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.
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