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

Healthcare provider perspective on barriers and facilitators in the care of pediatric injury patients at a tertiary hospital in Northern Tanzania: A qualitative study

Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). The recovery of injured children in LMICs is often impeded by barriers in accessing and receiving timely and quality care at healthcare facilities. The purpose of this study was to identify the barriers and the facilitators in pediatric injury care at Kilimanjaro Christian Medical Center (KCMC), a tertiary zonal referral hospital in Northern Tanzania. In this study, focus group discussions (FGDs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the barriers and facilitators in pediatric injury care. Five FGDs were completed from February 2021 to July 2021. Participants (n = 30) were healthcare providers from the emergency department, burn ward, surgical ward, and pediatric ward. De-identified transcripts were analyzed with team-based, applied thematic analysis using qualitative memo writing and consensus discussions. Our study found barriers that impeded pediatric injury care were: lack of pediatric-specific injury training and care guidelines, lack of appropriate pediatric-specific equipment, staffing shortages, lack of specialist care, and complexity of cases due to pre-hospital delays in patients presenting for care due to cultural and financial barriers. Facilitators that improved pediatric injury care were: team cooperation and commitment, strong priority and triage processes, benefits of a tertiary care facility, and flexibility of healthcare providers to provide specialized care if needed. The data highlights barriers and facilitators that could inform interventions to improve the care of pediatric injury patients in Northern Tanzania such as: increasing specialized provider training in pediatric injury management, the development of pediatric injury care guidelines, and improving access to pediatric-specific technologies and equipment.

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

INTRODUCTION

Sub-Saharan Africa has the highest rate of unintentional paediatric injury deaths. The Pediatric Resuscitation and Trauma Outcome (PRESTO) model predicts mortality using patient variables available in low-resource settings: age, systolic blood pressure (SBP), heart rate (HR), oxygen saturation, need for supplemental oxygen (SO) and neurologic status (Alert Verbal Painful Unresponsive (AVPU)). We sought to validate and assess the prognostic performance of PRESTO for paediatric injury patients at a tertiary referral hospital in Northern Tanzania.

METHODS

This is a cross-sectional study from a prospective trauma registry from November 2020 to April 2022. We performed exploratory analysis of sociodemographic variables and developed a logistic regression model to predict mortality using R (V.4.1). The logistic regression model was evaluated using area under the receiver operating curve (AUC).

RESULTS

499 patients were enrolled with a median age of 7 years (IQR 3.41-11.18). 65% were boys, and in-hospital mortality was 7.1%. Most were classified as alert on AVPU Scale (n=326, 86%) and had normal SBP (n=351, 98%). Median HR was 107 (IQR 88.5-124). The logistic regression model based on the original PRESTO model revealed that AVPU, HR and SO were statistically significant to predict in-hospital mortality. The model fit to our population revealed AUC=0.81, sensitivity=0.71 and specificity=0.79.

CONCLUSION

This is the first validation of a model to predict mortality for paediatric injury patients in Tanzania. Despite the low number of participants, our results show good predictive potential. Further research with a larger injury population should be done to improve the model for our population, such as through calibration.

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^-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.

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

Introduction

Pediatric injuries in low- and middle-income countries are a leading cause of morbidity and mortality worldwide. Implementing hospital-based trauma registries can reduce the knowledge gap in both hospital care and patient outcomes and lead to quality improvement initiatives. The goal of this study was to create a pediatric trauma registry to provide insight into the epidemiology, outcomes, and factors associated with poor outcomes in injured children.

Methods

This was a prospective observational study in which a pediatric trauma registry was implemented at a large zonal referral hospital in Northern Tanzania. Data included demographics, hospital-based care, and outcomes including morbidity and mortality. Data were input into REDCap© and analyzed using ANOVA and Chi-squared tests in SAS(Version 9.4)©.

Results

365 patients were enrolled in the registry from November 2020 to October 2021. The majority were males (n=240, 65.8%). Most were children 0-5 years (41.7%, n=152), 34.5% (n=126) were 6-11 years, and 23.8% (n=87) were 12-17 years. The leading causes of pediatric injuries were falls (n=137, 37.5%) and road traffic injuries (n=125, 34.5%). The mortality rate was 8.2% (n=30). Of the in-hospital deaths, 43.3% were children with burn injuries who also had a higher odds of mortality than children with other injuries (OR 8.72, p<0.001). The factors associated with in-hospital mortality and morbidity were vital sign abnormalities, burn severity, abnormal Glasgow Coma Score, and ICU admission.

Conclusion

The mortality rate of injured children in our cohort was high, especially in children with burn injuries. In order to reduce morbidity and mortality, interventions should be prioritized that focus on pediatric injured patients that present with abnormal vital signs, altered mental status, and severe burns. These findings highlight the need for health system capacity building to improve outcomes of pediatric injury patients in Northern Tanzania.

Predicting morbidity and mortality in Australian paediatric trauma with the Paediatric Age-Adjusted Shock Index and Glasgow Coma Scale

BACKGROUND

Paediatric age-adjusted shock index (SIPA) has emerged as a predictor of morbidity and mortality in trauma. Poor sensitivity and low generalisability demonstrated in previous studies have limited its use. We evaluate the use of SIPA in the general Australian paediatric trauma population and the combination of SIPA with GCS.

METHODS

All patients from January 2015 to August 2020 at a major Australian paediatric trauma centre were reviewed. Pre-arrival SIPA (pSIPA) and arrival SIPA (aSIPA) were calculated. If SIPA was elevated or the Glasgow Coma Scale ≤ 13, SIPA with mental state (SIPAms) was marked positive for pre-arrival (pSIPAms) and arrival (aSIPAms) respectively.

RESULTS/DISCUSSION

Data from 480 patients were analysed. pSIPA and aSIPA poorly predicted outcomes of morbidity. Only aSIPA predicted mortality. However, both pre-arrival and arrival SIPAms variables predict mortality, major trauma (ISS≥12), hospital LOS, need for ICU admission, and major surgery. Furthermore, median ISS and lactate were significantly higher in positive pSIPA, aSIPA, pSIPAms, and aSIPAms groups than negative. aSIPAms has a sensitivity of 76% and specificity of 70% for major trauma.

CONCLUSION

Broad inclusion criteria reduce SIPA's ability to predict morbidity. Combining it with GCS improves this and is most valuable when calculated at arrival. In addition, the score is more reliable for major trauma (ISS≥12). Future studies should evaluate the use of SIPAms in activation criteria.