Measuring nursing care in pediatric cardiac intensive care units

By Patricia A. Hickey, PhDJean Anne Connor DNSc, RN, CPNPChristine A. Lagrasta MS, RN, CPNP-PC/AC

Despite advances in practice, pediatric critical care nurses have been chal­lenged to design a workload tool that truly captures the skill and cognitive complexity required to deliver compre­hensive patient care. Prior efforts to cre­ate nursing workload tools have focused on adult intensive care patients and do not capture the current scope and com­plexity of pediatric critical care nursing. Information technology provides an effective, efficient means to overcome these limitations.

In 2009, efforts began in the Boston Children’s Hospital pediatric cardiac critical care unit to develop a tool that could qualify and quantify the complex assessment, monitoring and therapeu­tic interventions performed by nurses caring for cardiovascular patients. An expert panel of cardiac nurse clinicians developed a detailed description of the autonomous nature and comprehensive nursing management required for a complex pediatric cardiac popula­tion. The result is a tool called CAMEO: Complexity Assessment & Monitoring to Ensure Optimal Outcomes.

CAMEO monitors nursing activity in 19 domains of care (Figure 1). Each domain contains specific items of care, scored from basic to complex. To obtain an overall score, each activity is given a cognitive complexity value based on a scale from 1 to 5. The total score is calculated across the 19 domains of care and then classified as I-V in overall complexity of care.

To test the nursing CAMEO tool, information was gathered on 75 patients, from 1 day to 47 years old, who were admitted to the CICU for surgical recov­ery (86%) and/or medical intervention (14%). The data showed that the majority of patient care activities involved com­plicated elements. Standard intensive care monitoring of less than one hour was reported in 42% of patients. Vaso­active intravenous medication requiring titration was noted in 78% patients. Ven­tilated patients (72%) required a num­ber of interventions to maintain airway patency and acid-base balance as well as to achieve weaning goals.

Additional nursing activities were also identified and tracked, including care focused on teaching and anticipatory guidance to patients and families and coordination of services such as social work, case management, interpreter services, and clergy. Precepting new staff, quality monitoring, research data collection, clinical management plans and other regulatory documentation were also identified. Among the 75 patients, 80% met Class III or IV, with 7% categorized as Class V.

Now, the CAMEO tool is moving from “proof of concept” to daily practice in the pediatric cardiac intensive care unit. Twice each day, the CAMEO is com­pleted electronically to provide frontline nursing staff with the ability to quantify nursing care based on the cognitive complexity required to maintain safe care practices and promote optimal healing. This real-time quantification of nursing resource use and benchmark­ing supports both the daily assessment needs of bedside clinicians and the needs of administrative leaders seek­ing to justify and support appropriate resource utilization.

CAMEO complements the “Tracking, Trajectory and Triggering” platform, also known as “T3.” A monitoring tool developed at Boston Children’s Cardiac Intensive Care Unit, T3 links data from bedside monitors keeping watch over a child and presents their readouts togeth­er, in context, on the same screen. T3 reduces “information overload” in the ICU and improves decision-making for doctors and nurses.

Further adaptation of the CAMEO to qualify and quantify nursing care has begun in the medical/surgical and neo­natal intensive care units, with the goal of having a complexity tool that cap­tures the practice of critical care nursing throughout all of Boston Children’s Hospital intensive care units. Develop­ment of a nursing CAMEO for step-down and general ward patients is already under way. CAMEO was/is funded by Boston Chil­dren’s Hospital, Program Patient Safety & Quality, 2009 and 2012, and supported by Boston Children’s Hospital Cardiac Intensive Care Unit.