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External validation of the PRESTO pediatric tool for predicting in-hospital mortality from traumatic injury
Ashleigh Nazareth1, Recep Gezer2, Etienne St-Louis3
1Faculty of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada.
Insights
The Pediatric Resuscitation and Trauma Outcome (PRESTO) model is validated for pediatric trauma benchmarking in high-resource settings. It performs comparably to the Injury Severity Score (ISS) but is simpler to use.
Area of Science:
- Trauma care quality improvement
- Pediatric emergency medicine
- Health outcomes research
Background:
- Trauma system benchmarking is essential for improving pediatric trauma care quality.
- The Pediatric Resuscitation and Trauma Outcome (PRESTO) model facilitates risk-adjusted in-hospital mortality comparisons, particularly in under-resourced settings.
- Validation of PRESTO in high-resource environments is needed.
Purpose of the Study:
- To validate the PRESTO model in a high-resource setting using Canadian provincial Trauma Registry (TR) data.
- To compare the performance of the PRESTO model against the standard Injury Severity Score (ISS) for benchmarking pediatric trauma outcomes.
Main Methods:
- Retrospective case-control study of pediatric major trauma patients (<16 years) from 2013-2021 using TR data.
- PRESTO model utilized demographic, vital sign, and outcome data to estimate predicted mortality (Pm).
- Model performance assessed by comparing Pm between non-survivors and survivors and by receiver-operator curve analysis (AUROC) against ISS.
Main Results:
- A cohort of 647 pediatric trauma patients (11% in-hospital mortality) was analyzed.
- The PRESTO model demonstrated a significantly higher predicted mortality for non-survivors compared to survivors (p < 0.001).
- PRESTO and ISS showed comparable performance, with non-significantly different AUROCs (0.819 vs. 0.816, p = 0.95).
Conclusions:
- The PRESTO model is validated and performs effectively in a high-resource setting like a Canadian province.
- PRESTO offers comparable benchmarking capabilities to ISS but with greater simplicity in derivation.
- PRESTO has the potential to serve as a valuable tool for benchmarking in-hospital mortality across Canadian institutions over time.
Background:
Benchmarking is crucial for quality improvement of trauma systems. The Pediatric Resuscitation and Trauma Outcome (PRESTO) model allows risk-adjusted comparisons of in-hospital mortality for pediatric trauma populations in under-resourced environments. Our aim was to validate PRESTO in a high-resource setting using provincial Trauma Registry (TR) data and compare it to the standard benchmarking model, the Injury Severity Score (ISS).
Methods:
This retrospective case-control study collected demographic, vital sign, and outcome data from the TR for patients aged <16 years sustaining major trauma from 2013 to 2021. The PRESTO model estimates predicted probability of in-hospital mortality (Pm) using the age, heart rate, blood pressure, oxygen saturation, neurological status, and use of airway supplementation. PRESTO was assessed by comparison of Pm in patients who died and survived and comparison of area under the receiver-operator curve (AUROC) with that of ISS. Statistical analysis was performed using R.
Results:
We included 647 patients, of which 69 died in-hospital (11%). The cohort was 37% female, with a median age of 8 and median ISS of 17. The median Pm for cases was significantly higher compared to controls (1.0 vs. 5.2 × 10-5, p < 0.001). The AUROC for PRESTO and ISS were not significantly different (0.819 and 0.816, respectively; p = 0.95).
Conclusion:
PRESTO is valid in a resource-rich environment, such as a Canadian province. It performs equally well to ISS but is simpler to derive. In the future, PRESTO may serve to benchmark levels of in-hospital mortality within or across institutions over time across Canada.
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