Redefining "dead on arrival": Identifying the unsalvageable patient for the purpose of performance improvement.
BACKGROUND
Significant variation exists across registries in the criteria used to identify patients with no chance of survival, with potential for profound impact on trauma center mortality. The purpose of this study was to identify the optimal case definition for the unsalvageable patient, for the purpose of exclusion from performance improvement (PI) endeavors.


METHODS
Data were derived from the American College of Surgeons' Trauma Quality Improvement Program for 2012 to 2013. We proposed three potential case definitions for the unsalvageable patient: (1) no signs of life as determined by local providers (NSOL), (2) prehospital cardiac arrest (PHCA), and (3) a proxy definition (PROXY) based on presenting vital signs, defined as emergency department (ED) heart rate = 0, ED systolic blood pressure = 0, and Glasgow Coma Scale score motor component = 1. Case definitions were compared using standard predictive tests to determine specificity and positive predictive value (PPV) for in-hospital mortality. After the optimal definition was identified, hierarchical logistic regression was used to assess the impact of including unsalvageable patients on trauma center risk-adjusted mortality. The impact on trauma center performance was determined as change in outlier status and performance decile after exclusion of patients who met the optimal case definition.


RESULTS
During the study period, 223,643 patients met inclusion criteria across 192 trauma centers. Overall in-hospital mortality was 7.2%. The PROXY definition had excellent PPV for death, with less than 1% of patients meeting the PROXY criterion surviving. By contrast, NSOL and PHCA had PPVs low enough such that many of these patients went on to live (33% and 10%, respectively). After exclusion of patients who met the PROXY definition, 7% of trauma centers changed performance decile. This change was greatest for patients with penetrating injury and shock, with change in performance decile at 23% and 33% of centers, respectively.


CONCLUSIONS
The PROXY case definition has excellent predictive utility to identify patients who, based on presenting vital signs, will go on to die. PROXY should be used to exclude unsalvageable patients from PI endeavors.
From the Sunnybrook Research Institute (J.P.B., W.X., D.G., S.M., P.K., H.T., A.B.N), and Department of Surgery (P.K., H.T., A.B.N.), Sunnybrook Health Sciences Center; Clinical Epidemiology Program (J.P.B., S.M., P.K., A.B.N), Institute of Health Policy, Management and Evaluation, Division of General Surgery (J.P.B., D.G., S.M., P.K., H.T., A.B.N., S.R.), Department of Surgery (S.R.), St. Michael's Hospital, and Institute of Medical Science (S.R.), University of Toronto, Toronto, Ontario, Canada; and Trauma Quality Improvement Program (W.X., A.B.N.), American College of Surgeons, Chicago, Illinois.
James P
JP
Byrne
Wei
W
Xiong
David
D
Gomez
Stephanie
S
Mason
Paul
P
Karanicolas
Sandro
S
Rizoli
Homer
H
Tien
Avery B
AB
Nathens
D019985:Benchmarking; D002423:Cause of Death; D016208:Databases, Factual; D003643:Death; D004636:Emergency Service, Hospital / Q000592:standards*; D004638:Emergency Treatment / Q000379:methods / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D009864:Ontario; D058996:Quality Improvement; D012042:Registries; D015203:Reproducibility of Results; D012189:Retrospective Studies; D013647:Task Performance and Analysis; D014193:Trauma Centers / Q000592:standards; D015599:Trauma Severity Indices; D017211:Treatment Failure; D014218:Triage / Q000379:methods / Q000592:standards*; D014947:Wounds and Injuries / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy