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Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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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6 Delivering Patient-Centered Trauma Care

Responding to patients’ needs and delivering optimal outcomes along the continuum of care demands a central focus on the patient. Patient-centered care—defined as “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)—has long been recognized as a core aim of a health care system; however, patient-centered care is far from the norm (Berwick, 2009; IOM, 2001, 2013a). For providers, a system’s structure, incentives, and culture commonly are insufficiently aligned to support patient-centered care. Too often, patients face uncoordinated care and difficulties in navigating health care systems. Patients, families, and communities are afforded only limited opportunities to engage in and shape their own care or to help in the design and functioning of a learning health system (IOM, 2013a). These challenges are especially acute in the trauma setting, which is typically seen as a crisis environment characterized by loss of control and helplessness for patients and their support networks (Hasse, 2013).

Even though trauma care is highly complex, particularly on the battlefield, patient-centeredness is an essential component of a learning trauma care system. Only a trauma care system structured around the patient experience, one that considers and actively engages the patient, family, and community, can achieve optimal short- and long-term outcomes for injured patients. This chapter analyzes the extent to which military and civilian trauma systems have adopted a patient-centered approach, identifying gaps and opportunities to improve.

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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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TRAUMA CARE STRUCTURED AROUND THE PATIENT EXPERIENCE

Trauma care structured around the patient experience encompasses seamless care across the continuum of care, a holistic focus on patients’ needs, and proactive consideration of the needs of special populations. Each of these aspects is discussed in the sections below.

Seamless Transitions Across the Continuum of Care

As discussed in Chapter 2, a patient’s journey from point of injury to rehabilitation and community reentry1 is complex, involving numerous providers and multiple transitions between care settings. Transition points pose the greatest risk in terms of degradation in quality of care (e.g., treatment interruption, handoff errors) (IOM, 2013a). With insufficient attention to patient centeredness, these transitions can be abrupt and disorganized, with too little communication among providers, the patients, and their family members at different levels of care.

In the early years of the wars in Afghanistan and Iraq, the military’s continuum of care was particularly fragmented, with limited communication among the various roles of care (the roles of care are described in Chapter 2). In the absence of effective information management systems, military providers would use a variety of improvised communication strategies, such as writing clinical information on patients’ dressings (Eastridge et al., 2006). Gaps in communication were attributed to a multitude of factors, including the fast operational tempo, immature theater infrastructure, high casualty load, and limited prehospital data collection (DHB, 2015; Eastridge et al., 2006; Rotondo et al., 2011).

As the wars progressed, communication and the overall functioning of the care continuum improved in efficiency and efficacy, facilitated in the later years by the efforts of the Joint Trauma System (JTS). The JTS established weekly patient management video teleconferences so that medical providers at all levels could review and discuss patients’ treatments and outcomes in real time as they moved along the evacuation chain (Blackbourne et al., 2012; Pruitt and Rasmussen, 2014). This served not only as a performance improvement mechanism, but also afforded care providers at receiving treatment facilities a deeper understanding of earlier patient management strategies. Over time, casualty evacuations improved substantially in both speed and capability, driven by the recognition that patient outcomes could be improved by reducing time to definitive care

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1 Community reentry refers to reintegration into one’s previous lifestyle—returning to work and resuming former leisure activities, for example (Richmond and Aitken, 2011).

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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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and providing earlier advanced care. Median prehospital evacuation times2 in Afghanistan were reduced from 90 to 43 minutes after a 2009 mandate for prehospital helicopter evacuation in 60 minutes or less (Kotwal et al., 2016). Further, adopting civilian air ambulance standards—staffing medical evacuation (MEDEVAC) helicopters with critical care-trained flight paramedics—was shown to reduce the risk of mortality by 66 percent as compared to standard MEDEVAC practices where helicopters are staffed by emergency medical technicians certified at the emergency medical technician (EMT)-Basic level (Mabry et al., 2012).

Despite progress over the course of the wars in Afghanistan and Iraq, opportunities remain to further improve communication and the coordination of care. Multiple assessments conducted by the military have noted persistent barriers to effective communication and seamless care transitions (DHB, 2015; Rotondo et al., 2011). In the absence of a common communication portal and knowledge of currently deployed medical providers, clinicians cannot communicate consistently with one another. The Defense Health Board has emphasized that communication is particularly limited among the services, an alarming reality given that the management and execution of casualty evacuation is a joint operation (DHB, 2015). On the battlefield, the flow of information is predominantly unidirectional up to the JTS; there is far less transmission of important clinical information and advances in care to front-line providers (Rotondo et al., 2011). The use of data-sharing technologies and telemedicine to improve communication among prehospital and hospital-based providers in both military and civilian sectors is discussed in Chapter 4.

In both military and civilian settings, seamless transition to rehabilitation is arguably the weakest link in the trauma continuum of care (Eastman et al., 2013). Although rehabilitation is often thought of as a phase of care that begins following completion of the acute medical and surgical interventions, initiating rehabilitation during the acute care phase is essential to optimize recovery from both physical impairments (e.g., prevention of secondary complications associated with immobility) and psychosocial consequences (e.g., building confidence, independence, and motivation) (Ficke et al., 2012). During recent conflicts in Afghanistan and Iraq, more attention has been paid to early and comprehensive rehabilitation. Examples of efforts to expand the military trauma system to incorporate multidisciplinary, state-of-the-art rehabilitation are the advanced rehabilitation programs located at the three military treatment facilities that treat a large proportion of the most severe combat casualties: the Center for the Intrepid in San Antonio, Texas; the Military Advanced Training Center at

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2 In this context, evacuation times were defined as time elapsed from initial call to arrival at the treatment facility (Kotwal et al., 2016).

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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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Walter Reed National Military Medical Center in Bethesda, Maryland; and the Comprehensive Combat and Complex Casualty Care (C5) program at Naval Medical Center San Diego in California. These three centers employ interdisciplinary teams, innovative technologies, and a sports medicine model to deliver holistic and patient-centered care. The use of a sports medicine model represents a paradigm shift in the military’s approach to rehabilitative care, expanding well beyond restoring basic functionality to pushing patients to the limits of possibility with the goal of returning them to duty and as active participants in society. The Advanced Rehabilitation Centers participate in research, coordinate with the Uniformed Services University of the Health Sciences (USUHS) and the U.S. Department of Veterans Affairs (VA), and leverage public and private partnerships to provide and advance state-of-the-art care.

The VA Polytrauma/TBI System of Care (PSC) provides an integrated continuum of rehabilitation services to address the physical and mental health needs of veterans and service members with impairments resulting from polytrauma and traumatic brain injury. The PSC coordinates and delivers care at a variety of sites across the United States, linking specialized rehabilitation services provided at regional referral centers, network sites, and VA facilities (VA, 2016b).

Although the military learned over time to build capacity and capability for effective transition support, the policies and infrastructure needed to deliver such support were slow in coming and challenges persist in the transition of ongoing care from the military to the VA and in the capacity within the military to meet the needs of all injured service members, especially with regards to behavioral health and well-being (GAO, 2012). Care coordination and case management programs that assist recovering service members and their caregivers and families by facilitating access to care, services, and benefits (e.g., service-specific wounded warrior programs) were strengthened following the highly publicized exposure of deficiencies at Walter Reed Army Medical Center in 2007 (GAO, 2012). In 2009, the U.S. Department of Defense (DoD) sought to improve quality of care and transition of recovering service members by establishing uniform guidelines, procedures, and standards for Recovery Coordination Programs, management of which was assigned to the Service Wounded Warrior Program commanders (DoD, 2009). Similarly, a Federal Recovery Coordination Program, jointly developed by DoD and VA, assists with interdepartmental coordination and continuity of rehabilitative care for service members who are unlikely to return to duty and veterans, in part by establishing a federal recovery coordinator as a single point of contact for DoD and VA case managers, as well as patients and their families (GAO, 2012). Although an evaluation of these and other DoD and VA rehabilitation support programs

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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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is beyond the scope of this report,3 the committee emphasizes that, as with acute trauma care advances, there is great need and opportunity for military lessons learned and best practices related to rehabilitative care to be translated to the civilian sector.

It must be acknowledged, however, that application of military lessons learned on seamless transition to rehabilitation is constrained by significant differences in health care delivery between military and civilian sectors. Unlike the civilian sector, where health care is largely privatized, the military offers service members universal health care through the Military Health System. This affects care in two major ways. First, DoD can establish policy requiring the services to offer programs that smooth the transition to rehabilitation. In the civilian sector, the burden of managing the overwhelming process of transitioning to one of the many different types of rehabilitation facilities4 or appropriate outpatient services most often falls to patients, their families, and their health care providers. Second, access to rehabilitative care for wounded service members is not limited by insurance coverage. In the civilian sector, however, lack of access to high-quality rehabilitative care for uninsured and underinsured individuals has been associated with poorer long-term outcomes for trauma patients (Davidson et al., 2011; Mackersie, 2014). As a result, even optimal acute care delivered in the prehospital setting and at the trauma center may be undermined by lack of effective rehabilitative care and support after discharge.

Despite these challenges, some programs to facilitate more seamless transitions to rehabilitation have been developed in the civilian sector. Multidisciplinary discharge rounds5 represent a promising practice by which the transition to rehabilitation can be enhanced for trauma patients. At Baltimore Shock Trauma, the implementation of multidisciplinary discharge rounds was associated with a 15 percent decrease in length of stay, which likely contributed to a 36 percent increase in patient volume and a dramatic reduction in the number of instances the trauma center went on bypass status (i.e., was not able to accept admissions), revealing other benefits of greater care coordination beyond those that may be experienced by the patient (Dutton et al., 2003). Further, a growing body of research funded by the National Institutes of Health (NIH) shows that a transitional

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3 Evaluations of DoD and VA rehabilitation programs can be found in recent GAO (2012) and Institute of Medicine reports (2013b).

4 Upon trauma patient discharge from the acute care hospital, post-acute care settings may include inpatient rehabilitation facilities, skilled nursing facilities, outpatient facilities, or the patient’s home (e.g., home health agencies).

5 Multidisciplinary teams—consisting of the trauma physician, “an orthopedic surgeon, the hospital bed manager, the unit’s discharge planner, the unit nursing staff, and physical, occupational, and speech therapists”—review the patient’s plan of care (Dutton et al., 2003, p. 913).

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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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care model6 in which an advanced practice nurse assumes responsibility for managing the flow between phases of care within a clinical team enhances the transition out of acute care, reduces readmissions, and increases cost savings in patients with chronic illnesses and complex treatment regimens (Coleman et al., 2006; Naylor et al., 1994, 1999, 2004). This model highlights an opportunity to reduce fragmentation across the phases of trauma care if applied to injured patients as they transition from acute care to rehabilitation (Richmond, 2016). Despite the demonstrated success of such strategies, implementation of these kinds of programs to ensure a seamless transition to rehabilitation is nowhere near universal.

A Holistic Focus on Patients’ Needs

In the deployed setting, the driving aim of military medicine is to save lives. Indeed, trauma care providers in both military and civilian settings have made extraordinary progress in reducing mortality among severely injured patients. The record number of soldiers with triple limb amputations in the latter years of the wars in Afghanistan and Iraq attests to the increased capacity of medical providers to keep wounded warriors alive despite the severity of their injuries (DCBI Task Force, 2011). However, patients, families, and medical providers all acknowledge that a focus on survival alone is insufficient; functional recovery, quality of life, and reintegration into society are important outcomes (Richmond and Aitken, 2011).

The scope of trauma’s impact is vast. Its immediate physical and psychosocial effects influence a patient’s functional outcomes and quality of life for years to come. In a civilian study of long-term outcomes among patients who had experienced a prolonged stay in the surgical intensive care unit, only 55 percent of patients contacted at follow-up had achieved maximum function 3 years after sustaining a severe injury (Livingston et al., 2009). In another analysis, trauma patients reported limitations in mobility (48 percent), daily activities (55 percent), and self-care (18 percent), as well as pain (63 percent) and cognitive complaints (65 percent) (Holtslag et al., 2007). Trauma patients who have been hospitalized for serious injuries are at high risk for posttraumatic stress disorder (PTSD) and other mental health disorders like depression (O’Donnell et al., 2010). The National Study on the Costs and Outcomes of Trauma found that 20.7 percent of patients with an injury scoring 3 or higher on the Abbreviated Injury Scale screened positive for PTSD 1 year after injury and 6.6 percent had symptoms consistent with depression (Zatzick et al., 2008). These findings are echoed in the military sector (Grieger et al., 2006; Hoge et al., 2006; Milliken et

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6 In this model, an advanced practice nurse assumes responsibility for discharge planning and follow-up care (Naylor and Keating, 2008).

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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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al., 2007) and incidence rates may be higher in certain subpopulations of wounded warriors such as amputees and survivors with traumatic brain injuries and severe genitourinary injuries. For example, nearly 66 percent of combat amputees have received one or more behavioral health diagnoses (Melcer et al., 2010).

To achieve maximum recovery and reintegration, survivors of severe injuries will require significant rehabilitative care and psychosocial support focused on healing the whole person—physical, emotional, cognitive and spiritual aspects—including survivor support networks (families, loved ones, and other care providers). The findings and recommendations of the Army Dismounted Complex Blast Injury (DCBI) Task Force concerning DCBI and its associated physical and psychosocial consequences exemplify how the military has taken a holistic approach to addressing the needs of wounded warriors (see Box 6-1). The task force specifies four areas of focus for all battle injuries: “(1) comprehensive pain management at the [point of injury], (2) complex behavioral health challenges facing . . . warriors and their families, (3) the incorporation of a rehabilitation mindset and philosophy throughout the spectrum of care, and (4) spiritual considerations for long-term care and rehabilitation” (DCBI Task Force, 2011, p. E-1). Currently, the JTS lacks access to long-term outcome data, including functional recovery and quality-of-life indicators. To assess the effectiveness of a holistic approach to care, a systematic process for collecting information on patient-reported quality-of-life outcomes is needed.

Psychosocial Support

The behavioral health impacts of traumatic injury are particularly insidious because of the wide-ranging effects of psychosocial disorders on survivors’ functional outcomes and long-term quality of life. Zatzick et al. (2008) showed that symptoms consistent with a diagnosis of depression or PTSD were associated with impairments in physical function, activities of daily living, and return to work 12 months after injury (Zatzick et al., 2008). Consequently, effective mental health screening and early intervention are important secondary prevention strategies to mitigate the development of such disorders and their downstream effects.7 Since onset of PTSD, depression, and other psychological disorders may occur months after injury (Grieger et al., 2006), it is important to continue providing proactive support and monitoring for symptoms throughout the post-acute care period.

A holistic approach to the care of trauma survivors means integrating supportive behavioral health efforts with the treatment and restoration of

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7 A comprehensive evaluation of screening tools and treatment options for PTSD and other mental health sequelae of traumatic injury is beyond the scope of this report.

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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:"6 Delivering Patient-Centered Trauma Care." 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.
×

physical functions in trauma management. The military learned the importance of embedding behavioral health specialists as integral members of treatment teams during acute (definitive) and post-acute care to assist patients and their loved ones with the psychological recovery from injury (Ficke et al., 2012; Gajewski and Granville, 2006). Civilian-sector research on the associated benefits has shown promising results. A recent clinical trial showed that patients receiving a stepped care intervention—care management, psychopharmacology, and cognitive behavioral psychotherapy as needed—from a trauma center-based mental health team during inpatient and outpatient care had significantly reduced PTSD symptoms and improvements in physical function over the course of the 1-year study period as compared to controls who received standard care (Zatzick et al., 2013). Similar collaborative care approaches that link trauma survivors to evidence-based behavioral health services have been implemented in military and civilian trauma centers (see Box 6-2). The integration of behavioral health care as a standard component of treatment for severe injury may help to break down barriers to care associated with stigma concerns (Hoge et al., 2006).

In addition to integrating professional behavioral health specialists into clinical trauma teams, peer support programs are used in both military and civilian sectors, particularly for amputees (Gajewski and Granville, 2006; Marzen-Groller and Bartman, 2005). Such programs have been shown to encourage an optimistic future outlook, decrease the sense of isolation, and promote coping abilities and self-management (Marzen-Groller and Bartman, 2005; May et al., 1979). The military uses peer visitors trained through the Amputee Coalition of America (Gajewski and Granville, 2006). These peer visitors, amputees themselves, augment the support provided by a patient’s family. Often, peer visitors serve as role models for patients, and can provide a unique firsthand account of the rehabilitation process and offer practical suggestions for managing the difficulties associated with an amputation. These peer visitors consistently receive the highest satisfaction rating from patients attending the Amputee Clinic at the Walter Reed Army Medical Center in Bethesda, Maryland (Pasquina et al., 2008).

Peer support can also be obtained remotely. For example, the Trauma Survivors Network is an online network through which trauma patients and families connect with one another and obtain advice, support, and information needed to advance the rehabilitation and recovery process. Developed by the American Trauma Society, a leading trauma advocacy organization, the Network provides resources and programs requested by patients and their families (TSN, 2016a).

White House–led efforts to address the needs of military service members and veterans related to mental health, traumatic brain injury, and substance abuse have led to significant investments in research and a pro-

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

liferation of programs to facilitate access to services (Weinick et al., 2011). However, the committee found little evaluation of such programs targeted specifically to survivors of traumatic injury beyond TBI patients. Further focus on optimal methods for providing holistic care and improving behavioral health outcomes in wounded warriors more broadly is warranted given the higher risk of behavioral health disorders in this population. Such investigations would also have relevance to the civilian sector where the burden of trauma is significantly higher.

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

Pain Management

A key aspect of care that needs to be structured around the patient experience is pain control, beginning in the prehospital environment and continuing through evacuation, definitive care, and post-acute care (Ficke et al., 2012). Thus, effective pain management necessitates coordination of all medical providers throughout the patient transport system (JTS, 2013b). Early delivery of pain medication not only relieves suffering but also is associated with a reduced risk of PTSD in both military and civilian settings (Bryant et al., 2009; Holbrook et al., 2010; McGhee et al., 2008). Pain management therefore is an important secondary prevention strategy in the context of mitigating mental health sequelae of physical trauma. However, attention must also be paid to the substance abuse risks associated with pain medication (e.g., opioids). The military has observed an association between prescription drug misuse and the rising number of prescriptions written for chronic pain management among service members wounded during the wars in Afghanistan and Iraq (IOM, 2013c). Nonphysician prehospital providers and physicians alike need to be educated on the risks of opioid medications related to substance abuse and the value of a multimodal approach for increasing the effectiveness of pain management medications while reducing adverse effects (e.g., hypotension) and the risk of narcotic dependence (JTS, 2013b). The challenges associated with pain medication misuse are not limited to the military. Opioid abuse has risen to epidemic proportions in the United States, prompting action from the White House to address the rising incidence of substance abuse disorders and overdose-related deaths (White House, 2016).

The military has made significant advances in the care of acute pain, including the development of JTS and tactical combat casualty care (TCCC) pain management guidelines and the use of oral transmucosal fentanyl8 (fentanyl lollipops) to deliver rapid pain control on the battlefield (DCBI Task Force, 2011). In 2009, the Army Surgeon General chartered the Army Pain Management Task Force to develop recommendations for a comprehensive pain management strategy that applies principles of holistic and multimodal care, employs state of the art science and technology, and synchronizes pain management efforts and approaches across DoD and the VA in order to optimize quality of life for service members suffering from acute and chronic pain (DoD, 2010). One initiative that emerged from the Task Force report is an adaption of the Project Extension for Community Healthcare Outcomes (ECHO) model (discussed in Box 3-1) to better fa-

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8 Oral transmucosal fentanyl provides pain relief more quickly than morphine. Oral delivery also eliminates the need to obtain intravenous access on the battlefield. At this time, however, only Special Operations Forces medics are equipped with this medication, limiting its use throughout the military (DCBI Task Force, 2011).

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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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cilitate a team approach to complex pain management. In September 2015, the Defense Health Agency initiated a formal collaboration with Project ECHO, building on the success of an Army pilot program (Army Pain ECHO) focused on pain management (Katzman and Olivas, 2016).

Yet despite these efforts, pain associated with traumatic injury remains a significant challenge, particularly in the prehospital setting. In an evaluation of a convenience sample of 309 casualties evacuated to Role 2 or Role 3 facilities in Afghanistan from October 2012 to March 2013, less than 40 percent of the casualties received pain medication at the point of injury9 (Shackelford et al., 2015). Recent initiatives aimed at tracking pain levels upon soldiers’ entry to Role 2 and 3 military treatment facilities (MTFs) have found that 71 percent experience pain at a level of 5 or greater on a scale of 0-10. Pain control is one of 10 major areas of emphasis within DoD’s Combat Casualty Care Research Program (MRMC, 2016). The Defense and Veterans Center for Integrative Pain Management, located within the Uniformed Services University of the Health Sciences, was established in 2003 to improve pain management in military and civilian sectors through research and policy (DVCIPM, 2016).

Supporting the Needs of Special Populations

A focus on the patient requires consideration of the subpopulations of patients that a trauma system may be expected to serve, including pediatric patients, the elderly, women, and vulnerable populations.

Pediatric Patients

Tragically, children are frequently killed and injured in wartime. The Geneva Convention dictates that host national casualties receive adequate medical care.10 DoD doctrine further stipulates that the “commitment of resources should be decided first based on the mission and immediate tactical situation and then by medical necessity, irrespective of the casualty’s national or combatant status” (Cubano et al., 2013, p. 30). Thus, pediatric care is a critical aspect of the military medical mission and needs to be planned for and resourced as such.

Throughout Operation Enduring Freedom and Operation Iraqi Freedom, U.S. military medical personnel cared for thousands of injured host national children (Matos et al., 2008). From 2001 to 2011, children ac-

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9 This figure may represent an underestimate caused by incomplete documentation of care delivered at the point of injury (Shackelford et al., 2015).

10 Geneva Convention I and II, Article 12; Geneva Convention III, Article 13; Geneva Convention IV, Article 27; Additional Protocol I, 1977, Articles 9, 10, and 11.

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

counted for 5.8 percent of admissions and 11 percent of bed days11 in combat support hospitals (Borgman et al., 2012). These data show that pediatric trauma care represents an important and unavoidable component of the military’s medical mission. While the provision of pediatric care fulfills a number of ethical obligations, in some instances it can also support the military’s combat mission. In one anecdote shared with the committee, an Iraqi sheik provided U.S. personnel with information that led directly to the capture of numerous insurgents after a military physician provided care for that sheik’s child (Burnett et al., 2008).

Despite the foreseeable need to provide pediatric care in the battlefield environment, the military was largely unprepared for the realities of its pediatric mission at the start of the wars in Afghanistan and Iraq. Hospitals across the two countries lacked the personnel, equipment, and training required to support the effective delivery of pediatric care (Matos et al., 2008). These gaps were highlighted in testimony presented to the committee, with military nurses strongly asserting a lack of preparation for the challenges of pediatric care (Bridges, 2016). Pediatric support for in-theater hospitals has seen improvement, including the development of a pediatric critical care teleconsultation service and the addition of pediatric information to clinical practice guidelines, but numerous challenges to providing advanced care for pediatric patients in the deployed setting remain (Borgman et al., 2012; Burnett et al., 2008). For example, although pediatric supply kits were developed to augment combat support hospital resources, the kits had to be requested by hospital commanders, who may not have known that such resources were available (Cubano et al., 2013).

The military’s recent operations reconfirm a lesson learned repeatedly throughout the history of warfare: the injury and death of children is an inevitable consequence of battle. Throughout Operation Enduring Freedom and Operation Iraqi Freedom, pediatric casualties often were more severely injured than their adult counterparts, remained in the hospital longer, and required significant unanticipated logistical supplies and resources (Borgman et al., 2012). While the military has adapted to the challenge of pediatric trauma care (see Box 6-3), additional improvements are necessary, particularly in the use of pediatric specialists and the predeployment training of clinical teams (Borgman et al., 2012). Pediatricians may be deployed to fill slots at MTFs in theater, but there currently are no specific requirements for placement of pediatricians at combat support hospitals. Numerous reports and surveys of deployed surgeons reaffirm the need for greater pediatric training and preparation. It is important that these lessons not be lost by medical planners and policy makers during preparation for future operations.

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11 The percentage of bed days reflects a provider’s workload.

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

As discussed in Chapter 1, in the civilian sector, trauma is the most common single cause of mortality and morbidity among individuals under age 46. In 2014, approximately 10,000 children and adolescents died as a result of traumatic injury (NCIPC, 2015a). More than 7.8 million were treated in emergency departments (NCIPC, 2015b), of which 166,000 were hospitalized (NCIPC, 2015c). Several factors are known to affect the occurrence of childhood injuries, including age, sex, behavior, and environment. Relative to their female counterparts, male children younger than 18 have higher rates of injury (Borse et al., 2008), a finding thought to reflect greater risk-taking behavior and exposure to contact sports (Fabricant et al., 2013; Sorenson, 2011). Among infants and toddlers, falls are a common mechanism of injury, while bicycle- and motor vehicle-related injuries become more common as pediatric patients age (NCIPC, 2015e). While blunt injuries represent the majority of traumatic presentations among pediatric

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

patients, penetrating injuries account for 10-20 percent of pediatric admissions (Cotton and Nance, 2004). Like older-adult patients (discussed below), pediatric patients often have limited physiological reserves and tend to be at increased risk for poor outcomes after injury.

Facilities specifically designed to manage pediatric trauma can better meet the unique health needs of younger patients, including providing access to age- and physiologically appropriate postdischarge care. In many states, there are special designations for pediatric hospitals that do not treat adults and Level I trauma centers that do not treat pediatric patients (ATS, 2016; Potoka et al., 2000). Proximal facilities work collectively with emergency medical services (EMS) agencies and the trauma system to ensure that injured children are transported to and treated at pediatric trauma centers. In Pennsylvania, for example, the University of Pittsburgh Medical Center–Presbyterian has an affiliation with the Children’s Hospital

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

of Pittsburgh (University of Pittsburgh, 2016). Recently, a pediatric trauma quality improvement program (TQIP) was launched by the American College of Surgeons and made available to Level I and II trauma centers to support benchmarking and quality improvement activities specific to this patient population (ACS, 2016).

Despite the prominence of pediatric trauma and efforts to promote readier access to specialized pediatric care, very limited research is currently available on pediatric trauma and the unique care preferences and needs of pediatric trauma patients (Upperman et al., 2010). Understandings of adult trauma may not be applicable to younger injured patients. Therefore, creating patient-centered approaches appropriate to younger trauma patients will require developing interventions and quality improvement measures relevant to this population.

The Elderly

Among the increasing number of adults older than 64 within the U.S. population, trauma represents a leading and growing cause of death and disability, often associated with a loss of independence (Rhee et al., 2014). In 2014, more than 4.3 million nonfatal injuries occurred among adults over the age of 65 (NCIPC, 2015d). The risk of traumatic injury increases with age as people experience pronounced changes in the sensory apparatus, cognition, and strength (Perdue et al., 1998). Following injury, older adults have higher rates of complications and mortality relative to younger trauma patients (Champion et al., 1989). Declining physiological reserves limit these patients’ ability to survive minor injuries and alter their trajectories for postinjury recovery (CDC, 2012; Champion et al., 1989). A higher prevalence of preexisting comorbid conditions also complicates clinical presentations and outcomes for these patients (CDC, 2012). Traumatic brain injury (Thompson et al., 2006) and hip fracture (MacKenzie et al., 2006) are two of the most common and debilitating injuries occurring among older adults, and are associated with long-term functional impairment, nursing home admission, decreased independence, and shortened life expectancy (Hall et al., 2000; Magaziner et al., 2000; Thompson et al., 2006; Wolinsky et al., 1997). In one study following a specific population of women, one-fifth of hip-fracture patients died within 1 year (Farahmand et al., 2005). A separate analysis found that one-third of those who lived independently before their injury remain in a nursing home for at least 1 year (Zafar et al., 2015).

In light of the burden of geriatric trauma, minimal information is available on where and how older adults should be managed for traumatic injuries. Although there is some evidence to suggest that injured persons over the age of 65 should lower the threshold for field triage directly to a

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

trauma center (Calland et al., 2012), several studies have shown that the older patient is much less likely to get to a Level I/II center compared to a younger patient with similar injuries (Chang et al., 2008; Nakamura et al., 2012). The reasons for this apparent undertriage of the elderly trauma patient are not well understood but could be related to the inadequacy of current triage criteria, an implicit bias against the benefits of trauma center care for the elderly, and in some cases, a preference on the part of the older patient for treatment at the hospital with which they are most familiar, regardless of its status as a trauma center. At the same time, there is controversy as to how elderly patients can benefit from care at a Level I hospital and how aggressively to manage the severely compromised elderly trauma patient. In the absence of data, the Eastern Association for the Surgery of Trauma (EAST) guideline for the evaluation and management of geriatric trauma concludes that patients should “receive care at centers that have devoted specific resources to attaining excellence in the care of the injured using similar criteria to those used in younger patients” (Calland et al., 2012, p. S348).

Also unknown is how patient preferences within this population can and should be incorporated in treatment decisions, especially when it involves end-of-life decisions (Lilley et al., 2016). Better understanding is needed of what older trauma patients want from their care in terms of location, continuity, and resources in order to ensure that the care they receive aligns with both what they want and with what they need physiologically.

Women

There is a dearth of research with which to understand the gender-specific predictors of trauma outcomes and posttraumatic recovery in women (Sethuraman et al., 2014). Differences in outcomes according to biological sex have been reported (Magnotti et al., 2008; Wohltmann et al., 2001; Yang et al., 2014), but the mechanisms and factors underlying these associations are poorly understood.

Currently, a lack of understanding of women’s unique health care needs hinders the delivery of patient-centered, evidence-based care for women with traumatic injuries. In the United States, 7 percent of women experience traumatic injuries during pregnancy; moreover, traumatic injuries are the most common cause of nonobstetric death among pregnant women (Barraco et al., 2010). Women also are more likely than men to experience intimate partner violence and PTSD, and less likely to seek care following trauma (Tolin and Foa, 2006). Biological sex-based and socially constructed gender-based differences are known to affect health care utilization patterns, health care outcomes, and access to postdischarge care (Sethuraman et al., 2014). Scientifically rigorous research is needed to address sex- and

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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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gender-based differences in trauma and trauma care needed among female patients, and to produce evidence that can be used to provide care that accounts for these differences.

Vulnerable Populations

Numerous studies have pointed to differential health outcomes in vulnerable populations, such as racial and ethnic minorities and patients who are uninsured. Data suggest, for example, that non-Hispanic black versus non-Hispanic white patients and uninsured versus commercially or publicly insured patients sustain higher risk-adjusted rates of mortality after injury (Haider et al., 2008, 2013b). Insured black patients are nearly 20 percent more likely to die after severe injury than equivalently injured insured white patients, and injured uninsured white patients are nearly 50 percent more likely to die than similarly injured white insured patients (Haider et al., 2008). Minority patients use more emergency services relative to white patients, and uninsured, urban, and nonwhite patients experience particularly high rates of traumatic injury, especially penetrating injuries (Haider et al., 2008). These groups have special health needs, and their care needs to be culturally dexterous and patient-centered if it is to achieve the best possible outcomes. Variations in hospital-level factors (Zafar et al., 2015, 2016) and a myriad of interrelated patient-, provider- and, systems-level characteristics (Haider et al., 2013a) have been associated with differential outcomes experienced by vulnerable groups of patients. Despite widespread recognition of these disparities, however, little is known about the patient perspective of these groups, how such factors affect the experiences of patients sustaining a traumatic injury, or what can be done to address these special needs in meaningful ways.

Vulnerable populations in many instances also suffer lack of access to trauma care, even in America’s largest cites. For example, the south side of Chicago, which is currently suffering from an epidemic of violence and intentional injury, has not had a trauma center since the last one closed due to financial difficulties nearly two decades ago, earning it the label “trauma desert” (Crandall et al., 2013). After suffering a traumatic injury such as a gunshot wound, patients injured in that part of the city need to be transported several miles in city traffic to reach the nearest trauma center. The resultant delays in access to care have been associated with increased mortality. Crandall et al. (2013) demonstrated a 23 percent increase in the odds of death for patients in Chicago who suffered a gunshot wound and had to be transported more than 5 miles.

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

ENGAGING PATIENTS, FAMILIES, AND COMMUNITIES

Patient-centered care for trauma, as for all conditions, requires proactive engagement of patients, families, and communities in care, system design, and trauma research.

Engagement in Care

To continuously improve and to deliver better patient outcomes, a trauma system needs to reflect understanding of the needs and wants of injured patients. True patient-centered care engages patients and their families in both clinical decision making and the design of care processes. In such a model, patients and providers work together, making care decisions that take into account a patient’s preferences, life circumstances, and values, as well as the best available scientific evidence (IOM, 2013a).

Given the nature of trauma, patients often lack the physical and mental capacity to engage in shared decision making at the time of injury; as a result, decisions may be made with little to no patient input (Willis et al., 2013). In the military, for example, one report documents soldiers developing “do not resuscitate” pacts with their fellow service members in the event of a particularly damaging traumatic injury (DCBI Task Force, 2011). That soldiers felt driven to make these unofficial arrangements suggests that the military’s trauma system and its providers neither sufficiently understood nor adequately took into account the preferences of those it served. In civilian hospitals, residents spend on average only 2.7 minutes with a surgical patient during morning rounds, with teams inviting questions from patients only 7.7 percent of the time (Gupta, 2013). When consulted on their hospital experience, patients emphasize the “lack of time with residents, fragmentation of care among teams, poor communication with patients/family members, lack of appropriate explanations of the care plan, and the need for better patient-centered care among hospital staff” (Gupta, 2013).

Nurses often are particular champions of patient-centered approaches to the care of trauma survivors, helping to ensure the alignment of clinical decisions with patient values and preferences (Hasse, 2013). In the intense trauma setting, a critical role for all providers but one that is especially well suited to nurses is helping patients and their families understand what is happening in a timely manner so that critical clinical decisions can be made. This may include explanation of medical jargon, purposes of tests, treatment options, and what to expect during treatment (Hasse, 2013). Educating patients and their families about the patient’s injury and its associated effects (e.g., clinical, financial, social) prior to the transition to rehabilitation also helps address the patient’s holistic needs and optimize recovery. This mindset needs to permeate all actors and processes within

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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 trauma care system, particularly in light of evidence that interventions provided in the prehospital and hospital settings influence a patient’s long-term outcomes and quality of life.

There are ample opportunities, even with trauma, to engage patients and families in care decisions. Examples include documenting patients’ preferences in the primary care setting (in the military, prior to deployment), consulting and involving families in the event of a traumatic injury, and working with patients and their caregivers during the transition to rehabilitation. Involvement of families and caregivers is a particularly important component of patient-centered trauma care that enhances a patient’s motivation to recover, encourages independence, and fosters family support (DCBI Task Force, 2011). Family involvement also bolsters communication, understanding, and shared decision making; family-centered rounds, for example, which incorporate patients and their caregivers into the care team, improve the bidirectional exchange of information between families and providers (Davidson et al., 2007; Mangram et al., 2005; Williams, 2005).

Engagement in System Design

Patient-centered trauma care is not limited to patient–provider interactions; it also extends to patient, family, and community engagement at the organizational and system levels. Having experienced trauma care firsthand, patients, families, and other caregivers possess unique and invaluable perspectives on the design and care delivery of trauma systems. A learning trauma care system leverages these insights to improve the system’s design and care processes, and ultimately, patient outcomes (see Box 6-4). The involvement of patients, families, and communities as advocates for improvement initiatives will help ensure that the patient remains the focus of such efforts and that patients’ feedback and values guide system design (IOM, 2013a).

One strategy for promoting patient engagement is the use of patient and family advisory councils. These councils offer patients and families opportunities to engage directly with an organization’s decision-making structures. Through involvement with such councils, patients and families can participate in performance improvement initiatives, help reform service delivery practices, participate in the selection of new executives, and assist in the development of educational programs for care providers. Patient and family advisory councils can also advise a hospital on how to improve the efficiency and patient-centeredness of its operations. Participation on patient rounds, for example, may generate new suggestions and ideas for improvement (Balik et al., 2011; Johnson et al., 2008; Ponte et al., 2003). A number of patient and family advisory councils have been established in civilian trauma centers (Willis et al., 2013) and VA hospitals (VA, 2016a,c).

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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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In one example, a patient and family advisory council established at York Hospital in York, Pennsylvania (a Level I trauma center), identified and completed four improvement projects: (1) the revision of an informational handbook for trauma patients and their families, (2) the use of whiteboards to inform patients and families about the patient’s daily care plan and identify members of the clinical team, (3) improved communication techniques for nonverbal (e.g., intubated) patients, and (4) an exploration of the impact of PTSD on trauma patients (Willis et al., 2013). At this time, however, the use of these councils in military treatment facilities and civilian trauma centers remains limited.

Another approach for engaging patients, families, and communities is transparent measurement, in which the system commits to gathering and responding to outcome and experience measures provided by patients and families. The collection and use of these measures (assessed in Chapter 7)

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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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not only support quality improvement activities but also demonstrate to patients and families that their experiences and opinions matter.

Engagement in Trauma Research

Within a learning trauma care system, research generates new knowledge and drives innovative advances in care. Trauma research is enhanced when its design and execution are patient centered. Everyone is at risk of trauma. Thus there is an imperative for all members of the public to participate in processes that work to improve trauma care. In this context, patient and other stakeholder involvement is helpful in prioritizing research topics and outcome measures.

Patient-centered outcomes research, as defined by the Patient-Centered Outcomes Research Institute (PCORI), “is the evaluation of questions and outcomes meaningful and important to patients and caregivers” (Frank et al., 2014, p. 1513). Information derived from the engagement of patients, families, and caregivers in the design of clinical research is predicted to increase the relevance of the research to their health decisions. By addressing those clinical questions most important to these stakeholders, PCORI aims to advance the uptake of this information and its use to improve patient outcomes (Frank et al., 2014). While still evolving, evidence demonstrates a variety of positive results emerging from such engagement in research, including not only enhanced relevance of research results to patients but also improved study recruitment and retention rates, and increased validity of outcome measures (Brett et al., 2014; Cashman et al., 2008; Edwards et al., 2011). PCORI is currently funding a 3-year study on trauma in the civilian sector—A Comparative Effectiveness Trial of Optimal Patient-Centered Care for U.S. Trauma Care Systems (PCORI, 2016).

The type of patient–researcher partnership encouraged by PCORI, whereby investigators and patients identify clinical questions together is not inconsistent with the more traditional approach to research funded by other federal entities, including the National Institutes of Health and DoD (Greenberg et al., 2014). In the past decade, for example, institutional review boards for many of the proposed DoD research studies involving trauma methods and practices included patient advocates and/or former patients.

SUMMARY OF FINDINGS AND CONCLUSIONS

CONCLUSION: A patient-centered approach to trauma care is necessary to achieve optimal immediate-, near-, and long-term outcomes for trauma patients. Thus, it is essential for military and civilian trauma systems to

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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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proactively maximize patient, family, and community engagement and continue to refine the delivery of trauma care so that patients’ holistic needs are supported seamlessly across the continuum of care.

Related findings:

  • In both the military and civilian sectors, patient care across the trauma continuum of care is fragmented, particularly during the latter stages in which a patient is transitioning from hospital-based care to rehabilitation and recovery.
  • Opportunities exist to improve patient, family, and community engagement in trauma care delivery, trauma system design and improvement processes, and trauma research.

REFERENCES

ACS (American College of Surgeons). 2016. Pediatric Trauma Quality Improvement Program. https://www.facs.org/quality-programs/trauma/tqip/pediatric-tqip (accessed May 20, 2016).

ATS (American Trauma Society). 2016. Trauma center levels explained. http://www.amtrauma.org/?page=traumalevels (accessed April 22, 2016).

Balik, B., J. Conway, L. Zipperer, and J. Watson. 2011. Achieving an exceptional patient and family experience of inpatient hospital care. Cambridge, MA: Institute for Healthcare Improvement.

Barraco, R. D., W. C. Chiu, T. V. Clancy, J. J. Como, J. B. Ebert, L. W. Hess, W. S. Hoff, M. R. Holevar, J. G. Quirk, B. J. Simon, and P. M. Weiss. 2010. Practice management guidelines for the diagnosis and management of injury in the pregnant patient: The EAST Practice Management Guidelines Work Group. Journal of Trauma 69(1):211-214.

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

Blackbourne, L. H., D. G. Baer, B. J. Eastridge, F. K. Butler, J. C. Wenke, R. G. Hale, R. S. Kotwal, L. R. Brosch, V. S. Bebarta, M. M. Knudson, J. R. Ficke, D. Jenkins, and J. B. Holcomb. 2012. Military medical revolution: Military trauma system. Journal of the American Academy of Orthopaedic Surgeons 73(6 Suppl. 5):S388-S394.

Borgman, M. A., R. I. Matos, L. Blackbourne, and P. C. Spinella. 2012. Ten years of military pediatric care in Afghanistan and Iraq. Journal of the American Academy of Orthopaedic Surgeons 73(6 Suppl. 5):S509-S513.

Borgman, M. A., R. I. Matos, and P. C. Spinella. 2015. Isolated pediatric burn injury in Iraq and Afghanistan. Pediatric Critical Care Medicine 16(2):e23-e27.

Borse, N. N., J. Gilchrist, A. M. Dellinger, R. A. Rudd, M. F. Ballesteros, and D. A. Sleet. 2008. CDC childhood injury report: Patterns of unintentional child injuries among 0-19 year olds in the United States, 2000-2006. Atlanta, GA: CDC.

Brett, J., S. Staniszewska, C. Mockford, S. Herron-Marx, J. Hughes, C. Tysall, and R. Suleman. 2014. A systematic review of the impact of patient and public involvement on service users, researchers and communities. Patient 7(4):387-395.

Bridges, E. 2016. Nursing in the context of a learning trauma care system. Paper presented to the Committee on Military Trauma Care’s Learning Health System and Its Translation to the Civilian Sector, January 15, Washington, DC.

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

Bryant, R. A., M. Creamer, M. O’Donnell, D. Silove, and A. C. McFarlane. 2009. A study of the protective function of acute morphine administration on subsequent posttraumatic stress disorder. Biological Psychiatry 65(5):438-440.

Burnett, M. W., P. C. Spinella, K. S. Azarow, and C. W. Callahan. 2008. Pediatric care as part of the US Army medical mission in the Global War on Terrorism in Afghanistan and Iraq, December 2001 to December 2004. Pediatrics 121(2):261-265.

Calland, J. F., A. M. Ingraham, N. Martin, G. T. Marshall, C. I. Schulman, T. Stapleton, and R. D. Barraco. 2012. Evaluation and management of geriatric trauma: An Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery 73(5):S345-S350.

Cashman, S. B., S. Adeky, A. J. Allen, 3rd, J. Corburn, B. A. Israel, J. Montano, A. Rafelito, S. D. Rhodes, S. Swanston, N. Wallerstein, and E. Eng. 2008. The power and the promise: Working with communities to analyze data, interpret findings, and get to outcomes. American Journal of Public Health 98(8):1407-1417.

CDC (U.S. Centers for Disease Control and Prevention). 2012. Guidelines for field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2011. Morbidity and Mortality Weekly Report 61(1):1-20.

Champion, H. R., W. S. Copes, D. Buyer, M. E. Flanagan, L. Bain, and W. J. Sacco. 1989. Major trauma in geriatric patients. American Journal of Public Health 79(9):1278-1282.

Chang, D. C., R. R. Bass, E. E. Cornwell, and E. J. MacKenzie. 2008. Undertriage of elderly trauma patients to state-designated trauma centers. Archives of Surgery 143(8):776-781.

Coleman, E. A., C. Parry, S. Chalmers, and S. J. Min. 2006. The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine 166(17): 1822-1828.

Cotton, B. A., and M. L. Nance. 2004. Penetrating trauma in children. Seminars in Pediatric Surgery 13(2):87-97.

Crandall, M., D. Sharp, E. Unger, D. Straus, K. Brasel, R. Hsia, and T. Esposito. 2013. Trauma deserts: Distance from a trauma center, transport times, and mortality from gunshot wounds in Chicago. American Journal of Public Health 103(6):1103-1109.

Cubano, M. A., M. K. Lenhart, J. A. Bailey, G. P. Costanzo, B. J. Eastridge, J. R. Ficke, C. M. Hults, and Z. T. Stockinger, editors. 2013. Emergency war surgery (4th ed.). Fort Sam Houston, TX: Office of the Surgeon General, Borden Institute.

Davidson, G. H., C. A. Hamlat, F. P. Rivara, T. D. Kopesell, G. J. Jurkovich, and S. Arbabi. 2011. Long-term survival of adult trauma patients. Journal of the American Medical Association 305(10):1001-1007.

Davidson, J. E., K. Powers, K. M. Hedayat, M. Tieszen, A. A. Kon, E. Shepard, V. Spuhler, I. D. Todres, M. Levy, J. Barr, R. Ghandi, G. Hirsch, and D. Armstrong. 2007. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. Critical Care Medicine 35(2):605-622.

DCBI (Dismounted Complex Blast Injury) Task Force. 2011. Dismounted Complex Blast Injury. San Antonio, TX: Fort Sam Houston, Office of the Surgeon General.

DHB (Defense Health Board). 2015. Combat trauma lessons learned from military operations of 2001-2013. Falls Church, VA: DHB.

DoD (U.S. Department of Defense). 2009. Department of Defense instruction 1300.24—Recovery Coordination Program. Washington, DC: DoD.

DoD. 2010. Pain Management Task Force report: Providing a standardized DoD and VHA vision and approach to pain management to optimize the care for warriors and their families. Washington, DC: DoD.

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

Dutton, R. P., C. Cooper, A. Jones, S. Leone, M. E. Kramer, and T. M. Scalea. 2003. Daily multidisciplinary rounds shorten length of stay for trauma patients. Journal of Trauma 55(5):913-919.

DVCIPM (Defense & Veterans Center for Integrative Pain Management). 2016. Home. http://www.dvcipm.org (accessed April 22, 2016).

Eastman, A. B., E. J. MacKenzie, and A. B. Nathens. 2013. Sustaining a coordinated, regional approach to trauma and emergency care is critical to patient health care needs. Health Affairs 32(12):2091-2098.

Eastridge, B. J., D. Jenkins, S. Flaherty, H. Schiller, and J. B. Holcomb. 2006. Trauma system development in a theater of war: Experiences from Operation Iraqi Freedom and Operation Enduring Freedom. Journal of Trauma 61(6):1366-1372.

Edwards, V., K. Wyatt, S. Logan, and N. Britten. 2011. Consulting parents about the design of a randomized controlled trial of osteopathy for children with cerebral palsy. Health Expectations 14(4):429-438.

Fabricant, P. D., A. Robles, T. Downey-Zayas, H. T. Do, R. G. Marx, R. F. Widmann, and D. W. Green. 2013. Development and validation of a pediatric sports activity rating scale: The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS). American Journal of Sports Medicine 41(10):2421-2429.

Farahmand, B. Y., K. Michaelsson, A. Ahlbom, S. Ljunghall, and J. A. Baron. 2005. Survival after hip fracture. Osteoporosis International 16(12):1583-1590.

Ficke, J. R., B. J. Eastridge, F. K. Butler, J. Alvarez, T. Brown, P. Pasquina, P. Stoneman, and J. Caravalho. 2012. Dismounted complex blast injury report of the Army Dismounted Complex Blast Injury Task Force. Journal of Trauma and Acute Care Surgery 73(6 Suppl. 5):S520-S534.

Frank, L., E. Basch, J. V. Selby, and Patient-Centered Outcomes Research Institute. 2014. The PCORI perspective on patient-centered outcomes research. Journal of the American Medical Association 312(15):1513-1514.

Fuenfer, M. M., P. C. Spinella, A. L. Naclerio, and K. M. Creamer. 2009. The U.S. military wartime pediatric trauma mission: How surgeons and pediatricians are adapting the system to address the need. Military Medicine 174(9):887-891.

Gajewski, D., and R. Granville. 2006. The United States Armed Forces Amputee Patient Care Program. Journal of the American Academy of Orthopaedic Surgeons 14(10 Spec. No.):S183-S187.

GAO (U.S. Government Accountability Office). 2012. Recovering servicemembers and veterans: Sustained leadership attention and systematic oversight needed to resolve persistant problems affecting care and benefits. Washington, DC: GAO.

Greenberg, C., G. J. Chang, and H. Nelson. 2014. Patient-centered outcomes research: Is this really something new? http://bulletin.facs.org/2014/01/patient-centered-outcomes-research-is-this-really-something-new (accessed February 1, 2016).

Grieger, T. A., S. J. Cozza, R. J. Ursano, C. Hoge, P. E. Martinez, C. C. Engel, and H. J. Wain. 2006. Posttraumatic stress disorder and depression in battle-injured soldiers. American Journal of Psychiatry 163(10):1777-1783.

Gupta, M. 2013. Patient feedback makes us better surgeons. http://bulletin.facs.org/2013/11/patient-feedback-makes-us-better-surgeons (accessed February 2, 2016).

Haider, A. H., D. C. Chang, D. T. Efron, E. R. Haut, M. Crandall, and E. E. Cornwell, 3rd. 2008. Race and insurance status as risk factors for trauma mortality. Archives of Surgery 143(10):945-949.

Haider, A. H., V. K. Scott, K. A. Rehman, C. Velopulos, J. M. Bentley, E. E. Cornwell, 3rd, and W. Al-Refaie. 2013a. Racial disparities in surgical care and outcomes in the United States: A comprehensive review of patient, provider, and systemic factors. Journal of the American College of Surgeons 216(3):482-492.

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

Haider, A. H., P. L. Weygandt, J. M. Bentley, M. F. Monn, K. A. Rehman, B. L. Zarzaur, M. L. Crandall, E. E. Cornwell, and L. A. Cooper. 2013b. Disparities in trauma care and outcomes in the United States: A systematic review and meta-analysis. Journal of the American Academy of Orthopaedic Surgeons 74(5):1195-1205.

Hall, S. E., J. A. Williams, J. A. Senior, P. R. Goldswain, and R. A. Criddle. 2000. Hip fracture outcomes: Quality of life and functional status in older adults living in the community. Australian and New Zealand Journal of Medicine 30(3):327-332.

Hasse, G. L. 2013. Patient-centered care in the adult trauma intensive care unit. Journal of Trauma Nursing 20(3):163-165.

Hoge, C. W., J. L. Auchterlonie, and C. S. Milliken. 2006. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association 295(9):1023-1032.

Holbrook, T. L., M. R. Galarneau, J. L. Dye, K. Quinn, and A. L. Dougherty. 2010. Morphine use after combat injury in Iraq and post-traumatic stress disorder. New England Journal of Medicine 362(2):110-117.

Holtslag, H. R., E. F. van Beeck, E. Lindeman, and L. P. Leenen. 2007. Determinants of long-term functional consequences after major trauma. Journal of Trauma 62(4):919-927.

IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

IOM. 2013a. Best care at lower cost: The path to continuously learning health care in America. Washington, DC: The National Academies Press.

IOM. 2013b. Returning home from Iraq and Afghanistan: Readjustment needs of veterans, service members, and their families. Washington, DC: The National Academies Press.

IOM. 2013c. Substance use disorders in the U.S. armed forces. Washington, DC: The National Academies Press.

IOM. 2014. Treatment of posttraumatic stress disorder in military and veteran populations: Final assessment. Washington, DC: The National Academies Press.

Johnson, B., M. Abraham, J. Conway, L. Simmons, S. Edgman-Levitan, P. Sodomka, J. Schlucter, and D. Ford. 2008. Partnering with patients and families to design a patient- and family-centered health care system: Recommendations and promising practices. Bethesda, MD: Institute for Family-Centered Care.

JTS (Joint Trauma System). 2013a. Clinical practice guideline: Burn care. San Antonio, TX: JTS.

JTS. 2013b. Clinical practice guideline: Management of pain, anxiety, and delirium. San Antonio, TX: JTS.

Katzman, J., and C. Olivas. 2016. U.S. Department of Defense. http://echo.unm.edu/initiatives/armed-services (accessed April 22, 2016).

Kotwal, R. S., J. T. Howard, J. A. Orman, B. W. Tarpey, J. A. Bailey, H. R. Champion, R. L. Mabry, J. B. Holcomb, and K. R. Gross. 2016. The effect of a golden hour policy on the morbidity and mortality of combat casualties. JAMA Surgery 151(1):15-24.

Lilley, E. J., K. J. Williams, E. B. Schneider, K. Hammouda, A. Salim, A. H. Haider, and Z. Cooper. 2016. Intensity of treatment, end-of-life care, and mortality for older patients with severe traumatic brain injury. Journal of Trauma and Acute Care Surgery 80(6):998-1004.

Livingston, D. H., T. Tripp, C. Biggs, and R. F. Lavery. 2009. A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit. Journal of Trauma 67(2):341-348.

Mabry, R. L., A. Apodaca, J. Penrod, J. A. Orman, R. T. Gerhardt, and W. C. Dorlac. 2012. Impact of critical care-trained flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan. Journal of the American Academy of Orthopaedic Surgeons 73(2 Suppl. 1):S32-S37.

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

MacKenzie, E. J., F. P. Rivara, G. J. Jurkovich, A. B. Nathens, K. P. Frey, B. L. Egleston, D. S. Salkever, and D. O. Scharfstein. 2006. A national evaluation of the effect of trauma-center care on mortality. New England Journal of Medicine 354(4):366-378.

Mackersie, R. C. 2014. For the care of the underserved. Journal of Trauma and Acute Care Surgery 77(5):653-659.

Magaziner, J., W. Hawkes, J. R. Hebel, S. I. Zimmerman, K.M. Fox, M. Dolan, G. Felsenthal., and J. Kenzora. 2000. Recovery from hip fracture in eight areas of function. Journals of Gerontology Series A: Biological Sciences and Medical Sciences 55(9):M498-M507.

Magnotti, L. J., P. E. Fischer, B. L. Zarzaur, T. C. Fabian, and M. A. Croce. 2008. Impact of gender on outcomes after blunt injury: A definitive analysis of more than 36,000 trauma patients. Journal of the American College of Surgeons 206(5):984-992.

Mangram, A. J., T. McCauley, D. Villarreal, J. Berne, D. Howard, A. Dolly, and S. Norwood. 2005. Families’ perception of the value of timed daily “family rounds” in a trauma ICU. The American Surgeon 71(10):886-891.

Marzen-Groller, K., and K. Bartman. 2005. Building a successful support group for post-amputation patients. Journal of Vascular Nursing 23(2):42-45.

Matos, R. I., J. B. Holcomb, C. Callahan, and P. C. Spinella. 2008. Increased mortality rates of young children with traumatic injuries at a US Army combat support hospital in Baghdad, Iraq, 2004. Pediatrics 122(5):e959-e966.

May, C. H., M. C. McPhee, and D. J. Pritchard. 1979. An amputee visitor program as an adjunct to rehabilitation of the lower limb amputee. Mayo Clinic Proceedings 54(12):774-778.

McGhee, L. L., C. V. Maani, T. H. Garza, K. M. Gaylord, and I. H. Black. 2008. The correlation between ketamine and posttraumatic stress disorder in burned service members. Journal of Trauma 64(Suppl. 2):S195-S198.

Melcer, T., G. J. Walker, M. Galarneau, B. Belnap, and P. Konoske. 2010. Midterm health and personnel outcomes of recent combat amputees. Military Medicine 173(3):147-154.

Milliken, C. S., J. L. Auchterlonie, and C. W. Hoge. 2007. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. Journal of the American Medical Association 298(18):2141-2148.

MRMC (U.S. Army Medical Research and Materiel Command). 2016. Combat Casualty Care Research Program (CCCRP). http://mrmc.amedd.army.mil/index.cfm?pageid=medical_r_and_d.ccc.overview (accessed February 2, 2016).

Nakamura, Y., M. Daya, E. M. Bulger, M. Schreiber, R. Mackersie, R. Y. Hsia, N. C. Mann, J. F. Holmes, K. Staudenmayer, Z. Sturges, M. Liao, J. Haukoos, N. Kuppermann, E. D. Barton, C. D. Newgard, and WESTRN Investigators. 2012. Evaluating age in the field triage of injured persons. Annals of Emergency Medicine 60(3):335-345.

Naylor, M., and S. A. Keating. 2008. Transitional care: Moving patients from one care setting to another. American Journal of Nursing 108(Suppl. 9):58-63.

Naylor, M., D. Brooten, R. Jones, R. Lavizzo-Mourey, M. Mezey, and M. Pauly. 1994. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Annals of Internal Medicine 120(12):999-1006.

Naylor, M. D., D. Brooten, R. Campbell, B. S. Jacobsen, M. D. Mezey, M. V. Pauly, and J. S. Schwartz. 1999. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. Journal of the American Medical Association 281(7):613-620.

Naylor, M. D., D. A. Brooten, R. L. Campbell, G. Maislin, K. M. McCauley, and J. S. Schwartz. 2004. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society 52(5):675-684.

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

NCIPC (National Center for Injury Prevention and Control). 2015a. WISQARS fatal injury reports: 2014, United States, all injury deaths and rates per 100,000, all races, both sexes, ages 0 to 18. http://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html (accessed April 28, 2016).

NCIPC. 2015b. WISQARS overall all injury causes nonfatal injury and rates per 100,000, 2014, United States, all races, both sexes, ages 0 to 18, disposition: All cases. http://webappa.cdc.gov/sasweb/ncipc/nfirates2001.html (accessed April 28, 2016).

NCIPC. 2015c. WISQARS overall all injury causes nonfatal injury and rates per 100,000, 2014, United States, all races, both sexes, ages 0 to 18, disposition: Hospitalized. http://webappa.cdc.gov/sasweb/ncipc/nfirates2001.html (accessed April 28, 2016).

NCIPC. 2015d. WISQARS overall all injury causes nonfatal injuries and rates per 100,000, 2014, United States, all races, both sexes, ages 65 to 85+, disposition: All cases. http://webappa.cdc.gov/sasweb/ncipc/nfirates2001.html (accessed April 28, 2016).

NCIPC. 2015e. WISQARS 10 leading causes of nonfatal injury, United States, 2014, all races, both sexes, disposition: All cases. http://webappa.cdc.gov/sasweb/ncipc/nfilead2001.html (accessed April 28, 2016).

O’Donnell, M. L., M. Creamer, A. Holmes, S. Ellen, A. C. McFarlane, R. Judson, D. Silove, and R. A. Bryant. 2010. Posttraumatic stress disorder after injury: Does admission to intensive care unit increase risk? Journal of Trauma 69(3):627-632.

Parkland. 2016. Trauma care coordination. http://www.parklandhospital.com/phhs/traumacare-coordination.aspx (accessed February 25, 2016).

Pasquina, P. F., J. W. Tsao, D. M. Collins, B. L. Chan, A. Charrow, A. M. Karmarkar, and R. A. Cooper. 2008. Quality of medical care provided to service members with combat-related limb amputations: Report of patient satisfaction. Journal of Rehabilitation Research and Development 45(7):953-960.

PCORI (Patient-Centered Outcomes Research Institute). 2016. A comparative effectiveness trial of optimal patient-centered care for US trauma care systems. http://www.pcori.org/research-results/2013/comparative-effectiveness-trial-optimal-patient-centered-care-ustrauma-care (accessed February 1, 2016).

Perdue, P. W., D. D. Watts, C. R. Kaufmann, and A. L. Trask. 1998. Differences in mortality between elderly and younger adult trauma patients: Geriatric status increases risk of delayed death. Journal of Trauma 45(4):805-810.

Ponte, P. R., G. Conlin, J. B. Conway, S. Grant, C. Medeiros, J. Nies, L. Shulman, P. Branowicki, and K. Conley. 2003. Making patient-centered care come alive: Achieving full integration of the patient’s perspective. Journal of Nursing Administration 33(2):82-90.

Potoka, D. A., L. C. Schall, M. J. Gardner, P. W. Stafford, A. B. Peitzman, and H. R. Ford. 2000. Impact of pediatric trauma centers on mortality in a statewide system. Journal of Trauma 49(2):237-245.

Pruitt, B. A., Jr., and T. E. Rasmussen. 2014. Vietnam (1972) to Afghanistan (2014): The state of military trauma care and research, past to present. Journal of the American Academy of Orthopaedic Surgeons 77(3 Suppl. 2):S57-S65.

Rhee, P., B. Joseph, V. Pandit, H. Aziz, G. Vercruysse, N. Kulvatunyou, and R. S. Friese. 2014. Increasing trauma deaths in the United States. Annals of Surgery 260(1):13-21.

Richmond, T. 2016. Nursing in the context of a learning trauma care system. Paper presented to the Committee on Military Trauma Care’s Learning Health System and Its Translation to the Civilian Sector, January 15, Washington, DC.

Richmond, T. S., and L. M. Aitken. 2011. A model to advance nursing science in trauma practice and injury outcomes research. Journal of Advanced Nursing 67(12):2741-2753.

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

Rotondo, M., T. Scalea, A. Rizzo, K. Martin, and J. Bailey. 2011. The United States military Joint Trauma System assessment: A report commissioned by the U.S. Central Command Surgeon, sponsored by Air Force Central Command, a strategic document to provide a platform for tactical development. Washington, DC: DoD.

Sethuraman, K. N., E. G. Marcolini, M. McCunn, B. Hansoti, F. E. Vaca, and L. M. Napolitano. 2014. Gender-specific issues in traumatic injury and resuscitation: Consensus-based recommendations for future research. Academic Emergency Medicine 21(12):1386-1394.

Shackelford, S. A., M. Fowler, K. Schultz, A. Summers, S. M. Galvagno, K. R. Gross, R. L. Mabry, J. A. Bailey, R. S. Kotwal, F. K. Butler. 2015. Prehospital pain medication use by U.S. Forces in Afghanistan. Military Medicine 180(3):304-309.

Sorenson, S. B. 2011. Gender disparities in injury mortality: Consistent, persistent, and larger than you’d think. American Journal of Public Health 101(Suppl. 1):S353-S358.

Thompson, H. J., W. C. McCormick, and S. H. Kagan. 2006. Traumatic brain injury in older adults: Epidemiology, outcomes, and future implications. Journal of the American Geriatrics Society 54(10):1590-1595.

Tolin, D. F., and E. B. Foa. 2006. Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Bulletin 132(6):959-992.

TSN (Trauma Survivors Network). 2016. About us. http://www.traumasurvivorsnetwork.org/pages/about-us (accessed February 2, 2016).

University of Pittsburgh. 2016. UPMC Presbyterian. http://www.emergencymedicine.pitt.edu/patient-care/upmc-presbyterian (accessed April 22, 2016).

Upperman, J. S., R. Burd, C. Cox, P. Ehrlich, D. Mooney, and J. I. Groner. 2010. Pediatric applied trauma research network: A call to action. Journal of Trauma 69(5):1304-1307.

VA (U.S. Department of Veterans Affairs). 2016a. James A. Haley Veterans’ Hospital—Tampa, Florida: Veteran and Family Advisory Council. http://www.tampa.va.gov/patients/Veteran_and_Family_Advisory_Council.asp (accessed February 2, 2016).

VA. 2016b. Polytrauma/TBI System of Care. http://www.polytrauma.va.gov/about/Treatment_Settings_and_Services.asp (accessed April 28, 2016).

VA. 2016c. VA Palo Alto Health Care System: Veteran and Family Centered Care (VFCC). http://www.paloalto.va.gov/services/vfcc.asp (accessed February 2, 2016).

Weinick, R. M., E. B. Beckjord, C. M. Farmer, L. T. Martin, E. M. Gillen, J. Acosta, M. P. Fisher, J. Garnett, G. C. Gonzalez, T. C. Helmus, L. H. Jaycox, K. Reynolds, N. Salcedo, and D. M. Scharf. 2011. Programs addressing psychological health and traumatic brain injury among U.S. military servicemembers and their families. Santa Monica, CA: RAND Corporation.

White House. 2016. Fact sheet: Obama administration announces additional actions to address the prescription opioid abuse and heroin epidemic. https://www.whitehouse.gov/the-press-office/2016/03/29/fact-sheet-obama-administration-announces-additionalactions-address (accessed April 22, 2016).

Williams, C. M. 2005. The identification of family members’ contribution to patients’ care in the intensive care unit: A naturalistic inquiry. Nursing in Critical Care 10(1):6-14.

Willis, R., A. Krichten, K. Eldredge, and D. Carney. 2013. Creating a patient and family advisory council at a Level 1 trauma center. Journal of Trauma Nursing 20(2):86-88.

Wohltmann, C. D., G. A. Franklin, P. Q. Boaz, F. A. Luchette, P. A. Kearney, J. D. Richardson, and D. A. Spain. 2001. A multicenter evaluation of whether gender dimorphism affects survival after trauma. American Journal of Surgery 181(4):297-300.

Wolinsky, F. D., J. F. Fitzgerald, and T. E. Stump. 1997. The effect of hip fracture on mortality, hospitalization, and functional status: A prospective study. American Journal of Public Health 87(3):398-403.

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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.
×

Yang, K. C., M. J. Zhou, J. L. Sperry, L. Rong, X. G. Zhu, L. Geng, W. Wu, G. Zhao, T. R. Billiar, and Q. M. Feng. 2014. Significant sex-based outcome differences in severely injured Chinese trauma patients. Shock 42(1):11-15.

Zafar, S. N., A. Obirieze, E. B. Schneider, Z. G. Hashmi, V. K. Scott, W. R. Greene, D. T. Efron, E. J. MacKenzie, E. E. Cornwell, 3rd, and A. H. Haider. 2015. Outcomes of trauma care at centers treating a higher proportion of older patients: The case for geriatric trauma centers. Journal of the American Academy of Orthopaedic Surgeons 78(4):852-859.

Zafar, S. N., A. A. Shah, C. K. Zogg, Z. G. Hashmi, W. R. Greene, E. R. Haut, E. E. Cornwell, 3rd, and A. H. Haider. 2016. Morbidity or mortality? Variations in trauma centres in the rescue of older injured patients. Injury 47(5):1091-1097.

Zatzick, D., G. J. Jurkovich, F. P. Rivara, J. Wang, M. Y. Fan, J. Joesch, and E. MacKenzie. 2008. A national US study of posttraumatic stress disorder, depression, and work and functional outcomes after hospitalization for traumatic injury. Annals of Surgery 248(3):429-437.

Zatzick, D., G. Jurkovich, F. P. Rivara, J. Russo, A. Wagner, J. Wang, C. Dunn, S. P. Lord, M. Petrie, S. O’Connor, and W. Katon. 2013. A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors. Annals of Surgery 257(3):390-399.

Suggested Citation:"6 Delivering Patient-Centered Trauma Care." 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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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.

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