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Redefining “dead on arrival

Identifying the unsalvageable patient for the purpose of performance improvement

Byrne, James P. MD; Xiong, Wei MSc; Gomez, David MD, PhD; Mason, Stephanie MD; Karanicolas, Paul MD, PhD; Rizoli, Sandro MD, PhD; Tien, Homer MD, MSc; Nathens, Avery B. MD, PhD

Journal of Trauma and Acute Care Surgery: November 2015 - Volume 79 - Issue 5 - p 850–857
doi: 10.1097/TA.0000000000000843
Original Articles

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.

CONCLUSION 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.

Submitted: April 21, 2015; Revised: July 13, 2015; Accepted: July 17, 2015.

This work was the winning presentation at the 2015 American College of Surgeons’ Committee on Trauma (ACS COT) Regional Resident Paper Competition (Region XII) and was a poster presentation at the 2015 Eastern Association for the Surgery of Trauma (EAST) Annual Meeting.

Address for reprints: James P. Byrne, MD, Sunnybrook Research Institute, Sunnybrook Health Sciences Center, 2075 Bayview Ave, Room D-574, Toronto, Ontario, Canada, M4N 3M5; email:

© 2015 Lippincott Williams & Wilkins, Inc.