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Pretransport Pediatric Risk of Mortality (PRISM) score underestimates the requirement for intensive care or major
R A Orr1, S T Venkataraman, M I Cinoman
1Department of Anesthesiology/Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, PA.
Insights
The Pediatric Risk of Mortality (PRISM) score often underestimates the need for intensive care and interventions in critically ill children during interhospital transport. This suggests PRISM is not a reliable triage tool for pediatric patient transfers.
Area of Science:
- Pediatric Critical Care Medicine
- Healthcare Quality and Safety
- Transport Medicine
Background:
- Interhospital transport of critically ill children requires accurate assessment of patient acuity.
- The Pediatric Risk of Mortality (PRISM) score is used to predict severity of illness.
- The utility of pretransport PRISM scores in guiding resource allocation and intervention needs during pediatric transfers is unclear.
Purpose of the Study:
- To evaluate whether pretransport Pediatric Risk of Mortality (PRISM) scores underestimate the need for intensive care and interventions in pediatric patients undergoing interhospital transport.
- To assess the accuracy of PRISM scores in identifying children at risk for clinical deterioration during transport.
Main Methods:
- Prospective, descriptive study of 156 pediatric patients transferred to a tertiary care center.
- Two PRISM scores were calculated: Referral PRISM (telephone data) and Team PRISM (on-site data before intervention).
- Admission location (ICU vs. non-ICU) and number of major clinical interventions were recorded.
Main Results:
- Referral PRISM scores underestimated Team PRISM scores.
- A significant proportion of patients admitted to the ICU (75%) had a low Team PRISM score (<=10).
- Many children requiring major interventions during transport also had low Team PRISM scores (71% for any intervention, 63% for transport team intervention).
Conclusions:
- Pretransport PRISM scores inadequately predict the need for intensive care and major interventions in pediatric interhospital transport.
- Patients with low PRISM scores may still require intensive care and interventions, indicating they are not low-risk.
- The PRISM score is not recommended as a severity of illness measure or triage tool for pediatric interhospital transport.
Objective:
To test the hypothesis that a pretransport Pediatric Risk of Mortality (PRISM) score underestimates the requirement for both intensive care and interventions during pediatric interhospital transport.
Design:
Prospective, descriptive study.
Setting:
All children were treated in a regional hospital and then transported to a pediatric tertiary care center by a pediatric critical care specialty team.
Patients:
Children (n = 156) with a median age of 1.3 yrs (range newborn to 18 yrs).
Interventions:
None related to the study.
Measurements And Main Results:
Two sets of Pediatric Risk of Mortality scores were calculated: one from data collected over the telephone at the time of the referral (Referral PRISM), and one from both the referring hospital's records and from data collected by the transport team on arrival at the referring hospital and before the team provided any intervention (Team PRISM). The admission area used on arrival at the tertiary care center (intensive care unit [ICU] vs. non-ICU) and the number of major clinical interventions performed by both the referring hospital staff and the transport team were recorded. The Therapeutic Intervention Scoring System was used to assess the cumulative level of medical care provided up to 8 hrs after admission to the pediatric tertiary care hospital. No patient died during transport. The overall in-hospital mortality rate was 5.1%. Median Therapeutic Intervention Scoring System scores were higher for patients admitted to the ICU (16 vs. 4, p < .001). Whereas median PRISM scores were significantly higher in those children admitted to the ICU (4 vs. 0, p < .001), 58 (75%) of 77 ICU admissions had a Team PRISM score of < or = 10. Forty-four (71%) of 62 children who required at least one major intervention at some time during the transport process and 15 (63%) of 24 children who required at least one major intervention by the transport team had a Team PRISM score of < or = 10. Referral PRISM scores underestimated Team PRISM scores.
Conclusions:
PRISM scores determined before interhospital transfer of pediatric patients underestimated the requirement for intensive care and the performance of major interventions in the pretransport setting. Many patients with low PRISM scores required intensive care on admission to the receiving hospital and major interventions during the transport process, and, therefore, were not at "low risk" for clinical deterioration. The PRISM score should not be used as a severity of illness measure or triage tool for pediatric interhospital transport.