External validation of the PRESTO pediatric tool for predicting in-hospital mortality from traumatic injury.

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, 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.