Measuring care complexity: a retrospective cross-sectional observational study - CardioMEO PediCARE (Ancona, Italy)

Abstract

Background: The increasing clinical complexity of pediatric patients, combined with global nursing workforce shortages, requires reliable tools to measure nursing care complexity and support evidence-based staffing decisions. In highly specialized settings such as pediatric cardiovascular units, patient acuity and cognitive nursing workload are particularly demanding. However, data on validated tools for assessing care complexity in pediatric contexts remain limited.

Objective: To measure nursing care complexity in pediatric cardiovascular patients and to identify clinical and organizational factors associated with higher complexity levels using validated pediatric acuity tools.

Material and methods: A retrospective cross-sectional observational study was conducted on 313 patient records from the Pediatric and Congenital Cardiac Surgery and Cardiology Unit and the Pediatric Intensive Care Unit of a tertiary university hospital in Italy (January-December 2022). Nursing care complexity was assessed using the CAMEO II tool for intensive care and the Inpatient CAMEO tool for ward settings. Descriptive statistics were performed. Associations between complexity and categorical variables were analyzed using chi-square tests. Simple and multiple linear regression analyses were conducted to identify predictors of baseline complexity (T0). Statistical significance was set at p 0.05.

Results: All patients admitted to the intensive care unit showed medium nursing care complexity. In the inpatient cardiac unit, 27% of patients had low complexity and 73% had medium complexity; no high-complexity cases were observed. Younger age was significantly associated with higher complexity (B = -0.29, p 0.001). Urgent admission (B = 6.73, p 0.001) and longer hospital stay (B = 0.37, p 0.001) were also significant predictors. Organizational variables, including day of the week and work shift, were not significantly associated with complexity. The regression model explained 46% of the variance in baseline complexity scores (adjusted R² = 0.451).

Discussion and conclusions: In pediatric cardiovascular settings, nursing care complexity is primarily driven by patient-related clinical factors rather than organizational variables. Younger and urgently admitted patients with longer hospital stays require higher cognitive nursing workload. The systematic implementation of validated acuity tools such as CAMEO II and Inpatient CAMEO may support evidence-based workforce planning, optimize nurse-to-patient ratios according to patient acuity, and enhance quality and safety of care. These findings are particularly relevant in the context of healthcare resource constraints and contribute to improving organizational decision-making in specialized pediatric settings.