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The effect of dead-on-arrival and emergency department death classification on risk-adjusted performance in the American College of Surgeons Trauma Quality Improvement Program

Calland, James Forrest MD; Nathens, Avery B. MD, PhD; Young, Jeffrey S. MD; Neal, Melanie L. MS; Goble, Sandra MS; Abelson, Jonathan; Fildes, John J. MD; Hemmila, Mark R. MD

Journal of Trauma and Acute Care Surgery: November 2012 - Volume 73 - Issue 5 - p 1086–1092
doi: 10.1097/TA.0b013e31826fc7a0

BACKGROUND The American College of Surgeons’ Trauma Quality Improvement Program is focused on identifying variations in outcomes across trauma centers for the purposes of performance improvement. In previous analyses, patients who died in the emergency department were excluded. We investigated the effect of inclusion and exclusion of emergency department (ED) deaths (dead on arrival [DOA] and died in ED [DIE]) on analyses of overall risk-adjusted trauma center performance.

METHODS Data for patients admitted to 65 Trauma Quality Improvement Program hospitals during the 2009 calendar year was used. A logistic regression model was developed to estimate risk-adjusted mortality. Trauma centers were then ranked based on their observed-to-expected (O/E) mortality ratio with 90% confidence intervals (CIs) and classified by outlier status: low outliers/high performers had a 90% CI for O/E mortality ratio of less than 1, and high outliers/low performers had a 90% CI for O/E mortality ratio of greater than 1. Changes in outlier status, rank, and quartile were examined with and without DOA and DIE patients included in the analyses to discern the impact of such exclusions on overall risk-adjusted center-specific performance.

RESULTS Thirty-one trauma centers (48%) reported no DOA patients in 2009, while 6 centers (9%) reported more than 10. Of 224 patients, 14 (6.2%) had a documented time of death of more than 30 minutes after ED arrival despite being recorded as DOA. Forty-one trauma centers (63%) changed rank by three positions or less. Ten trauma centers changed their quartile ranking by a single quartile, but no centers were found to change quartile rank more than one quartile. Changes in outlier status occurred for 6 trauma centers (9%).

CONCLUSION The relative frequency of patients classified as DOA varies greatly between trauma centers. Misclassification of patients as DOA occurs. Inclusion of ED deaths in risk-adjusted analysis of mortality results in a small but insignificant change in predicting the outcome results of a trauma center. This change is less than the rate of finding a center to be a high or low outlier by chance alone using the 90% CI. Inclusion of DOA and DIE patients in risk-adjusted analysis of mortality is appropriate and eliminates the bias introduced by exclusion of ED deaths owing to misuse of the DOA classification.

LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Supplemental digital content is available in the article.

From the Department of Surgery (J.F.C., J.S.Y.), School of Medicine (J.A.), University of Virginia, Charlottesville, Virginia; Department of Surgery (A.B.N.), University of Toronto, Toronto, Ontario, Canada; National Trauma Data Bank (S.G., M.L.N.), and Trauma Quality Improvement Program (S.G., M.L.N.), the American College of Surgeons, Committee on Trauma, Chicago, Illinois; Department of Surgery (J.J.F.), University of Nevada, Las Vegas, Nevada; and Department of Surgery (M.R.H.), University of Michigan, Ann Arbor, Michigan.

Submitted: September 12, 2011, Revised: July 28, 2012, Accepted: August 1, 2012.

This study was part of the paper presentation at the 70th annual meeting of the American Association for the Surgery of Trauma, September 14–17, 2011, in Chicago, Illinois.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Address for reprints: James Forrest Calland, MD, Division of Acute Care Surgery and Outcomes Research, Department of Surgery, University of Virginia, Box 80709, Private Clinics Bldg, Rm 4553, Charlottesville, VA 22908; email:

© 2012 Lippincott Williams & Wilkins, Inc.