Pediatric Risk of Admission (PRISA): A Measure of Severity of Illness for Assessing the Risk of Hospitalization From the Emergency Department,☆☆,

Presented in part at the Society for Academic Emergency Medicine Annual Meeting, Washington DC, May 1997, and at the Ambulatory Pediatric Association Annual Meeting, Washington DC, May 1997.
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Abstract

Study objective: The development and validation of a pediatric emergency department severity of illness assessment method, using hospital admission as the primary outcome.

Methods: A random sample of 25% of ED charts from 4 consecutive months in a university-affiliated pediatric hospital was reviewed, after exclusion of children with minor injuries and children triaged to the nonurgent clinic. Sampled data included components of the medical history, physical findings, physiologic variables, diagnoses, and ED therapies. Univariate and multivariate logistic regression analyses, with bootstrapping validation, were performed to develop a bias-corrected model estimating the probability of hospital admission.

Results: Of the 2,683 ED patients whose records were reviewed, 643 (24%) were admitted to the hospital. The final model, which yielded a Pediatric Risk of Admission (PRISA) score, included the following: 3 components of the medical history, 3 chronic disease factors, 9 physiologic variables, 2 therapies, and 4 interaction terms. Overall, the number of hospital admissions was well predicted in both the 80% development and 20% validation samples. In the former, 514 admissions were predicted and 514 were observed; in the latter, 126.9 admissions were predicted and 129 were observed. The Hosmer-Lemeshow goodness-of-fit test demonstrated good agreement between observed and expected admissions in consecutive deciles of admission probability; total χ2 was 10.49 (P=.233) for the development sample and 11.85 (P=.222) for the validation sample. The areas under the receiver operating characteristic curves (±SE) were .86±.011 and .825±.024, respectively. As the risk of hospital admission increased, the proportions of patients using unique hospital-based resources and using ICU resources increased, and the proportion of patients dying increased.

Conclusion: The probability of admission to the hospital can reliably be estimated from data available during the pediatric ED stay. Applications for this method include studies of quality and efficiency of care and measurements of severity of illness.

[Chamberlain JM, Patel KM, Ruttimann UE, Pollack MM: Pediatric Risk of Admission (PRISA): A measure of severity of illness for assessing the risk of hospitalization from the emergency department. Ann Emerg Med August 1998;32:161-169.]

Section snippets

INTRODUCTION

Intensive care and trauma systems have benefited from the development and use of severity assessment methods, using mortality as the primary outcome. For example, methods of measuring severity in the pediatric ICU (PICU) have enabled evaluation of quality using severity-adjusted mortality rates,1 identification of care characteristics associated with quality of care,2, 3 assessment of efficiency of bed use,4, 5 and prediction of length of stay.6 Similar studies have been performed for trauma

MATERIALS AND METHODS

The study was performed at Children’s National Medical Center, an urban, university-affiliated, nonprofit, private hospital providing primary, secondary, and tertiary care for the District of Columbia and surrounding metropolitan area. The average annual ED patient census is 54,000. Patients are triaged by a registered nurse with pediatric emergency experience and are medically evaluated by house staff (first-, second-, and third-year residents in pediatrics, emergency medicine, and family

RESULTS

There were 21,288 ED visits during the study period. After exclusion of patients with minor injuries and those triaged to the nonurgent clinic, the 25% randomization resulted in a sample of 2,683 patients. The median age was 64 months, with a range of 2 days to 24 years. Other patient characteristics are shown in Table 1. A total of 15.2% of these children arrived by emergency medical transport (ambulance, helicopter), and 25.8% were referred from either physician offices or other EDs. Chief

DISCUSSION

EDs treat approximately 27 million children per year, of whom 5% are admitted to hospitals.9 Large tertiary care centers admit 10% to 15% of pediatric ED patients. Despite the large volume of pediatric patients and the costs associated with this treatment, little has been done to measure the quality of ED care, particularly with regard to patient outcomes. Structure has been assessed by comparing rates of board certification of physicians.27 Process of ED care measures have included patient

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    From the George Washington University School of Medicine and Health Sciences,* Children’s National Medical Center, and National Institute on Alcohol Abuse and Alcoholism, The National Institutes of Health,§ Washington DC.

    ☆☆

    Reprint no. 47/1/91519

    Address for reprints: James M Chamberlain, MD Emergency Medicine Children’s Hospital National Medical Center 111 Michigan Avenue, NW Washington DC 20010 202-884-4177 Fax 202-884-3573 E-mail [email protected]

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