Comparison of the Pediatric Resuscitation and Trauma Outcome (PRESTO) Model and Pediatric Trauma Scoring Systems in a Middle‐Income Country

Abstract

Background The pediatric resuscitation and trauma outcome (PRESTO) model was developed to aid comparisons of risk‐adjusted mortality after injury in low‐ and middle‐income countries (LMICs). We sought to validate PRESTO using data from a middle‐income country (MIC) trauma registry and compare its performance to the Pediatric Trauma Score (PTS), Revised Trauma Score, and pediatric age‐adjusted shock index (SIPA). Methods We included children (age < 15 years) admitted to a single trauma center in South Africa from December 2012 to January 2019. We excluded patients missing variables necessary for the PRESTO model—age, systolic blood pressure, pulse, oxygen saturation, neurologic status, and airway support. Trauma scores were assigned retrospectively. PRESTO's previously high‐income country (HIC)‐validated optimal threshold was compared to MIC‐validated threshold using area under the receiver operating characteristic curves (AUROC). Prediction of in‐hospital death using trauma scoring systems was compared using ROC analysis. Results Of 1160 injured children, 988 (85%) had complete data for calculation of PRESTO. Median age was 7 (IQR: 4, 11), and 67% were male. Mortality was 2% (n = 23). Mean predicted mortality was 0.5% (range 0–25.7%, AUROC 0.93). Using the HIC‐validated threshold, PRESTO had a sensitivity of 26.1% and a specificity of 99.7%. The MIC threshold showed a sensitivity of 82.6% and specificity of 89.4%. The MIC threshold yielded superior discrimination (AUROC 0.86 [CI 0.78, 0.94]) compared to the previously established HIC threshold (0.63 [CI 0.54, 0.72], p < 0.0001). PRESTO showed superior prediction of in‐hospital death compared to PTS and SIPA (all p < 0.01). Conclusion PRESTO can be applied in MIC settings and discriminates between children at risk for in‐hospital death following trauma. Further research should clarify optimal decision thresholds for quality improvement and benchmarking in LMIC settings.

Validation of the Pediatric Resuscitation and Trauma Outcome (PRESTO) model in injury patients in Tanzania

“…This was also found in Traynor et al , who applied PRESTO to South African trauma data, and represents a strength of this scoring system for use in LMICs. 7 …”

“…It was initially validated using the United States National Trauma Data Bank and has subsequently been validated in a middle-income setting (South Africa) and an LMIC setting (Rwanda). [5][6][7] In its application and validation in Rwanda, it was shown to be similarly effective in predicting child mortality as the Revised Trauma Score and Kampala Trauma Score, and to outperform the Kampala Trauma Score in children less than 5 years of age. 6 Due to PRESTO's success in both low-income 6 and middle-income 7 settings, and potential differences in causes, presentations and outcomes of specific childhood injuries in Tanzania, we sought to validate this scale in our population of paediatric injury patients at a tertiary zonal referral hospital in Northern Tanzania.…”

“…[5][6][7] In its application and validation in Rwanda, it was shown to be similarly effective in predicting child mortality as the Revised Trauma Score and Kampala Trauma Score, and to outperform the Kampala Trauma Score in children less than 5 years of age. 6 Due to PRESTO's success in both low-income 6 and middle-income 7 settings, and potential differences in causes, presentations and outcomes of specific childhood injuries in Tanzania, we sought to validate this scale in our population of paediatric injury patients at a tertiary zonal referral hospital in Northern Tanzania. We also sought to assess the effectiveness of the PRESTO model in prognostic performance of injury-related mortality in our population.…”

“…Due to PRESTO’s success in both low-income 6 and middle-income 7 settings, and potential differences in causes, presentations and outcomes of specific childhood injuries in Tanzania, we sought to validate this scale in our population of paediatric injury patients at a tertiary zonal referral hospital in Northern Tanzania. We also sought to assess the effectiveness of the PRESTO model in prognostic performance of injury-related mortality in our population.…”

A cohort of pediatric injury patients from a hospital-based trauma registry in Northern Tanzania

“…The mortality rate of injured children in our cohort was considerably high at 8.2%. In other pediatric registry studies, mortality rates ranged from 0.3% to 7.0% [ 3 , 9 , 12 , 29 , 32 ]. More specifically, a multi-site study at 10 centers in LMICs found an overall mortality rate of 0.8% for admitted pediatric injured patients [12] .…”