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1, 2011
Summary
This study evaluated the outcome of patients in a pediatric intensive care unit (ICU) of a developing
country applying Pediatric Index of Mortality (PIM) version-2 scoring system. A total of 163 consecu-
tive patients were prospectively studied. Data included demographics, diagnoses at admission, PIM-2
score, the duration of ICU stay and hospital outcome. Predicted mortality and standardized mortality
ratio (SMR) were calculated. Respiratory and neurological illnesses were the main admission diagnoses.
The mean length of stay was 5.4 [95% Confidence Intervals (CI): 4–6.9] days. The mean predicted
mortality was 6.2% (95% CI: 4.3–8.1); the observed mortality rate was 5.5%, the SMR being 0.89.
Hosmer–Lemeshow analysis calibrated PIM-2 for the case mix [2 ¼ 5.64 (df ¼ 7), p ¼ 0.58]. The area
under the ROC curve was 0.82 (95% CI: 0.72–0.92) showing a good discriminant function.
Performance of the pediatric ICU in Barbados is comparable to that of developed world by
risk-adjusted outcome evaluation.
ß The Author [2010]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com 9
doi:10.1093/tropej/fmq031 Advance Access published on 12 May 2010
S. HARIHARAN ET AL.
Percentage (%)
cases. Patients get admitted from Emergency
Department directly and from the general wards. A 20
Senior Registrar in pediatric medicine takes care of
the unit around the clock under the supervision of a 15
Consultant. The nurse–patient ratio is 1:1. The
Radiology department and the Pathology, 10
Microbiology laboratories of the hospital have
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and central venous lines. The unit has facilities for
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blood gas analyses, portable radiograph and
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Approval of Ethics Committee was obtained prior
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to conducting the study. All patients consecutively
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admitted to the pediatric ICU over a period of
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1 year from January 2008 to December 2008 were
enrolled for prospective collection of data. The FIG. 1. Diagnostic categories.
demographic data recorded were the age and
gender of the patients. The diagnoses on admission
were noted. PIM-2 scoring system was applied on the illnesses. The denominations of the diagnostic cate-
day of admission to all the patients before any thera- gories are shown in Fig. 1.
peutic intervention was undertaken. Patients were Overall, the patients stayed in the ICU ranging
followed up throughout their stay in ICU and from 1 to 92 days and the mean LOS was 5.4 [95%
during the entire hospital stay to record their final Confidence Intervals (CI): 4–6.9] days. 84% of the
outcome. The length of stay (LOS) in ICU was re- patients had mechanical ventilatory support during
corded. The hospital outcome was classified into their stay in ICU.
either ‘Discharged’ or ‘Died’. The predicted mortality according to the PIM2
The regression equation published with PIM-2 score ranged from 0 to 87.8% with a mean of
scoring system was used to calculate the predicted 6.2% (95% CI: 4.3–8.1). The observed mortality
mortality in the ICU patients. rate was 5.5%, the SMR being 0.89. Table 1 shows
Mann–Whitney U-test was used to compare the age, LOS and the outcomes in all the patients
PIM-2 scores and LOS between survivors and studied. Hosmer–Lemeshow Chi-square analyses
non-survivors. Hosmer–Lemeshow goodness-of-fit for goodness-of-fit for PIM-2 system showed a
analysis was done to calibrate the scoring system. good calibration of the model to our case-mix [H–L
Receiver Operating Characteristic curve (ROC) ana- 2 ¼ 5.64 (df ¼ 7), p ¼ 0.58]. The distribution of the
lyses were done to analyze the discriminant function deciles of risk in our case-mix has been depicted in
of the system. Standardized mortality ratio (SMR) Table 2.
(ratio of the observed to the predicted mortality Figure 2 shows the ROC curve for PIM-2 scoring
rate) was obtained for the case mix. The statistical system. The area under the curve (AUC) for the
significance was fixed at p < 0.05 level. Statistical ROC curve for PIM-2 system was 0.82 (95% CI:
analyses were done using the Statistical Package for 0.72–0.92).
Social Sciences (SPSSÕ ), (version 12) (Chicago, IL,
USA) software.
Discussion
The major finding of the present study is the reason-
Results ably good performance of the PIM-2 scoring system
During the period of study, 163 patients were in a pediatric ICU of a Caribbean developing
admitted to the ICU. The median age of the patients country.
was 5 years, 1–8 [Interquartile ranges, (IQR)]. Of There have been many published reports compar-
these 163 patients, 94 were males (57.7%). ing several different versions of pediatric prognostic
Respiratory illnesses such as bronchiolitis and pneu- scoring systems such as PIM, PRISM and PELOD
monia were the most common diagnoses on admis- [5, 7, 8]. Some reports found PIM to be performing
sion followed by neurological and cardiovascular well in pediatric ICUs compared to other systems
TABLE 1
Comparison of survivors and non-survivors
Age, mean SD (years) 4.9 4.4 4.9 4.3 4.7 5.0 0.43
Gender (n) (%)
Male 94 (57.7) 90 (58.4) 4 (44.4)
Female 69 (42.3) 64 (41.6) 5 (55.6)
LOS, mean SD 5.4 9.2 5.2 8.7 9.1 14.9 0.32
Predicted mortality, mean SD (%) 6.2 12.1 5.4 10.3 20 26.5 0.001
TABLE 2
Hosmer-Lemeshow goodness-of-fit analysis for PIM 2
1 17 16.4 0 0.6 17
2 29 27.9 0 1.1 29
3 12 11.6 0 0.4 12
4 19 18.3 0 0.7 19
5 15 15.4 1 0.6 16
6 15 15.3 1 0.7 16
7 14 15.2 2 0.8 16
8 15 15.1 1 0.9 16
9 18 18.7 4 3.3 22
0.6
admit neonates who had been delivered elsewhere
and/or transferred from other neonatal units [18].
0.4 However, the pediatric ICU in Barbados does not
admit neonates.
The LOS of patients varied widely, although there
0.2 was no statistical significant difference between sur-
vivors and non-survivors. LOS in pediatric ICU has
been found to be an important predictor of quality,
0.0 enabling the comparison of resource utilization
0.0 0.2 0.4 0.6 0.8 1.0 among different institutions [19]. Organizational fac-
1 - Specificity tors known to foster team-oriented care are asso-
ciated with shorter LOS. Also the size of the
FIG. 2. ROC curve for PIM-2. pediatric ICU is an important factor in that a rela-
tively larger size pediatric ICU may keep pediatric
ICU beds occupied longer [19]. Our pediatric ICU
[12, 13, 16, 17]. PIM is also better in terms of its is 4 bedded that would have contributed to the rela-
simplicity, validity, discriminatory power, etc. tively shorter mean LOS. Despite this, there were
Hence, we applied the current version of PIM in patients who stayed for months, due to the unavail-
our unit. ability of a high-dependency unit in the hospital.
Calibration of a prognostic model is done by test- developed countries [18]. Although this may be inter-
ing ‘the degree of correspondence between the prob- preted that the unit is performing well, it may be dif-
abilities of the outcome as predicted by the score and ficult to arrive at such conclusion because like the
the observed frequency of the outcome, at different Trinidad study, there could have been overprediction
levels of probability’. A good calibration is tradition- of mortality. There is an opinion that performance
ally represented by a p-value > 0.1 [20]. Calibration evaluation of ICUs by prognostic models may have
of a prognostic model is usually done by Hosmer– errors since many units evaluated this way qualify
Lemeshow goodness-of-fit test, which compares the with ‘honors’ due to ‘grade inflation’ [22].
predicted and observed outcomes in subgroups of Our study has few limitations. The number of pa-
patients belonging to deciles of risk. The PIM-2 scor- tients studied may be relatively smaller to calibrate
ing system when introduced, calibrated well for risk applying goodness-of fit analysis, although this has
10. Slater A, Shann F, Pearson G. Paediatric Index of mortality risk in infantile intensive care. J Trop
Mortality (PIM) Study Group. PIM 2: a revised version Pediatr 2004;50:334–8.
of the Paediatric Index of Mortality. Intensive Care 18. Hariharan S, Chen D, Merritt-Charles L. Risk-adjusted
Med 2003;29:278–85. outcome evaluation in a multidisciplinary intensive care
11. Angus DC, Sirio CA, Clermont G, et al. International unit. West Indian Med J 2007;56:228–33.
comparisons of critical care outcome and resource con- 19. Ruttimann UE, Pollack MM. Variability in duration of
sumption. Crit Care Clin 1997;13:389–407. stay in pediatric intensive care units: a multi-institu-
12. Slater A, Shann F. ANZICS Paediatric Study Group. tional study. J Pediatr 1996;128:35–44.
The suitability of the Pediatric Index of Mortality 20. Tibby SM, Murdoch IA. Calibration of the paediatric
(PIM), PIM2, the Pediatric Risk of Mortality index of mortality score for UK paediatric intensive
(PRISM), and PRISM III for monitoring the quality care. Arch Dis Child 2002;86:65.
of pediatric intensive care in Australia and New 21. Prieto Espuñes S, López-Herce Cid J, Rey Galán C,