Risk-adjusted outcome evaluation in a multidisciplinary intensive care unit

Validity of Pediatric Index of Mortality 2 score as an Outcome Predictor in Pediatric ICU of a Public Sector Tertiary Care Hospital in Pakistan

Pediatric Index of Mortality 2 (PIM-2) is one of the leading mortality scores used in intensive care units all around the world. We assessed its validity as an outcome predictor in a pediatric intensive care unit (PICU) of Mayo Hospital/King Edward Medical University Lahore, Pakistan. We enrolled 154 consecutive admissions, aged 1 month to 13 years, requiring intensive care from January to June of 2019. Patient demographics along with PIM-2 data were collected; PIM-2 score and mortality risk was calculated; and the outcome recorded as death or survival. The median age at admission was 0.50 years (interquartile range [IQR]: 0.24–1.78) and the median weight was 5.0 kg (IQR: 3.08–10.0) with females constituting 54%; malnutrition was also common (66%). Observed mortality was 29.9% (46 out of 154) and expected mortality (cut-off ≥ 99.8%) was 27.9% with a standardized mortality ratio of 1.07 (95% confidence interval [CI]: 0.79–1.41). Sepsis was the most common diagnosis at admission (27.9%) with the highest mortality (52.2%). Chi-square analysis revealed a sensitivity of 54.3% and a specificity of 83.3% (p-value 0.00). PIM-2 score showed acceptable discrimination between survivors and nonsurvivors with an area under the receiver operating characteristic curve of 0.75 (95% CI: 0.67–0.84) (p-value = 0.00); however, poor calibration according to Hosmer–Lemeshow goodness of fit test (Chi-square = 15.80, df = 7, and p-value of 0.027 [< 0.1]), thus requiring recalibration according to local population characteristics.

Do Serially Recorded Prognostic Scores Predict Outcome Better Than One-Time Recorded Score on Admission? A Prospective Study in Adult Intensive Care Patients

OBJECTIVES

The prognosticating ability of one-time recorded Acute Physiology and Chronic Health Evaluation (APACHE) IV score was compared with serially recorded Mortality Prediction Model (MPM) II scores.

DESIGN AND METHODS

A prospective observational study was conducted for a period of 6 months. Acute Physiology and Chronic Health Evaluation IV score was recorded during the first day on intensive care unit (ICU) admission. Mortality Prediction Model II was recorded on admission, 24, 48, and 72 hours. Predicted mortality was compared with observed mortality. The systems were calibrated and tested for discriminant functions.

RESULTS

One hundred and fifty patients were studied. The observed mortality was 21.3%. The mean predicted hospital mortality by APACHE IV was 20.6%. The mean predicted hospital mortality rate by serial MPM II measurements was 27.7%, 24.3%, 25.5%, and 25.8%. The area under the receiver-operating characteristic curve was 0.87 for APACHE IV and 0.82, 0.84, 0.85, and 0.89 for MPM II series. Both systems calibrated well with similar degree of goodness of fit.

CONCLUSION

Acute Physiology and Chronic Health Evaluation IV on admission predicted hospital mortality better than serially recorded MPM, which overestimated mortality. Also, APACHE IV had a slightly better discrimination compared to MPM II on admission. One-time recording of APACHE IV on admission may be sufficient for prognostication of ICU patients rather than serial MPM scores.

Outcomes and Health-related Quality of Life following Intensive Care Unit Stay in Barbados

OBJECTIVES

To evaluate the hospital outcome and health-related quality of life (HRQOL) in adult patients admitted to intensive care units (ICUs) in Barbados.

METHODS

A prospective observational study was done in the medical and surgical intensive care units of the Queen Elizabeth Hospital, Barbados, to evaluate the outcomes and HRQOL in adult patients. The acute physiology and chronic health evaluation (APACHE) IV score was applied on admission to one hundred and fifty patients admitted to the ICUs. The HRQOL was evaluated by using Short Form 36 (SF-36) in 63 survivors, three months after ICU discharge.

RESULTS

There was no significant difference between medical and surgical ICUs with respect to age, gender, APACHE IV scores, 90-day mortality, and length of stay. The mean (± SD) APACHE IV score was 42.6 (± 23.7). The observed mortality was 32.7% and the standardized mortality ratio (SMR) was 1.85. The APACHE IV scores were significantly higher in non-survivors compared to survivors (p < 0.001). Patients with APACHE IV of > 45, and who were ventilated in the first 24 hours had the highest mortality (66%). The mean ICU length of stay was 7.2 days.

CONCLUSION

In this study, the SF-36 scores in all eight dimensions indicated that the HRQOL in the majority of the survivors was average or above average. There was a significant negative correlation between APACHE IV score and the SF-36 score.

Pediatric Index of Mortality and PIM2 scores have good calibration in a large cohort of children from a developing country

OBJECTIVE

Our objective was to validate the Pediatric Index of Mortality (PIM) and PIM2 scores in a large cohort of children from a developing country.

DESIGN

Prospective observational study.

SETTING

Pediatric intensive care unit of a tertiary care teaching hospital.

PATIENTS

All children aged <18 years admitted between June 2011 and July 2013.

MEASUREMENTS AND MAIN RESULTS

We evaluated the discriminative ability and calibration as measured by the area under the receiver operating characteristic (ROC) curves, the Hosmer-Lemeshow goodness-of-fit (GOF), and standardized mortality ratio (SMR), respectively. Of the 819 children enrolled, 232 (28%) died. The median (IQR) age of the study subjects was 4 years (0.8, 10). The major reasons for ICU admission as well as mortality were sepsis/severe sepsis. The area under ROC curves for PIM and PIM2 was 0.72 (95% CI: 0.67-0.75) and 0.74 (95% CI: 0.70-0.78), respectively. The goodness-of-fit test showed a good calibration across deciles of risk for the two scores with P values being >0.05. The SMR (95% CI) was 0.99 (0.85-1.15) and 1 (0.85-1.16) for PIM and PIM2, respectively. The calibration across different age and diagnostic subgroups was also good.

CONCLUSION

PIM and PIM2 scores had good calibration in our setup.

Application of pediatric index of mortality version 2: score in pediatric intensive care unit in an African developing country

Introduction

Outcome of patients admitted to PICU can be evaluated by many illness severity scoring systems. This prospective observational study evaluated the outcome of patients admitted to PICU in Fayoum University hospital of a developing country using the pediatric index of mortality version 2 scoring system.

Methods

All patients included in this study were subjected to data collection including demographics, diagnoses at admission, duration of ICU stay (DOS), pediatric index of mortality version 2 (PIM2) score and hospital outcome. The ratio of observed to predicted mortality (standardized mortality ratio (SMR)) was calculated for the set of patients.

Results

The study included 205 patients. The main causes of admission were respiratory, cardiovascular and neurological illnesses. Patients stay in ICU ranged from 1 - 45 days with a median 6 (interquartile range (IQ): 3-9) days. Discriminatory function of PIM2 scoring system was acceptable with the area under the ROC curve 0.76 (95%CI: 0.60-0.91). PIM2 calibrated well using Hosmer Lemeshow analysis (H-L X2= 1.410, df= 8, p=0.9). The mean predicted mortality was 5.6 (95% CI: 3.43 - 7.91) and the observed mortality was 8.8% giving a SMR 1.55.

Conclusion

PIM2 scoring system show adequate discriminatory function and well calibrated for the case mix of patients in PICU of Fayoum, Egypt. It can be used as beneficial tool for evaluation of risk adjusted mortality. Further larger scale studies in cooperation with other Egyptian universities and neighboring countries can improve the performance of our PICUs and critical care services.