Joseph M. Civetta

Therapeutic intervention scoring system: a method for quantitative comparison of patient care.

A Therapeutic Intervention Scoring System (TISS) is presented to allow quantitative comparison of patient care and research experiences of different intensive care units. 57 items of therapeutic intervention are scored on a one to four basis according to intensity of involvement. The points acquired per patient per 24 hours are summated by an experienced observer. TISS has been used to: 1) determine appropriate utilization of intensive care facilities at the Massachusetts General Hospital; 2) provide information on nurse staffing ratios for various patient care areas; 3) quantitatively validate a clinical classification of critically ill patients into four categories, thereby simplifying and organizing activities relating to patient care; 4) analyze cost of intensive care relative to the extent of care offered. Assumptions inherent in formulating this system are discussed. If other intensivists incorporate this system into their experience, meaningful comparisons between intensive care units can occur.

Therapeutic intervention scoring system

The Therapeutic Intervention Scoring System (TISS) introduced in 1974 has become a widely accepted method of classifying critically ill patients. In response to requests to update the system because of recent innovations in critical care, some items have been deleted, some have been added, and certa

Terminology update: optimal PEEP.

: The term, optimal PEEP, requires redefinition in the light of new clinical data. With the onset of acute respiratory failure heralded by blood gas evidence of decreased oxygenation, PEEP is supplied in quantities sufficient to restore intrapulmonary shunt (Qsp/Qt) to a preselected goal of 15%. This is compatible with published criteria defining adequate blood gas exchange. Now rather than permitting reduction of cardiac output to be the end point of PEEP application, selective cardiovascular interventions to support preload, contractility, or afterload are made as appropriate so that cardiac function may be maintained until the preselected endpoint of shunt reduction of 15% can be made.

Clinical utility of a colorimetric end-tidal CO2 detector in cardiopulmonary resuscitation and emergency intubation

The purposes of this study were to evaluate the clinical utility of a colorimetric end-tidal CO2 (ETCO2) detector in confirming proper endotracheal intubation in patients requiring emergency intubation, to determine if this new device can be used as an adjunct to judge the effectiveness of cardiopulmonary resuscitation (CPR), and to determine whether the device can predict successful resuscitation from cardiopulmonary arrest. We studied prospectively 110 patients requiring emergency intubation for either respiratory distress (53 patients) or cardiopulmonary arrest (57 patients) by recording the color range of the indicator after the initial intubation. In patients who suffered a cardiopulmonary arrest, the color range was also recorded during CPR after the endotracheal tube was confirmed to be in the tracheal position and perfusion optimized, and at the moment CPR was stopped. The ETCO2 detector was 100% specific for correct endotracheal intubation in all patients. It was also highly sensitive (0.98) for correct endotracheal intubation in patients with respiratory distress. However, it was not sensitive (0.62) in patients with cardiopulmonary arrest and low perfusion. The sensitivity improved (0.88) when we used the ETCO2 range obtained after attempts to increase perfusion. A low ETCO2 color range in 19 patients undergoing CPR was interpreted as low cardiac output and prompted the physicians to attempt to increase perfusion. Of the patients who underwent CPR, no patient whose ETCO2 level remained less than 2% was successfully resuscitated. Those patients who had an ETCO2 level ≥2% had a significantly higher incidence of successful resuscitation. We conclude that the colorimetric ETCO2 detector is reliable and provides reassurance of correct endotracheal tube placement in patients requiring emergency intubation for respiratory distress. This device helps identify patients with low perfusion during CPR and is a useful prognostic indicator of successful short-term resuscitation.

Maintaining quality of care while reducing charges in the ICU. Ten ways.

We believed that the dilemma of controlling costs yet maintaining quality of care might be approached in 10 ways designed to improve efficiency of care: principles of management, elimination of standing orders, classification of patients, written guidelines, mandatory communication, no repetitive orders, single order for single test, removal of monitoring catheters, constant administrative attention, and feedback. We monitored quality of care using the therapeutic intervention scoring system (TISS), mortality, utilization of bed days in the ICU, and the total hospitalization of 50 patients treated in April 1983 and, 8 months after the interventions, 50 patients treated in February 1984. There were no differences in the patient population, severity, outcome, or days. The total lab bills were

Abdominal CT scanning in critically ill surgical patients.

10,000 in 1983 and

Assessment of the Sterility of Long-Term Cardiac Catheterization Using the Thermodilution Swan-Ganz Catheter

6300 in 1984 (p less than 0.01). The total number of tests decreased by 2803 (42%) from 6685 to 3882, or 56 per patient per admission. Calculated ICU laboratory charges per patient decreased

Continuous positive airway pressure (CPAP) by face mask.

3226 (53%) from

Suspected vascular trauma of the extremities: The role of arteriography in proximity injuries

6210 to

Risk and detection of pulmonary artery catheter-related infection in septic surgical patients

2894. In 1983, while patients spent 15% of their hospital days in the ICU, they accumulated 61% of their total laboratory charges. In 1984, ICU days were 19% and ICU laboratory charges were 46% of the total. If the decrease of