title: Predicting mortality in sick African children: the FEAST Paediatric Emergency Triage (PET) Score.
abstract: BACKGROUND
  Mortality in paediatric emergency care units in Africa often occurs within the first 24 h of admission and remains high. Alongside effective triage systems, a practical clinical bedside risk score to identify those at greatest risk could contribute to reducing mortality.
  
  
  METHODS
  Data collected during the Fluid As Expansive Supportive Therapy (FEAST) trial, a multi-centre trial involving 3,170 severely ill African children, were analysed to identify clinical and laboratory prognostic factors for mortality. Multivariable Cox regression was used to build a model in this derivation dataset based on clinical parameters that could be quickly and easily assessed at the bedside. A score developed from the model coefficients was externally validated in two admissions datasets from Kilifi District Hospital, Kenya, and compared to published risk scores using Area Under the Receiver Operating Curve (AUROC) and Hosmer-Lemeshow tests. The Net Reclassification Index (NRI) was used to identify additional laboratory prognostic factors.
  
  
  RESULTS
  A risk score using 8 clinical variables (temperature, heart rate, capillary refill time, conscious level, severe pallor, respiratory distress, lung crepitations, and weak pulse volume) was developed. The score ranged from 0-10 and had an AUROC of 0.82 (95 % CI, 0.77-0.87) in the FEAST trial derivation set. In the independent validation datasets, the score had an AUROC of 0.77 (95 % CI, 0.72-0.82) amongst admissions to a paediatric high dependency ward and 0.86 (95 % CI, 0.82-0.89) amongst general paediatric admissions. This discriminative ability was similar to, or better than other risk scores in the validation datasets. NRI identified lactate, blood urea nitrogen, and pH to be important prognostic laboratory variables that could add information to the clinical score.
  
  
  CONCLUSIONS
  Eight clinical prognostic factors that could be rapidly assessed by healthcare staff for triage were combined to create the FEAST Paediatric Emergency Triage (PET) score and externally validated. The score discriminated those at highest risk of fatal outcome at the point of hospital admission and compared well to other published risk scores. Further laboratory tests were also identified as prognostic factors which could be added if resources were available or as indices of severity for comparison between centres in future research studies.
authors.affiliation: Medical Research Council Clinical Trials Unit (MRC CTU) at UCL, London, UK. elizabeth.george@ucl.ac.uk.
authors.forename: Elizabeth C
authors.initials: EC
authors.lastname: George
authors.affiliation: Medical Research Council Clinical Trials Unit (MRC CTU) at UCL, London, UK. rmjlasw@ucl.ac.uk.
authors.forename: A Sarah
authors.initials: AS
authors.lastname: Walker
authors.affiliation: Department of Paediatrics, Mulago Hospital, Makerere University, Kampala, Uganda. skwalube@yahoo.co.uk.
authors.forename: Sarah
authors.initials: S
authors.lastname: Kiguli
authors.affiliation: Department of Paediatrics, Mbale Regional Referral Hospital, Mbale, Uganda. polupotolupot@yahoo.com.
authors.forename: Peter
authors.initials: P
authors.lastname: Olupot-Olupot
authors.affiliation: Department of Paediatrics, Mulago Hospital, Makerere University, Kampala, Uganda. opokabob@yahoo.com.
authors.forename: Robert O
authors.initials: RO
authors.lastname: Opoka
authors.affiliation: Department of Paediatrics, Soroti Regional Referral Hospital, Soroti, Uganda. charlesengoru@yahoo.co.uk.
authors.forename: Charles
authors.initials: C
authors.lastname: Engoru
authors.affiliation: Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya. sakech@gmail.com.
authors.forename: Samuel O
authors.initials: SO
authors.lastname: Akech
authors.affiliation: Department of Paediatrics, St Mary's Hospital, Lacor, Uganda. richard_nyeko@yahoo.com.
authors.forename: Richard
authors.initials: R
authors.lastname: Nyeko
authors.affiliation: Department of Paediatrics, Joint Malaria Programme, Teule Hospital, Muheza, Tanzania. mtoveg2002@yahoo.co.uk.
authors.forename: George
authors.initials: G
authors.lastname: Mtove
authors.affiliation: Department of Paediatrics, Joint Malaria Programme, Teule Hospital, Muheza, Tanzania. hugh.reyburn@lshtm.ac.uk.
authors.forename: Hugh
authors.initials: H
authors.lastname: Reyburn
authors.affiliation: Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya. jberkley@kemri-wellcome.org.
authors.forename: James A
authors.initials: JA
authors.lastname: Berkley
authors.affiliation: Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya. ampoya@kemri-wellcome.org.
authors.forename: Ayub
authors.initials: A
authors.lastname: Mpoya
authors.affiliation: Wellcome Trust Centre for Clinical Tropical Medicine and Department of Paediatrics, Faculty of Medicine, Imperial College, London, UK. m.levin@imperial.ac.uk.
authors.forename: Michael
authors.initials: M
authors.lastname: Levin
authors.affiliation: Medical Research Council Clinical Trials Unit (MRC CTU) at UCL, London, UK. jane.crawley@gmail.com.|Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. jane.crawley@gmail.com.
authors.forename: Jane
authors.initials: J
authors.lastname: Crawley
authors.affiliation: Medical Research Council Clinical Trials Unit (MRC CTU) at UCL, London, UK. diana.gibb@ucl.ac.uk.
authors.forename: Diana M
authors.initials: DM
authors.lastname: Gibb
authors.affiliation: Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya. k.maitland@imperial.ac.uk.|Wellcome Trust Centre for Clinical Tropical Medicine and Department of Paediatrics, Faculty of Medicine, Imperial College, London, UK. k.maitland@imperial.ac.uk.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Maitland
authors.affiliation: Medical Research Council Clinical Trials Unit (MRC CTU) at UCL, London, UK. a.babiker@ucl.ac.uk.
authors.forename: Abdel G
authors.initials: AG
authors.lastname: Babiker
mesh_terms: D000293:Adolescent; D000349:Africa; D017677:Age Distribution; D002648:Child; D046688:Child Mortality / Q000639:trends*; D002675:Child, Preschool; D004636:Emergency Service, Hospital / Q000639:trends*; D006776:Hospitals, Pediatric / Q000458:organization & administration*; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000639:trends*; D007630:Kenya; D008297:Male; D010372:Pediatrics / Q000458:organization & administration; D011379:Prognosis; D018570:Risk Assessment; D014218:Triage