Measuring Acuity and Pediatric Critical Care Nursing Workload by Using ICU CAMEO III.

BACKGROUND: The Intensive Care Unit Complexity Assessment and Monitoring to Ensure Optimal Outcomes (ICU CAMEO III) acuity tool measures patient acuity in terms of the complexity of nursing cognitive workload. OBJECTIVE: To validate the ICU CAMEO III acuity tool in US children's hospitals. METHODS: Using a convenience sample, 9 sites enrolled children admitted to pediatric intensive care units (ICUs). Descriptive statistics were used to summarize patient, nursing, and unit characteristics. Concurrent validity was evaluated by correlating the ICU CAMEO III with the Therapeutic Intervention Scoring System-Children (TISS-C) and the Pediatric Risk of Mortality III (PRISM III). RESULTS: Patients (N = 840) were enrolled from 15 units (7 cardiac and 8 mixed pediatric ICUs). The mean number of ICU beds was 23 (range, 12-34). Among the patients, 512 (61%) were diagnosed with cardiac and 328 (39%) with noncardiac conditions; 463 patients (55.1%) were admitted for medical reasons, and 377 patients (44.9%) were surgical. The ICU CAMEO III median score was 99 (range, 59-163). The ICU CAMEO complexity classification was determined for all 840 patients: 60 (7.1%) with level I complexity; 183 (21.8%) with level II; 201 (23.9%), level III; 267 (31.8%), level IV; and 129 (15.4%), level V. Strong correlation was found between ICU CAMEO III and both TISS-C (ρ = .822, P < .001) and PRISM III (ρ = .607, P < .001) scores, and between the CAMEO complexity classifications and the PRISM III categories (ρ = .575, P = .001). CONCLUSION: The ICU CAMEO III acuity tool and CAMEO complexity classifications are valid measures of patient acuity and nursing cognitive workload compared with PRISM III and TISS-C in academic children's hospitals.

Refinement of the Intensive Care Unit Complexity Assessment and Monitoring to Ensure Optimal Outcomes III Acuity Tool.

BACKGROUND: The Intensive Care Unit (ICU) Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO) acuity tool quantifies patient acuity in terms of nursing cognitive workload complexity. OBJECTIVES: The aim of this study was to refine the ICU CAMEO II acuity tool. An expert panel of nursing staff from 4 pediatric ICUs convened to refine the CAMEO II across a large, freestanding children's hospital in the United States. METHOD: This study used a modified Delphi technique. RESULTS: Through a series of 4 Delphi rounds, the expert panel identified Domains of Care and nursing care items that were suitable to be collapsed or bundled. The number of Domains of Care decreased from 18 to 10. Each of the expert panel members then completed the ICU CAMEO II tool and the newly revised tool, ICU CAMEO III, on 5 to 10 patients. Sixty completed ICU CAMEO II tools, and ICU CAMEO III tools were available for comparison. The average difference of the 2 tools' total scores was 5 points (minimum, 4; maximum, 7). The level of agreement between the 2 tools by CAMEO Complexity Classification level (I-V) was 90%. DISCUSSION: The ICU CAMEO III acuity tool is a streamlined measure to describe and quantify the acuity of pediatric critical care nursing. Use of this acuity measure will support projection of staffing models, staffing assignments, and benchmarking across pediatric ICUs. Further research is underway to validate the CAMEO III for multisite use.

Clinical descriptors of pneumothorax following chest tube removal in paediatric cardiac surgery.

BACKGROUND: There is limited data describing the characteristics of paediatric post-operative cardiac surgery patients who develop pneumothoraces after chest tube removal. Patient management after chest tube removal is not standardised across paediatric cardiac surgery programmes. The purposes of this study were to describe the frequency of pneumothorax after chest tube removal in paediatric post-operative cardiac surgical patients and to describe the patient and clinical characteristics of those patients who developed a clinically significant pneumothorax requiring intervention. METHODS: A single-institution retrospective descriptive study (1 January, 2010-31 December, 2018) was utilised to review 11,651 paediatric post-operative cardiac surgical patients from newborn to 18 years old. RESULTS: Twenty-five patients were diagnosed with a pneumothorax by chest radiograph following chest tube removal (0.2%). Of these 25 patients, 15 (1.6%) had a clinically significant pneumothorax and 8 (53%) did not demonstrate a change in baseline clinical status or require an increase in supplemental oxygen, 14 (93%) required an intervention, 9 (60%) were <1 year of age, 4 (27%) had single-ventricle physiology, and 5 (33%) had other non-cardiac anomalies/genetic syndromes. CONCLUSIONS: In our cohort of patients, we confirmed the incidence of pneumothorax after chest tube removal is low in paediatric post-operative cardiac surgery patients. This population does not always exhibit changes in clinical status despite having clinically significant pneumothoraces. We suggest the development of criteria, based on clinical characteristics, for patients who are at increased risk of developing a pneumothorax and would require a routine chest radiograph following chest tube removal.

The Measurement of Pediatric Inpatient Nursing Using the Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO©) Tool.

PURPOSE: Physiologic measurement of patient acuity has been used to predict patient outcomes, length of stay, and resource utilization. To date, these tools are not sufficiently comprehensive to inform nurse staffing assignments and have limited practical application. The Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO©) acuity tool was initially developed and validated to quantify patient acuity in terms of complexity of nursing cognitive workload in pediatric intensive care units (ICU). This article describes development and implementation of the Inpatient CAMEO© in the pediatric inpatient setting. DESIGN AND METHODS: Utilizing a modified Delphi technique, an expert panel convened to scale and implement the Inpatient CAMEO© in the pediatric inpatient units through four Delphi rounds. RESULTS: The expert panel identified care items unique to the pediatric inpatient setting and assigned a cognitive workload scale of 1-5. To consolidate the tool, the panel identified items to be classified as "Standard of Care" and developed a new baseline score for the Inpatient CAMEO©. Expert panel members served as unit-based ambassadors to foster the expansion and implementation of the new Inpatient CAMEO©. CONCLUSIONS: The Inpatient CAMEO© describes and quantifies acuity beyond the intensive care setting. The implementation and use of the Inpatient CAMEO© was accomplished through unit-based ambassadors and the support of leadership. PRACTICE IMPLICATIONS: Quantifying nursing cognitive workload in both direct and indirect care is important to determining nursing assignments and comprehensive staffing models in the pediatric inpatient setting.

Scaling the Measurement of Pediatric Acuity Using the Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO II) Tool.

BACKGROUND: The Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO) acuity tool was developed to quantify patient acuity in terms of nursing cognitive workload complexity. An expert panel including representatives from 4 intensive care units (ICUs) convened to scale and implement the CAMEO II across the ICUs in a large, freestanding children's hospital in the United States. OBJECTIVES: The aims of this study were to scale and implement a standardized acuity measure of pediatric critical care nursing. METHOD: This study used a modified Delphi technique. RESULTS: Through a series of 3 Delphi rounds, the expert panel identified care items not characterized in the original CAMEO and assigned each of these items a cognitive workload scale of 1 to 5. The expert panel identified 4 additional Domains of Care while confirming the original 14 Domains of Care in the first CAMEO version. The panel agreed that a number of care items could be classified as "Standard of Care," reducing items in the CAMEO and generating a baseline score. The panel, serving as ambassadors and unit-based experts, then implemented the refined CAMEO II in each of the 4 ICUs. DISCUSSION: Utilization of the CAMEO II across ICUs provides a standardized measure to describe and quantify the acuity of pediatric critical care nursing. Use of this acuity measure informs projection of staffing models and benchmarking across pediatric ICUs. Further research is needed to validate the CAMEO II for multisite use.

Validation of the Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO II) Acuity Tool for Pediatric Critical Care Nursing.

BACKGROUND: The Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO II) acuity tool was developed to quantify patient acuity in terms of nursing cognitive workload complexity in a large, freestanding children's hospital in the United States. OBJECTIVES: To describe the acuity and complexity of pediatric critical care nursing at a large children's hospital and correlate the CAMEO II with pediatric physiologic measures. METHODS: Construct validation was conducted correlating the CAMEO II to a pediatric classification system and 2 physiologic acuity tools. Descriptive statistics summarized patient characteristics. Construct validity across tools was evaluated using the Spearman correlation coefficient. RESULTS: CAMEO II was described both continuously and as ordinal complexity levels (I-V). Among 235 patients who completed CAMEO II across 4 intensive care units (ICUs), the mean total score was 99.06 (median, 97; range, 59-204). The CAMEO II complexity classification for 235 patients was as follows: I: 22 (9.4%), II: 53 (22.6%), III: 56 (23.8%), IV: 66 (28.1%), and V: 38 (16.2%). Findings from the 235 patients across the 4 ICUs revealed a significant correlation between the CAMEO II and the Therapeutic Intervention Scoring System-Children (ρ = 0.567, P < .001), CAMEO II and Pediatric Risk of Mortality III (ρ = 0.446, P < .001), and the CAMEO II and Score for Neonatal Acute Physiology Perinatal Extension II (ρ = 0.359, P = .013). DISCUSSION: Utilization of CAMEO II across ICUs provides an opportunity to validate the current complexity of pediatric critical care nursing in a large children's hospital.

Competency-based Professional Advancement Model for Advanced Practice RNs.

The process of developing a 3-tiered advanced practice RN (APRN) competency-based professional advancement model at Boston Children's Hospital is described. The model recognizes the contributions of entry-level and expert APRNs to advanced clinical practice and outcomes, impact, and leadership, while incorporating the tenets of Patricia Benner's Novice to Expert Model and the American Association of Critical- Care Nurses Synergy Model of Care.

Simulation training improves team dynamics and performance in a low-resource cardiac intensive care unit.

INTRODUCTION: Although simulation training has been utilized quite extensively in highincome medical environments, its feasibility and effect on team performance in lowresource pediatric Cardiac Intensive Care Unit (CICU) environments has not been demonstrated. We hypothesized that lowfidelity simulationbased crisis resource management training would lead to improvements in team performance in such settings. METHODS: In this prospective observational study, the effect of simulation on team dynamics and performance was assessed in 23 healthcare providers in a pediatric CICU in Southeast Asia. A 5day training program was utilized consisting of various didactic sessions and simulation training exercises. Improvements in team dynamics were assessed using participant questionnaires, expert evaluations, and video analysis of time to intervention and frequency of closedloop communication. RESULTS: In subjective questionnaires, participants noted significant (P < 0.05) improvement in team dynamics and performance over the training period. Video analysis revealed a decrease in time to intervention and significant (P < 0.05) increase in frequency of closedloop communication because of simulation training. CONCLUSIONS: This study demonstrates the feasibility and effectiveness of simulationbased training in improving team dynamics and performance in lowresource pediatric CICU environments, indicating its potential role in eliminating communication barriers in these settings.

Complexity Assessment and Monitoring to Ensure Optimal Outcomes Tool for Measuring Pediatric Critical Care Nursing.

BACKGROUND: Historically, nursing productivity has been measured in adult settings and based on time, intensity, and resource allocation. OBJECTIVE: To develop a comprehensive measure of pediatric critical care nursing workload. METHODS: An expert panel of pediatric critical care nurses used a modified Delphi method to identify 14 domains of nursing care with a number of corresponding care items in each domain. By consensus, they assigned each care item a cognitive complexity rating from 1 to 5. The panel next developed a classification system (classes I-V) to support interpretation of the patient's total score. The Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO) tool was initiated with a cohort of 75 pediatric cardiac critical care patients to verify comprehensive capture of nursing care. Results of completed CAMEO tools were summarized by using descriptive statistics. RESULTS: The cognitive workload across 14 domains of care was described, and each care item in the domain was scored. The range of CAMEO total scores was 25 to 230 (median, 124). For the initial cohort of patients, the cognitive complexity of care classifications were 13% as class I or II, 80% as class III or IV, and 7% as class V. CONCLUSIONS: The CAMEO tool was comprehensive in describing and quantifying the cognitive workload of pediatric critical care nurses. The CAMEO classification process informs staffing needs that support synergy between the needs of patients and their families and nurses' knowledge and skill. Articulation of nursing care focused on informed clinical decision making is needed to justify the value of skilled nurses.