而成。通过原点使用多变量回归分析计算各自权重；TISS-76评分用作预测值。在另一个10000条记录的随机样本中进行交叉验证，并将TISS-76的评分与TISS-28获得的评分进行比较（r = 0.96，r² = 0.93）。对ICU中的护理活动进行清点并分为六类：a）TISS-28中的活动；b）TISS-28中未包含的患者护理活动；c）间接患者护理（与患者相关但未直接接触患者的活动，如与家属联系、维持物资供应）；d）组织活动（如会议、实习生监督、研究）；e）个人活动（针对护士自身，如休息、去卫生间）；f）其他。在1个月期间，由独立评估者每日从患者记录中确定TISS-76和TISS-28评分。在1周期间，所有值班护士使用一种称为“工作抽样”的方法对其活动进行评分。
验证分析包括1820对有效的TISS-76和TISS-28记录。TISS-28的平均值（28.8±11.1）高于TISS-76的平均值（24.2±10.2）（p < 0.00）。TISS-28解释了TISS-76中86%的变异（r = 0.93，r² = 0.86）。“工作抽样”产生了10079条护理活动记录，其中5530条可与TISS-28记录匹配。样本取自医学ICU（19.3%）、外科ICU（19.1%）和综合ICU（61.6%）。在这些样本中，51.1%来自大学医院，35.8%来自床位>500张的医院，7.1%来自床位为300至500张的医院，5.8%来自床位<300张的医院。样本在早班（43.0%）、中班（32.9%）和夜班（24.1%）进行评分。根据匹配的TISS评分（0至20分、20至35分、35至60分和>60分），将该工作活动样本分为四组。在连续的TISS评分组中，用TISS-28评分的活动所花费时间的比例显著增加。在较低的TISS评分组（0至20分）中，分配给TISS-28中未包含的患者护理活动的时间比例显著更大。将间接患者护理和组织活动与TISS评分水平相关联时，所花费时间的比例无显著差异。在连续的TISS评分组中，个人活动所花费时间的比例显著下降。每班个人活动所花费的平均时间在1小时40分钟（TISS评分为0至20分组）和1小时16分钟（TISS评分>60分组）之间变化。中班用于患者护理活动的时间明显多于早班或夜班。相反，护士在中班用于个人护理活动的时间明显减少。间接患者护理活动在三个班次中所消耗的时间无显著差异。一名典型护士每班能够完成相当于46.35个TISS-28分的工作（一个TISS-28分等于每位护士每班10.6分钟）。
简化版的TISS-28解释了TISS-76中86%的变异，因此在ICU临床实践中可替代原始版本。每班一名典型护士能够完成相当于46个TISS-28分的护理活动。
