Original Article 395

Transport Risk Index of Physiologic Stability,

Version II (TRIPS-II): A Simple and Practical
Neonatal Illness Severity Score
Shoo K. Lee, MBBS, FRCPC, PhD 1, 2 Khalid Aziz, MBBS, FRCPC 3 Michael Dunn, MBBS, FRCPC 1
Maxine Clarke, MD, FRCPC 4 Lajos Kovacs, MD, FRCPC 5 Cecil Ojah, MBBS, FRCPC 6 Xiang Y. Ye, MSc 2
for The Canadian Neonatal Network

1 Department of Pediatrics, University of Toronto, Toronto, Ontario, Address for correspondence Shoo K. Lee, MBBS, FRCPC, PhD,
Canada Professor of Paediatrics, Department of Paediatrics, University of
2 Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Toronto, 600 University Avenue, Rm 782, Toronto, ON, Canada M5G
Ontario, Canada 1X5 (e-mail: sklee@mtsinai.on.ca).
3 Department of Pediatrics, University of Alberta, Edmonton, Alberta
4 Department of Pediatrics, Queen’s University, Kingston, Ontario,
Canada
5 Department of Pediatrics, McGill University, Montreal, Quebec
6 Department of Pediatrics, Saint John Regional Hospital, Saint John,
New Brunswick, Canada

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Am J Perinatol 2013;30:395–400.

Abstract Objective Derive and validate a practical assessment of infant illness severity at
admission to neonatal intensive care units (NICUs).
Study Design Prospective study involving 17,075 infants admitted to 15 NICUs in
2006 to 2008. Logistic regression was used to derive a prediction model for mortality
comprising four empirically weighted items (temperature, blood pressure, respiratory
status, response to noxious stimuli). This Transport Risk Index of Physiologic Stability,
version II (TRIPS-II) was then validated for prediction of 7-day and total NICU mortality.
Results TRIPS-II discriminated 7-day (receiver operating curve [ROC] area, 0.90) and
total NICU mortality (ROC area, 0.87) from survival. Furthermore, there was a direct
association between changes in TRIPS-II at 12 and 24 hours and mortality. There was
Keywords good calibration across the full range of TRIPS-II scores and the gestational age at birth,
► neonates and addition of TRIPS-II improved performance of prediction models that use gesta-
► mortality tional age and baseline population risk variables.
► risk adjustment Conclusion TRIPS-II is a validated benchmarking tool for assessing infant illness
► outcomes severity at admission and for up to 24 hours after.

Neonatal illness severity scores such as the Clinical Risk Index
for Babies (CRIB)1 and the Score for Neonatal Acute Physiolo-
gy, version II (SNAP-II)2 are important for risk adjustment and
benchmarking outcomes in neonatal intensive care units
(NICUs). However, both CRIB and SNAP-II have been criticized
because they are derived from measurements taken over a
12-hour period. Consequently, interventions during this pe-
riod may affect scores and limit their ability to truly measure
illness severity at admission. In addition, CRIB is only validat-
ed for infants with a birth weight of < 1,500 g, and neither
SNAP-II nor CRIB is validated for sequential measurements to
determine change in physiologic stability over time.
The Transport Risk Index of Physiologic Stability (TRIPS)3 is
a simple, practical, empirically weighted measure of neonatal

received Copyright © 2013 by Thieme Medical DOI http://dx.doi.org/

November 28, 2011 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0032-1326983.
accepted after revision New York, NY 10001, USA. ISSN 0735-1631.
May 29, 2012 Tel: +1(212) 584-4662.
published online
September 21, 2012
396 TRIPS-II for Assessment of Illness Severity Lee et al.
illness severity that comprises four physiologic measure-
ments (temperature, respiratory status, blood pressure, re-
sponse to noxious stimuli) that correlate with NICU mortality
and can be measured within 1 minute without need for
laboratory support. TRIPS has been validated for outborn
infants of all birth weights requiring transport to a NICU,
and its predictive performance for mortality and major
morbidity in the NICU is equivalent to SNAP-II. However,
unlike SNAP-II, TRIPS is derived from measurements that are
obtained within 1 minute, and therefore provides a true
reflection of stability at the exact time when it is measured.
The objective of this study was to determine whether
TRIPS can be adapted to measure illness severity for both
inborn and outborn infants admitted to the NICU and wheth-
er sequential measurement can give an accurate assessment
of changes in physiologic stability over time. We compared
the predictive performance of the extended TRIPS version II
(TRIPS-II) with SNAP-II and assessed its ability to measure
neonatal illness severity sequentially over a 24-hour period.
Methods
Study Population
We examined all infants (n ¼ 19,165) who were admitted to
15 tertiary level NICUs in the Canadian Neonatal Network
from January 2006 to December 2008. Infants who were
dying at admission and for whom a decision was made not
to resuscitate (moribund) or infants with missing information
regarding gestational age (GA) at birth were excluded. Each of
the 15 participating NICUs served a distinct geographic
region, and together they comprised 60% of all tertiary
NICU beds in Canada, ranging in size from 20 to 83 beds,
102 to 964 admissions, and 0 to 7,000 births annually. Two
NICUs admitted only outborn infants, and outborn infants
comprised 3.5 to 28.6% of admissions at the other 13 NICUs.
Two-thirds of the sample (two-thirds of inborn infants and
two-thirds of outborn infants) were randomly assigned to the
derivation cohort and the remainder to the validation cohort
using a split sample method.4
Measurement of Variables
We prospectively collected data on the four physiologic
parameters that were used to derive TRIPS3: temperature,
blood pressure, respiratory distress, response to noxious
stimuli. These were collected immediately (within
15 minutes) upon admission to the NICU and then again 12
and 24 hours later. Consequently, any changes in the TRIPS-II
score as measured at admission to the NICU and subsequently
were at least in part impacted by care provided to the infant
after admission to the NICU.
Variable Definitions
Study variables were defined according to the Canadian
Neonatal Network Abstractor’s Manual. For GA at birth, the
estimate was based on early prenatal ultrasound, time since
last menstruation, pediatric estimate, or obstetric estimate, in
that order. An infant was defined as small for GA if the birth
weight was less than the 3rd percentile for GA according to
American Journal of Perinatology Vol. 30 No. 5/2013
the growth charts established by Kramer et al.5 The SNAP-II
neonatal illness severity score was calculated from six em-
pirically weighted physiologic measurements made during
the first 12 hours of admission to the NICU, as previously
described.2
Derivation of TRIPS-II
Since the original TRIPS was designed to assess transport-
related effects on mortality, it was validated against 7-day
mortality in the NICU, as mortality after 7 days is more likely
to reflect care in the NICU than care during transportation.3
However, with TRIPS-II we wished to determine whether a
simple score based on physiology at this early stage could
accurately predict overall mortality in the NICU for both
inborn and outborn infants. We therefore validated TRIPS-II
against total NICU mortality, which is well defined and has
been previously used to validate other measures of physio-
logic stability. All infants were followed until death or
discharge.
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Univariate Analysis
Using data collected at admission from infants in the deriva-
tion cohort each of the four physiologic variables was grouped
as a categorical variable with two or three categories as per
TRIPS.3 The association between NICU mortality and each of
the four physiologic categorical variables was then examined
using both the chi-square test and logistic regression.
Multivariable Analysis
To derive TRIPS-II, the methods of Pollack et al4 were used. We
first conducted multiple logistic regressions for the predic-
tion of NICU mortality using covariables of all the physiologic
categorical variables identified as significantly associated
with mortality in the univariate analysis. The final model
used to construct TRIPS-II was derived by a stepwise selection
procedure with significance levels of 0.15 and 0.05 for enter-
ing and staying, respectively.
Assignment of Variable Scores
In the final logistic regression model, the β-coefficient of a
variable, which represents the log odds ratio that a variable is
associated with the outcome (i.e., a variable with a high
β-coefficient is more predictive of the outcome than one
with low β-coefficient) independent of other risks, was used
to weight the impact of a variable for prediction of the
outcome. We used the coefficients of the variables retained
in the final model to assign score points for each physiologic
variable. The TRIPS-II score was then created by simple
addition of the score points and represents an infant’s status
as captured by physiologic variables.
Validation Procedures
Predictive Performance and Criterion Validity
We used data from the validation cohort and the area under
the receiver operating curve (ROC) technique of Hanley and
McNeil6 to assess performance of TRIPS-II measured at ad-
mission in predicting the criterion standard of NICU mortality
 TRIPS-II for Assessment of Illness Severity Lee et al. 397

for infants of all GAs at birth, and for infants born at 32 weeks
or less and more than 32 weeks GA separately. An ROC area of
1.0 indicates perfect discrimination whereas an area of 0.5 is
nondiscriminative. Previously published physiology-based
illness severity scores have included ROC areas between 0.7
and 0.9.1,2,7
logic stability.2 We also compared TRIPS-II with GA alone, as
GA is predictive of mortality in the Canadian NICU popula-
tion.9 ROC areas derived from the same cases were compared
using the method of Hanley and McNeil,6 with a p value of less
than 0.05 indicating a significant difference between ROC
curves.

Calibration Comparison of Performance of Prediction Models, with

Hosmer and Lemeshow’s8 method was used to test goodness of
fit and assess deviations between the observed and expected
rates of NICU mortality. A p value of less than 0.05 implies that
the difference between the observed and expected values is
significant, with poor goodness of fit, whereas a p value of
greater than 0.05 indicates that there is no significant differ-
ence between the observed and expected values.
Ability to Detect Change in Infant Status
We stratified infants into three categories with increasing
TRIPS-II score at admission: 0 to 10, 11 to 30, and more than
30. For each category, we further separated the infants into
and without TRIPS-II
The impact of TRIPS-II on the performance of prediction
models was assessed by deriving logistic regression models
for prediction of NICU mortality using baseline population
variables previously identified by Sankaran et al9 as predic-
tive of mortality (GA, small for GA, 5-minute Apgar < 7,
cesarean section, multiple births, inborn status) for the
Canadian NICU population. We then added TRIPS-II to the
regression models and compared the ROC areas of models
with and without TRIPS-II using the method of Hanley and
McNeil.6 This analysis was also performed using SNAP-II in
place of TRIPS-II for further comparison between TRIPS-II and

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three groups: SNAP-II.

1. TRIPS-II at 12 hours postadmission less than TRIPS-II at

admission,
2. TRIPS-II at 12 hours postadmission TRIPS-II equal to TRIPS-
II at admission, and
3. TRIPS-II at 12 hours postadmission greater than TRIPS-II at
admission.
Finally, we calculated and graphed the NICU mortality
rates for the three groups within each TRIPS-II at admission
category separately for the 12- and 24-hour postadmission
TRIPS-II.
Comparison of TRIPS-II with GA and SNAP-II as Prediction
Models
We compared TRIPS-II with SNAP-II for prediction of NICU
mortality, as SNAP-II is a well-validated measure of physio-
Results
A total of 19,165 infants admitted to 15 tertiary-level NICUs in
the Canadian Neonatal Network from January 2006 to
December 2008 were reviewed. A total of 42 infants who
were moribund on admission (n ¼ 30) or missing informa-
tion regarding GA at birth (n ¼ 12) were excluded from the
study. Of the remaining 19,123 infants, a complete set of the
four relevant physiologic measurements was available for
17,075 (89.3%) infants, all of whom were included in the
study. Out of the 17,075 infants, 610 (3.6%) died before
discharge from a NICU with 300 (49.2%) of those deaths
occurring within the first 7 days of life.
No significant differences were observed in the character-
istics or mortality of infants between the derivation and
validation cohorts (►Table 1). In addition, there were no

Table 1 Characteristics of infants in the derivation and validation cohorts

Characteristics Derivation cohort Validation cohort p Valuea

Infants (n) 11,383 5,692 Not applicable
Birth weight, g (mean  SD) 2339  1008 2344  997 0.77
Gestational age, wk (mean  SD) 34  5 34  5 0.71
Inborn (%) 76.7 76.8 0.29
Female sex (%) 45.0 43.6 0.08
Cesarean (%) 51.4 52.0 0.43
Multiple births (%) 20.3 19.7 0.40
5-min Apgar < 7 (%) 14.1 13.9 0.72
Small for gestational age (%) 15.5 15.8 0.54
Total mortality (%) 3.61 3.50 0.7
Mortality within 7 d (%) 1.75 1.77 0.9

Abbreviation: SD, standard deviation.

a
p value < 0.05 indicates significant difference between derivation and validation cohorts.

American Journal of Perinatology Vol. 30 No. 5/2013

398 TRIPS-II for Assessment of Illness Severity Lee et al.

Table 2 TRIPS-II: model regression, items, physiologic ranges, score points

TRIPS-II variable Beta coefficient 95% confidence TRIPS-II score points

interval
Temperature (°C)
< 36.1 or > 37.6 0.52 0.29 0.74 5
36.1–37.6 0
Respiratory status
Severe 2.34 2.05 2.63 23
Moderate or none 0
Systolic blood pressure (mm Hg)
< 30 1.25 0.55 1.95 13
30–40 0.75 0.49 1.01 8
> 40 0
Response to noxious stimuli
None, seizure, muscle relaxant 1.30 1.05 1.63 13
Lethargic response, no cry 0.54 0.31 0.78 5

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Withdraws vigorously, cries 0

Abbreviation: TRIPS-II, Transport Risk Index of Physiologic Stability, version II. Note: Variables are significant if 95% confidence intervals do not cross 0.

significant differences between the two cohorts in terms of
the physiologic measurements recorded.
TRIPS-II Variables and Scores Assigned
The TRIPS-II component items (temperature, respiratory
status, blood pressure, and response to noxious stimuli)
and the scores assigned to each item through derivation of
TRIPS-II using data collected at admission are shown
in ►Table 2. The β-coefficient (95% confidence interval) of
these scores demonstrated that all four component variables
were directly and significantly (p < 0.05) correlated with
NICU mortality (e.g., the mortality log odds ratio for temper-
ature [<36.1°C or > 37.6°C versus 36.1°C to 37.6°C] was 0.52
[0.29 to 0.74]). In comparison to TRIPS,3 the component scores
in TRIPS-II assigned greater weight to respiratory status and
reduced weight to blood pressure.
Prediction of NICU Mortality
The predictive performance of TRIPS-II for NICU mortality
(►Table 3) was significantly (p < 0.05) better than GA at birth
but not significantly better than SNAP-II. Addition of TRIPS-II
to the prediction model that included GA at birth plus other

Table 3 Outcome prediction (ROC areas) for TRIPS-II, SNAP-II, GA, GA þ variables, SNAP-II þ GA þ variables, and
TRIPS-II þ GA þ variables models

ROC areas for TRIPS-II SNAP-II GA GA þ variablesa SNAP-II þ GA þ TRIPS-II þ GA þ

outcome variables variablesa
prediction
Total NICU mortality
All GA 0.87 (0.33) 0.86 (0.37) 0.76b (0.00) 0.86 (0.10) 0.91b,c (0.11) 0.90b,d (0.54)
b b,c
GA 32 wk 0.81 (0.02) 0.84 (0.37) 0.84 (0.35) 0.86 (0.08) 0.89 (0.31) 0.88b,d (0.24)
GA > 32 wk 0.86 (0.32) 0.81 (0.20) 0.60b (0.24) 0.83 (0.97) 0.90c (0.70) 0.90b,d (0.43)
Mortality within 7 d of NICU admission
All GA 0.90 (0.30) 0.91 (0.15) 0.72b (0.00) 0.86b (0.28) 0.93b,c (0.73) 0.91b,d (0.19)
GA 32 wk 0.84 (0.62) 0.89b (0.31) 0.84 (0.52) 0.87 (0.95) 0.91b,c (0.75) 0.90b,d (0.53)
GA > 32 wk 0.90 (0.22) 0.88b (0.59) 0.58b (0.62) 0.84b (0.40) 0.91c (0.54) 0.91d (0.20)

Abbreviations: GA, gestational age; NICU, neonatal intensive care unit; ROC, receiver operating curve; SNAP-II, Score for Neonatal Acute Physiology,
version II; TRIPS-II, Transport Risk Index of Physiologic Stability, version II. Notes: ROC areas for TRIPS-II are based on data measured on admission to the
NICU (within 15 min). Parentheses contain p values for Hosmer-Lemeshow goodness-of-fit statistic (p < 0.05 indicates poor goodness of fit).
a
Variables for mortality within 7 d of NICU admission and total NICU mortality: small for GA, 5-min Apgar < 7, cesarean section.
b
ROC areas significantly different (p < 0.05) from TRIPS-II for each outcome.
c
ROC areas significantly different (p < 0.05) between the GA þ variables model and the SNAP-II þGA þ variables model, for each outcome.
d
ROC areas significantly different (p < 0.05) between the GA þ variables model and the TRIPS-II þ GA þ variables model, for each outcome.

American Journal of Perinatology Vol. 30 No. 5/2013


Fig. 1 Mortality rate associated with TRIPS-II and change in TRIPS-II
postadmission. Abbreviations: NICU, neonatal intensive care unit;
TRIPS-II, Transport Risk Index of Physiologic Stability, version II.
baseline population risk variables significantly (p < 0.05)
improved model prediction; the effect could also be achieved
by using SNAP-II in place of TRIPS-II.
Calibration
Good fit between the model and the data for TRIPS-II was
demonstrated with the Hosmer and Lemeshow goodness-of-
fit statistics (Hosmer-Lemeshow chi-square ¼ 8.3 [df ¼ 5],
p ¼ 0.14). TRIPS-II predicted mortality well across the full
range of GA groups and TRIPS-II scores. Overall, the total NICU
mortality rate increases as TRIPS-II increases (►Fig. 1).
Ability to Detect Change in Infant Status
Grouping of infants according to TRIPS-II at admission and
12 hours postadmission showed that in 28.7% of all infants
TRIPS-II decreased at 12 hours postadmission, in 60.6% of all
infants there was no change in TRIPS-II, and in 10.7% of all
infants there was an increase in TRIPS-II between admission
and 12 hours postadmission. Change in TRIPS-II at 12 hours
postadmission was associated with change in total NICU
mortality (►Fig. 1). For each admission TRIPS-II category,
decrease in TRIPS-II postadmission was associated with lower
mortality than if TRIPS-II was unchanged, whereas an in-
crease in TRIPS-II postadmission was associated with higher
mortality. Similar results were observed with change in
TRIPS-II at 24 hours postadmission.
Discussion
We have derived and established the validity of TRIPS-II as a
risk-weighted benchmarking tool for assessment of the risk of
mortality at admission to NICUs and for the 24 hours after
admission. The physiologic parameters from which the
TRIPS-II score is derived can be measured within 1 minute
and can therefore accurately assess the mortality risk at
the time of measurement, at admission, and at 12 and
24 hours thereafter. Furthermore, change in TRIPS-II over
the initial 12-hour period is directly correlated with change in
total NICU mortality risk.
By expanding the original TRIPS3 from a measure of
sickness prior to transport in outborn infants to an index
that has been validated for use in all infants at admission and
during the subsequent 24 hours, TRIPS-II represents an
TRIPS-II for Assessment of Illness Severity Lee et al. 399
important advance over existing neonatal illness severity
scores. It overcomes a key deficiency of CRIB and SNAP-II,1,2
which have the potential to be affected by interventions
during the first 12 hours after NICU admission. The concern
is that better performing hospitals may be disadvantaged in a
benchmarking process based on CRIB or SNAP-II scores, as
effective interventions during the first 12 hours after admis-
sion could reduce the “baseline” scores, such that better
performing hospitals appear to simply be starting with
healthier infants. This would then diminish the reporting of
their overall improvement rate, and the assessed impact of
any quality improvement measures implemented. Indeed,
this concern is supported by our finding that change in TRIPS-
II over the initial 12-hour period is directly correlated with
change in NICU mortality risk.
Although TRIPS-II did not improve upon prediction of SNAP-
II, it confirms that both TRIPS-II and SNAP-II are valid for use as
illness severity scores. However, TRIPS-II offers advantages over
SNAP-II and CRIB because it is practical, simple to use, can be
easily measured within a 1-minute period, and can be used
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sequentially to assess changes in an infant’s condition and
mortality risk during the first 24 hours of NICU care, including
the periods prior to and during transport for outborn infants
and after admission to the NICU. This will permit more in-depth
examination of NICU care during this period and may provide
insights into ways to improve the quality of care prior to and
during transport and during initial NICU care, which is consid-
ered crucial to infant outcomes.
The four components of TRIPS-II can also give an indication of
possible reasons for change in patient status, enabling identifi-
cation of potential remedies. For instance, deterioration in
TRIPS-II over 24 hours that is attributable to a specific subscore
(e.g., temperature) may identify interventions (e.g., improved
temperature monitoring and regulation, better management of
blood pressure) that may improve the quality of NICU care.
However, to distinguish nonpreventable deterioration from
poor quality of care, it will be important to compare outcomes
of similar patients admitted to different institutions.
Risk adjustment using TRIPS-II can also provide a common
basis for comparing outcomes of inborn and outborn infants,
which have traditionally been considered different. This may
provide important insights into specific reasons for why
outborn infants have poorer outcomes than inborn infants,
which could then lead to development of strategies to im-
prove the quality of care for outborn infants.
Limitations
The sample only included 89% of the study population, which
could result in bias. In addition, we only assessed overall and
7-day mortality, and future validation could also assess
prediction for other NICU outcomes and major morbidities
(e.g., intraventricular hemorrhage, chronic lung disease, peri-
ventricular leukomalacia). Although it is possible that prac-
tice variations may influence use of medications such as
paralytics and narcotics, which may affect the TRIPS-II score,
it is likely that use of these drugs are also correlated with
physiologic stability of the infant and are therefore proxies for
American Journal of Perinatology Vol. 30 No. 5/2013
400 TRIPS-II for Assessment of Illness Severity Lee et al.
illness severity. Future studies should look into this further. It
may also not be possible to fully extrapolate the TRIPS-II score
to populations in different countries/regions of the world due
to differences in ethnic mix of the population and local
neonatal practices; the score should therefore be validated
in other countries. TRIPS-II is not intended for use in ethical
decision making and should not be used as a substitute for
clinical judgment.
Conclusions
We have derived and validated a score of infant physiologic
status that is empirically weighted, practical and easy to use,
and highly suitable for assessment of care following admission
to NICUs. TRIPS-II is applicable to infants of all GAs and is a
potentially useful tool to enhance performance review and
quality improvement initiatives. Validation in other populations
should be undertaken to verify utility and generalizability.
Canadian Neonatal Network Site Investigators
Shoo K. Lee (Director, Canadian Neonatal Network);
Prakesh Shah (Mount Sinai Hospital, Toronto, ON); Wayne
Andrews (Janeway Children’s Health and Rehabilitation
Centre, Saint John’s, NL); Francine Lefebvre (St. Justine’s
Hospital, Montreal, QC); Wendy Yee (Foothill’s Hospital,
Calgary, AB); Barbara Bullied (Everett Chalmers Hospital,
Fredericton, NB); Rody Canning (Moncton Hospital, Mon-
cton, NB); Gerarda Cronin (St. Boniface General Hospital,
Winnipeg, MB); Kimberly Dow (Kingston General Hospital,
Kingston, ON); Michael Dunn (Sunnybrook Health Sciences
Centre, Toronto, ON); Suzanne Ferland (St. François d’Assise
Hôpital, Québec City, QC); Adele Harrison (Victoria General
Hospital, Victoria, BC); Andrew James (Hospital for Sick
Children, Toronto, ON); Zarin Kalapesi (Regina General
Hospital, Regina, SK); Lajos Kovacs (Jewish General Hospi-
tal, Montreal, QC); Jean Lachapelle (Hôpital Maisonneuve-
Rosemont, Montréal, QC); David S. C. Lee (St. Joseph’s Health
Centre; London, ON); Douglas D. McMillan (IWK Health
Centre, Halifax, NS); Cecil Ojah (Saint John Regional Hospi-
tal, Saint John, NB); Abraham Peliowski (Royal Alexandra
Hospital, Edmonton, AB); Bruno Piedboeuf (Centre Hospi-
talier Universitaire de Quebec, Sainte Foy, QC); Patricia Riley
(Montreal Children’s Hospital, Montreal, QC); Daniel
Faucher (Royal Victoria Hospital, Montreal, QC); Nicole
Rouvinez-Bouali (Children’s Hospital of Eastern Ontario,
Ottawa, ON); Koravangattu Sankaran (Royal University
Hospital, Saskatoon, SK); Mary Seshia (Health Sciences
Centre, Winnipeg, MB); Sandesh Shivananda (Hamilton
Health Sciences Centre, Hamilton, ON); Todd Sorokan (Royal
Columbian Hospital, New Westminster, BC); Anne Synnes
(Children’s and Women’s Health Centre of British Columbia,
Vancouver, BC); Herve Walti (Centre Hospitalier Universi-
taire de Sherbrooke, Fleurimont, QC)
Canadian Neonatal Network Coordinating Center
(Toronto, ON): Priscilla Chan, M.Sc.; Sarah A. De La Rue,
Ph.D.; Ruth Warre, Ph.D.; Xiang Y. Ye, M.Sc.; Woojin Yoon,
M.Sc.
American Journal of Perinatology Vol. 30 No. 5/2013
Acknowledgments
This study was supported by Grant MOP-53115 from the
Canadian Institutes of Health Research. Additional funding
was provided by the B.C. Children’s Hospital Foundation;
Calgary Regional Health Authority; Dalhousie University
Neonatal-Perinatal Medicine Research Fund; Division of
Neonatology, Children’s Hospital of Eastern Ontario; Child
Health Program, Health Care Corporation of Saint John’s;
The Neonatology Program, Hospital for Sick Children;
Lawson Research Institute; Mount Sinai Hospital; Ontario
Ministry of Health and Long-Term Care; Saint Boniface
Hospital, Saint Joseph’s Health Centre; Sunnybrook Health
Sciences Centre; University of Saskatchewan Neonatal
Research Fund; University of Western Ontario; Victoria
General Hospital; Winnipeg Health Sciences Centre. The
Canadian Neonatal Network Coordinating Centre (Mater-
nal-Infant Care Research Centre) is supported by the
Ministry of Health and Long-term Care, Ontario, Canada.
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Conflict of Interest
The authors have no conflict of interest, real or perceived,
and the study sponsors played no role in the study design;
the collection, analysis, and interpretation of data; the
writing of the report; and the decision to submit the paper
for publication.
The first draft of the manuscript was written by Dr. Shoo
K. Lee. No honorarium, grant, or other form of payment
was given to anyone to produce the manuscript.
References
1 Cockburn F, Cooke RWI, Gamsu HR, et al. The CRIB (clinical risk
index for babies) score: a tool for assessing initial neonatal risk and
comparing performance of neonatal intensive care units. Lancet
1993;342:193–198
2 Richardson DK, Corcoran JD, Escobar GJ, Lee SK. SNAP-II and
SNAPPE-II: Simplified newborn illness severity and mortality
risk scores. J Pediatr 2001;138:92–100
3 Lee SK, Zupancic JA, Pendray M, et al. Transport risk index of
physiologic stability: a practical system for assessing infant trans-
port care. J Pediatr 2001;139:220–226
4 Pollack MM, Ruttimann UE, Getson PR. Pediatric risk of mortality
(PRISM) score. Crit Care Med 1988;16:1110–1116
5 Kramer MS, Platt RW, Wen SW, et al. A new and improved
population-based Canadian reference for birth weight for gesta-
tional age. Pediatrics 2001;108:E35
6 Hanley JA, McNeil BJ. A method of comparing the areas under
receiver operating characteristic curves derived from the same
cases. Radiology 1983;148:839–843
7 Chien LY, Whyte R, Thiessen P, et al. Snap-II predicts severe
intraventricular hemorrhage and chronic lung disease in the
neonatal intensive care unit. J Perinatol 2002;22:26–30
8 Hosmer D, Lemeshow S. Assessing the fit of the model. In: Hosmer
D, Lemeshow S, eds. Applied Logistic Regression. New York, NY:
John Wiley and Sons; 1989:135–175
9 Sankaran K, Chien LY, Walker R, Seshia M, Ohlsson A; Canadian
Neonatal Network. Variations in mortality rates among Canadian
neonatal intensive care units. CMAJ 2002;166:173–178