Tag Archives: TQIP

Performance Improvement

DOA vs DIE: What Does It Mean?

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When a trauma patient is delivered to the emergency department but ends up in the morgue, two acronyms are typically thrown around. The first is DOA, which many people (think they) know about. This stands for “dead on arrival.” The other is DIE, which many are less familiar with. It stands for “died in ED,” and is less familiar to some.

What do they really mean, and why is the difference important?  It can be quite confusing. All US trauma centers report data to the National Trauma Data Bank (NTDB). This database actually recognizes three types of ED death:

  • DOA. This is defined as declared dead on arrival with no or minimal resuscitative attempts. This is usually construed to mean no invasive procedures.
  • Died after failed resuscitation. This is a death within 15 minutes of arrival and does include invasive procedures.
  • DIE. These deaths occur in the ED but outside the 15 minutes in the previous category. Obviously, invasive procedures will have been performed.

The ACS Trauma Quality Improvement Program (TQIP) lumps the last two together when constructing reports for subscribing trauma centers. The objective is to exclude truly nonsalvageable patients from analysis to allow us to learn from patients who actually may have some chance of survival. Incorrectly classifying a DOA patient as DIE can significantly and adversely impact the mortality numbers for a center within TQIP.

Unfortunately, DOA is frequently misunderstood by those collecting data for their hospital’s trauma registry. What is an invasive procedure? Inserting an IV? Mechanical CPR? Intubation? REBOA?

The confusion typically occurs because the trauma team has a certain sequence of life-saving maneuver that they carry out based on ATLS principles. They must do this at the same time patient salvageability is being assessed. What denotes that transition from DOA to DIE?

Unfortunately, there is no literature that really dissects this. Here are my thoughts:

  • Mechanical CPR. This is commonplace to offload some of the work prehospital providers are doing during transport of the critical patient. DOA
  • IV insertion. This is a routine procedure and is something that could have been done in the prehospital setting. DOA
  • IO insertion. Same as IV insertion. DOA
  • Fluid administration. Again, this is a continuation of prehospital care. DOA
  • IV drug administration. This one is tricky. If one cycle of ACLS drugs are given while quickly assessing signs of life, DOA. Otherwise, DIE.
  • Intubation. This is pretty invasive, right? But again, EMS may have done this in the field. So if it is done while assessing signs of life and then the patient is quickly pronounced, DOA. Otherwise, DIE
  • Pelvic splint. Wrapping the pelvis should be routine in initial management of blunt traumatic arrest. DOA
  • Central line insertion. This is invasive and takes a little time. DIE
  • REBOA. Really? DIE

Bottom line: This is a difficult concept, and I’m sure some will disagree with my opinions above. I look at whether the cares provided are a continuation of prehospital support, are minimally invasive, AND ensure that they are only routinely applied while a rapid search for signs of life is in progress. Anything above and beyond this should be considered DIE.

Please share your opinions via comments here or by Twitter!

Performance Improvement

When Is It Not An “Unplanned ICU Admission?”

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All US trauma centers verified by the American College of Surgeons (ACS) must now subscribe to the ACS Trauma Quality Improvement Program (TQIP). This program allows each center to benchmark themselves against other trauma centers that are just like them (level, volume, acuity, etc).  Every quarter, TQIP members receive a report that details their performance in a number of key categories. The report slices and dices a large number of data points, and shows how they compare to those other trauma centers.

One of the more interesting portions of the TQIP report deals with risk-adjusted complications. The one I wrote about yesterday, the “ICU bounce back,” is officially called an “unplanned ICU admission.”

I’ve had several trauma centers ask me what constitutes an unplanned ICU admission. Is it any bounce back? What about patients who were never in the ICU?

This questions is particularly important to me because my own center’s TQIP report shows that we have a significant number of unplanned ICU admissions. But I know for a fact that they are not surprises. We have an inpatient trauma unit, with capabilities somewhere between the usual ward bed and an ICU bed. Patients can get telemetry, continuous oximetry, vital signs every 2 hours, and more. It functions as a kind of step-down unit, so we frequently admit patients who may require ICU admission at other hospitals.

Every once in a while, a patient who is receiving care in the trauma unit shows signs that they are going to need a true ICU level of care. In that case, we promptly move them to the ICU before they decompensate any further.

Is that situation an “unplanned ICU admission?” In my opinion, no. The patient received the highest level of care while outside the ICU, and ultimately a considered decision was made to move them. In my mind, this is a “planned ICU admission.”

Bottom line: There are two issues at play if your “unplanned ICU admissions” get flagged on your TQIP report. The first is determining if it was truly unplanned. If the Rapid Response Team (RRT) was called, then it was almost certainly unplanned. But if the patient was being monitored properly, showed signs that they would need an ICU level of care, and was preemptively transferred there, it was not. Similarly, if one of your surgical specialists wants the patient transferred (e.g. MAP goals), then that is also a planned admission.

The second factor is figuring out why the admissions are getting reported to TQIP as unplanned. This is usually a trauma registrar issue. They may be looking for any ward to ICU transfer, and classifying it as unplanned. Educate all your registrars on the nuances of what is planned and what isn’t.

If you are on the receiving end of a TQIP variance on unplanned ICU admissions, use the drill-down tool to identify the exact patient records involved. Review the involved medical records, paying close attention to vital signs, monitoring, and all decision making leading up to the time of the ICU transfer. If it isn’t truly unplanned, educate your registrars. But if it is, make sure that it was properly dealt with by your trauma performance improvement program.