Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary (2009)

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3 Traumatic Brain Injury and the Military Health System Michael S. Jaffee Traumatic brain injury (TBI) presents the Military Health System (MHS) with a number of clinical and logistical challenges to treating injuries in the field, transporting injured personnel to higher level care facilities when indicated, and returning injured personnel to active duty or transferring them for therapy in specialized stateside medical centers. Because of the large number of TBI cases in military settings, meeting these challenges is a high priority. The magnitude of the challenge Data obtained from the Defense and Veterans Brain Injury Center (DVBIC) indicate that nearly a third of all combat injuries treated at the Walter Reed Army Medical Center (WRAMC) in early 2008 involved TBI and that ~20 percent of patients evacuated by air from the Opera- tion Iraqi Freedom (OIF) combat zone were classified as having at least a head or neck injury.  This chapter is based on the author’s presentation and responses to questions during the plenary session of the NAE-IOM workshop on Harnessing Operational Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System on June 11, 2008. The author would like to thank IOM staff member David Butler for his assistance in preparing this material for publication. 31 

32 Systems Engineering to Improve Traumatic Brain Injury CARE TABLE 3-1 DVBIC Data—TBI Patient Demographics, by Branch of Service Number of Percentage of Branch of Service Patients Patients Army Active duty 3,652 62 Reserve 203 3 National Guard 672 11 Marine Corps Active duty 995 17 Reserve 73 1 Air Force Active duty 90 2 Reserve 2 < 0.5 Navy Active duty 124 2 Reserve 25 0.42 Civilian/NATO 89 2 Missing data 1 < 0.5 Total 5,926 Source: DVBIC data through February 29, 2008. Many TBIs are the result of blast exposure. Information from the Joint Theater Trauma System (JTTS) indicates that about 40 percent of soldiers exposed to a blast have evidence of a TBI; Defense and Veterans Brain Injury Center (DVBIC) data show that blasts contribute to more than half of combat TBIs. The majority—some 62 percent—of military TBI patients are members of the active-duty Army, reflecting both their relatively greater numbers in theater and their higher exposure to combat and other haz- ardous environments. Table 3-1 shows patient demographics by branch of service as of early 2008. Most diagnosed TBIs (86 percent) are characterized as mild (mTBI); moderate (7 percent), severe (4 percent), and penetrating wounds (3 per- cent) are far less common. However, these figures may underestimate the true incidence of mTBI. The quantification of moderate, severe, and penetrating TBIs is relatively straightforward because of the frank nature of the injury, but mTBIs are much more difficult to identify. Patients may not immediately experience, recognize, or seek care for mTBI The Joint Theater Trauma System (JTTS) was established in December of 2004. The  implementation of the JTTS involved establishing a theater trauma registry, clinical practice guidelines, and clear lines of communication between the casualties’ point of injury through the health care continuum. 

Traumatic Brain Injury and the Military Health System 33 i ­njuries, and they or their caregivers (as well as screening mechanisms) may attribute TBI symptoms to other diseases. To get a better estimate of mTBIs among participants in OIF/ Operation Enduring Freedom (OEF), the military services have been gathering data by various means, such as surveys conducted in theater and immediately after deployment. The VA has also been screening new entrants to its programs, and the RAND Corporation has generated an estimate extrapolated from the results of a telephone survey of previously deployed personnel (RAND, 2008). All of these sources report that the incidence rate of TBI ranges from 10 to 20 percent (Traumatic Brain Injury Task Force, 2007). The dis- parities may in part reflect what was being measured and at what point in time it was being measured. Self-reports of TBI symptoms are not the same as positive results from TBI screening instruments or diagnoses of TBI by health professionals. Measurements taken immediately after exposure to potential TBI-initiating events may well generate differ- ent figures than measurements taken later, when symptoms may have resolved for some and become manifest for others. Another confusing element is the extent to which concussion is considered a synonym for mTBI. A concussion is defined as a “head trauma-induced alteration in mental status that may or may not involve loss of consciousness” (American Academy of Neurology, 1997). This is different than, although consistent with, DOD’s current definition of TBI (DOD, 2007). Responses by the Department of Defense and Other Federal Agencies In light of the challenges presented by TBI and other health prob- lems experienced by deployed military personnel, the president, Con- gress, the federal government in general, and DOD in particular, have all convened high-level groups to identify and address these issues. These include the President’s Commission on Care for America’s Returning Wounded Warriors, the congressionally chartered Veterans Disability Benefits Commission, the federal interagency Task Force on Returning Global War on Terror Heroes, the DOD Secretary’s Independent Review Group on Rehabilitative Care and Administrative Processes at WRAMC  As noted in the preceding chapter, post-traumatic stress disorder and mTBI have some common symptoms. 

34 Systems Engineering to Improve Traumatic Brain Injury CARE and National Naval Medical Center, the DOD Office of the Inspector General’s Review of DOD/VA Interagency Care Transition, and the Defense Health Board Task Force on Mental Health. A joint DOD/ VA Senior Oversight Committee was then formed to “streamline, de- c ­ onflict, and expedite the two Departments’ efforts to improve support of wounded, ill, and injured service members’ and veterans’ recovery, rehabilitation, and reintegration” (Davis and Day, 2008). Among the lines of action for the Overarching Integrated Product Team, also known as the “Red Cell,” was the creation of the Defense Center of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury. DCoE is described as a “Center of Centers,” comprising the (aforementioned) DVBIC, National Intrepid Center of Excellence, Center for Deploy- ment Psychology, Deployment Health Clinical Center, and Center for the Study of Traumatic Stress. Of these, DVBIC—formerly called the Defense and Veterans Head Injury Program or DVHIP—is the longest standing entity, having been established in 1992 as a collaboration between DOD and VA. The original, congressionally directed missions of DVBIC were to provide subject-matter expertise on TBI clinical care, clinical standards, research, and education for DOD and VA. More recently, DVBIC has also as- sumed responsibility for surveillance of TBI casualties. As of June 2008, the DVBIC network consisted of 10 military treatment facilities, four VA polytrauma centers, and two civilian part- ners. Its purpose—and more broadly, a goal of DCoE—is to provide a continuum of high-quality care for all forms of TBI, from the point of injury through acute care, rehabilitation, and chronic care, as well as the transition to disparate providers, as the need arises. The military’s health care delivery for its active force is arrayed along a continuum of five echelons. Table 3-2 lists the echelons and their as- sociated care setting(s) and gives examples of the type of care delivered and the facilities that deliver them. Echelons of Military Care The effective triage, stabilization, and transportation of injured per- sons to the appropriate care facility are vital to their survival. Casualty evacuation (CASEVAC) from the field to initial care in a Level Ib or Level II facility may be performed by whichever land or air vehicle can most quickly deliver the patient to the facility. Tactical (Level II to III) and 

Traumatic Brain Injury and the Military Health System 35 TABLE 3-2 Echelons of Care in the Military Health System Echelon Care Setting(s) Care Delivered Representative Facilities In Theater Level Ia Field: self aid, buddy First Aid; airway, aid, combat medic, hemorrhage control, corpsman field dressings, IV fluid, analgesia, Level Ib Battalion Aid Station stabilization for further evacuation Level II Forward Surgical Urgent resuscitative 555th FST, Afghanistan Team (FST); and salvage surgery, (Patel et al., 2004); Surgical Shock stabilization for SSTP, Al Taqaddum, Trauma Platoon further evacuation Iraq (Chambers et al., (SSTP), Forward 2006) Resuscitative Surgical System In-theater clinic Minor care, basic Sickbay, USS Abraham (land or ship based) laboratory and x-ray Lincoln services Level III Combat Support Resuscitation, initial 325th CSH, Al Asad; Hospital (CSTH); surgery, definitive 31st CSH, Baghdad; Air Force Theater and reconstructive 332nd Expeditionary Hospital (AFTH); surgery, post-op Medical Dental Group; U.S. Navy Hospital care, intensive care, AFTH, Balad; Ship stabilization for US Navy Ship Mercy further evacuation Out of Theater Level IV Regional medical Definitive care: Landstuhl Regional center, general and Medical Center general hospital specialized medical (Germany) and surgical care, reconditioning and rehabilitating services for those returning to duty in theater, stabilization for further evacuation Level V Medical center Comprehensive Walter Reed Army diagnostic, medical, Medical Center; psychological, National Naval Medical surgical, and Center (Bethesda) rehabilitative care Sources: Jaffee, 2008; Jenkins et al., undated; Rasmussen et al., 2006. 

36 Systems Engineering to Improve Traumatic Brain Injury CARE s ­ trategic (Level III to IV) medical evacuation (MEDEVAC) is more likely to be carried out by air transports, which have the personnel and equip- ment to provide en route care and are dedicated to moving patients. The military’s goals are to perform CASEVAC from a (Level I) bat- talion aid station to Level II care within 38 minutes, tactical evacuation (EVAC) within one hour, and strategic EVAC in 24 to 72 hours. If patients require treatment beyond the level of care available or appropriate at the Level IV Landstuhl Regional Medical Center, they are directed to various sites in the continental United States (CONUS), depending on the type and severity of their injuries. Penetrating TBIs are treated at the National Naval Medical Center; severe and moderate TBIs are sent to Walter Reed or Brooke Army Medical Center; and mild, symptomatic injuries are sent to one of seven regional medical centers. mTBI cases returning to garrison are treated at their duty stations or mobilization sites. The surgical workload in a Level III care facility—the highest level of care available in theater—is quite different from the workload in a civilian trauma center. The 332nd Expeditionary Medical Dental Group AF Theater Hospital (AFTH) in Balad, Iraq, for example, has approximately four times as many admissions as a typical highest level (Level I) trauma center in the United States. Indeed, virtually all care at Balad AFTH is traumatic care, because the vast majority of patients (> 90 percent) have penetrating traumas (compared to 30 percent in the busiest stateside civilian facility); high-velocity gunshot wounds, blast injuries, and multiple traumas are common. In a stateside civilian facil- ity, less than 10 percent of admitted trauma patients require surgery, and most of those require only one surgical specialty, whereas most patients admitted to the Balad AFTH need surgery, and the majority require more than one specialty and multiple procedures. Components of an Effective Care Delivery System There are seven core components of an effective program for treat- ing TBI at a military treatment facility: 1. early identification or screening mechanisms 2. an assessment capacity, that is, having enough providers to per- form proper assessments 

Traumatic Brain Injury and the Military Health System 37 3. a treatment capacity based on proven treatment modalities 4. coordinated care, including a capability for adequate patient f ­ ollow-up 5. ongoing education for care providers, service members, and p ­ atients and their families 6. a link into the DOD TBI surveillance system to enable a better understanding of the scope of the problem 7. a feedback system and tools to maintain and improve unit perfor- mance and the quality of care to ensure that the program remains efficient and effective over time Several factors can complicate the delivery of TBI care at mili- tary facilities. For example, TBI requires a multidisciplinary clinical response. Unlike heart disease and cardiology, no single specialty has the default responsibility for the treatment of TBI. Depending on the specific injuries, several departments, including neurology, neurosurgery, ophthalmology, otolaryngology, physical medicine and rehabilitation, psychiatry, and psychology, as well as multiple therapy units, such as physical, occupational, and speech therapy, could plausibly take the lead. As a result, there is little consistency in care management among and between facilities. A second factor is the relatively high rate of personnel turnover as the result of tour rotations, [re]deployments, and separations at the end of service. Thus it is difficult to train and retain skilled professionals at particular care locations. Capacity, a third factor, noted in the discussion of DVBIC above, is being addressed through partnerships with VA and civilian entities. The challenge of such partnerships is that non-DOD facilities may not apply the same standards of care or may not have the same level of expertise as military facilities. Accreditation, through, for example, the Commission for Accreditation of Rehabilitation Facilities, is one way to manage this issue. The educational component of a program for TBI includes clinical training for providers who render care in theater, during pre-­deployment and deployment, and back in CONUS. The training includes programs intended to increase the awareness of TBI by service members and their commanders, not only to improve care, but also to reduce the stigma  In general, the clinical information (Class 1 randomized controlled trial) on treating severe TBI is better than the information on treating mTBI. 

38 Systems Engineering to Improve Traumatic Brain Injury CARE associated with TBI injuries. Providing patients and their families with information about TBI prognosis and recovery expectations and DOD services helps them cope with the injury. The educational mission can be extended to reserve and guard components of the military and to the civilian community. Care coordination is another vital component of TBI medical ser- vices. Good coordination can ensure that patients do not “fall through the cracks” as they make their way through different levels of care and between facilities. Both DOD and VA have established systems for co- ordinating care since 2006. Expert care coordination for TBI patients, one of DVBIC’s goals, is delivered through a network of regional care-coordination sites, 14 of which were located in the United States and Germany as of early 2008. More sites are planned to increase their geographic focus in areas where demand is high. VA’s care-coordination system is intended to facilitate services for patients with polytraumatic injuries in general, with special emphasis on TBI. There are four levels of care in the VA system (which should not be confused with DOD’s levels of care). The highest, Level I, is provided at four polytrauma rehabilitation centers (PRCs) located in Minneapolis; Palo Alto; Richmond, Virginia; and Tampa. PRCs include brain injury centers (VA’s component of DVBIC), which provide a full range of acute, comprehensive medical and rehabilitative services to patients with highly complex injuries, including an emerging consciousness program for patients with severe TBI to facilitate their return to awareness and improve responsiveness. PRCs are augmented by 21 Level II polytrauma network sites (one in each of the VA’s Veterans Integrated Service Network regions) that provide inpatient and outpatient post-acute rehabilitation in settings closer to veterans’ homes (VA, 2008). The 76 Level III polytrauma sup- port clinic teams (PSCTs) are composed of rehabilitation providers who supply long-term polytrauma management, primarily on an outpatient basis. PSCTs also head the comprehensive TBI screening, performing a four-question preliminary screen (with appropriate ­ follow-up) for every OIF/OEF veteran who requests any sort of care. As of fall 2007, 54 Level IV polytrauma points of contact (PPOC) were available at VA facilities that do not provide higher level care. These PPOCs are http://www.biausa.org/elements/pdfs/awareness/dvbic_fact_sheet.pdf.  In 2007, Congress directed that a fifth center be established in San Antonio. See http://  www.usmedicine.com/article.cfm?articleID=1658&issueID=104. 

Traumatic Brain Injury and the Military Health System 39 intended to serve as local sources of expertise on the entire polytrauma system of care and provide referrals to appropriate providers and facili- ties (Sigford, 2007). Data on patients in the MHS formerly were collected through dis- parate, service-specific systems. The JTTS, which is under the Office of the Secretary of Defense, consolidated these into a single Joint Theater Trauma Registry. The objective of the registry is to log information at a patient’s first point of contact with MHS and follow that person forward. Modules are being developed for the system to gather specific information on some outcomes, including treatment for TBI. JTTS staff positioned at each of the Level III hospitals in theater and some of the major CONUS hospitals collect data. However, the system is in its infancy and—as of spring 2008—there was a backlog of some 17,000 charts to be entered into the database. These data can be important because symptoms may have clinical significance long after they are reported or have seemingly been resolved. The Medical Com- munications for Combat Casualty Care system and its Armed Forces Health Longitudinal Technology Application-Theater are also intended to systematize the collection of medical information in the field. JTTS also facilitates other DOD-wide collaborations in trauma management, policy development, research, education, medical resource allocation, and clinical care (DOD, 2008). Both DOD and VA are advancing the use of telehealth technologies to help deliver services to patients in theater and in rural, nonurban, and underserved areas in the United States. Two current applications are teleconsultations that connect experts on TBI to on-site care pro- viders and teleconferencing that enables patients and their families to meet their VA treatment team before they transition out of DOD care. Virtual support groups, which will link patients in disparate locations, are in the planning stage. Research Questions and Initiatives The TBI clinical-care delivery system is supported and enriched by a framework of scientific and medical research by agencies throughout DOD. This framework has three primary elements that track the time- line from exposure to potentially hazardous conditions to the decision to return an injured warrior to duty or separate him or her from service. 

40 Systems Engineering to Improve Traumatic Brain Injury CARE The three elements are: (1) protection and prevention, (2) clinical as- sessment, and (3) injury management. Protection and Prevention One component of the protection and prevention element is hel- met design. In the past, the driving consideration was the prevention or mitigation of a penetrating injury. This is, of course, still vital, but the considerations have been expanded to include the mitigation of blast effects. Sensors placed in a helmet can provide information about its acceleration, a proxy for acceleration of the head and brain during a concussive event. The goal of this research is to develop a blast dosimeter that can provide an objective measure of the force experienced and yield information about how injuries vary with the magnitude of the force. Lessons are also being learned from how well materials used in athletic helmets protect against blunt-force trauma. A more general research question is the mechanism of blast injury, which can result from the detonation of a vehicle-borne or person-borne explosive device, rocket-propelled grenade (RPG), or improvised explo- sive device (IED) (DOD, 2008). Relatively little is known about such injuries, both because explosives were not used as primary weapons in conflicts prior to OIF/OEF and because modern body armor now saves the lives of many more people exposed to blasts. Table 3-3 categorizes blast injuries by mechanism. Briefly, a primary blast injury is caused solely by the direct effect of blast overpressure on tissue. Because air is easily compressible, a primary blast injury almost always affects air-filled structures, such as the lung, ear, and gastro­ intestinal tract. Secondary blast injuries are caused by objects propelled by the force of the explosion. These include fragments of shell casings and materials in the surrounding environment that are thrown or frag- mented by the blast. The impact of these objects can cause closed and open TBIs. Tertiary injuries, a feature of high-energy explosions, occur when the force of a blast propels a person into objects in the surrounding environment. DOD includes skin speckling from the residue of explo- sive products and blunt and crush injuries caused by blast-collapsed structures in this category (DOD, 2006). Quaternary effects result from  An “open-head” TBI is caused by a penetrating wound; the skull remains intact in a “closed-head” injury. 

TABLE 3-3 Blast Injuries by Mechanism Category Mechanism Representative Effects Primary Direct exposure to blast overpressure • Eardrum rupture and middle ear damage • Blast lung injury (BLI)a • Abdominal hemorrhage and perforation • Eye rupture Secondary Impact of blast-energized debris from the • Penetrating ballistic (fragmentation) or blunt injuries device and surrounding environment • Eye penetration Tertiary Displacement of the person by the blast or • Fracture and traumatic amputation debris impact • Stripping of soft tissues • Skin speckling with explosive product residue • Blunt injuries • Crush injuries Quaternary Exposure to the heat and fire by-products • Burns from radiant and convective heat generated by the blast • Injury or incapacitation from inhaled toxic fire gases Quinaryb Exposure to toxic agents released by the blast • Illnesses, injuries, or diseases caused by chemical, biological, or radiological substances (i.e., “dirty bombs”) a “Blast lung injury (BLI) . . . is a direct consequence of the blast wave from high explosive detonations upon the body. . . . The blast wave’s impact upon the lung results in tearing, hemorrhage, contusion, and edema with resultant ventilation-perfusion mismatch” (CDC, 2008). b Note that some sources (CDC, 2006) combine quaternary and quinary injuries into an “all other” category, and others define the quinary mechanism and effects differently (Kluger et al., 2007). Sources: DOD, 2006; Jaffee, 2008; Warden, 2006. 41 

42 Systems Engineering to Improve Traumatic Brain Injury CARE exposure to the heat and chemicals generated by a blast, that is, explosive by-products. Quinary effects are caused by nuclear, biological, or chemi- cal agents released by the blast, either because they were included with the charge or because they were in the environment around it. The means by which a blast directly induces a closed-head injury is a subject of scientific debate. Among the theories that have been advanced are the formation of air emboli in blood vessels, small-scale cavitation, exposure to blast-generated electromagnetic fields, and overpressure or underpressure effects. The last of these has received a great deal of attention. Overpres- sure and underpressure waves can cause ruptures of the tympanic membranes in the ears, a mechanism called barotrauma. There are two hypotheses for how these waves are transmitted to the brain: directly through the skull, eyes, and ears; and indirectly through the great vessels of the chest (Bhattacharjee [2008] reporting on the research of Ibolja Cernak et al., Johns Hopkins University). Empirical modeling of blast effects has yielded estimates of injury types as a function of distance from the event. However, the value of these estimates depends on how representative they are of real-world conditions. Open-air blasts, for example, are the easiest to model, but battlefield environments are often cluttered with buildings and vehicles that can channel, reflect, and redirect explosive forces. Animal models are also being used to model blast effects, using shock tubes to transmit the energy of detonations and deflagrations.10 These studies have shown axonal damage, swelling, edema, and reactive gliosis. Rafols and colleagues (2004) have reported a genetic change, alternation in the expression of inducible nitric oxide synthetase. Another complication in the analysis of TBI in combat situations is that most blast injuries involve other modalities, a circumstance that has been called “blast plus.” A soldier riding in a HMMWV (popularly  Cavitation is the sudden formation and collapse of bubbles in liquids (blood or cerebral fluid, for example) caused by a mechanical force such as violent shaking.  A blast generates a shock front that compresses the air, creating an initial overpressure wave. This is followed by a negative (underpressure) phase that results from the vacuum behind the shock front. A second, smaller overpressure may in turn be generated by the underpressure, and so on as the wave dissipates. These wave phases may cause different types of damage to the brain. 10 A detonation induces a shock wave that propagates at supersonic speed, whereas a deflagration generates a subsonic wave. Detonations thus create higher pressures and are more destructive. 

Traumatic Brain Injury and the Military Health System 43 referred to as a “Humvee”), for example, may experience a blast that throws shrapnel and causes his vehicle to suddenly decelerate, whipping the head of its occupants and possibly driving them into the roof, all of which may contribute to brain injuries. In contrast, TBIs in other circumstances, such as motor vehicle accidents or sports collisions, are typically single-mechanism injuries. For this reason, the extent to which lessons learned in civilian cases are applicable to the military, including whether the pathophysiology of injury, pattern of co-morbidities, and natural history of recovery, are debatable. Clinical Assessment Military health care providers also face many other controversies. Per- haps the most basic is the definition of TBI itself. The definition of mTBI currently used by DOD and VA is based on a definition developed by the American Congress of Rehabilitation Medicine that identifies a person as having mTBI if he or she experiences either a loss of consciousness or an alteration of consciousness (GAO, 2008).11 Disagreements about whether to use only loss of consciousness or either loss or alteration of conscious- ness have not been resolved. Research indicates that “[i]njuries associated with loss of conscious- ness carried a much greater risk of health problems than [did] injuries as- sociated with altered mental status” (Hoge et al., 2008). However, there is wide consensus that altered consciousness ought to be a diagnostic criterion (DVBIC Working Group, 2006),12 and nearly two-thirds of military mTBI cases qualify for the diagnosis on the basis of alteration of consciousness. Thus, if this criterion is dropped, it may lead to missed cases and the negative health consequences that flow from them. The differential diagnosis of mTBI and the identification of co-morbidities pose additional challenges. 11 Specifically, the standards define a person as having mTBI if “the person had a t ­ raumatically-induced physiological disruption of brain function as demonstrated after an event by at least one of the following: (1) any period of loss of consciousness; (2) any loss of memory for events immediately before or after the event; (3) any alteration in mental state at the time of the event, for example feeling dazed, disoriented, or confused; and (4) a focal neurological deficit or deficits that may or may not have been transient, for example loss of coordination, speech difficulties, or double vision” (GAO, 2008, p. 9). 12 U.S. Central Command subsequently mandated the use of clinical guidelines that included the alteration of consciousness criterion (Casscells, 2008). 

44 Systems Engineering to Improve Traumatic Brain Injury CARE Another controversy concerns the utility of post-deployment screenings, which are performed as part of the Post-Deployment Health Assessment and Re-Assessment program. Although some studies exist (Schneiderman et al., 2008; Schwab et al., 2007), screening instruments used by the military have not, by and large, been validated in military populations. DVBIC is conducting outreach to military personnel, their families, and medical service providers to educate them about mTBI signs and symptoms and thus complement screening efforts (RAND, 2008). Several panels and commissions, including the Armed Forces Epide- miological Board13 (AFEB, 2006), the Army Surgeon General’s TBI Task Force (Traumatic Brain Injury Task Force, 2007), a group constituted by DOD to review operations at Walter Reed and National Naval Medical Centers (Independent Review Group, 2007), and the Defense Health Board, an advisory panel convened under the Office of the ­ Assistant Secretary of Defense for Health Affairs (OSD/HA) (DOD Task Force on M ­ ental Health, 2007), have advised DOD either to consider or imple- ment a combination of baseline and post-deployment neuro­cognitive screening, or post-injury testing. In addition, the National Defense Authorization Act for Fiscal Year 2008 (P.L. 110-181) directed DOD to develop and deploy an “evidence-based means of assessing traumatic brain injury . . . including a system of pre-deployment and post-deployment screenings of cognitive ability in members for the detection of cognitive impairment” (§1618). All of these recommendations and directives have influenced the system of care. Current policy requires pre-deployment baseline screen- ing using the Automated Neuropsychological Assessment Metric, an Army-developed instrument for which normative data from military populations are available. Other instruments are also being considered by DOD. Separately, DOD is evaluating information technologies and sys- tems issues related to testing. The Army, Navy, and Air Force use dif- ferent software and hardware, making it difficult to implement a single automated system for all of the services and for software written for one branch of the military to communicate or be combined with software written for another. 13 The AFEB is now a part of the Defense Health Board, which also comprises the for- mer Amputee Patient Care Program Board of Governors and the Armed Forces Institute of Pathology Scientific Advisory Board. 

Traumatic Brain Injury and the Military Health System 45 Military Health Care System VA Health Care System Prevention and Protection Continuum Outreach and Education Continuum Clinical Care Continuum Screening Prevention Diagnosis and Acute Care Rehabilitative Long-Term Gradation and Recovery Care Care Entry Combat Exposure Separation or Retirement Protection Research Diagnostic and Care Research Long-Term Care Research FIGURE 3-1 TBI Health Care Delivery and Research Collaboration System. Source: Jaffee, 2008. Figure 3-1.eps Injury Management The integration of care delivery within and among the services and between them and other providers is an important goal for TBI man- agement. DOD is taking steps to encourage systems collaboration and facilitate the interface between MHS and VA health care systems. Figure 3-1 shows the major components of the care and research network. Systems engineering technologies and techniques have the potential to make important contributions in this vital area. References AFEB (Armed Forces Epidemiology Board). 2006. Traumatic Brain Injury in Military Service Members–2006-02. Memorandum for the Honorable William Winkenwerder, Jr., M.D., Assistant Secretary of Defense for Health Affairs. Available online at http://www. ha.osd.mil/afeb/2006/2006-02.pdf (accessed August 11, 2008). American Academy of Neurology. 1997. Practice parameter: the management of concussion in sports. Neurology 48(2): 581–585. Bhattacharjee, Y. 2008. Shell shock revisited: solving the puzzle of blast trauma. Science 319(5862): 406–408. Casscells, S.W. 2008. Statement on mental health by the Honorable S. Ward Casscells, M.D., Assistant Secretary of Defense for Health Affairs before the Subcommittee on Military Personnel, Armed Services Committee, U.S. House of Representatives, March 14, 2008. Available online at http://armedservices.house.gov/pdfs/MilPers031408/­ Casscells_­Testimony031408.pdf (accessed October 22, 2008). CDC (Centers for Disease Control and Prevention). 2006. Explosions and Blast Injuries: A Primer for Clinicians. Available online at http://www.bt.cdc.gov/masscasualties/explosions. asp (accessed July 30, 2008). 

46 Systems Engineering to Improve Traumatic Brain Injury CARE CDC. 2008. Blast Injuries: Blast Lung Injury. Available online at http://www.bt.cdc.gov/mass- casualties/blastlunginjury.asp (accessed July 30, 2008). Chambers, L.W., D.J. Green, B.L. Gillingham, K. Sample, P. Rhee, C. Brown, S. Brethauer, T. Nelson, N. Narine, B. Baker, and H.R. Bohman. 2006. The experience of the US Marine Corps’ Surgical Shock Trauma Platoon with 417 operative combat casualties during a 12 month period of Operation Iraqi Freedom. Journal of Trauma-Injury Infec- tion and Critical Care 60(6): 1155–1161; discussion 1161–1164. Davis, L.C., and K. Day. 2008. Statement of Dr. Lynda C. Davis, Deputy Assistant Secretary of the Navy for Military Personnel Policy, Department of Defense, and Ms. Kristin Day, Chief Consultant, Care Management and Social Work, Department of Veterans’ ­Affairs, before the U.S. Senate Committee on Veterans’ Affairs, March 11, 2008. Available online at http://veterans.senate.gov/public/index.cfm?pageid=16&release_id=11536&sub_ r ­ elease_id=11593&view=all (accessed August 13, 2008). DOD (U.S. Department of Defense). 2006. Department of Defense Directive Number 6025.21E: Medical Research for Prevention, Mitigation, and Treatment of Blast Injuries. July 5, 2006. Available online at http://www.dtic.mil/whs/directives/corres/pdf/ 602521p.pdf (accessed July 30, 2008). DOD. 2007. Traumatic Brain Injury: Definition and Reporting. Memorandum. HA Policy 07-030. Dated October 1, 2007. Available online at http://mhs.osd.mil/Content/docs/pdfs/ policies/2007/07-030.pdf (accessed August 13, 2008). DOD. 2008. Operational Medicine and Medical Force Readiness (OM&MFR). Avail- able online at http://deploymentlink.osd.mil/about.jsp?topic=6#ttm (accessed July 22, 2008). DOD Task Force on Mental Health. 2007. An Achievable Vision: Report of the DOD Task Force on Mental Health. Falls Church, VA: Defense Health Board. DVBIC Working Group (Defense and Veterans Brain Injury Center Working Group on the Acute Management of Mild Traumatic Brain Injury in Military Operational Settings). 2006. Clinical Practice Guideline and Recommendations 22 December 06. Available online at http://dvbic.org/public_html/pdfs/clinical_practice_guideline_recommendations. pdf (accessed August 7, 2008). GAO (Government Accountability Office). 2008. VA Health Care: Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain. GAO-08-276. Available online at http://www.gao.gov/new.items/d08276.pdf (accessed September 10, 2008). Hoge, C.W., D. McGurk, J.L. Thomas, A.L. Cox, C.C. Engel, and C.A. Castro. 2008. Mild traumatic brain injury in U.S. soldiers returning from Iraq. New England Journal of Medicine 358(5): 453-463. Independent Review Group on Rehabilitative Care and Administrative Processes at Walter Reed Army Medical Center and the National Naval Medical Center. 2007. Rebuilding the Trust. Available online at http://www.washingtonpost.com/wp-srv/nation/documents/ walter-reed/IRG-Report-Final.pdf (accessed August 11, 2008). Jaffee, M.S. 2008. TBI Overview in Military Health System. Presentation at the Workshop on Harnessing Operational Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System, The National Academies, Washington, D.C., June 11, 2008. 

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