Pretransport Pediatric Risk of Mortality (PRISM) score underestimates the requirement for intensive care or major interventions during interhospital transport.

OBJECTIVE: To test the hypothesis that a pretransport Pediatric Risk of Mortality (PRISM) score underestimates the requirement for both intensive care and interventions during pediatric interhospital transport. DESIGN: Prospective, descriptive study. SETTING: All children were treated in a regional hospital and then transported to a pediatric tertiary care center by a pediatric critical care specialty team. PATIENTS: Children (n = 156) with a median age of 1.3 yrs (range newborn to 18 yrs). INTERVENTIONS: None related to the study. MEASUREMENTS AND MAIN RESULTS: Two sets of Pediatric Risk of Mortality scores were calculated: one from data collected over the telephone at the time of the referral (Referral PRISM), and one from both the referring hospital's records and from data collected by the transport team on arrival at the referring hospital and before the team provided any intervention (Team PRISM). The admission area used on arrival at the tertiary care center (intensive care unit [ICU] vs. non-ICU) and the number of major clinical interventions performed by both the referring hospital staff and the transport team were recorded. The Therapeutic Intervention Scoring System was used to assess the cumulative level of medical care provided up to 8 hrs after admission to the pediatric tertiary care hospital. No patient died during transport. The overall in-hospital mortality rate was 5.1%. Median Therapeutic Intervention Scoring System scores were higher for patients admitted to the ICU (16 vs. 4, p < .001). Whereas median PRISM scores were significantly higher in those children admitted to the ICU (4 vs. 0, p < .001), 58 (75%) of 77 ICU admissions had a Team PRISM score of < or = 10. Forty-four (71%) of 62 children who required at least one major intervention at some time during the transport process and 15 (63%) of 24 children who required at least one major intervention by the transport team had a Team PRISM score of < or = 10. Referral PRISM scores underestimated Team PRISM scores. CONCLUSIONS: PRISM scores determined before interhospital transfer of pediatric patients underestimated the requirement for intensive care and the performance of major interventions in the pretransport setting. Many patients with low PRISM scores required intensive care on admission to the receiving hospital and major interventions during the transport process, and, therefore, were not at "low risk" for clinical deterioration. The PRISM score should not be used as a severity of illness measure or triage tool for pediatric interhospital transport.

Effect of position on pulmonary mechanics in healthy preterm newborn infants.

Preterm infants are often placed in the supine position to facilitate care and observation. Prone positioning may positively affect later neurodevelopmental outcome, but it may also affect pulmonary function. Using a computerized system, we examined the effect of positioning on pulmonary mechanics in spontaneously breathing healthy preterm infants. Eleven infants with a mean birth weight (+/- SD) of 1523 +/- 171 gm and a mean gestational age (+/- SD) of 31.7 +/- 1.5 weeks were studied during the first 2 weeks of life. Pulmonary mechanic measurements were obtained in both supine and prone positions by mask pneumotachography and esophageal balloon technique. Respiratory rate and oxygen saturation were unaffected by positioning. There was a statistically, but not clinically, significant increase in heart rate in the prone position. However, there were no significant differences in tidal volume, minute ventilation, pulmonary resistance, or dynamic compliance between positions. The contribution of intrasubject variability of serial measurements was assessed in a separate group of four infants studied three times in the same position. There was no significant difference in respiratory rate, tidal volume, dynamic compliance per kilogram, or total pulmonary resistance in the same infant when studied in the same position over time (p > or = 0.24). The maximum variability (95% confidence limit) was 25.5% for tidal volume, 21% for dynamic compliance, and 44.3% for resistance. Because prone positioning did not adversely affect pulmonary mechanics or oxygen saturation in these healthy preterm infants, we suggest that prone position be used to facilitate the developmental needs of these infants.