Simultaneous Prediction of New Morbidity, Mortality, and Survival Without New Morbidity From Pediatric Intensive Care

Abstract

Objective Assessments of care including quality assessments adjusted for physiological status should include the development of new morbidities as well as mortalities. We hypothesized that morbidity, like mortality, is associated with physiological dysfunction and could be predicted simultaneously with mortality. Design Prospective cohort study from December 4, 2011 to April 7, 2013. Setting and Patients General and cardiac/cardiovascular pediatric intensive care units at 7 sites. Measurements and Main Results Among 10,078 admissions, the unadjusted morbidity rates (measured with the Functional Status Scale (FSS), and defined as an increase of ≥ 3 from pre-illness to hospital discharge) were 4.6% (site range 2.6% to 7.7%) and unadjusted mortality rates were 2.7% (site range 1.3% – 5.0%). Morbidity and mortality were significantly (p<0.001) associated with physiological instability (measured with the PRISM III score) in dichotomous (survival, death) and trichotomous (survival without new morbidity, survival with new morbidity, death) models without covariate adjustments. Morbidity risk increased with increasing PRISM III scores and then decreased at the highest PRISM III values as potential morbidities became mortalities. The trichotomous model with covariate adjustments included age, admission source, diagnostic factors, baseline FSS and the PRISM III score. The three-level goodness of fit test indicated satisfactory performance for the derivation and validation sets (p>0.20). Predictive ability assessed with the volume under the surface (VUS) was 0.50 ± 0.019 (derivation) and 0.50 ± 0.034 (validation) (versus chance performance = 0.17). Site-level standardized morbidity ratios were more variable than standardized mortality ratios. Conclusions New morbidities were associated with physiological status and can be modeled simultaneously with mortality. Trichotomous outcome models including both morbidity and mortality based on physiological status are suitable for research studies, and quality and other outcome assessments. This approach may be applicable to other assessments presently based only on mortality.

Pediatric Medical Emergency Team Events and Outcomes: A Report of 3647 Events From the American Heart Association’s Get With the Guidelines-Resuscitation Registry

“…The in-hospital mortality for children who had a MET call was 6.7%, highlighting that this is a high-risk population with mortality rates even higher than those recently reported for >10 000 children admitted to PICUs (1.3%–5.0%) across 7 institutions. 12 …”

Incidence and Outcomes of Cardiopulmonary Resuscitation in PICUs

“…The details of patient selection and data collection have been previously published. 10, 11 Patients ranging in ages from newborn to less than 18 years were randomly selected from both the General/Medical PICUs and the Cardiac/Cardiovascular PICUs. There were no separate general surgical or neurological PICUs.…”

“…The Eunice Shriver Kennedy National Institute of Child Health and Human Development’s Collaborative Pediatric Critical Care Research Network (CPCCRN) embarked on an intensive prospective study of more than 10,000 admissions to its large academic PICUs with the primary aim to investigate the relationship of physiological instability to the development of morbidity and mortality. 10 As part of this effort, we prospectively evaluated the incidence and outcomes of PICU CPR events to accurately determine the current overall incidence of CPR occurring in the PICU, the characteristics of children who received CPR in the PICU, their survival rates, and the neurologic and functional outcomes of the survivors. We also sought to determine if incidences and outcomes vary between cardiac and non-cardiac critically ill children.…”

Focus on paediatrics

“…It is not relevant to the other 973.6 per 1000 admissions. Pollack et al [2] addressed this problem by exploring three (or "trichotomous") outcomes after PICU admission: significant new functional morbidity, intact survival, and death.…”

“…4 per 1000 PICU admissions [2] in contemporary United States (US) PICU practice questions the legitimacy of mortality as an endpoint for RCTs. It is not relevant to the other 973.6 per 1000 admissions.…”