The outcome of trauma patients with do-not-resuscitate orders.
BACKGROUND
Institutional variation in outcome of patients with do-not-resuscitate (DNR) orders has not been well described in the setting of trauma. The purpose of this study was to assess the impact of trauma center designation on outcome of patients with DNR orders.


METHODS
A statewide trauma database (Pennsylvania Trauma Outcome Study) was used for the analysis. Characteristics of patients with DNR orders were compared between state-designated level 1 and 2 trauma centers. Inhospital mortality and major complication rates were compared using hierarchical logistic regression models that included a random effect for trauma centers. We adjusted for a number of potential confounders and allowed for nonlinearity in injury severity score and age in these models.


RESULTS
A total of 106,291 patients (14 level 1 and 11 level 2 trauma centers) were identified in the Pennsylvania Trauma Outcome Study database between 2007 and 2011. We included 5953 patients with DNR orders (5.6%). Although more severely injured patients with comorbid disease were made DNR in level 1 trauma centers, trauma center designation level was not a significant factor for inhospital mortality of patients with DNR orders (odds ratio, 1.33; 95% confidence interval, 0.81-2.18; P = 0.26). Level 1 trauma centers were significantly associated with a higher rate of major complications (odds ratio, 1.75; 95% confidence interval, 1.11-2.75; P = 0.016).


CONCLUSIONS
Inhospital mortality of patients with DNR orders was not significantly associated with trauma designation level after adjusting for case mix. More aggressive treatment or other unknown factors may have resulted in a significantly higher complication rate at level 1 trauma centers.
Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California. Electronic address: mkazu45@gmail.com.
Kazuhide
K
Matsushima
Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
Eric W
EW
Schaefer
Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
Eugene J
EJ
Won
Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
Scott B
SB
Armen
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010414:Pennsylvania; D016414:Resuscitation Orders; D012189:Retrospective Studies; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014947:Wounds and Injuries / Q000150:complications / Q000401:mortality / Q000628:therapy*
Do-not-resuscitate; Level 1 versus level 2; Outcome; Trauma center