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DOI: 10.1542/peds.

2003-0960-L
2004;114;e424 Pediatrics
Tarnow-Mordi and Anne Greenough
Simon J. Broughton, Andrew Berry, Stephen Jacobe, Paul Cheeseman, William O.
Prediction Model for Retrieved Neonates
The Mortality Index for Neonatal Transportation Score: A New Mortality
 
 
 
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The Mortality Index for Neonatal Transportation Score: A New Mortality
Prediction Model for Retrieved Neonates
Simon J. Broughton, MRCP*; Andrew Berry, FRACP‡; Stephen Jacobe, FRACP‡; Paul Cheeseman, PhD*;
William O. Tarnow-Mordi, MRCP, DCH, FRCPCH§; and Neonatal Intensive Care Unit Study Group§;
Anne Greenough, MD, FRCP*
ABSTRACT. Objective. To develop a mortality pre-
diction score for retrieved neonates based on the infor-
mation given at the first telephone contact with a re-
trieval service.
Methods. Data from the New South Wales Newborn
and Pediatric Emergency Transport Service database
were examined. Analysis was performed with the results
for 2504 infants (median gestational age: 36 weeks; range:
24–43 weeks) who were <72 hours of age at the time of
referral and whose outcome (neonatal death or survival)
was known. The study population was divided randomly
into 2 halves, the derivation and validation cohorts. Uni-
variate analysis was performed to identify variables in
the derivation cohort related to neonatal death. The vari-
ables were entered into a multivariate logistic regression
analysis with neonatal death as the outcome. Receiver
operator characteristic (ROC) curves were constructed
with the regression model and data from the derivation
cohort and then the validation cohort. The results were
used to generate an integer-based score, the Mortality
Index for Neonatal Transportation (MINT) score. ROC
curves were constructed to assess the ability of the MINT
score to predict perinatal and neonatal death.
Results. A 7-variable (Apgar score at 1 minute, birth
weight, presence of a congenital anomaly, and infant’s
age, pH, arterial partial pressure of oxygen, and heart rate
at the time of the call) model was constructed that gen-
erated areas under ROC curves of 0.82 and 0.83 for the
derivation and validation cohorts, respectively. The 7
variables were then used to generate the MINT score,
which gave areas under ROC curves of 0.80 for both
neonatal and perinatal death.
Conclusion. Data collected at the first telephone con-
tact by the referring hospital with a regionalized trans-
port service can identify neonates at the greatest risk
of dying. Pediatrics 2004;114:e424–e428. URL: www.
pediatrics.org/cgi/doi/10.1542/peds.2003-0960-L; neonatal
mortality, retrieval, neonatal transport.
ABBREVIATIONS. CRIB, Clinical Risk Index for Babies; SNAP,
Score for Neonatal Acute Physiology; NETS, Newborn and Pedi-
atric Emergency Transport Service; NICUS, Neonatal Intensive
Care Unit Study; ROC, receiver operator characteristic; Pao
2
, ar-
terial partial pressure of oxygen; Paco
2
, arterial partial pressure of
carbon dioxide; MINT, Mortality Index for Neonatal Transporta-
tion; Fio
2
, fraction of inspired oxygen; TRIPS, Transport Risk
Index of Physiologic Stability; VLBW, very low birth weight; CI,
confidence interval.
P
rovision of the most effective neonatal trans-
port service requires accurate assessment of
disease severity and prediction of prognosis, to
facilitate appropriate triage and resource allocation.
The transport process starts at the time the retrieval
service receives the first call from the referring hos-
pital; therefore, it is desirable to predict outcomes
accurately at that point of contact. Unfortunately,
scores developed for assessment of infants during
the transport process have used data acquired after
the retrieval team has arrived at the referring hospi-
tal.
1,2
Prediction-of-mortality scores exist for the re-
trieved pediatric population and include the Pediat-
ric Index of Mortality score
3
and the pre-intensive
care unit Pediatric Risk of Mortality,
4
but such scores
are also calculated from data obtained at the trans-
port team’s first physical contact with the patient. In
addition, neither of these scores is easily applicable
to a neonatal population, because they are heavily
dependent on assessment of the level of conscious-
ness and pupillary signs. Other neonatal prediction
scores, including the Berlin score,
5
the Score for Neo-
natal Acute Physiology (SNAP),
6
and the Clinical
Risk Index for Babies (CRIB),
7
were not developed to
assess the outcomes of retrieved neonates and have
factors that limit their use in such populations. The
Berlin score requires classification of the degree of
respiratory distress, and the SNAP has 16 variables
and thus is time-consuming to calculate. Both the
CRIB and SNAP use data collected over 12 hours and
thus may reflect the effects of interventions rather
than the underlying risk at an early time point. The
National Institute of Child Health and Human De-
velopment network mortality prediction score
8
and
the CRIB II score
9
are both based on information
available shortly after birth but were developed for
use among very low birth weight (VLBW) infants,
whereas retrieved infants have a wide range of birth
weights and gestational ages. Therefore, the aim of
this study was to develop a new mortality prediction
score for the retrieved neonatal population that was
From the *Department of Child Health, Guy’s, King’s, and St. Thomas’
School of Medicine, King’s College, London, United Kingdom; ‡New South
Wales Newborn and Pediatric Emergency Transport Service, Wentworth-
ville, Australia; and §Westmead Hospital Perinatal Centre, University of
Sydney, Sydney, Australia.
Accepted for publication Apr 26, 2004.
doi:10.1542/peds.2003-0960-L
Address correspondence to Anne Greenough, MD, FRCP, Department of
Child Health, Kings College Hospital, Denmark Hill, London SE21 8DE,
United Kingdom. E-mail: anne.greenough@kcl.ac.uk
PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad-
emy of Pediatrics.
e424 PEDIATRICS Vol. 114 No. 4 October 2004 www.pediatrics.org/cgi/doi/10.1542/peds.2003-0960-L
at Indonesia:AAP Sponsored on May 27, 2014 pediatrics.aappublications.org Downloaded from
based on data collected at the time of the first call by
the referring hospital, when resource allocation is
decided. In addition, we wished to determine
whether the score predicted death in the VLBW pop-
ulation more accurately than did gestational age or
birth weight.
METHODS
Data Collection
Data were obtained from the New South Wales Newborn and
Pediatric Emergency Transport Service (NETS) database. NETS
provides an integrated transport service for New South Wales and
retrieves ϳ1650 patients each year, 50% of whom are neonates.
The retrieval process is started when a clinician from the referring
hospital contacts NETS. During that call, the infant’s name, date
and time of birth, medical history, and clinical data (gestational
age, birth weight, gender, and Apgar scores at 1 and 5 minutes)
are recorded (time of first call data). If deemed necessary, a re-
trieval team (specialist retrieval nurse and doctor) is then mobi-
lized. After arrival at the referring hospital, the retrieval team
collects additional data (time of first contact data). The infant is
stabilized by the retrieval team and, when the team is ready to
depart, another set of data is collected (time of stabilization data).
The infant is then transported to the accepting intensive care unit,
where a final set of data is collected (time of admission data). At
each of the 4 time points, collection of the following data was
attempted: heart rate, respiratory rate, fraction of inspired oxygen
(Fio
2
), arterial partial pressure of oxygen (Pao
2
), arterial partial
pressure of carbon dioxide (Paco
2
), pH, base excess, bicarbonate
level, oxygen saturation, and ventilator settings. Outcome data
(neonatal death or survival) were obtained from the Neonatal
Intensive Care Unit Study (NICUS) database, which contains data
on the outcomes of neonates admitted in New South Wales, Aus-
tralia. Ethical approval for this study was obtained from Western
Sydney Area Health Service, and permission to use the data from
the NICUS database was obtained from NICUS and each of the
local hospital consultants responsible for the NICUS database.
Model Development
Data for infants who were Ͻ72 hours of age at the time of the
first call, who had complete demographic data and blood gas data
for 2 of the 4 time points, and whose outcomes were known were
included in the analysis. The study population was divided ran-
domly into 2 halves, ie, the derivation cohort and the validation
cohort. The strategy described by Pollack et al
10
was used to build
the predictive model.
11,12
The derivation cohort was used for
model derivation, and the model’s accuracy was tested with the
validation cohort.
Univariate analysis was used to determine whether age (in
hours), gestational age, gender, birth weight, Apgar scores at 1
and 5 minutes, temperature, heart rate, respiratory rate, Fio
2
,
intubation status, Pao
2
, Paco
2
, pH, base excess, bicarbonate level,
oxygen saturation, presence of a congenital abnormality, oxygen-
ation index, time between the different time points in the retrieval
process, or total retrieval time differed (P Ͻ .2, with ␹
2
or Mann-
Whitney analysis as appropriate) between the infants who died
and those who survived. The variables that did differ were en-
tered into a multivariate logistic regression analysis with forward
stepwise entry, with death as the outcome. All of the variables that
differed between the 2 groups at P Ͻ .2 were initially entered, and
the least significant variables, identified by their logistic coeffi-
cient, odds ratio, and confidence intervals (CIs), were removed 1
at a time. At each stage, the resulting model was assessed with
receiver operator characteristic (ROC) curves. Goodness-of-fit test-
ing (with the Hosmer-Lemeshow goodness-of-fit test
13
) was used
for both the derivation and validation cohorts. A P value of Ͼ.05
implied no significant difference between the observed and ex-
pected values, and the goodness of fit was considered acceptable.
With the logistic coefficients, odds ratios, and CIs, integer score
points were assigned to each of the variables and a score was
generated, the Mortality Index for Neonatal Transportation
(MINT) score. Cutoff points for the individual variables were
obtained by assessing the model cutoff points used in clinical
practice and reported in the literature. ROC curves were con-
structed to determine the accuracy with which the MINT score
predicted perinatal or neonatal death for the whole population
and then for VLBW infants only. ROC curves were also con-
structed to assess whether gestational age or birth weight pre-
dicted death in the VLBW infant population.
Patients
During the study period (February 1992 to July 2001), 8806
infants were retrieved, of whom 6348 (72.1%) were Ͻ72 hours of
age at the time of the first call (Table 1). Complete demographic
and physiologic data were available for 3429 infants; of those 3429
infants, 2504 had outcome data recorded in the NICUS database
and 302 died (12% mortality rate). The 2504 infants (1585 male
patients) formed the study population. The median gestational
age was 36 weeks (range: 24-43 weeks) and the birth weight was
2782 g (range: 520-6140 g). The median age at the time of the first
contact with the retrieval service was 4.5 hours (range: 0-67.9
TABLE 1. Comparison of the Characteristics of All Infants Retrieved During the Study Period, Those Retrieved in the First 72 Hours,
Those Retrieved in the First 72 Hours With Complete Physiologic Data, and Those Retrieved in the First 72 Hours with Physiologic and
Outcome Data (Study Population)
All Retrieved
Infants
All Infants Infants Retrieved in 72 h
Complete
Demographic and
Physiologic Data
Study
Population
No. 8806 6348 3429 2504
Age, h 7.8 (0–659) 4.7 (0–67.9) 4.5 (0–67.9) 4.5 (0–67.9)
Gestational age, wk 37 (23–44) 37 (23–44) 37 (23–44) 36 (24–43)
Birth weight, g 2710 (520–6140) 2800 (520–6140) 2800 (520–6140) 2782 (520–6140)
Male, no. 5345 (60.6%) 3827 (60.2%) 2100 (61.2%) 1585 (63.2%)
Temperature, °C 36.7 (30–40) 36.6 (30–40) 36.7 (32–40) 36.6 (32–40)
Heart rate, beats per min 140 (40–300) 140 (40–300) 140 (40–256) 142 (50–236)
Respiratory rate, breaths per min 60 (7–135) 62 (10–135) 68 (20–135) 68 (20–135)
Fio
2
0.55 (0.21–1.0) 0.6 (0.21–1.0) 0.7 (0.21–1.0) 0.7 (0.21–1.0)
Oxygen saturation, % 96 (15–100) 95 (15–100) 95 (15–100) 95 (15–100)
Apgar score at 1 min 6 (0–10) 6 (0–10) 6 (0–10) 6 (0–10)
Apgar score at 5 min 8 (0–10) 8 (0–10) 8 (0–10) 8 (0–10)
Intubated, no. 705 (8.0%) 550 (8.7%) 422 (12.3%) 313 (12.5%)
Pao
2
, kPa 9.8 (1.1–80) 10.2 (1.1–80) 9.7 (1.1–78.5) 9.53 (1.1–78.5)
Paco
2
, kPa 5.7 (1.1–20.9) 5.7 (1.1–20.9) 5.7 (1.1–20.9) 6 (1.1–20.9)
pH 7.3 (6.47–7.9) 7.29 (6.47–7.7) 7.29 (6.47–7.63) 7.28 (6.47–7.63)
Base excess Ϫ4.8 (Ϫ33 to 25) Ϫ5.0 (Ϫ33 to 20) Ϫ5 (Ϫ30 to 20) Ϫ5 (Ϫ30 to 20)
Bicarbonate mmol/L 21 (1.2–40) 20.6 (2–38) 20.8 (2–40) 20.9 (2–40)
Results are presented as median (range) or number (%).
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hours); an age of 0 was recorded when the referring hospital called
the retrieval service before the infant was born.
RESULTS
The study population was significantly younger
than the NETS population, because only infants Ͻ72
hours of age were included in the analysis (Table 1).
The study patients also had significantly greater ox-
ygen requirements and were more likely to be intu-
bated at the time of the call.
The only significant difference between the deri-
vation and validation cohorts was the proportion of
infants who were intubated (Table 2). Univariate
analyses indicated that postnatal age, gestational
age, gender, birth weight, Apgar scores at 1 and 5
minutes, respiratory rate, intubation status, Pao
2
,
pH, base excess, and presence of a congenital abnor-
mality differed (P Ͻ .2) between infants who died
and those who survived (data not shown).
From the multivariate logistic regression analysis,
a 7-variable logistic regression model was generated
(Table 3). The 7-variable model was shown to have
the same area under the ROC curve as a model that
contained all of the variables. Removal of additional
variables resulted in a smaller area under the ROC
curve; therefore, the 7-variable model was used. The
equation used to generate the probability of death
from the model is as follows:
logit ϭϪ25.53 Ϫ 2.50expϪ02 · age ϩ 0.29 · Apgar
score at 1 minute ϩ 2.07expϪ04 · birth weight
Ϫ 0.88expϪ03 · Pao
2
ϩ 3.74 · pH Ϫ 1.75 · congenital
abnormality Ϫ 1.23 · intubation status
The probability of death (y) is given by the equation
y ϭ exp(logit)/[1 ϩ exp(logit)]. Age is expressed in
hours; for the presence of a congenital abnormality
and intubation status, yes ϭ 1.
The model generated areas under the ROC curve
of 0.82 for the generation cohort and 0.83 for the
validation cohort. The goodness of fit (Hosmer-
Lemeshow test) for the derivation cohort was 0.364,
and that for the validation cohort was 0.303.
With the information from the logistic regression
analysis, the MINT score was derived (Table 4). The
median MINT score for the study population was 3
(range: 0-33). Eighty per cent of infants with MINT
scores of Ͼ20 died (Fig 1). The MINT score had an
area under the ROC curve of 0.80 (95% CI: 0.76-0.83)
for death in the perinatal period (first week after
birth) and an area under the ROC curve of 0.80 (95%
CI: 0.76-0.83) for death in the neonatal period (first
month after birth) (Fig 2). For VLBW infants, the
MINT score had areas under the ROC curves for
perinatal and neonatal death of 0.69 (95% CI: 0.60-
0.77) and 0.68 (95% CI: 0.60-0.76), respectively. Ges-
tational age and birth weight had areas under the
ROC curves of 0.64 (95% CI: 0.56-0.73) and 0.67 (95%
CI: 0.59-0.76), respectively.
DISCUSSION
We generated and validated a prediction of mor-
tality score (MINT score) for retrieved neonates that
was based on data obtained at the first referral call.
The MINT score exhibited performance similar to
that of the Transport Risk Index of Physiologic Sta-
bility (TRIPS),
1
which was generated with a similar
population (the median gestational age of the study
population used for generation of the TRIPS was 36
weeks and the birth weight was 2610 g). The areas
TABLE 2. Characteristics of the Derivation and Validation Cohorts
Derivation Cohort Validation Cohort P
No. 1252 1252
Postnatal age, h 4.7 (0–67.9) 5.1 (0–67.4) .88
Gestational age, wk 36 (24–42) 36 (24–43) .70
Male, no. 794 (63.4) 794 (63.6) .95
Birth weight, g 2840 (580–5950) 2810 (520–5835) .75
Apgar score at 1 min 6 (0–10) 6 (0–10) .62
Apgar score at 5 min 8 (0–10) 8 (0–10) .67
Heart rate, beats per min 142 (50–204) 142 (100–236) .71
Respiratory rate breaths per min 68 (20–140) 68 (20–166) .50
Fio
2
0.7 (0.21–1.0) 0.7 (0.21–1.0) .20
Intubated, no. 213 (17.0) 169 (13.5) .04
Pao
2
, mm Hg 73 (16–590) 70 (8–539) .09
Paco
2
, mm Hg 44 (11–157) 45 (8–142) .11
pH 7.28 (6.53–7.63) 7.27 (6.47–7.61) .33
Base excess Ϫ5 (Ϫ29 to ϩ11) Ϫ5 (Ϫ29 to ϩ13) .83
Bicarbonate, mmol/L 20.4 (4.2–40) 21 (2.0–38) .27
Oxygen saturation, % 95 (22–100) 95 (20–100) .28
Congenital abnormality, no. 226 (18.0) 226 (18.0) .28
Died, no. 138 (11.0) 164 (13.1) .20
The data are displayed as number (%) or median (range).
TABLE 3. Logistic Coefficients, Odds Ratios, and 95% CIs of
the 7 Variables in the Model
Variable Logistic
Coefficient
(␤)
Odds
Ratio
95% CI
Postnatal age Ϫ0.025 0.976 0.965–0.985
Apgar score at 1 min 0.294 1.341 1.254–1.435
Birth weight 0.002 1.002 1.000–1.004
Pao
2
Ϫ0.008 0.997 0.994–0.999
pH 3.744 42.284 13.689–130.618
Congenital abnormality Ϫ1.747 0.174 0.122–0.249
Intubated Ϫ1.227 0.292 0.203–0.423
e426 MINT SCORES
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under the ROC curves for perinatal and neonatal
death for the TRIPS were 0.83 and 0.76 and those for
the MINT score were 0.80 and 0.80, respectively. The
TRIPS, however, is derived from data collected by a
member of the transport team immediately after ar-
rival at the referring hospital and immediately after
arrival at the destination hospital.
1
In contrast, the
MINT score uses data collected when the referring
hospital first contacts the transport team via tele-
phone. This is a major advantage, because decisions
are made at first contact regarding resource alloca-
tion. The MINT score has an additional advantage,
ie, it is based on 7 objective data items; although the
TRIPS comprises only 4 items, 1 is the response to
noxious stimuli, which is subjective.
The study population differed from the total NETS
population, because we included only infants for
whom the transport process started at Ͻ72 hours of
age (when most neonatal retrievals occur). We also
included only infants with complete demographic
data and blood gas data for at least 2 of the 4 time
points. The study population differed significantly
from the NETS population with respect to the pro-
portion of patients intubated and their greater oxy-
gen requirements. We were thus examining the sick-
est infants transported, as highlighted by the
mortality rate of 12%, compared with the rate of 10%
for the whole NETS population. A mortality predic-
tion score would be most useful for the sickest in-
fants. The MINT score, however, was developed
with only 39% of the eligible cohort, and we recom-
mend that it be prospectively validated before it is
put into widespread use.
The MINT score comprises 7 variables, including
the Apgar score at 1 minute. The 5-minute Apgar
score, rather than the 1-minute score, has been con-
sidered to be more predictive of neonatal death.
14
However, the National Institute of Child Health and
Human Development mortality prediction model
8
also used the 1-minute Apgar score. In this study,
both 1- and 5-minute Apgar scores were available for
all of the infants included and both were analyzed,
but the 1-minute Apgar score performed better. The
Pao
2
/Fio
2
ratio is included in the SNAP as a mea-
sure of oxygenation.
6
It was selected, rather than the
oxygenation index, arterial-alveolar oxygen differ-
ence, or arterial-alveolar oxygen ratio, for the SNAP
because it was statistically equivalent and avoided
the need to determine mean airway pressure or con-
current carbon dioxide tension. In our study, we
found that arterial oxygen tension, but not the in-
spired oxygen concentration or oxygenation index,
was significantly related to death. A possible expla-
nation for the difference was that more than one-
fourth of the infants were receiving 100% oxygen at
the time of the referral call. We excluded base excess
from our score because of colinearity and because,
although both pH and base excess were highly pre-
dictive, pH performed better. We included congeni-
tal abnormality in our analysis because congenital
abnormalities are known to have mortality effects
beyond those indicated by physiologic derange-
ments.
6
Indeed, the analysis demonstrated that the
presence of a congenital abnormality was signifi-
cantly associated with death, and that parameter was
Fig 1. Relationship of mortality rate to MINT score (ᮀ, number of
infants; I, mortality rate).
Fig 2. ROC curve for death in the neonatal period.
TABLE 4. MINT Score Point Allocation
% Died Points
pH
Ͻ6.9 59.52 10
6.91–7.1 23.78 4
Ͼ7.1 10.36 0
Age
0–1 h 25.16 4
Ͼ1 h 10.24 0
Apgar score at 1 min
0 44.44 8
1 30.10 5
2 22.11 2
3 18.50 2
Ͼ3 7.49 0
Birth weight
Ͻ750 g 62.50 5
751–1000 g 36.00 2
1001–1500 g 19.05 1
Ͼ1500 g 10.74 0
Pao
2
Յ3 kPa 28.57 2
Ͼ3 kPa 11.87 0
Congenital abnormality
Yes 22.27 5
No 9.55 0
Intubated at time of call
Yes 26.20 6
No 10.04 0
Maximum 40
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included in our model. Unfortunately, only the pres-
ence or absence of a congenital abnormality was
recorded at the time of the referral call. Therefore, we
cannot comment on whether weighting for the sever-
ity of the abnormality might have generated a more
accurate score. A better standardized classification
system must be available,
15
however, before this can
be appropriately investigated.
CONCLUSIONS
We have generated and validated an easy-to-use
mortality prediction score for retrieved neonates.
Such scores should not be used to ration health care;
instead, a high score should be used to indicate the
level or priority and the need for the most experi-
enced transport team. All of the data used in the
MINT score can be collected at the time of the first
telephone contact by the referring hospital with the
transport team. This score might be particularly use-
ful because it could facilitate more effective triage.
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e428 MINT SCORES
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DOI: 10.1542/peds.2003-0960-L
2004;114;e424 Pediatrics
Tarnow-Mordi and Anne Greenough
Simon J. Broughton, Andrew Berry, Stephen Jacobe, Paul Cheeseman, William O.
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