National Academies Press: OpenBook
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

A NATIONAL
TRAUMA CARE
SYSTEM

Integrating Military
and Civilian Trauma
Systems to Achieve
ZERO
Preventable
DEATHS
After Injury

Committee on Military Trauma Care’s Learning Health System and
Its Translation to the Civilian Sector

Donald Berwick, Autumn Downey, and Elizabeth Cornett, Editors

Board on Health Sciences Policy

Board on the Health of Select Populations

Health and Medicine Division

Images

THE NATIONAL ACADEMIES PRESS

Washington, DC

www.nap.edu

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This study was supported by Contract No. W81XWH-15-C-0045 with the U.S. Department of Defense, Contract No. HSHQDC-15-C-00080 with the U.S. Department of Homeland Security, and Contract No. DTNH2215H00491 with the U.S. Department of Transportation. The study received additional support from the American College of Emergency Physicians, the American College of Surgeons, the National Association of Emergency Medical Technicians, the National Association of EMS Physicians, and the Trauma Center Association of America. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-44285-5
International Standard Book Number-10: 0-309-44285-0
Digital Object Identifier: 10.17226/23511

Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.

Copyright 2016 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2016. A national trauma care system: Integrating military and civilian trauma systems to achieve zero preventable deaths after injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

Image

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Ralph J. Cicerone is president.

The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president.

The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

Learn more about the National Academies of Sciences, Engineering, and Medicine at www.national-academies.org.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

This page intentionally left blank.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

COMMITTEE ON MILITARY TRAUMA CARE’S LEARNING HEALTH SYSTEM AND ITS TRANSLATION TO THE CIVILIAN SECTOR

DONALD BERWICK (Chair), President Emeritus and Senior Fellow, Institute for Healthcare Improvement

ELLEN EMBREY, Managing Partner, Stratitia, Inc., and 2c4 Technologies, Inc.

SARA F. GOLDKIND, Research and Clinical Bioethics Consultant, Goldkind Consulting, LLC

ADIL HAIDER, Kessler Director, Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard School of Public Health

COL (RET) JOHN BRADLEY HOLCOMB, Director, Center for Translational Injury Research; Professor and Vice Chair of Surgery, UTHealth, The University of Texas Health Science Center at Houston

BRENT C. JAMES, Chief Quality Officer and Executive Director, Institute for Health Care Delivery Research, Intermountain Healthcare

JORIE KLEIN, Director of the Trauma Program, Parkland Health & Hospital System

DOUGLAS F. KUPAS, Associate Chief Academic Officer for Simulation and Medical Education, Associate Professor of Emergency Medicine, Geisinger Health System

CATO LAURENCIN, University Professor, Albert and Wilda Van Dusen Distinguished Professor of Orthopaedic Surgery, Professor of Chemical, Materials, and Biomedical Engineering; Director, The Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences; Director, Institute for Regenerative Engineering; Chief Executive Officer, Connecticut Institute for Clinical and Translational Science, University of Connecticut

ELLEN MACKENZIE, Fred and Julie Soper Professor and Chair, Department of Health Policy and Management, and Director, Major Extremity Trauma Research Consortium, Johns Hopkins University School of Hygiene and Public Health

DAVID MARCOZZI, Associate Professor and Director of Population Health, Department of Emergency Medicine, University of Maryland School of Medicine

C. JOSEPH MCCANNON, Co-Founder and CEO, The Billions Institute

NORMAN MCSWAIN, JR. (until July 2015), Trauma Director, Spirit of Charity, Tulane Department of Surgery

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

JOHN PARRISH, Chief Executive Officer, Consortia for Improving Medicine with Innovation and Technology; Distinguished Professor of Dermatology, Harvard Medical School

RITA REDBERG, Professor of Medicine, University of California, San Francisco

UWE E. REINHARDT (until August 2015), Professor of Economics and Public Affairs, Woodrow Wilson School of Public and International Affairs, Princeton University

JAMES ROBINSON, Assistant Chief, Denver Health EMS-Paramedic Division

THOMAS SCALEA, Physician-in-Chief, R. Adams Cowley Shock Trauma Center, University of Maryland, Department of Surgery

C. WILLIAM SCHWAB, Founding Chief, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Medicine Professor of Surgery, Perelman School of Medicine, University of Pennsylvania

PHILIP C. SPINELLA, Director, Pediatric Critical Care Translational Research Program and Blood Research Program, and Associate Professor, Department of Pediatrics, Washington University School of Medicine in St. Louis

Study Staff

AUTUMN DOWNEY, Study Director

ELIZABETH CORNETT, Research Assistant

CRYSTI PARK, Senior Program Assistant (until October 2015)

THELMA COX, Senior Program Assistant (October 2015-May 2016)

JOANNA ROBERTS, Senior Program Assistant (from April 2016)

MONICA GONZALES, Associate Program Officer (July 2015-December 2015)

REBECCA MORGAN, Senior Research Librarian

JOHN (JACK) HERRMANN, Senior Program Officer

FREDERICK (RICK) ERDTMANN, Director, Board on the Health of Select Populations

ANDREW M. POPE, Director, Board on Health Sciences Policy

Robert Wood Johnson Foundation Fellow

LEON DENT, Chief of Surgery, Nashville General Hospital; Associate Professor and Chair of Surgery, Meharry Medical College, Nashville, Tennessee

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

Consultants

RONA BRIERE, Senior Editor, Briere Associates, Inc.

JEREMY W. CANNON, Associate Professor of Surgery, Perelman School of Medicine, University of Pennsylvania

ALISA DECATUR, Briere Associates, Inc.

ERIN HAMMERS FORSTAG, Consultant Writer

ELLIOTT R. HAUT, Associate Professor of Surgery, Johns Hopkins University School of Medicine and the Johns Hopkins Bloomberg School of Public Health

COL (RET) RUSS S. KOTWAL, Assistant Professor, Uniformed Services University of the Health Sciences and Texas A&M Health Science Center

N. CLAY MANN, Professor, University of Utah School of Medicine

EMILY YAHN, Graphic Designer, Tangible Designs

Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

This page intentionally left blank.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

Dedication

Image

Dr. Norman McSwain (1937-2015) was an extraordinarily valued member of this committee. In honor of his immeasurable contribution to countless military and civilian injured, we humbly dedicate this effort to him. His legacy of training and translating and a laser focus on improving the outcomes of all injured persons permeates every page of this report. We hope he would approve of our efforts.

Norman’s leadership in all things trauma is legendary. He was a leader who helped establish emergency medical services (EMS) systems around the world. His focus was on rapid, expert treatment at the scene and speedy transport to qualified trauma centers. There is absolutely no question that his efforts saved an untold number of lives around the world. Very few, if any, physicians have had the impact that Norman had on care of the injured. He was always busy and held many jobs. He was trauma director of the Spirit of Charity Trauma Center, medical director and founder of PreHospital Trauma Life Support, chairman of the Tulane Medical Center Emergency Medicine Section and section chief of Trauma/Critical Care at Tulane, police surgeon for the New Orleans Police Department, and medical director for the New Orleans Jazz and Heritage

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

Festival for the past 30 years. Despite all of these many responsibilities, Norman famously made time for everyone who wanted to speak with him and learn from him.

Norman moved to New Orleans and Tulane University School of Medicine and Charity Hospital in 1977, where he remained until his death. Norman was the drive behind Charity’s response during Hurricane Katrina and, not surprisingly, was one of the last to leave. Typical of Norman, he never asked for recognition, he downplayed his role. His work as a trauma surgeon within Charity is best captured by the many residents and medical students he trained. They absolutely loved the man and are devastated by his death. Norman’s legacy lives on not only in New Orleans, where he is an icon, but also in his worldwide impact on emergency trauma care. Working with the National Association of Emergency Medical Technicians and the American College of Surgeons Committee on Trauma, he founded PreHospital Trauma Life Support (PHTLS), whose approach to prehospital care is the worldwide standard. PHTLS has trained more than 1 million providers in 64 countries since offering its first course in New Orleans in 1983. Over the past 14 years, Norman helped guide the Committee on Tactical Combat Casualty Care, revolutionizing prehospital care for military medics around the world. Within the last year, he was also a key member of the Hartford Consensus Working Group and this National Academies of Sciences, Engineering, and Medicine committee, devoted to helping to translate military advances in prehospital trauma care to the civilian sector to enable the nation to be better able to care for the millions of injured civilians. His message rings clearly through these important efforts. He was a passionate supporter of effective trauma systems: early hemorrhage control by immediate bystanders, integrated into timely, expert EMS and police response, and rapid transfer to a center where expert trauma care can be delivered.

Norman was also a huge personality. He lit up the room when he walked in. People felt his presence before they even saw him. Norman was famous for his humor and ready smile. He hosted wonderful parties, was always ready for a great dinner, and served as a shining example of what we can and should be. Norman inspired everyone. He had unlimited energy and passion and his enthusiasm was infectious. Once captured, you never left. He lived at 100 miles per hour every day. He battled his head and neck cancer publicly with grace and style so typical of Norman McSwain. He was a gentleman, a tireless advocate for what was right, a leader, a mentor, a superb team member, and friend to all of us.

Norman is survived by the many members of his biological family, his huge trauma family, and more important, all the trauma survivors who benefited from his extraordinary drive to improve prehospital trauma care around the world. His greeting to everyone will live on: “What have you done for the good of mankind today?”

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

John Armstrong, Florida Department of Health

Neal Dickert, Emory University School of Medicine

Brian J. Eastridge, The University of Texas Health Science Center at San Antonio

T. Bruce Ferguson, Jr., East Carolina Heart Institute and East Carolina Diabetes and Obesity Institute

Michael Lesk, Rutgers, The State University of New Jersey

Eve Marder, Brandeis University

Kathleen D. Martin, Lankenau Medical Center

Ricardo Martinez, North Highland

J. Wayne Meredith, Wake Forest Baptist Medical Center

Michael M. Merzenich, Posit Science Corporation

James B. Peake, CGI Federal

Peter J. Pronovost, Johns Hopkins Medicine

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

Kathleen Sebelius, Sebelius Resources, LLC

Peter Taillac, Utah Department of Health

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the report’s conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Lewis R. Goldfrank, New York University School of Medicine and Bellevue Hospital Center, and Mark R. Cullen, Stanford University. They were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Page xiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

Preface

War is to be avoided. But if it comes, and history says it will, morality and pragmatism converge on an imperative: to protect those sent into harm’s way. Those who serve in the military need and deserve a promise that, should they sustain a traumatic injury, the best care known will come to their assistance to offer them the best chance possible for survival and recovery and, further, that over time, learning and innovation will steadily increase that chance. Under the terms of the Geneva Convention, that same obligation extends to the care of civilian noncombatants who themselves are swept into conflict and injury.

Trauma, of course, is by no means confined to military conflict. In the United States, traumatic injury is a major threat to the health of the public, causing in the aggregate the loss of more years of life than any other source of illness or disability. For every war-related casualty, there are hundreds of trauma patients in civilian life.

The good news is that both the military and civilian sectors have made impressive—arguably remarkable—progress in the care of trauma over the past few decades, with concomitant gains in outcomes. For example, much has been learned and done about timely stabilization and rapid transfer to definitive care, approaches to resuscitation and management of hemorrhage, training and equipage of first responders, and protocols and guidelines for best practices. In military health care, major declines in trauma death rates among injured warriors testify to these advances. The best civilian emergency care systems show similar gains.

This progress has not occurred by chance. Much of the progress in military trauma care is associated with learning processes—lessons gained,

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

captured, and built upon pragmatically—just as contemplated in the description of a “learning health system” in the Institute of Medicine (IOM) report Best Care at Lower Cost.

This committee was convened to study and evaluate progress toward better trauma care and outcomes, especially in the military sector; to understand how that progress relates to elements of a learning health system; to recommend how learning and improvement could be even better; and to understand how both trauma care and learning can best be translated between the military and civilian trauma care systems.

As this report documents, the committee’s efforts revealed both good news and bad: on the one hand, superb trauma care characterized by important innovations with documented better outcomes, but on the other hand, serious limitations in the thoroughness of the diffusion of those gains over time and space, both within the military and between the military and civilian sectors. Even as the successes have saved many lives, the gaps have cost many lives. An especially significant challenge is to maintain readiness for expert trauma care in the military in the periods between wars. The committee found meeting this need to be one of the several reasons to view the military and civilian trauma care systems as, in many ways, the same system—not two systems, or at least much more closely interconnected than has been the case to date.

As the IOM’s learning health system concept emphasizes, progress toward such a system depends strongly on leadership, and this report contains a number of key recommendations for clearer and more consolidated leadership on a national scale to achieve better trauma care. The committee recommends that the United States adopt an overall aim for trauma care of “zero preventable deaths after injury,” and sets forth elements of system redesign that would be needed to achieve that aim.

This committee had the great privilege of extensive cooperation and advice from highly experienced military and civilian trauma care experts, many from the front lines of care. Committee members included such experienced caregivers, as well. For those members, such as me, whose careers have not included providing direct trauma care or serving in the military, this exploration has been a truly humbling experience. The committee read about and saw graphic images of some of the horrific forms of injury that today’s military combatants incur, and became more fully aware of the grave risks that the nation asks its soldiers, sailors, airmen, and marines to face. We heard compelling cases of heroic rescue in which advanced knowledge, teamwork, and modern technology were used to save lives that only a few years ago would surely have been lost. And we heard testimony from clinicians and care system managers whose courage, initiative, imagination, and unwillingness to concede led directly to crucial innovations, sometimes in the face of significant barriers of habit and bureaucracy. These are

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

heroes—both the injured and those who simply will not quit when trying to help them.

This report documents a number of important and badly needed changes in trauma care beginning with leadership toward a common, bold, shared aim. Accomplishing these changes will not be easy. Indeed, this committee is by no means the first group to suggest a number of these changes. Yet too many of the prior calls for consolidated leadership, strong systemic designs, and clear lines of responsibility have not been heeded. It is our hope that, in honor of the military and civilian trauma patients whose lives and function can be saved in the future, this time will be different. As one committee member put it, when it comes to trauma care, where you live ought not to determine if you live. It is time for a national goal owned by the nation’s leaders: zero preventable deaths after injury.

Donald Berwick, Chair

Committee on Military Trauma Care’s Learning Health System and Its Translation to the Civilian Sector

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

This page intentionally left blank.

Page xviii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

2 OVERVIEW OF CONTEMPORARY CIVILIAN AND MILITARY TRAUMA SYSTEMS

Essential Elements of a High-Performing Trauma Care System

System Leadership and Statutory Authority

Trauma System Plan

Creation, Verification, and Assurance of a Sustainable Trauma Care Workforce

Coordinated Injury Prevention Efforts

Prehospital and En Route Care

Definitive Care Facilities

Transfer to Rehabilitation

Trauma Management Information Systems and Quality Improvement Activities

Research

Integration with Disaster Preparedness Programs

The Importance of Inclusive Civilian Trauma Systems

Regional Variability in Trauma Systems Across the United States

Variability in Trauma System Access

Variability in Adoption of Best Trauma Care Practices

Variability in Emergency Medical Services Systems

Overview of the Military’s Trauma Care System

The Development of the Military’s Joint Trauma System

Distribution of Responsibility for Trauma Care in the Military

Variability in Trauma Systems Across the Military

How Military and Civilian Systems Interface for Bidirectional Translation

Training Pipeline and Practice at Military Trauma Centers

Societies and National Meetings

Military–Civilian Leadership-Level Partnerships

Conclusion

References

3 A FRAMEWORK FOR A LEARNING TRAUMA CARE SYSTEM

Characteristics of a Learning Health System

Setting Crisp, Quantifiable Aims

Focusing on the Needs of the Customer

Facilitating the Exchange of Tacit Knowledge

Measuring Team Performance

Applying Multiple Stimulants to Effect Change

Encouraging Experimentation and Improvisation

Regarding Agility as a Value

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page xxii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page xxiv Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

3-1 Learning System Model: Project ECHO

3-2 Learning System Model: 100,000 Homes Campaign

3-3 Learning System Model: Intermountain Healthcare’s Bottom-Up Approach to Clinical Management

3-4 Questions to Determine How Well a System Aligns with the Framework for a Learning Trauma Care System

4-1 The Military’s Focused Empiricism Approach to Learning and Continuous Improvement

4-2 Case Study: Damage Control Resuscitation

4-3 Military Performance Improvement Initiatives Related to Three Complications

4-4 Case Study: Severe Traumatic Brain Injury

4-5 METRC: A Model for a Military–Civilian Research Network

4-6 Overview of Federal Regulations on Human Subjects Protections Governing Research

4-7 Case Study: Use of Ketamine as an Analgesic

4-8 Health Insurance Portability and Accountability Act (HIPAA) Facts

4-9 An Example of Regulatory Barriers to Minimal-Risk Research

4-10 Case Study: Burn

4-11 Clinical Decision Support for Prevention of Venous Thromboembolism (VTE)

5-1 Characteristics of the Military Trauma Care Workforce in the Deployed Setting

5-2 Case Study: Fasciotomy Following Blunt Trauma

6-1 Case Study: Dismounted Complex Blast Injury

6-2 Holistic Care: Examples of Military and Civilian Collaborative Care Models

6-3 Case Study: Pediatric Trauma

6-4 Examples of Patient and Family Engagement Improving System Design

7-1 The Challenge of Culture

7-2 A Quality Program for Emergency Medical Services (EMS): The EMS Performance Improvement Center’s Prehospital Medical Information System

7-3 EMS Compass

7-4 A Pay-for-Participation Model for Trauma Care Quality Improvement

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

7-5 Diffusion of Military Leadership Responsibility for the Delivery of Combat Casualty Care

7-6 359 Lives: Impacts of Secretary Gates’s Golden Hour Policy

7-7 Case Study: Tourniquet Use and the Life-or-Death Decisions of Military Line Leadership

7-8 Examples of Successful White House–Led Military–Civilian Collaboration to Improve Trauma Care

8-1 The Benefits of a National Trauma Care System

A-1 Timeline for Greater Tourniquet Use

A-2 Joint Trauma System Clinical Practice Guidelines Relevant to Blunt Trauma with Vascular Injury

A-3 Joint Trauma System Clinical Practice Guidelines Relevant to Dismounted Complex Blast Injury

A-4 Joint Trauma System Clinical Practice Guidelines Relevant to Severe Traumatic Brain Injury

D-1 Specific Military Trauma System Gaps or Barriers in Data Collection, Distribution, and Use

FIGURES

1-1 Leading causes of death, United States: 2014, ages 1-46 years

1-2 Leading causes of years of potential life lost before age 75, United States, 2014

1-3 Case fatality rates during the Korean War, the Vietnam War, Operation Enduring Freedom, and Operation Iraqi Freedom

1-4 Military preventable deaths in the prehospital setting

1-5 Cumulative percent killed in action (KIA), percent died of wounds (DOW), case fatality rate (CFR), and average military injury severity score (mISS), Operation Enduring Freedom (A) and Operation Iraqi Freedom (B)

1-6 Wounded in action between 2001 and 2015, Operation Enduring Freedom and Operation Iraqi Freedom/Operation New Dawn

2-1 The trauma care chain of survival

2-2 Trauma centers in the United States, 2012

2-3 Lack of access to an appropriate level of trauma care is associated with higher trauma patient mortality

2-4 Variation in risk-adjusted mortality rates across trauma centers

Page xxvi Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

2-5 States with mandatory or model statewide advanced life support protocols, 2013

2-6 Military trauma care continuum

2-7 Organizational structure of the Joint Trauma System Directorate, showing linkages to the DoD’s Joint Trauma Analysis and Prevention of Injuries in Combat (JTAPIC) program, the DoD’s Combat Casualty Care Research program, and the Defense Medical Readiness Training Institute (DMRTI)

2-8 Organization chart for the U.S. Department of Defense’s Military Health System

3-1 How a continuously learning health system works

3-2 Components of a learning trauma care system

4-1 Digital capture of aggregate trauma patient data in multiple military data systems spanning the continuum of care

4-2 Digital capture of aggregate trauma patient data in multiple national-level civilian data systems spanning the continuum of care

4-3 Joint Trauma System operational cycle and links to the U.S. Department of Defense’s Combat Casualty Care Research Program

4-4 Timeline of assessments relevant to civilian trauma research

4-5 Funding sources for military medical research, 2013

4-6 Military medical research investment in trauma care, 2005-2013

4-7 NIH funding for medical conditions relative to their total disease burden

5-1 The trauma care workforce comprises the clinical team as well as a much larger number of support personnel

5-2 The episodic nature of trauma care in the military sector as compared with the civilian sector

5-3 Top 10 inpatient procedures in military treatment facilities, fiscal year 2014

5-4 Training pipeline for military physicians, nurses, and prehospital providers

5-5 Comparison of civilian and military emergency medical technician (EMT) performance on the National Registry assessment

5-6 Utilization of predeployment trauma training courses and programs

Page xxvii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

7-1 The conceptual framework of continuous quality improvement underlying ACS TQIP and other quality collaboratives

8-1 A conceptual model for a national trauma care system

8-2 The Joint Trauma System as a central repository that disseminates information, lessons learned, and best practices to combatant command Joint Theater Trauma Systems, as needed

8-3 Tiered roles and responsibilities for military and civilian stakeholders in a national trauma care system implicit in Recommendations 1-4

A-1 The top figures show left pneumothorax (yellow), lung contusion, and nondisplaced sixth rib fracture (red). The bottom figure shows splenic injury (black); femoral line contrast injection results in beam-hardening artifact from density of contrast in the interior vena cava

A-2 The image on the left shows right humerus fracture and axillary soft tissue injury. The image on the right shows left humerus fracture

A-3 Imaging shows transected right axillary artery

A-4 Cervical spine clearance documentation sheet

A-5 This 3-D CT image with representative axial images shows bilateral lower extremity below-the-knee amputations (incomplete on the right lower extremity) with extensive soft tissue injury with debris, fragments, and lower extremity fractures. Bilateral pneumatic tourniquets at the thigh cause loss of vascular opacification

A-6 Axial CT images demonstrate a soft tissue injury tract along the right groin extending to the perirectal region (yellow) with adjacent surgical packing. Soft tissue gas and pelvic hematoma are found along the tract. Note small amount of air in right hip joint (blue)

A-7 3-D image of the pelvis demonstrates subtle widening and misalignment of the symphysis pubis. There is a displaced fracture of the right sacrum as well as a nondisplaced left sacral alar fracture involving the neuroforamina (arrow). Overlying pelvic binder and surgical packing are present

A-8 Axial (left) and coronal (center) images demonstrate the displaced skull fragments within the brain parenchyma and adjacent hemorrhage. Low attenuation (R>L) is consistent with edema. Adjacent extraparenchymal hemorrhage is present as well. A post-contrast sagittal image (right) demonstrates a defect in the superior sagittal sinus (arrow) consistent with laceration adjacent to the skull defect with displaced fragments

Page xxviii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

A-9 3-D image (left) frontal view shows extension of fracture anteriorly to right orbit. Note metallic hardware from prior jaw surgery at maxilla (arrow). 3-D image cutaway view (center) shows intracranial calvarial fragments and 3-D image looking down (right) shows tangential nature of impact. No intracranial metal fragments were seen

A-10 Post-decompressive craniectomy changes are depicted. Axial CT images left and center demonstrate the skull defect and increased intraparenchymal hematoma (R>>L). Note ventriculostomy catheter (arrow) with adjacent blood in the lateral ventricle. There is also a subdural hematoma along the falx. Coronal image (right) demonstrates similar findings. Numerous calvarial fragments remain

TABLES

S-1 Learning Trauma Care System Components in Military and Civilian Settings

2-1 Description of Trauma Center Levels

3-1 Components of a Continuously Learning Health System

3-2 Characteristics That Distinguish Exceptional, High-Performing Learning Systems

3-3 Components of a Continuously Learning Trauma Care System

4-1 Current Major Trauma-Specific Data Repositories in the United States

4-2 Barriers and Solutions to Linking Prehospital Data to Hospital Data for Research Use

4-3 Examples of Registry-Driven Retrospective and Observational Studies

4-4 Traditional and Alternative Study Designs

4-5 Recommendations on the Need for a Centralized Research Institute to Address Knowledge Gaps in Trauma and Emergency Care

4-6 Examples of High-Priority Trauma Research Needs

4-7 Summary of Mechanisms for Knowledge Dissemination Used in the Military Trauma System

4-8 Civilian Tourniquet Use in 12 U.S. States, 2010-2014

5-1 Five Levels of Clinical Competence

5-2 Military–Civilian Predeployment Training Programs

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

This page intentionally left blank.

Page xxxi Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

Acronyms and Abbreviations

ACEP American College of Emergency Physicians
ACS American College of Surgeons
ACS COT American College of Surgeons Committee on Trauma
AEMT advanced emergency medical technician
AFMES Armed Forces Medical Examiner System
ASD(HA) Assistant Secretary of Defense for Health Affairs
ATLS advanced trauma life support
ATTC Army Trauma Training Center

CCCRP

Combat Casualty Care Research Program

CCFP critical care flight paramedics
CDC Centers for Disease Control and Prevention
CENTCOM U.S. Central Command
CFR case fatality rate
CFR Code of Federal Regulations
CMS Centers for Medicare & Medicaid Services
CoCOM combatant command
CONUS continental United States
CoTCCC Committee on Tactical Combat Casualty Care
CPG clinical practice guideline
CSI Congressional Special Interest
C-STARS Center for the Sustainment of Trauma & Readiness Skills
C-TECC Committee for Tactical Emergency Casualty Care

DALY

disability-adjusted life year

Page xxxii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
DCAS Defense Casualty Analysis System
DCBI dismounted complex blast injury
DCR damage control resuscitation
DHA Defense Health Agency
DHS U.S. Department of Homeland Security
DMRTI Defense Medical Readiness Training Institute
DoD U.S. Department of Defense
DoDTR Department of Defense Trauma Registry
DOT U.S. Department of Transportation
DOW died of wounds

EAST

Eastern Association for the Surgery of Trauma

ECCC Emergency Care Coordination Center
ECHO Extension for Community Healthcare Outcomes
EMR electronic medical record
EMR emergency medical responder
EMS emergency medical services
EMT emergency medical technician
ENA Emergency Nurses Association

FBI

Federal Bureau of Investigation

FDA U.S. Food and Drug Administration
FHP&R Force Health Protection and Readiness
FICEMS Federal Interagency Committee on EMS
FITBIR Federal Interagency Traumatic Brain Injury Research

GAO

U.S. Government Accountability Office

HHS

U.S. Department of Health and Human Services

HIPAA Health Insurance Portability and Accountability Act
HPSP Health Professionals Scholarship Program
HRSA Health Resources and Services Administration

IDF

Israel Defense Forces

IED improvised explosive device
IOM Institute of Medicine
IRB institutional review board

JCIDS

Joint Capabilities Integration and Development System

JTAPIC Joint Trauma Analysis and Prevention of Injury in Combat
JTS Joint Trauma System
JTTS Joint Theater Trauma System
Page xxxiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
KIA killed in action

MASH

mobile army surgical hospital

MEDEVAC medical evacuation
MERcURY Military En Route Care Registry
METRC Major Extremity Trauma Research Consortium
MHS Military Health System
MRMC U.S. Army Medical Research and Materiel Command
MTF military treatment facility

NAEMSP

National Association of EMS Physicians

NAEMT National Association of Emergency Medical Technicians
NASEMSO National Association of State EMS Officials
NEMSIS National EMS Information System
NHTSA National Highway Traffic Safety Administration
NIH National Institutes of Health
NQF National Quality Forum
NRAP National Research Action Plan
NREMT National Registry of Emergency Medical Technicians
NSCOT National Study on the Costs and Outcomes of Trauma
NTDB National Trauma Data Bank
NTDS National Trauma Data Standard
NTI National Trauma Institute
NTTC Navy Trauma Training Center

OEF

Operation Enduring Freedom

OIF Operation Iraqi Freedom

PACOM

U.S. Pacific Command

PCORI Patient-Centered Outcomes Research Institute
PHTR Pre-Hospital Trauma Registry
PTSD posttraumatic stress disorder

ROTC

Reserve Officer Training Corps

RTD returned to duty

SAMMC

San Antonio Military Medical Center

TACEVAC

tactical evacuation

TBI traumatic brain injury
TCAA Trauma Center Association of America
TCCC tactical combat casualty care
TNC trauma nurse coordinator
Page xxxiv Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
TOPIC-M Trauma Outcomes and Performance Improvement Course-Military
TQIP Trauma Quality Improvement Program
TXA tranexamic acid

USAISR

U.S. Army Institute of Surgical Research

USD(P&R) Under Secretary of Defense for Personnel and Readiness
USUHS Uniformed Services University of the Health Sciences

VA

U.S. Department of Veterans Affairs

WIA

wounded in action

YPLL

years of potential life lost

Page xxxv Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

Glossary

Allied health professionals: “The segment of the workforce that delivers services involving the identification, evaluation and prevention of diseases and disorders; dietary and nutrition services; and rehabilitation and health systems management” (ASAHP, 2014).

Benchmarking: “A systematic comparison of structure, process, or outcomes of similar organizations, used to identify the best practices for the purposes of continuous quality improvement” (Nathens et al., 2012, p. 443).

Case fatality rate: The percentage of fatalities among all wounded (Holcomb et al., 2006).

Clinical decision support: Tools and systems that provide “timely information, usually at the point of care, to help inform decisions about a patient’s care. [Clinical decision support] tools and systems help clinical teams by taking over some routine tasks, warning of potential problems, or providing suggestions for the clinical team and patient to consider” (AHRQ, 2015).

Combat support agency: An organizational body charged to provide department-level and tactical support to the joint operating forces of the U.S. military during combat and other military operations (e.g., Defense Health Agency, Defense Logistics Agency, Defense Intelligence Agency).

Page xxxvi Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

Combatant Command: “A unified or specified command with a broad continuing mission under a single commander established and so designated by the President, through the Secretary of Defense and with the advice and assistance of the Chairman of the Joint Chiefs of Staff” (DoD, 2016). There are nine combatant commands, covering both regional (e.g., Central Command, Pacific Command) and functional (e.g., Special Operations Command) areas.

Defense Health Agency: A combat support agency for health and medical operations within the U.S. Department of Defense, the Defense Health Agency is charged with developing strategies to contain costs, improve efficiency, and encourage collaboration and opportunities for joint operations between the three armed services.

Expert trauma care workforce: Each interdisciplinary trauma team at all roles of care includes an expert for every discipline represented. These expert-level providers oversee the care provided by their team members, all of whom must be minimally proficient in trauma care (i.e., appropriately credentialed with current experience caring for trauma patients).

Focused empiricism: An approach to process improvement under circumstances in which: (1) high-quality data are not available to inform clinical practice changes, (2) there is extreme urgency to improve outcomes because of high morbidity and mortality rates, and (3) data collection is possible. A key principle of focused empiricism is using the best data available in combination with experience to develop clinical practice guidelines that, through an iterative process, continue to be refined until high-quality data can be generated to further inform clinical practice and standards of care.

Inclusive trauma care system: “A trauma care system that incorporates every health care facility in a community in a system in order to provide a continuum of services for all injured persons who require care in an acute care facility; in such a system, the injured patient’s needs are matched to the appropriate hospital resources” (NHTSA, 2004).

Injury: “The result of an act that damages, harms, or hurts; unintentional or intentional damage to the body resulting from acute exposure to thermal, mechanical, electrical or chemical energy or from the absence of such essentials as heat or oxygen” (NHTSA, 2004).

Joint Theater Trauma System (JTTS): “A systematic and integrated approach to better organize and coordinate battlefield care to minimize morbidity and mortality and optimize the ability to provide essential care

Page xxxvii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

required for casualty injuries. . . . The components of the JTTS system include prevention, pre-hospital integration, education, leadership and communication, quality improvement/performance improvement, research, and information systems” (Eastridge et al., 2009, p. 853).

Learning health system: “A system in which science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience” (IOM, 2013, p. 136).

National EMS Information System (NEMSIS): NEMSIS seeks to improve prehospital care through the standardization, aggregation, and utilization of point-of-care EMS data at a local, state, and national levels. It is funded and led by the National Highway Traffic Safety Administration and includes several components, among them the National EMS Database.

National EMS Database: A component of NEMSIS, the National EMS Database is the national repository of standardized EMS event records entered at a local level. EMS event information is aggregated at a state level and then transmitted to the National EMS Database to facilitate research and assessment of the nation’s EMS systems.

Operation Enduring Freedom: The official U.S. government name for the War in Afghanistan (October 2001 to December 2014).

Operation Iraqi Freedom: The official U.S. government name for the Iraq War (March 2003 to September 2010).

Patient-centered care: “The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care” (Berwick, 2009, p. 560).

Performance improvement/quality improvement1: “Method for evaluating and improving processes that uses a multidisciplinary approach and that focuses on data, benchmarks, and components of the system being evaluated” (ACS, 2008, p. 45).

Preventable deaths after injury: Those casualties whose lives could have

__________________

1 These terms will be used interchangeably throughout the report.

Page xxxviii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

been saved by appropriate and timely medical care, irrespective of tactical, logistical, or environmental issues.

Readiness: The total military workforce is medically ready to deploy and the military medical force is ready to deliver health care (including combat casualty care) in support of the full range of military operations, domestically and abroad.

Tacit knowledge: Knowledge that is contextual and guided by personal experience, including insights and intuitions that may be difficult to formalize and communicate to others.

Tactical combat casualty care: A framework and set of continuously updated trauma management guidelines that focus on treating life-threatening injuries in the prehospital setting, while taking into account the tactical situation.

Transparency: “Ensuring that complete, timely, and understandable information is available to support wise decisions” (IOM, 2013, p. 142).

Trauma center: “A specialized hospital or facility with the immediate availability of specially trained health care personnel who provide emergency care on a 24-hour–7-day/week basis for injured people” (ACS, 2008).

Trauma patient: A patient who has suffered a serious and potentially disabling or life-threatening injury to one or more parts of the body as a result of an event such as a motor vehicle crash, gun violence, or fall. For the purposes of this report, the term trauma refers only to physical trauma.

Trauma system: “An organized, inclusive approach to facilitating and coordinating a multidisciplinary system response to severely injured patients. A trauma system encompasses a continuum of care provision and is inclusive of injury prevention and control, public health, EMS [emergency medical services] field intervention, ED [emergency department] care, surgical interventions, intensive and general surgical in-hospital care, and rehabilitative services, along with the social services and the support groups that assist injured people and their significant others with their return to society at the most productive level possible.” (ACS, 2008).

Trauma workforce: The multidisciplinary group of professionals responsible for the care of injured patients (e.g., surgeons, emergency physicians, nurses, medics, technicians, anesthesiologists, intensivists, radiologists, rehabilitation specialists) as well as the wide range of professionals who

Page xxxix Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

directly support the clinical mission (e.g., supply, operations, information technology, management, administration, research, education) and those who collect and analyze data for performance improvement and research purposes.

REFERENCES

ACS (American College of Surgeons). 2008. Regional trauma systems: Optimal elements, integration, and assessment, American College of Surgeons Committee on Trauma: Systems consultation guide. Chicago, IL: ACS.

AHRQ (Agency for Healthcare Research and Quality). 2015. Clinical decision support. http://www.ahrq.gov/professionals/prevention-chronic-care/decision/clinical/index.html (accessed May 9, 2016).

ASAHP (Association of Schools of Allied Health Professions). 2014. Who are allied health professionals? http://www.asahp.org/wp-content/uploads/2014/08/Health-Professions-Facts.pdf (accessed February 26, 2016).

Berwick, D. M. 2009. What “patient-centered” should mean: Confessions of an extremist. Health Affairs 28(4):w555-w565.

DoD (U.S. Department of Defense). 2016. Department of Defense dictionary of military and associated terms: Joint publication 1-02. Washington, DC: DoD.

Eastridge, B. J., G. Costanzo, D. Jenkins, M. A. Spott, C. Wade, D. Greydanus, S. Flaherty, J. Rappold, J. Dunne, J. B. Holcomb, and L. H. Blackbourne. 2009. Impact of joint theater trauma system initiatives on battlefield injury outcomes. American Journal of Surgery 198(6):852-857.

Holcomb, J. B., L. G. Stansbury, H. R. Champion, C. Wade, and R. F. Bellamy. 2006. Understanding combat casualty care statistics. Journal of Trauma 60(2):397-401.

IOM (Institute of Medicine). 2013. Best care at lower cost: The path to continuously learning health care in America. Washington, DC: The National Academies Press.

Nathens, A. B., H. G. Cryer, and J. Fildes. 2012. The American College of Surgeons Trauma Quality Improvement Program. Surgical Clinics of North America 92(2):441-454.

NHTSA (National Highway Traffic Safety Administration). 2004. Trauma system agenda for the future. Washington, DC: NHTSA.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×

This page intentionally left blank.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R1
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R2
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R3
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R4
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R5
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R6
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R7
Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R8
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R9
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R10
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R11
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R12
Page xiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R13
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R14
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R15
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R16
Page xvii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R17
Page xviii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R18
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R19
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R20
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R21
Page xxii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R22
Page xxiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R23
Page xxiv Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R24
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R25
Page xxvi Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R26
Page xxvii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R27
Page xxviii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R28
Page xxix Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R29
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R30
Page xxxi Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R31
Page xxxii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R32
Page xxxiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R33
Page xxxiv Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R34
Page xxxv Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R35
Page xxxvi Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R36
Page xxxvii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R37
Page xxxviii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R38
Page xxxix Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R39
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page R40
Next: Abstract »
A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury Get This Book
×
Buy Paperback | $75.00 Buy Ebook | $59.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

Advances in trauma care have accelerated over the past decade, spurred by the significant burden of injury from the wars in Afghanistan and Iraq. Between 2005 and 2013, the case fatality rate for United States service members injured in Afghanistan decreased by nearly 50 percent, despite an increase in the severity of injury among U.S. troops during the same period of time. But as the war in Afghanistan ends, knowledge and advances in trauma care developed by the Department of Defense (DoD) over the past decade from experiences in Afghanistan and Iraq may be lost. This would have implications for the quality of trauma care both within the DoD and in the civilian setting, where adoption of military advances in trauma care has become increasingly common and necessary to improve the response to multiple civilian casualty events.

Intentional steps to codify and harvest the lessons learned within the military’s trauma system are needed to ensure a ready military medical force for future combat and to prevent death from survivable injuries in both military and civilian systems. This will require partnership across military and civilian sectors and a sustained commitment from trauma system leaders at all levels to assure that the necessary knowledge and tools are not lost.

A National Trauma Care System defines the components of a learning health system necessary to enable continued improvement in trauma care in both the civilian and the military sectors. This report provides recommendations to ensure that lessons learned over the past decade from the military’s experiences in Afghanistan and Iraq are sustained and built upon for future combat operations and translated into the U.S. civilian system.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!