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Pediatric Risk of Mortality III Score - Predictor of Mortality and Hospital Stay
in Pediatric Intensive Care Unit

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DOI: 10.4103/JETS.JETS_89_19

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 Original Article

Pediatric Risk of Mortality III Score – Predictor of Mortality and

Hospital Stay in Pediatric Intensive Care Unit
Amarpreet Kaur, Gurmeet Kaur, Shashi Kant Dhir, Seema Rai, Amanpreet Sethi, Avneet Brar1, Paramdeep Singh2
Departments of Pediatrics and 2Radiology, Guru Gobind Singh Medical College and Hospital, Faridkot, 1Department of Pediatrics, Government Medical College and
Hospital, Amritsar, Punjab, India

Abstract
Background: Pediatric Risk of Mortality (PRISM) III score is one of the widely used scoring systems to quantify critical illness in the pediatric age
group. This study was carried out to find the association of PRISM III score with the outcome (discharge/mortality) and also hospital stay in survivors
and nonsurvivors. Setting: The study was conducted in a tertiary care hospital from January 2014 to June 2015. Materials and Methods: A total
of 524 patients were admitted, and after excluding the patients who met the exclusion criteria, 486 patients were analyzed. Statistical Analysis:
Logistic regression was used to find the association of variables under the PRISM III score with mortality. Linear regression was used to find
the association of PRISM III score with length of stay. Results: Mortality was 31%; male: female ratio was 1.5:1. Maximum patients presented
with respiratory system involvement (26.3%), and maximum mortality (20.3%) was observed in the patients with respiratory involvement.
Discrimination by the model between mortality and survival was excellent (receiver operating characteristic curve [0.903]). Maximum risk of
mortality was noticed in mechanically ventilated patients (odds ratio [OR]: 10.87) followed by lower systolic blood pressure (OR: 2.72), deranged
prothrombin time, partial thromboplastin time (OR: 1.50), deranged mental status (OR: 1.41), and tachycardia (OR: 1.37). Length of stay (LOS)
in patients increased till PRISM III score of 25. Average LOS in survivors was 4.327 days which was not accounted by difference in PRISM III
score between different patients. With each unit increase in PRISM III score, LOS increased by 5 h. Conclusions: PRISM III score has excellent
capacity to discriminate between survival and mortality. PRISM III score can be used to predict LOS among survivors.

Keywords: Length of stay, mortality, Pediatric Risk of Mortality III score, receiver operating characteristic curve

Introduction and the sample comprised 11,165 consecutive admissions.

This scoring system was labeled as PRISM III score, and
Critical illness in the pediatric age group is a familiar concept, diastolic blood pressure (BP), respiratory rate, PaCO2/FiO2,
but objectivity to critical illness was assigned only with the serum bilirubin, and calcium levels were not included in
development of scoring systems. the study, whereas systolic BP, temperature, percentage
First scoring system which was developed with the intention of acid–base gas parameters, serum creatinine, blood urea
to be used for critically sick pediatric patients was Physiologic nitrogen (BUN), white blood cell (WBC) count, and platelet
Stability Index. It was developed in 1984 by pediatric count were included, making a total of 17 parameters in the
intensivists, 34 variables from seven major physiologic systems scoring system. PRISM III score is institution independent and
were used, and points 0, 1, 3, and 5 were given to each variable can be calculated at 12 h and 24 h labeled as PRISM‑12 and
PRISM‑24, respectively.[2]
and increasing score corresponding with increasing severity.[1]
As the number of variables was large, a second‑generation Address for correspondence: Dr. Amarpreet Kaur,
scoring system called Pediatric Risk of Mortality (PRISM) Department of Pediatrics, Guru Gobind Singh Medical College and Hospital,
Faridkot, Punjab, India.
was developed by Pollack et al. in 1988. The number of E‑mail: [email protected]
variables was reduced from 34 to 14. Variables used in the
PRISM score were re‑evaluated in 1996 by Pollack et al. This is an open access journal, and articles are distributed under the terms of the
based on data from 32 pediatric intensive care units (PICUs), Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which
allows others to remix, tweak, and build upon the work non‑commercially, as long
Access this article online as appropriate credit is given and the new creations are licensed under the identical
terms.
Quick Response Code:
Website: For reprints contact: [email protected]
www.onlinejets.org
How to cite this article: Kaur A, Kaur G, Dhir SK, Rai S, Sethi A, Brar A.
Pediatric Risk of Mortality III score – Predictor of mortality and hospital
DOI:
stay in pediatric intensive care unit. J Emerg Trauma Shock 2020;13:146-50.
10.4103/JETS.JETS_89_19
Submitted: 26-Jul-2019. Revised: 22-Oct-2019. Accepted: 03-Feb-2020. Published: 10-Jun-2020

146 © 2020 Journal of Emergencies, Trauma, and Shock | Published by Wolters Kluwer ‑ Medknow
 Kaur, et al.: Pediatric risk of mortality III score

PRISM III score has been used in lot of studies to find its Statistical method
utility as a mortality score, but not much work has been done Descriptive analysis (mean and standard deviation) was used
on using it for predicting length of stay (LOS) in survivors. for sample characterization. Goodness of fit for the model was
Its role in estimating LOS can be further studied to ascertain assessed by Hosmer–Lemeshow goodness of fit. Observed
the objective effect of increase in PRISM‑III score on LOS as and expected mortality were compared. Receiver operating
India being resource‑poor country without any insurance cover. characteristic curve was used to estimate the capacity of the
model to discriminate between discharge and mortality. Area
Objectives
under the curve between 0.7 and 0.79 is acceptable, area ≥0.8
1. To ascertain the role of PRISM III score as mortality
is considered good, and area ≥0.9 is considered excellent
predictor
discrimination. Forward logistic regression was used to find the
2. To find the relation of PRISM III score to the LOS.
systems which are associated with mortality and to what extent.
Further logistic regression was used to find the association
Materials and Methods of variables in the PRISM score and other parameters like
mechanical admission which are associated with mortality.[3]
Study design Relation of PRISM score to hospital stay in survivors and
This was a prospective study conducted in the department of nonsurvivors was calculated. Linear regression was used to find
pediatrics. the association of hospital stay in survivors to PRISM III score.
Setting • Total patients included in the study = 486
The study was conducted from January 2014 to June 2015. Ours • Patients who left against medical advice = 17
is a tertiary care hospital with 6‑bedded PICU. Permission to start • Patients who stayed in <2 h = 9
the study was obtained from the institution’s ethics committee. • Patients who were discharged in 24 h = 12
Participants • Total number of patients admitted = 524.
Patients in the age group of 1 month to 14 years admitted in PICU
were included in the study. Readmissions were counted as separate
admission. Patients excluded from the study were those patients
Results
who stayed in PICU for <2 h or discharged from PICU in <24 h Participants
of PICU admission or admitted in continuous cardiopulmonary Total number of patients
resuscitation and did not achieve stable vital signs for ≥2 h and admitted = 524

newborns <1 month of age and children above 14 years of age.

Variables
Demographic details, diagnosis, date of admission, date of Patients who stayed in
less than 2 hours = 9
Total patients included in
the study = 486
discharge, outcome, mechanical ventilation, and LOS were Patients who left
Patients who were against medical
recorded on the pro forma sheet for the study. For PRISM III discharged in 24 advice = 17
score, various variables (systolic BP, heart rate, temperature, hours = 12

mental status, pupillary response, acidosis, pH, pCO2, total Descriptive data
CO2, PaO2, glucose, potassium, creatinine, BUN, WBC count, As shown in Table 1, the diseasewise distribution of patients, it
platelet count, prothrombin time, and partial thromboplastin was observed that maximum number of patients had respiratory
time [PT and PTT]) were recorded at 24 h of admission. disease (24.07%) followed by CNS diseases (20.57%) and
Data Source infectious diseases (13.79% of patients).
Admitted patients in the age group of 1 month to 14 years in Age groupwise distribution of the patients showed that 1% of
PICU. patients belonged to the neonatal age group, 43% were infants,
Bias 46.50% were children, and 10.50% were adolescents. Male:
As this study was based on scoring system, so chances of female ratio was 1.475:1.
bias are less. Hosmer–Lemeshow goodness of fit for PRISM score [Table 2]
depicted the model to be good fit with good calibration (P = 0.25).
Study size
Model was able to predict the outcome (discharge/mortality)
A total of 524 patients were admitted during the study,
correctly in 84.6% cases.
21 patients were excluded, and 17 patients left against medical
advice; hence, 486 patients formed the sample of the study. PRISM III score has good predictability with area under the
curve being 0.903 (95% confidence interval: 0.873–0.932).
Quantitative variables
The variables recorded were based on the scoring system and Main results
were recorded in the pro forma sheet, and the final PRISM III Using logistic regression [Table 3], it was found that increase in
score was calculated. PRISM score by 1 unit increased the mortality by 1.251 times.

Journal of Emergencies, Trauma, and Shock ¦ Volume 13 ¦ Issue 2 ¦ April-June 2020 147
 Kaur, et al.: Pediatric risk of mortality III score

point, that is, shock was 2.724 times linked to mortality. Fall
Table 1: Distribution of patients
in mental status, that is, Glasgow Coma Scale was 1.41 times
Characteristics of patients Value linked to mortality. Variables positively related to mortality were
Number of patients 486 prothrombin time, partial thromboplastin time, and heart rate.
Mortality, n (%) 151 (31.07) Deranged coagulation profile, that is, increase in PT and PTT
Agewise distribution, n (%) by 1 point lead to 50% increase in mortality. Tachycardia was
Infant (1 month‑12 months) 209 (43.00) responsible for 1.3 times increase in mortality. Increase in pH
Child (1‑12 years) 226 (46.50) was negatively related to mortality, that is, increase in pH by 1
Adolescent (>12 years) 51 (10.50)
point decreased mortality by 40% (Exp (B) = 0.606; P = 0.024).
Genderwise distribution, n (%)
Female 194 (39.92) Maximum mortality (42.38%) was seen when PRISM score
Male 292 (60.08) was >20 [Table 5], out of patients with score >20, maximum
Male:female 1.475:1 mortality (65.625%) was seen within <3 days of hospital stay.
Average length of stay (days)
On applying linear regression [Figure 1 and Table 6] to find
Survivors 5.537
Nonsurvivors 4.78
the relation of LOS in survivors with the PRISM score, it was
observed that the LOS which was not accounted for by the
Diagnosis Total, n (%) Mortality, n (%)
PRISM score was 4.327 days (intercept) and increase in PRISM
Diabetic ketoacidosis 28 (5.76) 5 (3.31)
score by 1 unit increased LOS by 5 h (coefficient B = 0.21 days).
Gastrointestinal infections 35 (7.20) 4 (2.6)
Liver disease 14 (2.88) 9 (6)
Gastrointestinal surgical conditions 12 (2.47) 7 (4.6) Discussion
Cardiovascular diseases 19 (3.91) 10 (6.6) Our model [Table 2] was able to predict 84.6% of the outcomes
Respiratory diseases 117 (24.07) 31 (20.5) and had good discriminatory power as area under the curve
Infectious diseases 67 (13.79) 29 (19.2) was 0.903, which is considered excellent, and discriminatory
Chronic infections 25 (5.14) 11 (7.3) power increases when this value approaches 1. Our results
Central nervous system diseases 100 (20.57) 30 (19.9)
are in consonance with other studies where AUC [Figure 2]
Accidents 4 (0.8) 2 (1.3)
was >0.9,[4‑7] while discriminatory power <0.9 was reported
Renal system diseases 18 (3.7) 3 (2)
by few other studies.[8‑10]
Hematological diseases 28 (5.8) 6 (4)
Miscellaneous 14 (2.88) 2 (1.3) Using logistic regression, it was found that mechanical
Burns 2 (0.4) 1 (0.7) ventilation, mental status, deranged coagulation profile,
Cranial surgeries 3 (0.6) 1 (0.7) tachycardia, PT and PTT, tachycardia, and increase in pH were
Total 486 (100) 151 (100) the risk factors for death.
Only few studies have commented on the risk factors.
Table 2: Outcome of patients A study by Costa et al. has reported that mechanical ventilation,
Observed Predicted outcome Percentage vasoactive drugs, nosocomial infections, and duration of
Discharge Mortality
correct hospitalization significantly affected the mortality as addition
of vasoactive drug increased mortality four fold.[10]
Outcome
Discharge 307 28 91.6 A study by Ana Lila found that variables significantly
Mortality 47 104 68.9 associated with mortality were abnormal papillary reflexes,
Overall percentage 84.6 acidosis, BUN, and WBC count. Abnormal papillary reflexes
had nine times risk of mortality, whereas acidosis had three
On further using logistic regression [Table 3] to find the relative times risk of mortality. Deranged BUN (odds ratio [OR]:
effect of various parameters under PRISM score, it was found 1.03) and WBC count (OR: 1.02) were directly related to
that cardiovascular and neurologic signs, hematologic tests, mortality.[11]
and chemistry tests affected the mortality, and results were Another study by Pollack et al. reported that abnormal papillary
statistically significant (P < 0.05). Increase in one point of reflexes, minimum systolic BP, and coma were significantly
cardiovascular and neurologic signs increased the mortality by associated with mortality.[2]
1.5 times. Increase in one unit of hematologic test or chemistry The difference in reporting of relation of different factors to
tests increased mortality by 1.2 times or 1.17 times, respectively. mortality in different studies could be due to the different
On further using logistic regression [Table 4], it was found system involvement at different centers on presentation.
that ventilated patients had 10.87 times more risk of mortality. In our study, the average LOS was 10.23 days [Table 1],
Variables which were negatively correlated to mortality were whereas in case of survivors, it was 5.537 days, and in
systolic BP and mental status. Fall in systolic BP below critical nonsurvivors, it was 4.78 days. Our study is in concordance

148 Journal of Emergencies, Trauma, and Shock ¦ Volume 13 ¦ Issue 2 ¦ April-June 2020
 Kaur, et al.: Pediatric risk of mortality III score

Table 3: Logistic regression with pediatric risk of mortality score, vital signs, and laboratory tests
Variables B SE Wald df Significant Exp(B) 95% CI for Exp(B)
Lower Upper
PRISM score 0.224 0.020 128.395 1 0.000 1.251 1.204 1.301
Constant −3.319 0.265 156.298 1 0.000 0.036
Step 1a
Cardiovascular and neurologic vital signs 0.433 0.037 134.709 1 0.000 1.541 1.433 1.658
Step 2b
Hematologic tests 0.181 0.058 9.649 1 0.002 1.198 1.069 1.343
Step 3c
Chemistry tests 0.161 0.070 5.349 1 0.021 1.175 1.025 1.346
a
0.0; b0.002; c0.021. SE: Standard error, CI: Confidence interval, PRISM: Pediatric risk of mortality

Table 4: Logistic regression with six variables of pediatric risk of mortality score (reaching significant levels)
Variables B SE Wald df Significant Exp(B) 95% CI for Exp(B)
Lower Upper
Systolic BP 1.002 0.089 127.817 1 0.000 2.724 2.290 3.241
Ventilator 2.386 0.296 64.863 1 0.000 10.870 6.082 19.426
PT and PTT 0.408 0.122 11.200 1 0.001 1.503 1.184 1.909
Mental status 0.344 0.096 12.736 1 0.000 1.410 1.168 1.703
HR 0.273 0.112 5.880 1 0.015 1.313 1.054 1.637
pH ‑0.500 0.222 5.090 1 0.024 0.606 0.393 0.936
CI: Confidence interval, SE: Standard error, BP: Blood pressure, PT: Prothrombin time, PTT: Partial thromboplastin time, HR: Heart rate

Figure 2: ROC curve

Figure 1: Relation between PRISM Score in survivors and hospital stay
On review of literature, we could find only one study in which
association between LOS and various other factors was studied,
with the study from Egypt, in which LOS in case of survivors
and it was concluded that average LOS (in both survivors
was 5.34 ± 5.82 days, and in case of nonsurvivors, it was
and nonsurvivors) was 1.4 days (intercept), which was not
3.82 ± 4.18 days.[12]
accounted for by PRISM III‑24 score or other factors.[7]
In other studies, the average length of stay varied from 3 days However, no other study has correlated LOS in survivors with
to 11.9 days.[6,9,10,11,13] the PRISM III score.
Further, linear regression [Table 6] was applied to find the The mean PRISM score in our study was 9.91, whereas in case
relation of LOS in survivors with the PRISM score, and it was of survivors, it was 5.72, and in case of nonsurvivors, it was
observed that 4.327 days (intercept) is the LOS not accounted 19.01, which is in concordance with study from Portugal in
for by the PRISM score. Increase in PRISM score by 1 unit which PRISM score in survivors was 5.6, and in nonsurvivors,
increased LOS by 5 h (coefficient B = 0.21 days). it was 19.7.[6]

Journal of Emergencies, Trauma, and Shock ¦ Volume 13 ¦ Issue 2 ¦ April-June 2020 149
 Kaur, et al.: Pediatric risk of mortality III score

Table 5: Pediatric risk of mortality score and length of stay

PRISM <3 days Days Days >14 days Total
score
Survivors Nonsurvivors Survivors Nonsurvivors Survivors Nonsurvivors Survivors Nonsurvivors Survivors Nonsurvivors
0‑5 89 3 96 8 18 3 8 2 211 16
6‑10 21 9 29 8 12 0 4 1 66 18
11‑15 10 27 13 7 15 3 2 2 40 39
16‑20 3 9 4 2 1 1 0 2 8 14
>20 1 42 3 11 3 9 3 2 10 64
Total 124 90 145 36 49 16 17 9 335 151
PRISM: Pediatric risk of mortality

Table 6: Linear regression model showing relationship of pediatric risk of mortality score of survivors and length of stay
Model Unstandardized coefficients Standardized coefficients t Significant 95% CI 95% CI for B
β for B
B SE Lower bound Upper bound
Constant 4.327 0.341 12.676 0.000 3.656 4.999
Survivor PRISM score 0.211 0.043 0.260 4.915 0.000 0.127 0.296
PRISM: Pediatric risk of mortality, CI: Confidence interval, SE: Standard error

Similar results were also reported by study from Brazil, in References

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