Benefit of a Tiered-Trauma Activation System to Triage Dead-on-Arrival Patients

Abstract

IntroductionAlthough national guidelines have been published for the management of critically injured traumatic cardiopulmonary arrest (TCPA) patients, many hospital systems have not implemented in-hospital triage guidelines. The objective of this study was to determine if hospital resources could be preserved by implementation of an in-hospital tiered triage system for patients in TCPA with prolonged resuscitation who would likely be declared dead on arrival (DOA).MethodWe conducted a retrospective analysis of 4,618 severely injured patients, admitted to our Level I trauma center from December 2000 to December 2008 for evaluation. All of the identified patients had sustained life-threatening penetrating and blunt injuries with pre-hospital TCPA. Patients who received cardiopulmonary resuscitation (CPR) for 10 minutes were assessed for survival rate, neurologic outcome, and charge-for-activation (COA) for our hospital trauma system.ResultsWe evaluated 4,618 charts, which consisted of patients seen by the MSM trauma service from December 2001 through December 2008. We identified 140 patients with severe, life-threatening traumatic injuries, who sustained pre-hospital TCPA requiring prolonged CPR in the field and were brought to the emergency department (ED). Group I was comprised of 108 patients sustaining TCPA (53 blunt, 55 penetrating), who died after receiving < 45 minutes of ACLS after arrival. Group II, which consisted of 32 patients (25 blunt, 7 penetrating), had resuscitative efforts in the ED lasting > 45 minutes, but all ultimately died prior to discharge. Estimated hospital charge-for-activation for Group I was approximately $540,000, based on standard charges of $5000 per full-scale trauma system activation (TSA).ConclusionFull-scale trauma system activation for patients sustaining greater than 10 minutes of prehospital TCPA in the field is futile and economically depleting.

Dead on arrival in a low-income country: results from a multicenter study in Pakistan

“…Another major finding of this study is the low rate of CPR use on those who presented as DOA to EDs [ 42 ]. In settings like the United States, the prevalence of CPR performance is very high in critically ill patients arriving at EDs (e.g., 108 of 140 cases in [ 14 ]). Our study showed that the patients brought to a private hospital were more likely to have CPR performed than other patients.…”

“…This imprecision results from patients without vital signs who are pronounced dead after receiving some care in the emergency department (ED) [ 9 ]. A common practice in some EDs is to define the above cases as DOA or dead on arrival, which introduces the risk of misclassification [ 8 , 9 , 13 , 14 ]. Nevertheless, the broad definition of DOA may include patients who were either declared dead upon arrival to an emergency department with no resuscitation attempt or those who died after failed resuscitation, usually within the first 15 to 60 minutes of arrival [ 8 , 9 , 15 ].…”

Performance of a simplified termination of resuscitation rule for adult traumatic cardiopulmonary arrest in the prehospital setting

“…Around 18% of adult patients with prehospital TCPA caused by a blunt mechanism still received transcatheter arterial embolisation or emergency surgery, and all who presented in asystole at the time of ED arrival ultimately died prior to discharge 7 8…”

Addressing Injuries in Vulnerable Populations: Research Collaborations and Partnerships

“…More specifically, there is a commentary regarding the healthcare disparities in trauma care as well as a manuscript addressing the benefit of a tiered trauma activation system. 6 , 7 Another manuscript examines the predictors of post-traumatic stress disorder among trauma victims and yet another manuscript assesses ED visits for traumatic brain injuries among older adults. 8 , 9 Two other manuscripts examine poisonings.…”