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
THE NATIONAL ACADEMIES PRESS
Washington, DC
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.
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.
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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
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
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
Dedication
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
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?”
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
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.
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,
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
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
Contents
PART I: INTRODUCTION, OVERVIEW, AND FRAMEWORK
Background and Rationale for this Study
The Societal Burden of Traumatic Injury
The Importance of Readiness to Deliver High-Quality Trauma Care
A Brief But Critical Window of Opportunity
A Vision for Optimal Trauma Care
Charge to the Committee and Study Scope
2 OVERVIEW OF CONTEMPORARY CIVILIAN AND MILITARY TRAUMA SYSTEMS
Essential Elements of a High-Performing Trauma Care System
System Leadership and Statutory Authority
Creation, Verification, and Assurance of a Sustainable Trauma Care Workforce
Coordinated Injury Prevention Efforts
Trauma Management Information Systems and Quality Improvement Activities
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
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
Applying Multiple Stimulants to Effect Change
Instituting Distributed System Management
A Framework for a Learning Trauma Care System
Digital Capture of the Trauma Patient Care Experience
Processes and Tools for Timely Dissemination of Trauma Knowledge
Systems for Ensuring an Expert Trauma Care Workforce
Leadership-Instilled Culture of Learning
Transparency and Aligned Incentives for Quality Trauma Care
Aligned Authority and Accountability for Trauma System Leadership
4 GENERATING AND APPLYING KNOWLEDGE TO IMPROVE TRAUMA OUTCOMES
Digital Capture of the Trauma Patient Care Experience
Digital Capture of Military Trauma Data
Digital Capture of Civilian Trauma Data
Barriers to Data Sharing Within and Between Military and Civilian Data Systems
Barriers to Timely Generation of Evidence to Inform Best Trauma Care Practices
Processes and Tools for Timely Dissemination of Trauma Knowledge
Clinical Decision Support Tools
Senior Visiting Surgeon Program
5 CREATING AND SUSTAINING AN EXPERT TRAUMA CARE WORKFORCE
The Military Health System Readiness Mission
The Civilian Trauma Care Workforce
The Military Trauma Care Workforce
Challenges to Ensuring an Expert Military Trauma Care Workforce
Trauma Workload and Environment
Competing Roles for Military Medical Providers
Recruitment and Retention in the Absence of Career Paths for Trauma Providers
Current Military Approaches to Achieving a Ready Medical Force
The Medical Education and Training Pipeline
Predeployment Training and Combat-Relevant Trauma Courses
Limitations of Current Medical Readiness Approaches
Lack of Standardized and Validated Training Modalities
Reliance on Just-in-Time and On-the-Job Training
Variability in Readiness of the Reserves and National Guard
Gaps in Leadership Education, Awareness, and Accountability
Summary of Findings and Conclusions
6 DELIVERING PATIENT-CENTERED TRAUMA CARE
Trauma Care Structured Around the Patient Experience
Seamless Transitions Across the Continuum of Care
A Holistic Focus on Patients’ Needs
Supporting the Needs of Special Populations
Engaging Patients, Families, and Communities
7 LEVERAGING LEADERSHIP AND FOSTERING A CULTURE OF LEARNING
Fostering a Culture of Learning
Demonstrating a Commitment to Transparency
Benchmarking Across the Military and Civilian Systems
Public Reporting of Performance Data
Promoting and Rewarding High-Quality Trauma Care
Military–Civilian Leadership Partnerships
Summary of Findings and Conclusions
8 A VISION FOR A NATIONAL TRAUMA CARE SYSTEM
The Need for Coordinated Military and Civilian Trauma Care Systems
A Vision for a National Trauma Care System
Demonstrating System Effectiveness
An Integrated Military–Civilian Framework for Learning to Advance Trauma Care
A Framework for Transparency of Trauma Data
Processes and Tools for Disseminating Trauma Knowledge
A Collaborative Military–Civilian Research Infrastructure in a Supportive Regulatory Environment
Systems and Incentives for Improving Transparency and Trauma Care Quality
Platforms to Create and Sustain an Expert Trauma Care Workforce
Boxes, Figures, and Tables
BOXES
1-1 Advances in Trauma System Organization During the Korean and Vietnam Eras
1-2 Tourniquets: Military Lessons Lost
1-3 Defining Preventable Deaths After Injury
1-4 Combat Casualty Care Statistics
1-7 Previous Reports on Prevention, Rehabilitation, and Mental Health
2-1 Strong State Legislation Enables a Coordinated, Regionalized Approach to Trauma Care in Maryland
2-2 Civilian Trauma System Stakeholders at the Federal Level
2-3 Implementation of Best Trauma System Practices in Pennsylvania
2-4 San Antonio as a Regional Learning Collaborative
2-5 Agreements Formalized in the Charter of the MHS/ACS Strategic Partnership
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
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
4-11 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
7-4 A Pay-for-Participation Model for Trauma Care Quality Improvement
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
1-4 Military preventable deaths in the prehospital setting
2-1 The trauma care chain of survival
2-2 Trauma centers in the United States, 2012
2-4 Variation in risk-adjusted mortality rates across trauma centers
2-5 States with mandatory or model statewide advanced life support protocols, 2013
2-6 Military trauma care continuum
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
4-4 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
5-2 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
5-6 Utilization of predeployment trauma training courses and programs
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
4-6 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
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 |
| 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 |
| 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 |
| 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 |
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).
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
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
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1 These terms will be used interchangeably throughout the report.
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
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.
