The Pediatric Risk of Hospital Admission Score: A Second-Generation
Severity-of-Illness Score for Pediatric Emergency Patients
James M. Chamberlain, MD*‡§; Kantilal M. Patel, PhD*§; and Murray M. Pollack, MD, MBA*㛳
ABSTRACT. Objective. To develop and validate a
second-generation severity-of-illness score that is appli-
cable to pediatric emergency patients. The Pediatric Risk
of Admission (PRISA) score was developed in a single
hospital and was recalibrated and validated in 2, previ-
ous, small studies from academic pediatric hospitals.
This study was performed to develop and validate a score
in a larger sample of diverse hospitals.
Methods. Emergency departments (EDs) were block
randomly selected as part of a study on ED quality on the
basis of 3 care characteristics: annual patient volume
(high or low compared with national median), presence
or absence of a pediatric emergency medicine subspecial-
ist, and presence or absence of residents. Patients were
selected randomly on the basis of daily arrival logs. Med-
ical records were photocopied, and abstracted data in-
cluded demographic, historical, physiologic, and thera-
peutic information. The total sample was randomly
divided into a 75% development sample and a 25% val-
idation sample. Univariate and multivariate analyses
were used to model the risk of mandatory admission,
admissions for which preidentified, inpatient medical
resources were used. The resulting multiple logistic re-
gression model coefficients were converted to integer
scores. Calibration (Hosmer-Lemeshow goodness of fit)
and discrimination (area under the ROC curve) were
used to measure performance. As a measure of construct
validity, proportions of patients in ordered risk intervals
were correlated with the outcomes of admission, manda-
tory admission, and ICU admission.
Results. Sixteen EDs enrolled 11 664 patients. Mean
patient age (ⴞSD) was 6.8 ⴞ 5.8 years, and 53% were
male. Nine percent arrived by emergency medical ser-
vices, and 6.9% were admitted. The most common diag-
noses were minor injuries, otitis media, and fever. The
multivariate analysis yielded a score with 7 historical
variables, 8 physiologic variables, 1 therapy (oxygen)
term, and 1 interaction term. Calibration was excellent. In
the development sample, 442 mandatory admissions
were predicted and 442 were observed (total ␹2 ⴝ 2.275),
and in the validation sample, 136.6 were predicted and
145 were observed (␹2 ⴝ 8.575). The area under the re-
From the *Department of Pediatrics, George Washington University School
of Medicine, Washington, DC; and ‡Department of Emergency Medicine,
§Center for Health Services and Community Research, Children’s Research
Institute, and 㛳Center for Hospital-Based Specialties and Department of
Critical Care Medicine, Children’s National Medical Center, Washington,
DC.
Accepted for publication Jul 6, 2004.
doi:10.1542/peds.2004-0586
No conflict of interest declared.
Address correspondence to James M. Chamberlain, MD, Department of
Pediatrics, George Washington University School of Medicine, 111 Michi-
gan Ave NW, Washington, DC 20010. E-mail: jchamber@cnmc.org
PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Acad-
emy of Pediatrics.
388 PEDIATRICS Vol. 115 No. 2 February 2005
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ceiver operator characteristic curve was 0.82 ⴞ 0.01 (SE) in
the development sample and 0.77 ⴞ 0.02 in the validation
sample. In ordered predicted risk intervals, the propor-
tion of patients with admissions, mandatory admissions,
and ICU admissions increased in a linear manner.
Conclusions. The second-generation PRISA II score
for pediatric ED patients has been developed and vali-
dated in a large sample of diverse hospitals. Performance
characteristics indicate that PRISA II will be useful for
institutional comparisons, benchmarking, and controlling
for severity of illness when enrolling patients in clinical
trials. Pediatrics 2005;115:388–395; emergency medicine,
health services research, severity-of-illness index.
ABBREVIATIONS. ED, emergency department; PRISA, Pediatric
Risk of Admission; PEM, pediatric emergency medicine; ROC,
receiver operator characteristic.
S
pecific components of the Emergency Medical
Services system and the Emergency Medical
Services–Children system have benefited from
the development and use of severity assessment
methods. For example, PICU severity methods have
enabled evaluation of quality of PICU care using
severity-adjusted mortality rates,1 identification of
PICU care characteristics associated with quality of
care,2,3 measurement of efficiency of bed use,4 and
measurement of severity-adjusted length of stay.5
Such methods have not been applied to pediatric or
adult emergency departments (EDs). Although se-
verity scales exist for specific diseases, there is no
widely accepted method that is applicable to all pe-
diatric ED patients.
Previous severity-of-illness methods applied to
hospital and ED environments (eg, trauma patients)
have used mortality as the outcome for quality-of-
care studies.6 However, mortality is not an appropri-
ate outcome for the predominant ED activities and is
so rare in the general pediatric ED population that it
cannot be used as a meaningful outcome measure.
One of the most important functions of ED practice is
the correct disposition of patients to either inpatient
or outpatient care settings. Overadmission results in
wasted resources and the risk of iatrogenic injury,
whereas failure to admit when necessary results in
delayed care and avoidable complications. We pro-
pose that the appropriate outcomes that are indica-
tive of pediatric ED quality are correct rates of hos-
pital admission and ED discharge.
We developed a severity-of-illness model using
hospital admission as the outcome. Initially devel-
oped and validated at a single institution, the Pedi-
atric Risk of Admission (PRISA) score uses compo-
nents of acute and chronic medical history,
physiology, and ED therapies to model the risk of
hospital admission. Higher PRISA scores were asso-
ciated with higher probability of medically manda-
tory admissions, ICU admission, and mortality.7 The
PRISA score subsequently has been validated in 2
other studies, including 1 multisite study.8,9
The purpose of this study was to develop a
second-generation pediatric ED severity-of-illness
(PRISA II) score in a large national sample of hospi-
tals. We used a sample of 16 EDs block randomly
selected to represent large and small EDs, those with
and without pediatric emergency medicine (PEM)
specialists, and those with and without residents
providing ED care.
METHODS
Site Selection
Sites were selected as part of a study to evaluate the association
of hospital care factors with quality of pediatric emergency med-
ical care.10 In brief, EDs were randomly selected to represent the
care factors of high or low volume (ⱕ or ⬎ the national median of
pediatric visits per year), presence or absence of a PEM specialist,
and presence or absence of residents delivering ED care such that
there were 2 EDs representing each of the 8 possible combinations
of factors. Volume was determined from the American Hospital
Association 1997 Annual Survey Database (Chicago, IL) and used
to randomly select EDs for telephone survey concerning the other
2 care factors. All selected hospitals had PICUs. The Institutional
Review Boards of the participating hospitals approved the study.
Patient Selection
A random-number generator was used to select 2 patients per
day, using the daily consecutive log of patient arrivals routinely
TABLE 1. Therapies Defining Mandatory Admission7
Therapies
Airway suctioning ⱖ2 h
Blood or blood product transfusion
Continuous intravenous drug infusions
Emergency dialysis/hemofiltration
Inhalation therapy
Interventional cardiac procedures
Intramuscular or intravenous antibiotics
Intravenous antiarrhythmic agents
Intravenous anticonvulsants
Intravenous electrolyte bolus
Intravenous buffer
Intravenous or intramuscular treatment
of pain
Mechanical ventilation
Operating room procedure
Oxygen
Arterial or central venous line
Tube thoracostomy
Cardiopulmonary resuscitation
Nasogastric or orogastric tube
Transfer to PICU
Physiologic status
Acute suicide risk
No oral intake
Acute coma or stroke
Absolute neutrophil count ⬍500
Platelet count ⬍20 000
Burns ⬎10% of total body surface area
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kept at each site. We attempted to enroll 750 patients at each site.
Actual patient enrollment ranged from 729 to 753 patients. For
sites that enrolled ⬎729, patients were randomly eliminated from
the sample to achieve a balanced sample of 729 patients from each
site, for a total study enrollment of 11 664 patients.
Data Management
After personal identifiers were masked, photocopied records
were submitted to the coordinating center. The entire ED record
and the first 24 hours of the inpatient record, where applicable,
were submitted. Data reliability was determined by interrater
reliability between the data abstractor and 1 of the authors (J.M.C.)
to maintain an intraclass correlation coefficient R ⬎ 0.75.
Outcomes
Admission was defined as admission to an inpatient ward or
admission to an observation area for ⬎12 hours. The primary
outcome for this study was mandatory admission. Admission was
classified as mandatory on the basis of a previously validated list
of services usually provided in acute care hospitals.7 Mandatory
admissions are considered those that receive a therapeutic re-
source that because of the therapy or its intensity is usually
delivered as an inpatient (Table 1). Nonmandatory admissions did
not receive one of these resources.
Identification of Potential Predictor Variables
Potential predictor variables included historical, physiologic,
and other risk factors. Unmeasured variables were assumed to be
normal. Several variable types were excluded from the potential
predictor variables. First, variables that are likely to be influenced
by hospital practice, individual practice patterns, or medical re-
cording practices were not included. Thus, we minimized the
consideration of therapeutic variables. Second, socioeconomic fac-
tors were not included as predictor variables. Third, we consid-
ered ranges of physiologic variables rather then absolute values to
reduce the effect of sampling frequency.
Multiple logistic regression was used to model the probability
of the mandatory admission using a process similar to develop-
Comment
Tracheostomy, endotracheal tube
Terbutaline for asthma, insulin for diabetes,
furosemide for severe fluid overload,
vasopressor for shock
Frequency ⱖ2 h, including hourly and
continuous balloon septostomy, valvotomy, etc
Lidocaine, procainamide, etc
Barbiturates, Dilantin, benzodiazepines, etc
Potassium ⱖ 1 mEq/kg, 3% saline as a bolus,
intravenous calcium
Intravenous bicarbonate or tromethamine
Narcotics, nonsteroidal anti-inflammatory agents
Greater than baseline
⬎12 h for children ⬎12 mo, ⬎8 h for infants
1–12 mo, and 6 h for neonates ⬍1 m
Any full-thickness burn
ARTICLES 389
ment of the PRISM III score.1 The patient sample was randomly
divided into a 75% development sample and a 25% validation
sample. The independent variables for possible inclusion in the
predictive model were selected using a multistep process. First,
variables were chosen for clinical relevance on the basis of clinical
experience and previous work in developing severity adjustment
models. Second, univariate analyses were used to determine as-
sociations with the dependent variable. For categorical variables,
this was performed using unadjusted odds ratios. Some categor-
ical variables were uncommon in ED populations and therefore
were combined with other, clinically similar variables. For exam-
ple, the chronic disease variables “HIV” and “oncologic disease”
were combined with other conditions into a single category “im-
munodeficiency.” For continuous variables, patients were strati-
fied into the age groups of neonates (0 –1 month), infants (⬎1–12
months), children (⬎12–144 months), and adolescents (⬎144
months). Univariate logistic regression analysis was used to de-
termine which variables and subranges significantly contributed
to the probability of hospital admission. The risk of hospital
admission relative to the midrange (40th– 60th percentiles) of dis-
charged patients was computed for the physiologic variables in
each age stratum. We assumed that deviations from the midrange
contributed to risk, with larger deviations reflecting higher risk.
We initially used deciles of physiologic values, then readjusted
these cutpoints on the basis of clinical relevance and performance
in the multivariate model. Neighboring deciles were combined
when the regression coefficients were similar.1 Variables with a
liberal significance level (P ⬍ .30) in univariate analysis were
included in the multivariate model. Third, forward and backward
stepwise inclusion of variables was used in the development of the
multiple logistic regression model. Variables were retained as long
as they contributed to a lower Akaike’s Information Criteria and
were statistically significant at P ⬍ .10. The regression coefficients
in the model were expressed as relative percentages by dividing
each of the coefficients by the sum of the regression coefficients
and multiplying by 100. The rounded percentages for each vari-
able and variable range are the components of the PRISA II score,
and the total for all variables is the PRISA II score for each patient.
Although most variables contribute to a higher risk of hospital
admission, a variable may have a negative regression coefficient
(and thus a corresponding negative integer score), indicating that
the presence of that variable in an individual patient contributes to
a lower risk of hospital admission.
Standard performance measures were used to assess the PRISA
II score. The area under the curve for the receiver operator char-
acteristic (ROC) curve was used to measure discrimination. Cali-
bration compared observed outcomes with predicted outcomes,
where the predicted outcomes were the number predicted by the
PRISA II score. The Hosmer-Lemeshow goodness-of-fit tests (␹2)
were used to measure calibration by comparing observed with
predicted admissions in 8 ordered risk intervals of predicted
admission probability. Risk intervals were chosen to be clinically
relevant, to ensure at least 10 predicted admissions in each inter-
val in the development sample, and to attempt to achieve a bal-
anced distribution of admitted patients across the intervals. Over-
all performance was also assessed with the standardized
admission ratio, the ratio of observed mandatory admissions to
predicted mandatory admissions. Comparison of mean PRISA II
score among different severity subgroups used the Kruskal-Wallis
test. Construct validity was assessed by comparing proportions of
patients with admission, mandatory admission, and ICU admis-
sion in the ordered PRISA II risk intervals using the Cochran-
Armitage test for linear trend in proportion.11
RESULTS
Sample and Patient Data
Institutional and patient characteristics are de-
picted in Table 2. The 16 sites ranged in annual
pediatric ED volumes from 1740 to 31 000 patients
(median: 13 905). Four sites had pediatric volumes
⬍8000, 4 sites had volumes between 8000 and 13 900,
4 sites had volumes between 13 900 and 17 500, and
4 sites had volumes ⬎17 500. Consistent with the
study design for site enrollment, 8 sites had residents
caring for patients in the ED, and 8 sites had at least
1 PEM specialist in the practice. The most common
chief complaints were fever (17.5%), nonspecific re-
spiratory complaints (14.5%), and injuries to the ex-

TABLE 2. ED and Patient Characteristic Variability

ED and Patient Characteristics Value Range in 16 Sites
Annual pediatric volume, median 13 905 1170–31 000*
Patient age, mean ⫾ SD 6.77 ⫾ 5.75 Mean 4.26–8.7 years*
Male gender 6135 (52.6%) 47.9%–58.3%†
Arrival by EMS 1094 (9.4%) 2.2%–21.5%‡
Outcomes
Hospital admissions 808 (6.9%) 1.4%–17%‡
ICU admissions 93 (0.8%) 0%–2.5%‡
Mortality 8 (0.1%) 0%–0.4%§
Common complaints
Fever 2038 (17.5%) 8.4%–26.6%‡
Respiratory 1690 (14.5%) 9.6%–21.5%‡
Extremity trauma 1211 (10.4%) 5.1%–21.1%‡
Head trauma 1094 (9.4%) 6.3%–15.8%‡
Common diagnoses
Minor injuries 2819 (24.2%) 12.1%–41.0%‡
Otitis media 1077 (9.2%) 4.8%–13.8%‡
Fever without a source 583 (5.0%) 0.3%–12.6%‡
Common diagnostic tests
Complete blood count 1617 (13.9%) 4.5%–19.9%‡
Chest radiograph 1465 (12.6%) 8.4%–20.2%‡
Electrolytes 1039 (8.9%) 1.8%–17.8%‡
Common therapies
Analgesics/antipyretics 2374 (20.4%) 14.5%–28.8%‡
Intravenous fluids 934 (8.0%) 2.1%–14.9%‡
Bronchodilators 703 (6.0%) 2.9%–9.3%‡
Oxygen 201 (1.7%) 0.4%–5.2%‡
The significance level refers to comparisons of the indicated variable among the 16 EDs.
* P ⬍ .001, Kruskal-Wallis test.
† P ⬍ .01, ␹2 test of homogeneity.
‡ P ⬍ .001, ␹2 test of homogeneity.
§ P ⬍ .01, Fisher’s exact test.

390 PEDIATRIC RISK OF HOSPITAL ADMISSION SCORE

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tremities (10.4%) and head (9.4%). The most common
diagnoses were minor injuries (24.2%), otitis media
(9.2%), and fever without a source (5.0%). There was
significant variability among the EDs for all institu-
tional and patient population characteristics (P ⬍ .01
for all variables).
Of the 11 664 patients, 808 (6.9%) were hospital-
ized and 93 (0.8%) patients were admitted to ICUs.
Three patients died in the ED and were included in
the hospitalized group. Of the 808 admitted patients,
587 (73%) were mandatory admissions. Admission
rates ranged from 1.4% to 17% (P ⬍ .001), and man-
datory admission rates ranged from 1.0% to 13.7% (P
⬍ .001) of ED patients.
Severity-of-Illness Model
Univariate analyses revealed 10 historical and 29
physiologic variables associated with mandatory
hospital admission. One therapeutic variable, oxy-
gen, was substantially more strongly associated with
the outcome than associated physiologic variables,
including pulse oximetry and respiratory rate, and
thus was included for testing in multivariate model-
ing. One variable, low temperature, was not statisti-
cally significant but was considered clinically signif-
icant and thus was retained in the model.
The component variables identified in multivariate
analysis are shown in Table 3. There are 16 variables
and 1 interaction term. Seven of the variables are
historical, 8 are physiologic, and 1 is a therapeutic
variable. For the physiologic variables, none required
multiple ranges and 3 (temperature, systolic blood
pressure, and diastolic blood pressure) are age-ad-
justed. The 1 therapeutic variable, oxygen, is 1 of the
most important predictor variables. Two of the vari-
ables, minor injury and the interaction term, were
negative. Thus, minor injury reduces the likelihood
of admission, whereas the interaction term attenu-
ates the cumulative effects of having both elevated
potassium and low serum bicarbonate.
Table 4 shows the PRISA II score. Variable abnor-
mality points ranged from a high of 14 for decreased

TABLE 3. Multiple Logistic Regression Modeling Mandatory Hospital Admission, Developed Using 75% of the Sample (N ⫽ 8782 ED
visits, 442 Mandatory Hospital Admissions)
Parameter Estimate Standard Error Adjusted Odds Ratio P
(95% Confidence Interval)
Intercept ⫺3.9724 0.0935 .0001
Historical factors
Age ⬍90 d 0.9646 0.1913 2.62 (1.80–3.82) .0001
Minor injury* ⫺0.4161 0.1689 0.66 (0.47–0.92) .0138
Abdominal pain in an adolescent† 2.6649 0.6226 14.37 (4.24–48.68) .0001
Immunodeficiency‡ 1.6308 0.2786 5.11 (2.96–8.82) .0001
Indwelling medical device§ 1.0540 0.2813 2.87 (1.65–4.98) .0001
Controller asthma medications储 1.3490 0.2512 3.85 (2.36–6.31) .0001
Referral status¶ 1.2533 0.1152 3.50 (2.79–4.39) .0001
Physiologic factors
Low temperature 1.0191 0.7460 2.77 (0.64–11.96) .1719
Neonates: ⬍35.5
Infants: ⬍35.5
Children: ⬍35.0
Adolescents: ⬍35.0
Decreased mental status# 3.3968 1.0940 29.87 (3.50–254.94) .0019
Low systolic BP 1.2262 0.2853 3.41 (1.95–5.96) .0001
Neonates: ⬍70
Infants: ⬍70
Children: ⬍83
Adolescents: ⬍100
High diastolic BP 0.7989 0.1389 2.22 (1.69–2.92) .0001
Neonates: ⬎59
Infants: ⬎59
Children: ⬎70
Adolescents: ⬎90
Low serum bicarbonate (⬍20) 2.2385 0.2278 9.38 (6.00–14.66) .0001
High potassium (⬎4.9) 2.3186 0.3090 10.16 (5.55–18.62) .0001
High BUN (⬎18) 1.5412 0.2986 4.67 (2.60–8.39) .0001
High WBC count (⬎20 000) 2.3985 0.2651 11.01 (6.55–18.51) .0001
Therapies
Oxygen** 2.0448 0.2100 7.49 (5.21–11.66) .0001
Interactions
Low bicarbonate and high potassium ⫺1.7213 0.6472 0.179 (0.05–0.64) .0077
BP indicates blood pressure, BUN, blood urea nitrogen; WBC, white blood cell.
* Strain, sprain, abrasion, laceration, and fracture without associated cranial, thoracic, or abdominal injury.
† Chief complaint of abdominal pain in a patient from that age group.
‡ HIV, oncologic disease, sickle cell hemoglobinopathy, and transplanted organ.
§ Tracheostomy, long-term venous catheter, dialysis catheter or shunt, ventricular drainage catheter, feeding tube, home apnea monitor,
and home oxygen.
储 Any asthma medication other than bronchodilators.
¶ Referral from a physician’s office or another ED.
# Listless, irritable, lethargic, obtunded, or comatose.
** Oxygen administered other than during inhaled bronchodilator treatments.

ARTICLES 391
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TABLE 4. The PRISA II Score mental status to ⫺7 as the interaction term to adjust
Parameter Score for low bicarbonate and high potassium (total of 19).
The maximum number of PRISA II points is 96. The
Age ⬍90 d 4
Minor injury* ⫺2 probability (P) of mandatory admission is calculated
Abdominal pain in an adolescent† 11 using the formula P ⫽ 1/(1 ⫹ e⫺R), where R ⫽
Immunodeficiency‡ 7 ⫺4.0250 ⫹ 0.2888*(PRISA II score) ⫺ 0.00279*(PRISA
Indwelling medical device§ 4
Controller asthma medications储 6
II score)2.
Referral status¶ 5 Overall, the PRISA II score performed very well.
Low temperature 4 Figure 1 illustrates the increasing PRISA II score with
Neonates: ⬍35.5 cohorts of increasing illness severity: ED discharges,
Infants: ⬍35.5
Children: ⬍35.0 nonmandatory hospital admissions, mandatory non-
Adolescents: ⬍35.0 ICU hospital admissions, and ICU admissions. There
Decreased mental status# 14 was a significant trend in increasing PRISA II scores,
Low systolic BP 5 and each group’s score was significantly different
Neonates: ⬍70
Infants: ⬍70 from the others with the exception of ICU admis-
Children: ⬍83 sions compared with mandatory non-ICU admis-
Adolescents: ⬍100 sions (P ⫽ .085).
High diastolic BP 3
Neonates: ⬎59
The Hosmer-Lemeshow goodness-of-fit test indi-
Infants: ⬎59 cated excellent calibration in both the development
Children: ⬎70 sample (␹2 ⫽ 2.275, degrees of freedom, df ⫽ 6, P ⫽
Adolescents: ⬎90 .8928; Table 5, Fig 2) and validation sample (␹2 ⫽
Low serum bicarbonate (⬍20) 9
High potassium (⬎4.9) 10 8.575, df ⫽ 7, P ⫽ .2846; Table 6, Fig 2). The stan-
High BUN (⬎18) 6 dardized mandatory admission ratios for the total
High WBC (⬎ 20 000) 10 samples were 1.00 ⫾ 0.04 and 1.06 ⫾ 0.07 in the
Oxygen** 9
Low bicarbonate and high potassium ⫺7
development and validation samples. The area un-
der the ROC curve was 0.822 ⫾ 0.012 in the devel-
The probability of mandatory admission, P ⫽ 1/(1 ⫹ e⫺R), where opment sample and 0.774 ⫾ 0.023 in the validation
R ⫽ ⫺4.0250 ⫹ 0.2888*(PRISA II score) ⫺ 0.00279*(PRISA II
score)2. sample (Fig 3).
* Strain, sprain, abrasion, laceration, and fracture without associ- Construct validity is depicted in Fig. 4. The figure
ated cranial, thoracic, or abdominal injury. illustrates the increasing proportion of patients with
† Chief complaint of abdominal pain in a patient from that age
group. admissions, mandatory admissions, and ICU admis-
‡ HIV, oncologic disease, sickle cell hemoglobinopathy, and trans- sions as PRISA II risk intervals increase (P ⬍ .0001).
planted organ.
§ Tracheostomy, long-term venous catheter, dialysis catheter or
DISCUSSION
shunt, ventricular drainage catheter, feeding tube, home apnea
monitor, and home oxygen. Severity-of-illness methods are important for mea-
储 Any asthma medication other than bronchodilators. suring and controlling for case-mix variability in
¶ Referral from a physician’s office or another ED.
# Irritable, lethargic, obtunded, or comatose.
many situations, including scientific studies and in-
** Oxygen administered other than during inhaled bronchodilator stitutional comparisons.12–16 Such tools have been
treatments. used extensively in pediatric and neonatal critical

Fig 1. PRISA II scores for outcome groups of increasing severity of illness. There is a significant linear trend (*P ⬍ .0001, Kruskal-Wallis
test). Comparison among groups shows that each group is significantly (P ⬍ .0001) different from the others except non-ICU, mandatory
admissions group versus ICU admissions group comparison (P ⫽ .0856).

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 TABLE 5. PRISA II Score Goodness-of-Fit in the Development Sample
Risk Interval No. of Observed Expected Standardized Mandatory
Patients Mandatory Mandatory Admission Ratio
Admissions Admissions (Observed/Expected ⫾ SE)
0%–1.49% 1572 14 15.43 0.907 ⫾ 0.253
1.5%–2.99% 4367 83 77.98 1.064 ⫾ 0.112
3.0%–4.99% 801 28 31.75 0.882 ⫾ 0.174
5.0%–9.99% 1208 77 77.52 0.993 ⫾ 0.110
10%–19.99% 448 68 67.12 1.013 ⫾ 0.112
20%–29.99% 93 23 23.72 0.970 ⫾ 0.177
30%–49.99% 182 77 72.19 1.066 ⫾ 0.091
50%–100% 111 72 76.29 0.944 ⫾ 0.062
Total 8782 442 442.00 1.000 ⫾ 0.041
Hosmer-Lemeshow goodness-of-fit test: total ␹2 ⫽ 2.275, df ⫽ 6, P ⫽ .8928.

Fig 2. Calibration of the PRISA II score. The

dotted line is the line of unity and repre-
sents perfect calibration. The intervals on
the x-axis correspond to the 8 risk intervals
used in calibration of the PRISA II score
(Table 5).

TABLE 6. PRISA II Goodness-of-Fit in the Validation Sample

Risk Interval No. of Observed Expected Standardized Mandatory
Patients Mandatory Mandatory Admission Ratio
Admissions Admissions (Observed/Expected ⫾ SE)
0%–1.49% 519 4 5.10 0.785 ⫾ 0.441
1.5%–2.99% 1460 34 25.97 1.309 ⫾ 0.194
3.0%–4.99% 254 12 10.08 1.191 ⫾ 0.309
5.0%–9.99% 400 26 25.81 1.007 ⫾ 0.190
10%–19.99% 149 20 22.33 0.896 ⫾ 0.194
20%–29.99% 19 9 4.87 1.847 ⫾ 0.390
30%–49.99% 43 16 16.65 0.961 ⫾ 0.191
50%–100% 38 24 25.81 0.930 ⫾ 0.107
Total 2882 145 136.62 1.061 ⫾ 0.075
Hosmer-Lemeshow goodness-of-fit test: total ␹2 ⫽ 8.575, df ⫽ 7, P ⫽ .2846.

care and have allowed comparisons among individ- tients with specific diseases,17–19 there are no widely
ual hospitals and among cohorts of hospitals. Al- accepted general severity measures that are applica-
though there are clinical severity scores for ED pa- ble to all pediatric emergency patients. The PRISA

ARTICLES 393
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 Fig 3. ROC curve of the PRISA II score.
Fig 4. Increasing severity of illness of admitted patients with increasing PRISA risk intervals (P ⬍ .001 for all outcomes, Cochran-Armitage
test for linear trend in proportions).
score was initially developed in a single institution7
and validated in 2 small samples of large academic
centers8,9; thus, it was necessary to revise the first-
generation PRISA score based on a contemporary set
of more diverse PEM patients.
The development of a severity measure that is
applicable to pediatric ED patients has been difficult.
A major barrier to developing an effective severity
method that is applicable to all ED patients has been
lack of a relevant outcome measure that occurs with
sufficient frequency. Because one of the most impor-
tant functions of ED practice is the correct disposi-
tion of patients to either inpatient or outpatient care
settings, we used this outcome in developing a se-
verity-of-illness method. In contrast to mortality and
its tight linkage with physiologic derangement, hos-
pital admission is influenced by several nonphysi-
394 PEDIATRIC RISK OF HOSPITAL ADMISSION SCORE
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ologic factors, including patient age, chronic history,
acute history, and variations in individual practice
and health system factors. Therefore, we calibrated
the score to mandatory admissions, a group of pa-
tients for whom most clinicians would agree under
most circumstances would be best cared for as inpa-
tients. We recognize, however, that there is still some
practice pattern variability in the use of the inpatient
therapies that compose the mandatory admission
list. Most of the criteria for mandatory admission can
be assessed on disposition from the ED, making this
a practical assessment for future use.
Despite these difficulties, PRISA II performs well.
First, mean PRISA II scores increased in patients with
increasing clinical severity, and the PRISA II scores
were ordered correctly for the patient groups by
increasing severity. Second, the goodness-of-fit data
for the development and validation samples were
excellent; throughout the range of admission risks,
the observed numbers of mandatory admissions
were very similar to the expected numbers. Third,
the discrimination of the score was very good with
an area under the curve of 0.82 for the development
sample and 0.77 for the validation sample.
The component variables of PRISA II are consis-
tent with the clinical assessment of children. The
score is composed of 16 variables and 1 adjustment
for physiologic interactions. Eight of the variables are
physiologic with relative values ranging from 3 to 14,
and 3 have age-adjusted scoring. There are 2 chief
complaint variables, minor injury and abdominal
pain in an adolescent. Minor injury has a score of ⫺2,
indicating reduced admission risk for a given set of
historical and physiologic variables, and abdominal
pain in an adolescent is a patient condition that,
regardless of other variables, is more likely to result
in admission. Other historical variables are impor-
tant in our model. Very young age by itself is a risk
factor, as are immunodeficiency, indwelling medical
devices, chronic asthma medications, and referral
status. One therapeutic variable, oxygen, was suffi-
ciently important to be included; its use is generally
well governed by other physiologic variables such as
respiratory distress and oxygen saturation. Of note,
the score of each variable is determined by its im-
portance in the presence of all variables. Thus, scores
may be lower or higher than might be expected if
that variable were assessed alone, out of the context
of other variables.
There are 2 limitations to this study. First, our
sample is not nationally representative of all hospi-
tals. The block random selection was designed to
include equal representation of academic and nonac-
ademic EDs, large and small EDs, hospitals with and
without PEM specialists, and all possible combina-
tions of these factors. Some may believe that different
comparison groups would be better. We believe that
although this is not a random sample of national
EDs, it perhaps is a better representation of the di-
versity of the types of EDs, which might not be
otherwise well captured in a relatively small random
national sample. Most important, our sample is well
defined so that future researchers will be able to
consider the impact of sample selection. Second, al-
though the PRISA II score is the best effort to date to
develop a general severity tool, the discrimination is
very good but is not sufficient for use in individual
patients. However, the use of PRISA II for large
groups of patients to compare performance and for
controlling for severity of illness and other case-mix
factors for studies is appropriate.
CONCLUSION
Severity-of-illness methods have been useful for
clinical research, for performance assessment, and
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for comparing institutional performance with exter-
nal benchmarks. We have developed and validated a
second-generation severity score for application in
EDs that treat children. In the study sample of 16
EDs, there were wide variations in severity-adjusted
admission rates, suggesting that this tool will be
useful for quality assessment.
ACKNOWLEDGMENT
This study was supported by the Agency for Health Care
Quality and Research, Grant RO1 HS10238-02.
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ARTICLES 395
 The Pediatric Risk of Hospital Admission Score: A Second-Generation
Severity-of-Illness Score for Pediatric Emergency Patients
James M. Chamberlain, Kantilal M. Patel and Murray M. Pollack
Pediatrics 2005;115;388
DOI: 10.1542/peds.2004-0586
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2005 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Univ Of Birmingham on June 2, 2015

 The Pediatric Risk of Hospital Admission Score: A Second-Generation
Severity-of-Illness Score for Pediatric Emergency Patients
James M. Chamberlain, Kantilal M. Patel and Murray M. Pollack
Pediatrics 2005;115;388
DOI: 10.1542/peds.2004-0586

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/115/2/388.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2005 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Univ Of Birmingham on June 2, 2015