External Validation of the PRESTO Pediatric Tool for Predicting In-Hospital Mortality from Traumatic Injury


      • Benchmarking trauma outcomes supports quality improvement. The standard tool, the Injury Severity Score (ISS), is imperfect in predicting pediatric mortality.
      • The Pediatric Resuscitation and Trauma Outcome Score (PRESTO) has been validated in low-and-middle-income countries. PRESTO performs equally well to ISS in a high-income context but is simpler to derive.



      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).


      This retrospective case-control study collected demographic, vital sign, and outcome data from the TR for patients aged <16 years sustaining major trauma from 2013-2021. 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.


      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 5.2x10-5, p < 0.001). The AUROC for PRESTO and ISS were not significantly different (0.819 and 0.816, respectively; p = 0.95).


      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.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Pediatric Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Olsen H.E.
        • Ikeda C.T.
        • Echko M.M.
        • Ballestreros K.E.
        • et al.
        • GBD 2017 Child and Adolescent Health Collaborators, Reiner RC
        Diseases, Injuries, and Risk Factors in Child and Adolescent Health, 1990 to 2017: Findings From the Global Burden of Diseases, Injuries, and Risk Factors 2017 Study.
        JAMA Pediatr. 2019; 173e190337
        • Staiger R.D.
        • Schwandt H.
        • Puhan M.A.
        • Clavien P.-A.
        Improving surgical outcomes through benchmarking.
        Br J Surg. 2018; 106: 59-64
        • St-Louis E.
        • Séguin J.
        • Roizblatt D.
        • Deckelbaum D.L.
        • Baird R.
        • Razek T.
        Systematic review and need assessment of pediatric trauma outcome benchmarking tools for low-resource settings.
        Pediatr Surg Int. 2017; 33: 299-309
        • Brown J.B.
        • Gestring M.L.
        • Leeper C.M.
        • Sperry J.L.
        • Peitzman A.B.
        • Billiar T.R.
        • et al.
        The value of the injury severity score in pediatric trauma: Time for a new definition of severe injury?.
        J Trauma Acute Care Surg. 2017; 82: 995-1001
        • St-Louis E.
        • Bracco D.
        • Hanley J.
        • Razek T.
        • Baird R.
        Development and validation of a new pediatric resuscitation and trauma outcome (PRESTO) model using the U.S. National Trauma Data Bank.
        J Pediatr Surg. 2018; 53: 136-140
        • St-Louis E.
        • Hassamal R.
        • Razek T.
        • Baird R.
        • Poenaru D.
        • Hardcastle T.C.
        Validation of the PRESTO score in injured children in a South-African quaternary trauma center.
        J Pediatr Surg. 2020; 55: 1245-1248
        • St-Louis E.
        • Petroze R.
        • Baird R.
        • Razek T.
        • Poenaru D.
        • Calland J.F.
        • et al.
        Calibration and validation of the pediatric resuscitation and trauma outcome model among injured children in Rwanda.
        J Pediatr Surg. 2020; 55: 2510-2516
        • Traynor M.D.
        • St. Louis E
        • Hernandez M.C.
        • Alsayed A.S.
        • Klinkner D.B.
        • Baird R.
        • et al.
        Comparison of the Pediatric Resuscitation and Trauma Outcome (PRESTO) Model and Pediatric Trauma Scoring Systems in a Middle-Income Country.
        World J Surg. 2020; 44: 2518-2525
      1. R Core Team. R: A language and environment for statistical computing 2021.

      2. SAS/Stat. 2016;
        • Bodner T.E.
        What Improves with Increased Missing Data Imputations?.
        Struct Equ Model Multidiscip J. 2008; 15: 651-675
        • White I.R.
        • Royston P.
        • Wood A.M.
        Multiple imputation using chained equations: Issues and guidance for practice.
        Stat Med. 2011; 30: 377-399
        • Baker S.P.
        • O’Neill B.
        • Haddon W.
        • Long W.B.
        The Injury Severity Score: A Method for Describing Patients with Multiple Injuries and Evaluating Emergency Care.
        J Trauma. 1974; 14: 187-196
        • Gruen R.L.
        • Gabbe B.J.
        • Stelfox H.T.
        • Cameron P.A.
        Indicators of the quality of trauma care and the performance of trauma systems.
        Br J Surg. 2011; 99: 97-104
        • Mann N.C.
        • Mullins R.J.
        • MacKenzie E.J.
        • Jurkovich G.J.
        • Mock C.N.
        Systematic Review of Published Evidence Regarding Trauma System Effectiveness.
        J Trauma Inj Infect Crit Care. 1999; 47: S25-S33
        • Nordin A.
        • Coleman A.
        • Shi J.
        • Wheeler K.
        • Xiang H.
        • Acker S.
        • et al.
        Validation of the age-adjusted shock index using pediatric trauma quality improvement program data.
        J Pediatr Surg. 2018; 53: 130-135
        • Hornor M.A.
        • Hoeft C.
        • Nathens A.B.
        Quality Benchmarking in Trauma: from the NTDB to TQIP.
        Curr Trauma Rep. 2018; 4: 160-169
        • Evans L.L.
        • Melhado C.
        • Miskovic A.
        • Subacius H.
        • Stein D.M.
        • Burd R.S.
        • et al.
        Benchmarking Pediatric Trauma Care in Mixed Trauma Centers: Center-Specific Risk-Adjusted Mortality Is Frequently Discordant Between Pediatric and Adult Cohorts.
        J Am Coll Surg. 2021; 233: S182
        • Loftis K.L.
        • Price J.
        • Gillich P.J.
        Evolution of the Abbreviated Injury Scale: 1990–2015.
        Traffic Inj Prev. 2018; 19: S109-S113
        • Grisoni E.
        • Stallion A.
        • Nance M.L.
        • Lelli J.L.
        • Garcia V.F.
        • Marsh E.
        The New Injury Severity Score and the Evaluation of Pediatric Trauma.
        J Trauma Inj Infect Crit Care. 2001; 50: 1106-1110
        • Scaife E.R.
        • Rollins M.D.
        Managing radiation risk in the evaluation of the pediatric trauma patient.
        Semin Pediatr Surg. 2010; 19: 252-256
        • Schafer J.L.
        Multiple imputation: a primer.
        Stat Methods Med Res. 1999; 8: 3-15