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Pediatric Index of Mortality 3-An Evaluation of Function Among ICUs In South Africa
Lincoln J Solomon1,2, Kuban D Naidoo3, Ilse Appel4
1Department of Paediatrics and Child Health, University of the Free State Faculty of Health Sciences School of Medicine Bloemfontein, South Africa.
Insights
The Pediatric Index of Mortality 3 shows good discrimination for predicting mortality in South African pediatric intensive care units. However, recalibration is needed due to differences in patient case-mix compared to the original derivation cohort.
Area of Science:
- Pediatric critical care medicine
- Health services research
- Biostatistics
Background:
- Accurate mortality risk assessment is crucial for pediatric intensive care units (PICUs).
- The Pediatric Index of Mortality 3 (PIM3) is a widely used model for predicting mortality in critically ill children.
- Evaluating PIM3 performance in diverse healthcare settings like South Africa is essential.
Purpose of the Study:
- To assess the performance of the Pediatric Index of Mortality 3 (PIM3) as a mortality risk assessment model in South African PICUs.
- To determine the model's discrimination and calibration in a local context.
Main Methods:
- A prospective study was conducted over 12 months (2016-2017) in nine tertiary/quaternary academic hospitals in South Africa.
- Data included patient demographics, diagnoses, PIM3 variables, PICU outcomes (death/survival), and length of stay for admissions aged 30 days to 18 years.
- Statistical analysis involved calculating the standardized mortality ratio (SMR) and the area under the receiver operating characteristic curve (AUC).
Main Results:
- The study included 3,681 admissions, with 354 deaths (9.6%).
- PIM3 predicted 277.47 deaths, resulting in an overall SMR of 1.28.
- The AUC was 0.81, indicating good discrimination, but the Hosmer-Lemeshow test showed poor calibration (p < 0.001).
- SMRs were greater than 1 for most age and diagnostic groups, suggesting over-prediction of mortality.
Conclusions:
- The Pediatric Index of Mortality 3 demonstrates good discrimination for predicting mortality in South African PICUs.
- Poor calibration may be attributed to differences in patient case-mix between the PIM3 derivation cohort and the South African cohort.
- Recalibration of the PIM3 model to the local South African setting is recommended for improved accuracy.
Objectives:
To evaluate the performance of the Pediatric Index of Mortality 3 as mortality risk assessment model.
Design:
This prospective study included all admissions 30 days to 18 years old for 12 months during 2016 and 2017. Data gathered included the following: age and gender, diagnosis and reason for PICU admission, data specific for the Pediatric Index of Mortality 3 calculation, PICU outcomes (death or survival), and length of PICU stay.
Setting:
Nine units that care for children within tertiary or quaternary academic hospitals in South Africa.
Patients:
All admissions 30 days to 18 years old, excluding premature infants, children who died within 2 hours of admission, or children transferred to other PICUs, and those older than 18 years old.
Interventions:
None.
Measurements And Main Results:
There were 3,681 admissions of which 2,253 (61.3%) were male. The median age was 18 months (interquartile range, 6-59.5 mo). There were 354 deaths (9.6%). The Pediatric Index of Mortality 3 predicted 277.47 deaths (7.5%). The overall standardized mortality ratio was 1.28. The area under the receiver operating characteristic curve was 0.81 (95% CI 0.79-0.83). The Hosmer-Lemeshow goodness-of-fit test statistic was 174.4 (p < 0.001). Standardized mortality ratio for all age groups was greater than 1. Standardized mortality ratio for diagnostic subgroups was mostly greater than 1 except for those whose reason for PICU admission was classified as accident, toxin and envenomation, and metabolic which had an standardized mortality ratio less than 1. There were similar proportions of respiratory patients, but significantly greater proportions of neurologic and cardiac (including postoperative) patients in the Pediatric Index of Mortality 3 derivation cohort than the South African cohort. In contrast, the South African cohort contained a significantly greater proportion of miscellaneous (including injury/accident victims) and postoperative noncardiac patients.
Conclusions:
The Pediatric Index of Mortality 3 discrimination between death and survival among South African units was good. Case-mix differences between these units and the Pediatric Index of Mortality 3 derivation cohort may partly explain the poor calibration. We need to recalibrate Pediatric Index of Mortality 3 to the local setting.
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