Nursing workload in intensive care units: a study using the Therapeutic Intervention Scoring System-28 (TISS-28).

The Therapeutic Intervention Scoring System-28 (TISS-28) is an instrument that has been used to measure severity of illness and nursing workload in intensive care units (ICUs). OBJECTIVES: To characterize the severity of illness and nursing workload using the TISS-28 in 11 ICUs of a university hospital in the city of S?o Paulo, Brazil. METHODS: In a prospective study, data were collected from 271 patients admitted to the ICUs in December 2000 and the patients were followed up for 1 week. RESULTS AND CONCLUSIONS: Most of the patients were males (60.0%) and their mean age was 51(+20.6) years. Surgical treatment (66.8%) and admissions from the operating room were predominant. The mortality rate was 25.0% and the average length of stay was 7.7 (+10.4) days. The mean TISS-28 score was 23 (range: 14-32 points). The lowest mean score was observed for patients from the Burn ICU and the highest mean score was obtained for patients from the Liver Transplant ICU. A change in TISS-28 scores was observed in the same ICU over the 7-day study period. Units differed in terms of severity of illness and nursing workload. Patients who died received a higher TISS-28 score than patients who survived (p=0.00). As the nursing staff are the largest economic investment in an ICU, so 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.     

Evaluation of an interdisciplinary data set for national intensive care unit assessment.

OBJECTIVES: To evaluate the ability of an interdisciplinary data set (recently defined by the Austrian Working Group for the Standardization of a Documentation System for Intensive Care [ASDI]) to assess intensive care units (ICUs) by means of the Simplified Acute Physiology Score II (SAPS II) for the severity of illness and the simplified Therapeutic Intervention Scoring System (TISS-28) for the level of provided care. DESIGN: A prospective, multicentric study. SETTING: Nine adult medical, surgical, and mixed ICUs in Austria. PATIENTS: A total of 1234 patients consecutively admitted to the ICUs. INTERVENTIONS: Collection of data for the ASDI data set. MEASUREMENTS AND MAIN RESULTS: The overall mean SAPS II score was 33.1+/-2.1 points. SAPS II overestimated hospital mortality by predicting mortality of 22.2%+/-2.9%, whereas observed mortality was only 16.8%+/-2.2%. The Hosmer-Lemeshow goodness-of-fit test for SAPS II scores showed lacking uniformity of fit (H = 53.78, 8 degrees of freedom; p < .0001). TISS-28 scores were recorded on 8616 days (30.6+/-1.5 points). TISS-28 scores were higher in nonsurvivors than in survivors (30.4+/-0.9 vs. 25.7+/-0.4, respectively; p < .05). No significant correlation between mean TISS-28 per patient per unit on the day of admission and mean predicted hospital mortality (r2 = .23; p < .54) or standardized mortality ratio per unit (r2 = -.22; p < .56) was found. CONCLUSIONS: Implementation of an interdisciplinary data set for ICUs provided data with which to evaluate performance in terms of severity of illness and provided care. The SAPS II did not accurately predict outcomes in Austrian ICUs and must, therefore, be customized for this population. A combination of indicators for both severity of illness and amount of provided care is necessary to evaluate ICU performance. Further data acquisition is needed to customize the SAPS II and to validate the TISS-28.     

The reliability and validity of the therapeutic activity index

PURPOSE: To assess the psychometric properties of the Simplified Therapeutic Intervention Scoring System (TISS 28) scale. MATERIALS AND METHODS: A prospective observational design was used. Patients were recruited from a medical-surgical intensive care unit (ICU) and 4 rehabilitation wards of 2 university-affiliated hospitals in Hong Kong. RESULTS: Data necessary for the calculation of the TISS 28, the Therapeutic Intervention Scoring System (TISS 76), and severity of illness scoring system (Simplified Acute Physiology Score [SAPS II]) were recorded for each patient during the first 24 hours after his/her admission to an ICU. A significant positive correlation was found between the TISS 76 and the TISS 28 scores as well as the TISS 28 and the SAPS II scores. There was a significant difference between the TISS 28 scores among ICU patients and patients in rehabilitation wards. A significant correlation was found between the TISS 28 scores of the first and second set of TISS 28 scores. CONCLUSIONS: Although the findings supported the validity and reliability of the TISS 28, there were limitations of the TISS 28 in measuring nursing workload in ICUs. Hence, continued amendment and validation of the TISS 28 on larger samples in different ICUs would be required so as to provide clinical nurses with a valid and reliable assessment of nursing workload.     

Nine equivalents of nursing manpower use score (NEMS)

Objectives: To develop a simplified Therapeutic Intervention Scoring System (TISS) based on the TISS-28 items and to validate the new score in an independent database. Design: Retrospective statistical analysis of a database and a prospective multicentre study. Setting: Development in the database of the Foundation for Research on Intensive Care in Europe with external validation in 64 intensive care units (ICUs) of 11 European countries. Measurements and results: Development of NEMS on a random sample of TISS-28 items, cross validation on another random sample of TISS-28, and external validation of NEMS in comparison with TISS-28 scored by two independent raters on the day of the visit to the ICUs participating in an international study. Multivariable regression techniques, Pearson's correlation, and paired sample t-tests were used (significance at p < 0.05 level). Intraclass correlation, rate of agreement, and kappa statistics were used for interrater reliability tests. The TISS-28 items were reduced to NEMS (9 items) in a random sample of 2000 records; the means of the two scores were no different: TISS-28 26.23 ± 10.38, NEMS 26.19 ± 9.12, NS. Cross-validation in a random sample of 996 records; mean TISS-28 26.13 ± 10.38, NEMS 26.17 ± 9.38, NS; R ² = 0.76. External validation on 369 pairs of TISS-28 and NEMS has shown that the means of the two scores were no different: TISS-28 27.56 ± 11.03, NEMS 27.02 ± 8.98, NS; R ² = 0.59. Reliability tests have shown an “almost perfect” interrater correlation. Similar to studies correlating TISS with Simplified Acute Physiology Score (SAPS)-I and/or Acute Physiology and Chronic Health Evaluation II scores, the value of NEMS scored on the first day accounts for 30.4 % of the variation of SAPS-II score. Conclusions: NEMS is a suitable therapeutic index to measure nursing workload at the ICU level. The use of NEMS is indicated for: (a) multicentre ICU studies; (b) management purposes in the general (macro) evaluation and comparison of workload at the ICU level; (c) the prediction of workload and planning of nursing staff allocation at the individual patient level.     

不同量表在测量ICU护理工作量中的应用

目的 了解应用护理活动评估量表(nursing activities score,NAS)和治疗干预评分系统28版(simplified therapeutic intervention scoring system,TISS-28)测量ICU护理工作量情况,分析两种量表间的一致性.方法 选择在自贡市两所医院ICU住院治疗的305例患者,同时应用TISS-28量表和NAS量表测量ICU护理工作量,分析两种量表间的一致性及测算两所医院ICU护患比.结果 两所医院应用TISS-28量表和NAS量表测量ICU的护理工作量比较,r=0.808,P＜0.001;r=0.925,P＜0.001,两种量表具有一定的相关性.其所测得两所医院的护患比比较,均P＞ 0.05,差异无统计学意义.结论 TISS-28量表和NAS量表内在一致性较好,具有简单、快速、有效的优势,可选择任何一种量表测量ICU护理工作量,为ICU护理人力资源的有效管理提供数据支持.     

Analysis of resource use and cost-generating factors in a German medical intensive care unit employing the Therapeutic Intervention Scoring System (TISS-28)

OBJECTIVE: Evaluation of resource use and costs of a medical intensive care unit (ICU) utilising the simplified Therapeutic Intervention Scoring System (TISS-28). DESIGN: Prospective observational study. SETTING:: Medical ICU of a tertiary care centre. PATIENTS: Consecutive patients with an ICU length of stay (LOS) more than 24 h. INTERVENTIONS: Over a 3 month period SAPS II, TISS-28 and SOFA were determined daily. Patients were retrospectively classified as receiving active (AT) or non-active (NAT) treatment according to TISS-28 variables, with AT representing a therapeutic intervention that could not be performed outside the ICU. Individual expenditure for all patients was calculated using a modified 'top-down' method. MEASUREMENTS AND RESULTS: Out of 303 consecutive patients, 241 (79.5%), including all non-survivors, were categorised AT. The hospital mortality was 14.5%. TISS-28 and ICU LOS were higher in patients receiving AT ( p<0.001). Patient-specific costs accounted for 36 EUR per TISS-point and daily treatment costs 1336 EUR for all patients. Daily costs of care were 68 EUR higher for AT, compared to NAT, patients ( p<0.001). There was no association between ICU costs and measures of severity of illness (SAPS II, SOFA). CONCLUSIONS: TISS-28 is a fast, reliable and readily applicable tool to identify patients receiving AT. Although total and daily costs of care were significantly higher in patients receiving AT, the difference of the daily costs was, albeit statistically significant, economically negligible. The main difference in ICU costs was attributable to ICU LOS. Therefore cost-saving strategies must aim at reducing ICU LOS, without compromising quality of care.     

Nursing activities score (NAS): A proposal for practical application in intensive care units

For over 30 years in an attempt to demonstrate the cost-benefit ratio of the intensive care unit (ICU) a variety of tools have been developed to measure not only the severity of illness of the patient but also to capture the true cost of nursing workload. In this context, the nursing activities score (NAS) was developed as a result of modifications to the therapeutic interventions scoring system-28 (TISS-28). The NAS is a tool to measure nursing workload ICU and it has been shown to be twice as effective in measuring how nurses spend their time caring for critically ill patients than the TISS-28. This paper discuss the introduction of the NAS into everyday use in an intensive care unit in Brazil and highlights the challenges of standardisation of operational definitions, training requirements and accurate completion of the documentation when using such a tool. The rationale and steps undertaken to achieve this are outlined and the benefits of such a process are highlighted.     

Validation of the simplified therapeutic intervention scoring system on an independent database

Objective: To evaluate the performance of the Simplified Therapeutic Intervention Scoring System on an independent database and determine its relation with the Therapeutic Intervention Scoring System in the quantification of nursing workload in intensive care. Design: Analysis of the database of a multicenter prospective Portuguese study. Setting: 19 intensive care units (ICUs) in Portugal. Patients: Data on 1094 patients consecutively admitted to the ICUs were collected during a period of 3 months. Methods: Collection of the data necessary for the calculation of the Therapeutic Intervention Scoring System (TISS-76) and the Simplified Therapeutic Intervention Scoring System (TISS-28) during the first 24 h in the ICU. Basic demographic statistics and all the variables necessary for the computation of the Simplified Acute Physiology Score II were also collected. Vital status at discharge from the hospital was registered. Regression techniques, Pearson's correlation and paired sample t-test were used. Results are presented as mean ± standard deviation except when stated otherwise. Reliability was evaluated by the use of intraclass correlation coefficients in a 5 % random sample. Measurements and results: After exclusion of all the patients with missing data, 1080 patients were analysed. The overall mean TISS-28 (29.82 ± 10.64) was significantly lower than the mean TISS-76 (31.14 ± 11.95). Both systems showed very significant differences between ICUs (p < 0.001). The correlation between the two was good, with TISS-28 explaining 72 % of the variation of TISS-76 (r = 0.85, r ² = 0.72). The relation between the two systems was TISS-28 = 6.22 + 0.85 TISS-76. In this cohort, reliability of data collection was very high, with intraclass correlation coefficients greater than 0.90 for both systems. Conclusions: TISS-28 was validated on this independent population. The results indicate that TISS-28 can replace TISS-76 for the measurement of the nursing workload in Portuguese ICUs Received: 29 October 1996 Accepted: 27 February 1997     

治疗干预评分系统-28在ICU护理工作量评估中的应用研究

[目的]探讨治疗干预评分系统-28(TISS-28)在重症监护病房(ICU)护理工作量评估中的应用。[方法]应用TISS-28评分软件,选择ICU病人24h内病情最重时进行评分,并记录ICU每天护士岗位职数。[结果]每位病人每天TISS-28评分为29.11分±8.29分,ICU每天总的TISS-28评分为236.38分±73.75分,每天满足病人直接护理需要的护士岗位职数为17.87人±5.93人,而实际每天护士岗位职数为13.45人±2.70人;ICU护士每天人均TISS-28评分为52.84分±14.00分;1周中每天的总工作量比较差异无统计学意义(P>0.05),1周中每天护士人均护理工作量比较差异有统计学意义(P<0.05)。[结论]TISS-28可准确、简便地测量ICU护理工作量,ICU护士处于超负荷工作状态,ICU护士人力资源现状与所需存在一定的差距。     

治疗干预评分系统-28在ICU护理工作量评估中的应用研究

[目的]探讨治疗干预评分系统-28（TISS-28）在重症监护病房（ICU）护理工作量评估中的应用。[方法]应用TISS-28评分软件,选择ICU病人24h内病情最重时进行评分,并记录ICU每天护士岗位职数。[结果]每位病人每天TISS-28评分为29.11分±8.29分,ICU每天总的TISS-28评分为236.38分±73.75分,每天满足病人直接护理需要的护士岗位职数为17.87人±5.93人,而实际每天护士岗位职数为13.45人±2.70人;ICU护士每天人均TISS-28评分为52.84分±14.00分;1周中每天的总工作量比较差异无统计学意义（P〉0.05）,1周中每天护士人均护理工作量比较差异有统计学意义（P〈0.05）。[结论]TISS-28可准确、简便地测量ICU护理工作量,ICU护士处于超负荷工作状态,ICU护士人力资源现状与所需存在一定的差距。     

Validation of “nine equivalents of nursing manpower use score” on an independent data sample

Objective: To compare the recently developed “nine equivalents of nursing manpower use score” (NEMS) with the simplified Therapeutic Intervention Scoring System (TISS-28). Design: Prospective single centre study. Setting: Adult 30-bed medical-surgical intensive care unit (ICU) in a tertiary care university hospital. Patients: Data from all patients admitted in 1997 to the ICU were included in the study. Methods and results: NEMS and TISS-28 items were recorded prospectively for each nursing shift. There were three shifts per day. The Simplified Acute Physiology Score (SAPS) II was calculated for the first 24 h of ICU stay and each patient's basic demographic data were collected. The agreement between NEMS and TISS-28 was assessed by calculating the mean difference and the standard deviation of the differences between the two measures. Further, regression techniques and Pearson's correlation were used. Altogether, 2743 patients with a total of 28'220 nursing shifts were included; 62 % of the shifts were used for postoperative/trauma patients and 38 % for medical patients. Mean NEMS was 26.0 ± 8.1 and mean TISS-28 was 26.5 ± 7.9. The scores differed by K 3 points in 49 % of all shifts. The bias was −0.5 ± 5.3 (95 % confidence interval −0.47 to −0.60) and the limits of agreement were −11.1 to +10.1. The relation between the two systems was NEMS = 4.7 ± 0.8 · TISS-28 (r = 0.78, r ² = 0.62, p < 0.001). Including postoperative/trauma patients only: NEMS = 1.9 + 0.9 · TISS-28, for medical patients this equation was: NEMS = 6.0 + 0.8 · TISS-28. First-day SAPS II explained 11 % of the variability in first-shift NEMS and 5 % of the variability in first-shift TISS-28. Conclusions: This study confirms a good agreement between TISS-28 and NEMS in a large, independent sample. However, as shown by the differences between medical and postoperative/trauma patients, a change in case mix may result in different regression equations. Further, wide limits of agreement indicate that there may be a rather large variability between the two measures at the individual level. Received: 9 October 1998 Accepted: 16 March 1999     

Serial measurement of Therapeutic Intervention Scoring System-28 (TISS-28) in a surgical intensive care unit

PurposeThe aim of the study was to assess the use of the Therapeutic Intervention Scoring System-28 (TISS-28) in surgical intensive care unit (ICU) patients and the relationship of the score to the type of surgery, severity of illness, and outcome in these patients.Materials and MethodsProspectively collected data from all patients admitted to a postoperative ICU between March 1, 2004, and June 30, 2006, were analyzed retrospectively.ResultsA total of 6903 patients were admitted during the study period (63.5% male; mean age, 62.3 years) constituting 29 140 observation days. The mean Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment (SOFA), and TISS-28 scores on the day of ICU admission were 36.9 ± 18.2, 5.8 ± 3.9, and 43.2 ± 10.8, respectively. The highest admission TISS-28 was observed in patients who underwent cardiothoracic surgery (47.7 ± 10.1), the lowest in neurosurgical patients (40 ± 9.6), and both declined during the 2 weeks after ICU admission; however, in trauma patients and those admitted after gastrointestinal surgery, TISS scores increased gradually after the first 2 to 5 days in the ICU. The TISS-28 score was moderately correlated to SAPS II (R² = 0.42; P < .001) and SOFA score (R² = 0.48; P < .001) throughout the ICU stay and was consistently higher in nonsurvivors than in survivors during the first 2 weeks in the ICU.ConclusionsThere are marked variations in TISS-28 scores according to the type of surgery. Therapeutic Intervention Scoring System-28 correlates with the severity of illness and outcome in these patients.     

TISS-28 in difficult to wean patients after long-term mechanical ventilation

PURPOSE: To compare the Therapeutic Intervention Scoring System (TISS) 28 in difficult to wean patients before and after transfer to a weaning center. PATIENTS AND METHODS: Using TISS-28, the authors investigated the difference between regular intensive care units (ICUs) and the respiratory ICU (RICU) of their hospital in difficult to wean patients after long-term mechanical ventilation (MV). Special emphasis was placed on the appropriateness of TISS-28 to cover the specific weaning activities. 63 tracheotomized patients ventilated for more than 14 days were included. RESULTS: In total, 15.9% of patients were not weaned, 20.6% of population was successfully weaned with noninvasive ventilation (NIV), and 63.5% of patients was successfully weaned without NIV. The transfer of patients from other ICUs to a weaning facility resulted in a significant reduction of total TISS-28 from 29.5 to 23.8 points (p<0.001) on average. CONCLUSION: The high weaning success rate in a specialized facility is associated with a significant reduction of TISS-28 scores. The use of TISS-28 in a weaning center for patients with prolonged MV to measure workload does not adequately mirror the efforts by physicians, nurses, physiotherapists, and other health-care personnel.     

Mortality after discharge from intensive care: the impact of organ system failure and nursing workload use at discharge

OBJECTIVES: Mortality after ICU discharge accounts for approx. 20-30% of deaths. We examined whether post-ICU discharge mortality is associated with the presence and severity of organ dysfunction/failure just before ICU discharge. PATIENTS AND METHODS: The study used the database of the EURICUS-II study, with a total of 4,621 patients, including 2,958 discharged alive to the general wards (post-ICU mortality 8.6%). Over a 4-month period we collected clinical and demographic characteristics, including the Simplified Acute Physiology Score (SAPS II), Nine Equivalents of Nursing Manpower Use Score, and Sequential Organ Failure Assessment (SOFA) score. RESULTS: Those who died in the hospital after ICU discharge had a higher SAPS II score, were more frequently nonoperative, admitted from the ward, and had stayed longer in the ICU. Their degree of organ dysfunction/failure was higher (admission, maximum, and delta SOFA scores). They required more nursing workload resources while in the ICU. Both the amount of organ dysfunction/failure (especially cardiovascular, neurological, renal, and respiratory) and the amount of nursing workload that they required on the day before discharge were higher. The presence of residual CNS and renal dysfunction/failure were especially prognostic factors at ICU discharge. Multivariate analysis showed only predischarge organ dysfunction/failure to be important; thus the increased use of nursing workload resources before discharge probably reflects only the underlying organ dysfunction/failure. CONCLUSIONS: It is better to delay the discharge of a patient with organ dysfunction/failure from the ICU, unless adequate monitoring and therapeutic resources are available in the ward.     

Nursing workload assessment in an intensive care unit: A retrospective observational study using the Nursing Activities Score

Background

Nursing Activities Score (NAS) is a promising tool for calculating the nursing workload in intensive care units (ICU). However, data on intensive care nursing activities in Portugal are practically non-existent.

Aim

To assess the nursing workload in a Portuguese ICU using the NAS.

Study Design

Retrospective cohort study developed throughout the analysis of the electronic health record database from 56 adult patients admitted to a six-bed Portuguese ICU between 1 June–31 August 2020. The nursing workload was assessed by the Portuguese version of the NAS. The study was approved by the Hospital Council Board and Ethics Committee. The study report followed the STROBE guidelines.

Results

The average occupancy rate was 73.55% (±16.60%). The average nursing workload per participant was 67.52 (±10.91) points. There was a correlation between the occupancy rate and the nursing workload. In 35.78% of the days, the nursing workload was higher than the available human resources, overloading nurse staffing/team.

Conclusions

The nursing workload reported follows the trend of the international studies and the results reinforce the importance of adjusting the nursing staffing to the complexity of nursing care in this ICU. This study highlighted periods of nursing workload that could compromise patient safety.

Relevance to Clinical Practice

This was one of the first studies carried out with the NAS after its cross-cultural adaptation and validation for the Portuguese population. The nursing workload at the patient level was higher in the first 24 h of ICU stays. Because of the ‘administrative and management activities’ related to the ‘patient discharge procedures’, the last 24 h of ICU stays also presented high levels of nursing workload. The implementation of a nurse-to-patient ratio of 1:1 may contribute to safer nurse staffing and to improve patient safety in this Tertiary (level 3) ICU.     

Case-mix-adjusted length of stay and mortality in 23 Finnish ICUs

Objectives  To create a tool for benchmarking intensive care units (ICUs) with respect to case-mix adjusted length of stay (LOS) and to study the association between clinical and economic measures of ICU performance. Design  Observational cohort study. Setting  Twenty-three ICUs in Finland. Patients  A total of 80,854 consecutive ICU admissions during 2000–2005, of which 63,304 met the inclusion criteria. Interventions  None. Measurements and results  Linear regression was used to create a model that predicted ICU LOS. Simplified Acute Physiology Score (SAPS) II, age, disease categories according to Acute Physiology and Chronic Health Evaluation III, single highest Therapeutic Intervention Scoring System score collected during the ICU stay and presence of other ICUs in the hospital were included in the model. Probabilities of hospital death were calculated using SAPS II, age, and disease categories as covariates. In the validation sample, the created model accounted for 28% of variation in ICU LOS across individual admissions and 64% across ICUs. The expected ICU LOS was 2.53 ± 2.24 days and the observed ICU LOS was 3.29 ± 5.37 days, P < 0.001. There was no association between the mean observed − mean expected ICU LOS and standardized mortality ratios of the ICUs (Spearman correlation 0.091, P = 0.680). Conclusions  We developed a tool for the assessment of resource use in a large nationwide ICU database. It seems that there is no association between clinical and economic quality indicators. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Comparison of Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) scoring systems in a single Greek intensive care unit

OBJECTIVE: To evaluate Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiology Score (SAPS) II scoring systems in a single intensive care unit (ICU), independent from the ICUs of the developmental sample; and to compare the performance of APACHE II and SAPS II by means of statistical analyses in such a clinical setting. DESIGN: Prospective, cohort study. SETTING: A single ICU in a Greek university hospital. PATIENTS: In a time interval of 5 yrs, data for 681 patients admitted to our ICU were collected. The original exclusion criteria of both systems were employed. Patients <17 yrs of age were dropped from the study to keep compatibility with both systems. Eventually, a total of 661 patients were included in the analysis. INTERVENTIONS: Demographics, clinical parameters essential for the calculation of APACHE II and SAPS II scores, and risk of hospital death were recorded. Patient vital status was followed up to hospital discharge. MEASUREMENTS AND MAIN RESULTS: Both systems showed poor calibration and underestimated mortality but had good discriminative power, with SAPS II performing better than APACHE II. The evaluation of uniformity of fit in various subgroups for both systems confirmed the pattern of underprediction of mortality from both models and the better performance of APACHE II over our data sample. CONCLUSIONS: APACHE II and SAPS II failed to predict mortality in a population sample other than the one used for their development. APACHE II performed better than SAPS II. Validation in such a population is essential. Because there is a great variation in clinical and other patient characteristics among ICUs, it is doubtful that one system can be validated in all types of populations to be used for comparisons among different ICUs.     

Validation of the new Intensive Care Nursing Scoring System (ICNSS)

OBJECTIVES: To validate a new Intensive Care Nursing Scoring System (ICNSS). DESIGN: Retrospective data collection. SETTING: Adult 19-bed intensive care unit (ICU) in a tertiary care university hospital. PATIENTS: A total of 1,538 patient records of which 30 documents were included in the validation. MEASUREMENTS AND RESULTS: Data included admission scores of the Acute Physiology and Chronic Health Evaluation II (APACHE II) and the Simplified Acute Physiology Scores II (SAPS II), daily Therapeutic Intervention Scores (TISS) and ICNSS scores. Data were compared using Spearman's correlation, t-test and chi-square test. Receiver operating characteristics (ROC) curve analysis was used to assess the ability of ICNSS and TISS to predict mortality. Intra-class correlation, percentage agreement and kappa statistics were used to test the validity of given scores. Nursing workload assessment using ICNSS showed that medical and emergency-operated patients caused a greater nursing workload than electively operated patients (p<0.001). Six variables of the sub-scale that described vital function nursing accounted for 27.4% of the variation of SAPS II and for 37% of the variation of APACHE II. The ICNSS sub-scale of vital function nursing accounted for a ROC area of 0.91. In the validity of the given ICNSS scores, kappa was 0.81 and weighted kappa 0.82. CONCLUSIONS: Nursing workload varied between the different admission types. ICNSS explained a similar percentage of the variation of the admission scores of APACHE II and SAPSS II as TISS and discriminated between non-survivors and survivors. ICNSS is a suitable nursing workload instrument to be used with the TISS score.     

Risk factors for prolonged stay in cardiac surgery intensive care units

Aims and objectives: To identify the factors that might affect the length of stay in the intensive care unit (ICU‐LOS) among cardiac surgery patients. Background: ICU‐LOS forms an important factor for assessing the effectiveness of the provided nursing care. A number of factors can be accused for increasing patient hospitalization. The nursing workload (NWL), among others, was found to play a significant role as it is closely associated with the quality of care. Design: An observational cohort study among 313 consecutive patients who were admitted to the cardiac surgery intensive care unit of a general, tertiary hospital of Athens, Greece from November 2008 to November 2009. Methods: Data collection was performed by using a short questionnaire (for basic demographic information) and two instruments, the Nursing Activities Score (NAS) and the logistic EuroSCORE, for assessing the NWL and the perioperative risk for each patient respectively. Results: ICU‐LOS of more than 2 days increased with age and was more common among females (p < 0·001 and p = 0·02, respectively). Multivariate logistic regression analysis revealed a positive association between increased perioperative risk and the increased ICU‐LOS [odd ratio (OR) 1·9, 95% confidence interval (CI) 1·0–3·5, p = 0·04], while patients with a first day NAS of more than 61·6% had an almost 5·2 times greater probability to stay in the cardiac surgery unit for more than 2 days (OR 5·2, 95% CI 3·0–8·8, p < 0·001). Conclusions: Increased level of NWL and patient perioperative risk are closely associated with increased ICU‐LOS. Relevance to clinical practice: The correlation between patient perioperative risk and ICU‐LOS encourages the early identification of high‐risk patients for prolonged hospitalization. Furthermore, the relationship between NWL and ICU‐LOS allows the early identification of these patients with the use of an independent nursing tool.