Impact of definitions on trauma center mortality rates and performance

Trauma center performance depends on quality metrics, such as mortality rates, but there have been few studies on how an exact definition of death can influence these statistics. The purpose of this study was to test the hypothesis that the mortality rate at one trauma center could be influenced by the interpretation of "dead on arrival." Personal communication suggests that this definition is applied variably throughout our state.

All deaths at our Level I trauma center from January 2009 to April 2011 were reviewed.

There were 11,121 trauma admissions, predominantly male (75%), with mean +/- SD of 39 +/- 20, 72% blunt, 22% penetrating, and 7% burn injuries. There were 661 deaths, of which 582 were "hospital deaths" and an additional 79 were classified as "dead on arrival," defined as patients arriving with no vital signs and receiving no hospital intervention. However, 23% (n = 136) of the hospital deaths also arrived with no vital signs but received some lifesaving intervention, for example, tube thoracostomy (n = 95, 70%), thoracotomy (n = 48, 35%), and/or central venous catheter (n = 21, 15%). The state-reported mortality rate each month was 5.3 +/- 1.4%. If those who arrived with no vital signs were excluded, the mortality rate each month was 4.0 +/- 1.2% (p < 0.001).

At this trauma center, approximately one fourth of the deaths reported to the state were patients who arrived with no vital signs. If any lifesaving intervention is attempted in these moribund patients, even if it is futile, it is termed "hospital death," rather than "dead on arrival." State regulations exclude patients who received any intervention from being classified as dead on arrival, but compliance with this definition is not audited. Therefore, unless there is strict compliance and standardized definitions, any comparison of trauma center quality based on mortality could be questioned.

Epidemiologic study, level III.