and Civilian Trauma
Systems to Achieve
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
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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
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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.
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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
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
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
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?”
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.
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
Boxes, Figures, and Tables
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)
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)
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-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
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
|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|
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|
|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|
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|
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|
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|
U.S. Government Accountability Office
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|
Israel Defense Forces
|IED||improvised explosive device|
|IOM||Institute of Medicine|
|IRB||institutional review board|
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|
mobile army surgical hospital
|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|
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|
Operation Enduring Freedom
|OIF||Operation Iraqi Freedom|
U.S. Pacific Command
|PCORI||Patient-Centered Outcomes Research Institute|
|PHTR||Pre-Hospital Trauma Registry|
|PTSD||posttraumatic stress disorder|
Reserve Officer Training Corps
|RTD||returned to duty|
San Antonio Military Medical Center
|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|
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|
U.S. Department of Veterans Affairs
wounded in action
years of potential life lost
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
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.
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.
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