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Suggested Citation:"Summary." 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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Summary

The sacrifices made by the men and women of the U.S. Armed Forces deserve the profound gratitude of our Nation. For all those who served and gave so much, we thank you. Medical history has been made with the delivery of clinical care under conditions and in environments that few of us can imagine. We must now honor the sacrifices of a generation by ensuring that the lessons learned over the longest period of armed conflict in the history of the United States are not lost.

Trauma care in the military and civilian sectors is a portrait of contradiction—lethal contradiction. On one hand, the nation has never seen better systems of care for those wounded on the battlefield or severely injured within the United States. On the other hand, many trauma patients,1 depending on when or where they are injured, do not receive the benefit of those gains. Far too many needlessly die or sustain lifelong disabilities as a result.

Since the Civil War, and even more dramatically between the Vietnam War and the present day, rates of survival from battlefield injuries have improved remarkably, even as advances in the kinetic energy and accuracy of weapons have increased their deadliness. In the Vietnam War, the case fatality rate—the percentage of fatalities among all wounded individuals—was 23 percent; in Afghanistan and Iraq, it was 9.3 percent (Rasmussen,

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1 A trauma patient is someone 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 committee uses the term trauma only in reference to physical trauma.

Suggested Citation:"Summary." 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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2015; Rasmussen et al., 2015). These impressive gains have not occurred by chance. They are the result of the systematic design and redesign of clinical care processes, systems of battlefield injury management, and support systems, all based on rapid learning from field experiences, the fostering of innovation, and carefully managed reflection involving all levels of care. This evolution was set in motion by a cadre of military medical leaders, many of whom exercised strong initiative acting as internal change agents and, determined to save lives by avoiding the mistakes of the past, championed the design of a better system for casualty care on the battlefield, built on a foundation of military medical history and more recent advances from civilian trauma systems.

Military trauma care system designs include balletic orchestration of evacuation sequences and handoffs using a tiered configuration of five “roles”—from immediate care at the site of injury, through stabilization in field hospitals, and eventually to definitive care in the United States. Points of emphasis in this battlefield system of care include projecting life-saving care far into the field and minimizing delays in patient transfer. Notable advances in military trauma management include, for example, the aggressive use of tourniquets, revised transfusion principles for hemorrhagic shock, and the overall doctrine of tactical combat casualty care, defining the optimal delivery of trauma care under demanding conditions of austerity and danger.

Support system redesigns have included the creation of the U.S. Department of Defense’s (DoD’s) Joint Trauma System (JTS), as well as an associated trauma registry to foster continual reflection and learning. Using an approach referred to as “focused empiricism,”2 the JTS works to support continuous real-time performance improvement through the capture and ongoing evaluation of patient care and outcome data in the DoD Trauma Registry (DoDTR), and through the dissemination of evidence-based clinical practice guidelines designed to reduce variations in practice. DoDTR data also support the creation of new knowledge through research, identifying clinical needs and providing direction to the military’s combat casualty care research program, which in turn generates new evidence and improves capabilities.

Although the Military Health System’s capacity to improve trauma care developed long before the Institute of Medicine (IOM) articulated the

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2 Focused empiricism is a concept embraced by U.S. military medical leadership to capture its 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 (Elster et al., 2013). 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.

Suggested Citation:"Summary." 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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principles of a “learning health system,”3 military trauma care is, at its best, an archetype of those principles in action. Despite that progress, however, military trauma care is by no means always “at its best”—not, at least, if that phrase implies consistency and the promise of the highest achievable quality over time and space. In the face of the common idealized image of the U.S. military—one involving a strong and professional command structure, absolute clarity of roles, consistent adherence to high technical standards, and continual curiosity and learning—the committee sees a paradox. Military trauma care, despite its laudable successes, is

  • inconsistent over time, with significant loss during interwar periods of clinical competence and hard-won lessons learned on the battlefield;
  • inconsistent over space, with many of the key, successful innovations in clinical care, systems of care, and support systems being confined to specific geographic commands or even regimental units, rather than becoming the universal norm;
  • inconsistent in the thoroughness of organizational commitment to total excellence in care, with, for example, ongoing existential threats to the highly successful JTS and highly variable ownership of trauma care quality and performance among line commanders;
  • inconsistent in its management of interfaces between prehospital and hospital-based care and again between acute trauma care and later phases, such as rehabilitation and long-term follow-up. These defects are especially evident when wounded warriors transition to the veterans health care system and to other components of civilian care and when long-term needs encompass, as they often do, dimensions of psychiatric care, social support, and reentry into civilian life;
  • inconsistent in the deployment of true trauma expertise, as medical personnel are too often assigned inappropriately on the basis of general medical skills rather than a needs-based requirement according to the particular skills of the provider; and
  • unclear in its leadership structures, with no single locus of combined responsibility and authority for maintaining the readiness and ensuring the performance of military trauma care teams and of the system as a whole. No one appears to be responsible for setting goals for the readiness of the medical force or for its performance,

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3 In a learning health system, “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).

Suggested Citation:"Summary." 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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nor do those line commanders who ultimately control resources in the field uniformly claim or reliably accept responsibility for monitoring and ensuring that standards of trauma care are being met on the battlefield.

These gaps lead to a military trauma care system that functions without the stability, standardization, leadership commitment, and resources that would allow it to fulfill the promise the nation owes to its men and women in combat: that the trauma care they will receive will be the best possible in the world, no matter when and where they are injured. The ultimate effect of these gaps is that approximately 1,000 American service members who perished on the battlefield between 2001 and 2011 (roughly 25 percent of all battlefield deaths) died of wounds they could potentially have survived (Eastridge et al., 2012).

The committee found that similar gaps—inconsistency in trauma care quality over time and geographic location, suboptimal transitions between phases of care, diffusion of responsibility—impede the process of continuous improvement and consistent adoption of military lessons learned in the civilian sector, where the burden of traumatic injury is staggering. Surprisingly, the public appears generally to be unaware that trauma is the leading cause of death for Americans under the age of 46 (Rhee et al., 2014). It accounts for approximately half of all deaths in this age group and was associated with an economic cost of approximately $670 billion in medical care expenses and lost productivity in 2013 alone (Florence et al., 2015). Further, because of its disproportionate effects on young people, trauma is the number one cause of years of potential life lost before age 75—greater than either cancer or heart disease (NCIPC, 2015b). Yet despite these sobering statistics, trauma remains a neglected epidemic in the United States. The expectation of survival after severe injury, which has helped drive the continuous improvement seen in military trauma care, has not yet permeated the American public’s expectations for civilian trauma care. Of the 147,790 U.S. deaths from trauma in 20144 (NCIPC, 2015a), as many as 20 percent may have been preventable with optimal trauma care (Kwon et al., 2014). This figure equates to nearly 30,000 preventable trauma deaths after injury5 in a single year—about 10 times the number of deaths from the terrorist attacks on September 11, 2001.6

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4 This figure excludes deaths due to poisoning (51,966), which are classified by the Centers for Disease Control and Prevention as injury-related deaths.

5 The committee defines preventable deaths after inury as those casualties whose lives could have been saved by appropriate and timely medical care, irrespective of tactical, logistical, or environmental issues.

6 During the terrorist attacks on September 11, 2001, 2,977 people perished (McCoy, 2015).

Suggested Citation:"Summary." 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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Since 2001, approximately 2 million U.S. civilians have died from trauma7 (NCIPC, 2015a). In this same period, approximately 6,850 U.S. service members died in theater8 (DCAS, 2016). Thus, the vast majority of the burden of trauma is borne by the civilian population. Dramatic action is needed to reduce these staggering statistics. Recognizing that the best strategy is to prevent the injury from occurring in the first place, when injuries do occur, the delivery of optimal trauma care represents a critical secondary prevention strategy to avert unnecessary death and disability. Given the military’s success in reducing trauma deaths, the civilian sector stands to reap tremendous benefits if best practices can be reliably adapted from the military, and if the same learning system properties that have been highly effective in portions of military trauma care can become manifest in its civilian counterpart. The increasing incidence of multiple-casualty incidents such as those in Sandy Hook, Boston, Paris, and San Bernardino lends additional urgency to the translation of wartime lessons to the civilian sector.

The end of the wars in Afghanistan and Iraq represents a unique moment in history in that there now exists a military trauma system built on a learning system framework and an organized civilian trauma system that is well positioned to assimilate and distribute the recent wartime trauma lessons learned and to serve as a repository and incubator for innovation in trauma care during the interwar period. Together, these two developments present an opportunity to integrate military and civilian trauma systems, thereby ensuring continuous bidirectional learning, but this will require unprecedented partnership across military and civilian sectors, along with a sustained commitment from trauma system leaders at all levels, to ensure that the necessary knowledge and tools are not lost. Recognizing the importance of this window of opportunity, a group of sponsors,9 representing both the military and civilian sectors, asked the National Academies of Sciences, Engineering, and Medicine to convene a committee charged with defining the components of a learning health system necessary to enable continued improvement in military and civilian trauma care, and with providing recommendations to ensure that lessons learned over the past

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7 This figure excludes deaths due to poisoning, which are classified by the Centers for Disease Control and Prevention as injury-related deaths, over the same time period (536,018).

8 The term “theater” refers to the theater of war, which is the area of air, land, and water that is, or may become, directly involved in the conduct of a war (DoD, 2016).

9 The Committee on Military Trauma Care’s Learning Health System and Its Translation to the Civilian Sector was established with funding from three federal agencies (DoD’s U.S. Army Medical Research and Materiel Command, the U.S. Department of Transportation’s National Highway Traffic Safety Administration, and the U.S. Department of Homeland Security’s Office of Health Affairs) and five professional organizations (the American College of Emergency Physicians, American College of Surgeons, National Association of Emergency Medical Services Physicians, National Association of Emergency Medical Technicians, and Trauma Center Association of America).

Suggested Citation:"Summary." 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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decade from the military’s experiences in Afghanistan and Iraq are both sustained and built upon for future combat operations and translated into the U.S. civilian system (the full statement of task is included in Box 1-6 in Chapter 1).

A LEARNING SYSTEM FRAMEWORK FOR CONTINUOUS IMPROVEMENT IN TRAUMA CARE

The committee was asked to identify and describe the key components of a learning health system necessary to optimize care of individuals who have sustained traumatic injuries in military and civilian settings. To that end, the committee turned to the IOM’s framework for a learning health system (IOM, 2013), adapting it for systems of trauma care and using it to “interrogate” the status quo. The committee found that although many of the individual components are in place, the full potential of a learning system is not being realized in either sector (as summarized in Table S-1).

The committee takes as its beacon the accomplishments of the 75th Ranger Regiment, a U.S. Army special operations force that, driven by the vision and action of its commanding officer, closed those gaps. For the 75th Rangers, the ability to deliver combat casualty care to their wounded comrades became as important as the more traditional military proficiencies of marksmanship, mobility, and communication. Constant reflection, data-driven performance improvement, and ambitious innovation, along with total support from the top and total involvement of the workforce, became their doctrine. The results set a new benchmark: virtually eliminating preventable trauma deaths under the most trying of conditions. Crucially, the line commanders, starting with the commanding officer, took full responsibility for the achievement of this goal (Kotwal et al., 2011).

By extrapolating from the outcomes of best-in-class trauma care delivery systems that exemplify the characteristics of a high-functioning learning system, one can estimate the societal benefit that could be achieved through the uniform provision of high-quality trauma care. Had the level of care achieved by the 75th Ranger Regiment been provided throughout the military during the wars in Afghanistan and Iraq, hundreds of service members who perished in the line of duty over a decade of war might have survived (Eastridge et al., 2012).10 In the civilian sector, as many as 200,000 American lives—a population the size of the city of San Bernardino, California—could have been saved in the same period of time if all trauma centers in the United States had achieved outcomes similar to those at the highest-

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10 Survivability determinations were based on medical information only and did not take into account resource restrictions or operational conditions that may have prevented timely access to appropriate medical care (Eastridge et al., 2012).

Suggested Citation:"Summary." 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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TABLE S-1 Learning Trauma Care System Components in Military and Civilian Settings

Digital Capture of the Trauma Patient Care Experience
Patient care experiences across the continuum of care are digitally captured and linked in information systems, including trauma registries, such that each patient experience yields information on the effectiveness, quality, and value of the trauma care delivered. Bottom-up design of data systems, where care generates the data, ensures that data capture is seamlessly integrated into the provider workflow and is available in real time for performance improvement primarily and research secondarily.
MILITARY SECTOR FINDINGS CIVILIAN SECTOR FINDINGS
Prehospital care is not consistently digitally captured and the prehospital registry does not link to data from hospital-based care. Prehospital care is unpredictably captured (particularly digitally) and does not link to the outpatient (emergency department) or inpatient experience at a national level.
Separate registries are maintained for en route care and other specialty areas, such as orthopedics and infectious disease.
Long-term care and outcomes are not digitally captured and linked to acute care for performance improvement.
DoD registry data are not linked to long-term outcomes in VA information systems.
Patient-level linkages are not possible between national registries for prehospital and hospital-based care.
Coordinated Performance Improvement and Research to Generate Evidence-Based Best Trauma Care Practices
The supply of knowledge is continuously and reliably expanded and improved through the systematic capture and translation of information generated by coordinated performance improvement and research activities.
MILITARY SECTOR FINDINGS CIVILIAN SECTOR FINDINGS
The Joint Trauma System’s use of registry-driven rapid-cycle performance improvement has enabled evidence-based improvements to patient care processes. Increased research investment is needed to address fundamental knowledge gaps in best trauma care practices. The American College of Surgeons National Trauma Data Bank and Trauma Quality Improvement Program have enabled evidence-based improvement to patient care processes. Increased research investment is needed to address fundamental knowledge gaps in best trauma practices.
Current federal regulations concerning privacy and human subjects protections and their interpretations expressed as “guidance documents” pose barriers to learning and continuous improvement in trauma care.
Current federal regulations concerning privacy and human subjects protections and their interpretations expressed as “guidance documents” pose barriers to learning and continuous improvement in trauma care.
Suggested Citation:"Summary." 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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Processes and Tools for Timely Dissemination of Trauma Knowledge
Trauma care providers have access to tools such as continuously updated clinical practice guidelines and clinical decision support tools to capture, organize, and disseminate the best available information to guide decision making and reduce variation in care and outcomes. Clinical decision support tools and telemedicine make knowledge of best trauma care practices available at the point of care.
MILITARY SECTOR FINDINGS CIVILIAN SECTOR FINDINGS
Guideline development and dissemination processes are agile but focused largely on surgical care (e.g., versus nursing care). Processes for guideline development exist but are fragmented and do not consistently capture and deliver the best and most up-to-date evidence available to guide, support, tailor, and improve clinical decision making and care, safety, and quality.
Telemedicine capabilities have been key in performance improvement efforts but are not optimally utilized.
No national-level entity or leader has been designated responsible for guideline development and dissemination.
Systems for Ensuring an Expert Trauma Care Workforce
Continuous learning and improvement are designed into trauma system processes. Ongoing individual skill building and team training, as well as feedback loops, build and sustain an expert trauma care workforce.
MILITARY SECTOR FINDINGS CIVILIAN SECTOR FINDINGS
Ensuring the appropriate expertise of the trauma care workforce is impeded by reduced caseloads during interwar periods, competition for resources with the beneficiary care mission, reliance on just-in-time training, and a lack of standardized training informed by best practices in military trauma care (e.g., clinical practice guidelines). Sharing of new civilian best trauma care practices/experiences with the military community is not occurring systematically (and vice versa), and no national framework has been defined for integrating military best practices into skill building, team building, and certification processes.
Suggested Citation:"Summary." 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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Patient-Centered Trauma Care
The trauma care process is managed around the patient experience, feedback is sought from trauma patients when the process is evaluated for improvement, and patients are involved in redesign of the trauma system and have a voice in trauma research. Patient-centered care features timely access to high-quality prehospital, definitive, and rehabilitative care, with seamless transitions between each of these echelons to ensure that physical and psychological health care needs are met.
MILITARY SECTOR FINDINGS CIVILIAN SECTOR FINDINGS
Patient care is fragmented across the trauma care continuum, and trauma systems do not optimally address the holistic needs of the patient. Patient care is fragmented across the trauma care continuum, and trauma systems do not optimally address the holistic needs of the patient.
Given the nature of trauma, decisions may be made with little to no patient input. Consequently, greater efforts are needed to engage patients and their families in decision making and in the design and evaluation of care processes. Given the nature of trauma, decisions may be made with little to no patient input. Consequently, greater efforts are needed to engage patients and their families in decision making and in the design and evaluation of care processes.
Leadership-Instilled Culture of Learning
Leadership will influence the extent to which a culture of learning and improvement permeates a trauma system. Leadership instills a culture of learning by defining learning as a central priority of a trauma system, removing barriers to improving care systems and, most notably at the point of care, setting quantifiable aims against which progress can continually be measured and promoting a nonpunitive environment.
MILITARY SECTOR FINDINGS CIVILIAN SECTOR FINDINGS
Commitment to creating an environment that promotes learning and continuous improvement is variable across DoD and over time. A pervasive cultural barrier impedes learning from mistakes, as liability concerns and fear of disciplinary action or loss of reputation (at the individual and organizational levels) trump patient safety and performance improvement goals.
Service parochialisms and an inconsistent level of understanding by senior medical and line leadership of the value of a learning trauma care system impede continuous learning and improvement.
Suggested Citation:"Summary." 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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Transparency and Aligned Incentives for Quality Trauma Care
Drawing on data from trauma registries and other information systems, performance improvement programs support the evolution and improvement of trauma systems by benchmarking systems’ performance against that of other similar organizations and by making performance information available at the provider, team, center, and system levels. Multiple complementary incentives are aligned to encourage continuous improvement and reward high-quality care.
MILITARY SECTOR FINDINGS CIVILIAN SECTOR FINDINGS
Military trauma care providers lack real-time access to their own performance data, although a weekly video teleconference is a means of obtaining feedback in a timely manner. Few military treatment facilities submit data to a trauma quality improvement program for benchmarking purposes, limiting transparency and performance improvement across DoD military treatment facilities. Trauma quality improvement programs exist for trauma centers but there is no common process in place for benchmarking safety, quality, processes, prices, costs, and outcomes of prehospital care or whole trauma systems, and for making that information available for care improvement and informed decision making by clinicians, patients, and their families.
There are no national metrics (such as those promulgated by the National Quality Forum) to drive national trauma quality initiatives.
Financial incentives cannot easily be used to drive improvement in trauma care quality given current military processes for budgeting and accountability for health care spending. Other levers (e.g., promotion) are not adequately employed.
Emergency medical services is not a provider type under the Social Security Act, so prehospital trauma care is not linked to national health care reform efforts to improve quality and reduce preventable deaths after injury.
Aligned Authority and Accountability for Trauma System Leadership
Responsibility, authority, and resources are aligned to enable leadership to steward the system. Defined leadership is accountable for trauma capabilities and system performance, with the authority to create and enforce policy and ensure that the many stakeholders involved work together to provide seamless, quality care.
MILITARY SECTOR FINDINGS CIVILIAN SECTOR FINDINGS
Responsibility, authority, and accountability for battlefield care are diffused across central and service-specific medical leadership, as well as line leadership, resulting in variability in care processes and outcomes across time, facilities, and geography. At a national level, there is no governmental civilian health lead for trauma care (including prehospital, in-hospital, and post-acute care) to support a learning health system for trauma care, despite past recommendations that such a lead agency be established.
Suggested Citation:"Summary." 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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performing centers (Hashmi et al., 2016). Yet no person, group, or institution in the United States bears responsibility for the aim for both military and civilian trauma care that informed this study: to eliminate preventable deaths after injury and minimize trauma-related disability. Concerted efforts aimed at establishing the type of “learning trauma care systems” the committee observed in the 75th Ranger Regiment and top-performing civilian trauma systems can save tens of thousands of lives on an annual basis and mitigate suffering for many times that number of trauma patients.

A VISION FOR A NATIONAL TRAUMA CARE SYSTEM

History has demonstrated that military and civilian trauma care are inextricably linked. In many ways, the successes of the military’s trauma system parallel the significant progress made over the past 50 years with the development and refinement of a regionalized, systems-based approach to trauma care across the civilian sector. Sophisticated civilian trauma care systems in the United States emerged from the successes and lessons of military trauma care during the wars in Korea and Vietnam, and, subsequently, DoD adopted and adapted the principles of civilian trauma care systems for application in the military and the development of the JTS over the course of the wars in Afghanistan and Iraq, demonstrating a continual ebb and flow between the two sectors.

Moreover, sustaining needed expertise and capacity in the military trauma care system is simply impossible absent integration with civilian trauma care systems, given the essential role of the civilian sector in facilitating combat-relevant research and maintaining the expertise of the military trauma care workforce. This linkage also is critical to (1) ensuring adequate preparedness for disasters and other mass casualty incidents, (2) ensuring full transfer of lessons learned between the two sectors, and (3) improving the civilian emergency and trauma care delivery system. Thus, it is neither feasible nor, in the face of the evidence, rational, to attempt to resolve the military’s trauma care capability challenges or to enhance its learning capacity without broadening those changes to encompass the civilian trauma care system and the relationships between the two. Military and civilian trauma care and learning will be optimized together, or not at all.

Conclusion: A national strategy and joint military and civilian approach for improving trauma care is lacking, placing lives unnecessarily at risk. A unified effort is needed to address this gap and ensure the delivery of optimal trauma care to save the lives of Americans injured within the United States and on the battlefield.

Suggested Citation:"Summary." 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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The committee envisions a national trauma care system grounded in sound learning health system principles applied across the delivery of care—from point of injury to hospitalization, rehabilitation, and beyond. Achieving this vision will require a systems approach that synergizes military and civilian efforts, committed leadership from both sectors, as well as a strategy that defines common standards, interoperable frameworks, and points of accountability to reduce variation in care and outcomes while supporting continuous learning and innovation at the point of care delivery.

RECOMMENDATIONS FOR LEADERSHIP

The success of the 75th Ranger Regiment demonstrates that eliminating preventable deaths after injury—the 20,000-30,000 that occur on a yearly basis in the United States and those on the battlefield—is an achievable goal (Hashmi et al., 2016; Kwon et al., 2014). However, accomplishing the necessary consistency, reliability, and constancy of uniformly superb trauma care—on a day-to-day basis as well as during mass casualty incidents—will require significant changes in leadership structures within DoD, in civilian trauma care, and in the combined efforts of the two sectors. The current absence of any higher authority to encourage coordination, collaboration, standardization, and alignment in trauma care across and within the military and civilian sectors has resulted in variation in practice, suboptimal outcomes for injured patients, and a lack of national attention and funding directed at trauma care at a level commensurate with its enormous societal burden. Leadership from the White House will be required to optimize U.S. trauma care delivery within and across the military and civilian sectors; to catalyze further development of the necessary public-private partnerships between governmental and civil society leaders; and to ensure accountability across the many federal agencies (e.g., DoD, the U.S. Department of Veterans Affairs [VA], the U.S. Department of Health and Human Services [HHS], the U.S. Department of Homeland Security [DHS], the U.S. Department of Transportation [DOT]) involved in trauma care. No level of government below the White House has the leverage to achieve this level of collaboration, and thereby to avert needless deaths and disability due to suboptimal trauma care.

Recommendation 1: The White House should set a national aim of achieving zero preventable deaths after injury and minimizing trauma-related disability.

Recommendation 2: The White House should lead the integration of military and civilian trauma care to establish a national trauma care system. This initiative would include assigning a locus of accountability

Suggested Citation:"Summary." 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 responsibility that would ensure the development of common best practices, data standards, research, and workflow across the continuum of trauma care.

To achieve the national aim (Recommendation 1), the White House should take responsibility for

  • creating a national trauma system comprising all characteristics of a learning organization as described by the Institute of Medicine;
  • convening federal agencies (including HHS, DOT, VA, DHS, and DoD) and other governmental, academic, and private-sector stakeholders to agree on the aims, design, and governance of a national trauma care system capable of continuous learning and improvement;
  • establishing accountability for the system;
  • ensuring appropriate funding to develop and support the system;
  • ensuring the development of a data-driven research agenda and its execution;
  • ensuring the reduction of regulatory and legal barriers to system implementation and success;
  • ensuring that the system is capable of responding domestically to any (intentional or unintentional) mass casualty incident; and
  • strategically communicating the value of a national trauma care system.

While national leadership for better coordination, learning, and improvement of trauma care is important, progress also is possible within DoD given some significant changes in leadership actions and accountability.

Through the JTS, DoD’s education and training enterprise, and its research investment over the course of the wars in Afghanistan and Iraq, the military has established an ad hoc system that has many of the components needed to support learning for improved trauma care. However, DoD has yet to achieve the full potential of a learning trauma care system, and improved linking of individual components into a unified system is needed. Additionally, this system has not been embraced across all combatant commands,11 nor is it guaranteed to be sustained over time. Several different groups have made recommendations to DoD leaders for sustaining and

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11 A combatant command is “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.

Suggested Citation:"Summary." 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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improving upon trauma care advances realized over the last decade, but these recommendations have not as yet been translated into action.

The military has no unified medical command, no single senior military medical leader, directorate, or division solely responsible for combat casualty care. The Defense Health Agency (DHA) was created to serve as the Military Health System’s joint combat support agency, but leadership responsibility for developing the structure and content of a robust learning trauma care system appears to be diffused across DHA, the Office of the Assistant Secretary of Defense for Health Affairs, and the military service medical commands. DHA has not yet established a single point of accountability responsible for driving requirements for trauma care across DoD. Oddly for a military system known for its command and control, with respect to battlefield trauma care and its continuous improvement, no one is in charge. Further, final authority and responsibility for the delivery of combat casualty care in the deployed setting is assigned to line commanders who have little education in or exposure to the principles of combat casualty care and trauma systems.

Overall, DoD’s current trauma care system and resources (1) are not aligned with or accountable to a specific DHA leader in support of its combat support agency mission, (2) lack consistency in training and practice across the services and combatant commands, and (3) fail to hold medical and line leadership accountable for the standards of trauma care provided and for combat casualty care outcomes.

Recommendation 3: The Secretary of Defense should ensure combatant commanders and the Defense Health Agency (DHA) Director are responsible and held accountable for the integrity and quality of the execution of the trauma care system in support of the aim of zero preventable deaths after injury and minimizing disability. To this end

  • The Secretary of Defense also should ensure the DHA Director has the responsibility and authority and is held accountable for defining the capabilities necessary to meet the requirements specified by the combatant commanders with regard to expert combat casualty care personnel and system support infrastructure.
  • The Secretary of Defense should hold the Secretaries of the military departments accountable for fully supporting DHA in that mission.
  • The Secretary of Defense should direct the DHA Director to expand and stabilize long-term support for the Joint Trauma System so its functionality can be improved and utilized across all combatant commands, giving actors in the system access to timely evidence, data, educational opportunities, research, and performance improvement activities.
Suggested Citation:"Summary." 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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To meet the needs of the combatant commanders, the accountable DHA leader should sustain and fund elements of a learning trauma care system that are performing well within DoD, and better align efforts that today are fragmented or insufficiently supported. Steps to take to these ends include

  • developing policies to support and foster effective engagement in the national learning trauma care system;
  • integrating existing elements of a learning system into a national trauma care system;
  • maintaining and monitoring trauma care readiness for combat and, when needed, for domestic response to mass casualty incidents;
  • continuously surveying, adopting, improving and, as needed, creating novel best trauma care practices, and ensuring their consistent implementation across combatant commands;
  • supporting systems-based and patient-centered trauma care research;
  • ensuring integration across DoD and, where appropriate, with the VA, for joint approaches to trauma care and development of a unified learning trauma care system;
  • arranging for the development of performance metrics for trauma care, including metrics for variation in care, patient engagement/satisfaction, preventable deaths, morbidity, and mortality; and
  • demonstrating the effectiveness of the learning trauma care system by each year diffusing across the entire system one or two deeply evidence-based interventions (such as tourniquets) known to improve the quality of trauma care.

As difficult as clarifying responsibility and authority for trauma care may be in the military, it is even more challenging in the civilian sector, where leadership in this area has been left mainly to states, counties, and municipalities, with little federal oversight to ensure the achievement of national goals or consistent practices. No single federal entity is accountable for trauma care capabilities in the United States. At the national level, coordinating bodies and processes are fragmented and severely underresourced for the magnitude of the task:

  • The Emergency Care Coordination Center (ECCC) was created by presidential directive in response to an IOM (2007) recommendation for the creation of a lead federal agency that would consolidate the many government programs involved in trauma care. The ECCC, however, is an unfunded office housed within the Office of the Assistant Secretary for Preparedness and Response, with little influence to link trauma care to broader health care reform efforts.
Suggested Citation:"Summary." 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 2005, the Federal Interagency Committee on EMS (FICEMS) was created to foster partnership and collaboration among federal agencies involved in emergency medical services. However, FICEMS lacks the authority and funding to fully execute this mission.
  • The National Highway Traffic Safety Administration staffs an Office for Emergency Medical Services, which has led several critical initiatives to improve prehospital care. However, this office is underresourced, and these efforts have been largely disconnected from HHS’s health care delivery reform efforts.
  • Current health care delivery reform efforts within the Centers for Medicare & Medicaid Services do not include the improvement of trauma care systems.
  • The American College of Surgeons imposes requirements for trauma center verification but has no influence over prehospital care organizations.

The lack of formal, funded mechanisms for coordination, communication, and translation in trauma care has contributed to inefficiency and variation across the civilian sector in clinical care practices, education and training, research efforts, and continuous performance improvement—all of which have contributed in turn to suboptimal outcomes for injured patients in the United States.

Recommendation 4: The Secretary of Health and Human Services (HHS) should designate and fully support a locus of responsibility and authority within HHS for leading a sustained effort to achieve the national aim of zero preventable deaths after injury and minimizing disability. This leadership role should include coordination with governmental (federal, state, and local), academic, and private-sector partners and should address care from the point of injury to rehabilitation and post-acute care.

The designated locus of responsibility and authority within HHS should be empowered and held accountable for

  • convening a consortium of federal (including HHS, DOT, VA, DHS, and DoD) and other governmental, academic, and private-sector stakeholders, including trauma patient representatives (survivors and family members), to jointly define a framework for the recommended national trauma care system, including the designation of stakeholder roles and responsibilities, authorities, and accountabilities;
Suggested Citation:"Summary." 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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  • developing a national approach to improving care for trauma patients, to include standards of care and competencies for prehospital and hospital-based care;
  • ensuring that trauma care is included in health care delivery reform efforts;
  • developing policies and incentives, defining and addressing gaps, resourcing solutions, and creating regulatory and information technology frameworks as necessary to support a national trauma care system of systems committed to continuous learning and improvement;
  • developing and implementing guidelines for establishment of the appropriate number, level, and location of trauma care centers within a region based on the needs of the population;
  • improving and maintaining trauma care readiness for any (intentional or unintentional) mass casualty incident, using associated readiness metrics;
  • ensuring appropriate levels of systems-based and patient-centered trauma care research;
  • developing trauma care outcome metrics, including metrics for variation in care, patient engagement/satisfaction, preventable deaths, morbidity, and mortality; and
  • demonstrating the effectiveness of the learning trauma care system by each year diffusing across the entire system one or two deeply evidence-based interventions (such as tourniquets) known to improve the quality of trauma care.

The measure of a learning system’s effectiveness is whether it is capable of supporting broad, rapid, meaningful change in practice. Accordingly, as directed in Recommendations 3 and 4, military and civilian stakeholders should commit to diffusing specific improvements in trauma care (e.g., broad availability of tourniquets or reliable application of a key trauma response protocol) every year throughout the system, and setting explicit, numeric aims for their adoption within aggressive time frames (e.g., within 6 months or 1 year). Diffusing straightforward, evidence-based practices—or attempting to do so—would test whether the learning trauma care system actually has value and impact, serve to highlight its deficiencies, and support its improvement. If successful, such efforts also could build confidence in the system among key actors (e.g., clinicians, medics) and increase its use.

While significant improvements to the learning system for trauma care are required, a complete redesign of the entire system (with all the consensus building and resource mobilization entailed) will not be accomplished overnight. Yet the urgent need to avoid preventable deaths after injury demands

Suggested Citation:"Summary." 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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concomitantly urgent action. It is by no means wise or necessary to wait for a full redesign of the system before taking action. Setting aims for the near term would be an efficient way to drive broad and needed improvement now. A beneficial by-product would be immediate continuous innovation in the learning system generated in pursuit of such aims.

RECOMMENDATIONS FOR AN INTEGRATED MILITARY–CIVILIAN FRAMEWORK FOR LEARNING TO ADVANCE TRAUMA CARE

Learning and improvement are difficult, if not impossible, without a continuous supply of data and narrative information. Learning systems are avid for such information, digest it rapidly, and maintain “memory” over time so that the information accumulates and lessons are retained. Such an information environment has strong cultural characteristics, nurturing curiosity, disclosure, trust, and shared learning, as well as, crucially, minimizing fear. Fear poisons learning. The emphasis on data use is for purposes of learning, not judgment.

In the world of trauma care, this bias toward information and data in the service of learning would take several forms, including robust and continuous registry-driven analyses, systems for communication and exchange of ideas, access to scientific insights, and total workforce engagement.

Ensuring Access to and Use of Rich and Timely Data and Information

In both the military and civilian sectors, patient data are fragmented across independent data systems and registries, limiting the extent to which patient care and systems of care can be evaluated and improved. Linkages are incomplete or entirely missing among prehospital care, hospital-based acute care, rehabilitation and post-acute care, and medical examiner data. Further, current systems are not optimally designed or used to afford providers real-time access to their (individual or team) performance data. The failure to collect, integrate, and share trauma care data across the continuum of care limits the ability to analyze long-term patient outcomes and use that information to improve performance at the front lines of care. The collection and integration of the full spectrum of patient care and long-term outcome data using patient-centric, integrated registry systems need to be a priority in both sectors if the full potential of a learning trauma care system is to be realized, deaths from survivable injuries are to be reduced, and functional outcomes for the injured are to be maximized.

Recommendation 5: The Secretary of Health and Human Services and the Secretary of Defense, together with their governmental, private,

Suggested Citation:"Summary." 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 academic partners, should work jointly to ensure that military and civilian trauma systems collect and share common data spanning the entire continuum of care. Within that integrated data network, measures related to prevention, mortality, disability, mental health, patient experience, and other intermediate and final clinical and cost outcomes should be made readily accessible and useful to all relevant providers and agencies.

To implement this recommendation, the following specific actions should be taken:

  • Congress and the White House should hold DoD and the VA accountable for enabling the linking of patient data stored in their respective systems, providing a full longitudinal view of trauma care delivery and related outcomes for each patient.
  • The Office of the National Coordinator for Health Information Technology should work to improve the integration of prehospital and in-hospital trauma care data into electronic health records for all patient populations, including children.
  • The American College of Surgeons, the National Highway Traffic Safety Administration, and the National Association of State EMS Officials should work jointly to enable patient-level linkages across the National EMS Information System project’s National EMS Database and the National Trauma Data Bank.
  • Existing trauma registries should develop mechanisms for incorporating long-term outcomes (e.g., patient-centered functional outcomes, mortality data at 1 year, cost data).
  • Efforts should be made to link existing rehabilitation data maintained by such systems as the Uniform Data System for Medical Rehabilitation to trauma registry data.
  • HHS, DoD, and their professional society partners should jointly engage the National Quality Forum in the development of measures of the overall quality of trauma care. These measures should include those that reflect process, structure, outcomes, access, and patient experience across the continuum of trauma care, from the point of injury, to emergency and in-patient care, to rehabilitation. These measures should be used in trauma quality improvement programs, including the American College of Surgeons Trauma Quality Improvement Program (TQIP).

Elements that promote the adoption of innovations and best practices include support from leadership, conduits for sharing knowledge, and mechanisms for identifying potentially beneficial practices of other orga-

Suggested Citation:"Summary." 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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nizations and sectors (IOM, 2013). Each is critical to the realization of a national system for trauma care that ensures the diffusion of best practices within and across the military and civilian sectors. Conduits for sharing knowledge could include clinical guidelines that enable the diffusion and uptake of knowledge within and across sectors, as well as person-to-person connections that enable the sharing of tacit knowledge—the kind of practical know-how that comes from experience at the front lines of care delivery.

The military utilizes a flexible and agile approach to guideline development, distinct from that found in the civilian sector. While this enables rapid and continuous improvement in the military sector, more formal processes also are needed to encourage joint military–civilian discussion of guidelines so as to enhance bidirectional translation. Telemedicine has significantly advanced opportunities to disseminate best practices by facilitating real-time access to trauma experts, but this potential remains underrealized in both military and civilian trauma care settings.

Recommendation 6: To support the development, continuous refinement, and dissemination of best practices, the designated leaders of the recommended national trauma care system should establish processes for real-time access to patient-level data from across the continuum of care and just-in-time access to high-quality knowledge for trauma care teams and those who support them.

The following specific actions should be taken to implement this recommendation:

  • DoD and HHS should prioritize the development and support of programs that provide health service support and trauma care teams with ready access to practical, expert knowledge (i.e., tacit knowledge) on best trauma care practices, benchmarking effective programs from within and outside of the medical field and applying multiple educational approaches and technologies (e.g., telemedicine).
  • Military and civilian trauma management information systems should be designed, first and foremost, for the purpose of improving the real-time front-line delivery of care. These systems should follow the principles of bottom-up design, built around key clinical processes and supporting actors at all levels through clinical transparency, performance tracking, and systematic improvement within a learning trauma care system. Therefore, the greater trauma community, with representation from all clinical and allied disciplines, as well as electronic medical record and trauma registry vendors,
Suggested Citation:"Summary." 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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  • should, through a consensus process, lead the development of a bottom-up data system design around focused processes for trauma care.

  • HHS and DoD should work jointly to ensure the development, review, curation, maintenance, and validation of evidence-based guidelines for prehospital, hospital, and rehabilitation trauma care through existing processes and professional organizations.
  • Military and civilian trauma system leaders should employ a multipronged approach to ensure the adoption of guidelines and best practices by trauma care providers. This approach should encompass clinical decision support tools, performance improvement programs, mandatory predeployment training, and continuing education. Information from guidelines should be included in national certification testing at all levels (e.g., administrators, physicians, nurses, physician assistants, technicians, emergency medical services).

The committee found that the research investment in trauma care is not commensurate with the importance of injury, which accounts for nearly 10 percent of total disability-adjusted life years (DALYs) lost in the United States each year (U.S. Burden of Disease Collaborators, 2013) but receives only about 1 percent of the National Institutes of Health’s (NIH’s) biomedical research budget. Despite being the leading cause of death for Americans under the age of 46, in 2015, injury research accounted for only $399 million of NIH’s approximately $30 billion budget (HHS, 2015; NIH, 2016). Although proportionality to disease burden is an overly simplistic method by which to set research budgets, this disparity indicates a lack of patient advocacy and public understanding of trauma and the role of research in addressing gaps in optimal trauma care.

Ultimately, to close critical gaps in knowledge of optimal trauma care practices and delivery systems, the United States needs a coordinated military–civilian trauma care research effort with defined objectives, a focus on high-priority needs, and adequate resourcing from both sectors. It is clear that current funding levels fall far short of the mark. In 2012, President Obama issued an executive order directing federal agencies to create a National Research Action Plan (NRAP) on posttraumatic stress disorder (PTSD), other mental health conditions, and traumatic brain injury. This presidential directive has been successful in drawing attention to the issue of traumatic brain injury, generating additional research investment, and requiring government agencies to coordinate their efforts. The success of the NRAP demonstrates how executive action from the White House can draw attention to overlooked areas of research such as trauma and induce

Suggested Citation:"Summary." 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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federal agencies to coordinate their efforts in the absence of a funded congressional mandate.

Recommendation 7: To strengthen trauma research and ensure that the resources available for this research are commensurate with the importance of injury and the potential for improvement in patient outcomes, the White House should issue an executive order mandating the establishment of a National Trauma Research Action Plan requiring a resourced, coordinated, joint approach to trauma care research across the U.S. Department of Defense, the U.S. Department of Health and Human Services (National Institutes of Health, Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, U.S. Food and Drug Administration, Patient-Centered Outcomes Research Institute), the U.S. Department of Transportation, the U.S. Department of Veterans Affairs, and others (academic institutions, professional societies, foundations).

This National Trauma Research Action Plan should build upon experience with the successful model of the NRAP and should

  • direct the performance of a gap analysis in the military and civilian sectors that builds on previous analyses, looking at both treatment (clinical outcome studies) and systems research to identify gaps across the full continuum of care (prehospital and hospital-based care and rehabilitation) and considering needs specific to mass casualty incidents (e.g., natural disasters, terrorist attacks) and special patient populations (e.g., pediatric and geriatric patient populations);
  • develop the appropriate requirements-driven and patient-centered research strategy and priorities for addressing the gaps with input from armed forces service members and civilian trauma patients;
  • specify an integrated military–civilian strategy with short-, intermediate-, and long-term steps for ensuring that appropriate military and civilian resources are directed toward efforts to fill the identified gaps (particularly during interwar periods), designating federal and industry stakeholder responsibilities and milestones for implementing this strategy; and
  • promote military–civilian research partnerships to ensure that knowledge is transferred to and from the military and that lessons learned from combat can be refined during interwar periods.

The execution of a National Trauma Research Action Plan would certainly require a significant infusion of trauma research funding. This

Suggested Citation:"Summary." 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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funding should be based on a determination of need stemming from the gap analysis recommended above and a review of current investments.

Beyond resources and infrastructure, research in a learning system for trauma care necessitates a regulatory environment that consciously fosters learning and exchange, or at least is not inimical to them, while protecting the interests of human subjects and addressing privacy concerns. The committee found that military and civilian trauma systems share barriers to the effective functioning of a learning trauma care system as a result of the current federal regulatory landscape, which impedes quality improvement and research activities.

Recommendation 8: To accelerate progress toward the aim of zero preventable deaths after injury and minimizing disability, regulatory agencies should revise research regulations and reduce misinterpretation of the regulations through policy statements (i.e., guidance documents).

In the process of implementing this recommendation, the following issues are points to consider:

  • Prior national committees and legislative efforts have recommended that Congress, in instances of minimal-risk research where requiring informed consent would make the research impracticable, amend the U.S. Food and Drug Administration’s (FDA’s) authority so as to allow the FDA to develop criteria for waiver or modification of the requirement of informed consent for minimal-risk research. The present committee supports these recommendations, which would address current impediments to the conduct of certain types of minimal-risk research in the trauma setting (e.g., diagnostic device results that would not be used to affect patient care).
  • For nonexempt human subjects research that falls under either HHS or FDA human subjects protections as applicable, DoD should consider eliminating the need to also apply 10 U.S.C. § 980, “Limitation on Use of Humans as Experimental Subjects” to the research.
  • HHS’s Office for Civil Rights should consider providing guidance on the scope and applicability of the Health Insurance Portability and Accountability Act (HIPAA) with respect to trauma care and trauma research such that barriers to the use and disclosure (sharing) of protected health information across the spectrum of care (from the prehospital or field setting, to trauma centers and hospitals, to rehabilitation centers and long-term care facilities) will be minimized.
Suggested Citation:"Summary." 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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  • The FDA, in consultation with DoD, should consider establishing an internal Military Use Panel, including clinicians with deployment experience and patient representative(s) (i.e., one or more injured soldiers), that can serve as an interagency communication and collaboration mechanism to facilitate more timely fielding of urgently needed medical therapeutic and diagnostic products for trauma care.
  • In trauma settings in which there are unproven or inadequate therapeutic alternatives for life-threatening injuries, the FDA should explore the appropriate scientific and ethical balance between pre-market and postmarket data collection such that potentially lifesaving products are made available more quickly (after sufficient testing). At the same time, the FDA should consider developing innovative methods for addressing data gaps in the postmarket setting that adhere to regulatory and statutory constraints.
  • Consistent with its approach to applications for rare diseases, the FDA should consider exercising flexibility in evidentiary standards for effectiveness within the constraints of applicable law when a large body of clinical evidence (albeit uncontrolled) supports a new indication for an FDA-approved product for the diagnosis or treatment of traumatic injury, and pragmatic, scientific, or ethical issues constrain the conduct of a randomized controlled trial (e.g., on the battlefield or in the prehospital setting).
  • A learning trauma care system involves continuous learning through pragmatic methods (e.g., focused empiricism) and activities that have elements of both quality improvement and research. HHS, when considering revisions to the Common Rule, should consider whether the distinction it makes between quality improvement and research permits active use of these pragmatic methods within a continuous learning process. Whatever distinction is ultimately made by HHS, the committee believes that it needs to support a learning health system. Additionally, HHS, working with DoD, should consider providing detailed guidance for stakeholders on the distinctions between quality improvement and research, including discussion of appropriate governance and oversight specific to trauma care (e.g., the continuum of combat casualty care, and prehospital and mass casualty settings).

Reporting on performance data and practice variation can drive the adoption of evidence-based trauma care practices by enabling comparison across centers and systems and identifying practices and design elements that are associated with superior performance. Although mechanisms currently exist that allow comparison across trauma centers, there are no

Suggested Citation:"Summary." 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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mechanisms in place to enable comparison across systems for prehospital care or regional trauma systems.

Recommendation 9: All military and civilian trauma systems should participate in a structured trauma quality improvement process.

The following steps should be taken to enable learning and improvement in trauma care within and across systems:

  • The Secretary of HHS, the Secretary of Defense, and the Secretary of the VA, along with their private-sector and professional society partners, should apply appropriate incentives to ensure that all military and civilian trauma centers and VA hospitals participate in a risk-adjusted, evidence-based quality improvement program (e.g., ACS TQIP, Vizient).
  • To address the full continuum of trauma care, the American College of Surgeons should expand TQIP to encompass measures from point-of-injury/prehospital care through long-term outcomes, for its adult as well as pediatric programs.
  • The Center for Medicare & Medicaid Innovation should pilot, fund, and evaluate regional, system-level models of trauma care delivery from point of injury through rehabilitation.

Learning from the military experience, the greatest opportunity to save lives is in the prehospital setting, and the integration of prehospital care into the broader trauma care system is needed to ensure the delivery of optimal trauma care across the health care continuum, best understand the impact of trauma care, and recognize and address gaps and requirements to prevent deaths after injury. Because emergency medical services (EMS) is not currently a provider type designated under the Social Security Act, HHS does not link the emergent medical care delivered out of hospital to value-based payment or other current health care reform efforts. As a result, EMS continues to be a patchwork of systems across the nation with differing standards of care, few universal protocols, and perverse payment standards, yielding inconstant quality of care and variable patient outcomes. Such a system is not optimally designed to serve as a training platform for the military during interwar periods.

Recommendation 10: Congress, in consultation with the U.S. Department of Health and Human Services, should identify, evaluate, and implement mechanisms that ensure the inclusion of prehospital care (e.g., emergency medical services) as a seamless component of health care delivery rather than merely a transport mechanism.

Suggested Citation:"Summary." 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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Possible mechanisms that might be considered in this process include, but are not limited to:

  • Amendment of the Social Security Act such that emergency medical services is identified as a provider type, enabling the establishment of conditions of participation and health and safety standards.
  • Modification of CMS’s ambulance fee schedule to better link the quality of prehospital care to reimbursement and health care delivery reform efforts.
  • Establishing responsibility, authority, and resources within HHS to ensure that prehospital care is an integral component of health care delivery, not merely a provider of patient transport. The existing Emergency Care Coordination Center could be leveraged as a locus of responsibility and authority (see Recommendation 4) but would need to be appropriately resourced and better positioned within an operational division of HHS to ensure alignment of trauma and emergency care with health delivery improvement and reform efforts.
  • Supporting and appropriately resourcing an EMS needs assessment to determine the necessary EMS workforce size, location, competencies, training, and equipping needed for optimal prehospital medical care.

Building Training Platforms to Ensure a Ready and Expert Trauma Care Workforce

Under current circumstances, it is impossible to maintain the readiness of an expert military trauma care workforce, especially during periods between wars. The Military Health System simply does not experience the clinical volume of trauma cases during interwar periods to allow trauma teams to acquire and maintain expertise in trauma care. There appears to be no credible plan in place for remedying this situation, which virtually ensures that wounded service members in a future war will, at least for a time, have worse outcomes than would have been achieved with full readiness. The committee was struck by a statement made by General Peter Chiarelli, former Vice Chief of Staff for the U.S. Army, during its July 2015 meeting:

We are going to repeat the same mistakes we have made before. We are going to think our doctors are trained. They are not going to be trained. You have just got to pray your son or daughter or granddaughter is not the first casualty of the next war. Pray they come in at about the year five mark. (Chiarelli, 2015)

Suggested Citation:"Summary." 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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The best clinical outcomes are achieved by trauma teams that care for trauma patients on a daily basis. In much the same way that military line leadership trains for combat constantly, military trauma teams need to regularly take care of actual trauma patients to ensure the highest quality of care for combat casualties. An expert military trauma workforce needs to be built and sustained to achieve trauma care capabilities defined by DoD—specifically, the Joint Capabilities and Integration Development System—as necessary to the success of its wartime mission. To this end, it will be necessary to establish trauma-specific career paths with defined standards for competency, and to achieve increased integration of the military and civilian trauma systems.

Recommendation 11: To ensure readiness and to save lives through the delivery of optimal combat casualty care, the Secretary of Defense should direct the development of career paths for trauma care (e.g., foster leadership development, create joint clinical and senior leadership positions, remove any relevant career barriers, and attract and retain a cadre of military trauma experts with financial incentives for trauma-relevant specialties). Furthermore, the Secretary of Defense should direct the Military Health System to pursue the development of integrated, permanent joint civilian and military trauma system training platforms to create and sustain an expert trauma workforce.

Specifically, within 1 year, the Secretary of Defense should direct the following actions:

  • Ensure the verification of a subset of military treatment facilities (MTFs) by the American College of Surgeons as Level I, II, or III trauma centers where permanently assigned military medical personnel deliver trauma care and accumulate relevant administrative experience every day, achieving expert-level performance. The results of a needs assessment should inform the selection of these military treatment facilities, and these new centers should participate fully in the existing civilian trauma system and in the American College of Surgeons’ TQIP and National Trauma Data Bank.
  • Establish and direct permanent manpower allocations for the assignment of military trauma teams representing the full spectrum of providers of prehospital, hospital, and rehabilitation-based care to civilian trauma centers. Provision should be made for these teams to obtain experience in prehospital care, burn care, pediatric trauma, emergency general surgery, and other aspects of trauma care across the system.
Suggested Citation:"Summary." 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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  • Identify the optimum placement of these teams based on criteria determined by the DHA including but not limited to volume, severity, diversity, and quality-of-care outcomes of trauma patients at the civilian trauma centers, as well as the required number of teams as determined by a comprehensive DoD assessment.
  • Develop and sustain a research portfolio focused on optimizing mechanisms by which all (active duty, Reserve, and National Guard) military medical personnel acquire and sustain expert-level performance in combat casualty care, to include research on evolving training modalities and technologies (e.g., simulation, telemedicine).
  • Hold the DHA accountable for standardizing the curricula, skill sets, and competencies for all physicians, nurses, and allied health professionals (e.g., medics, technicians, administrators). The development of these curricula, skill sets, and competencies should be informed by data from the DoD Trauma Registry and DoD-developed clinical practice guidelines (including tactical combat casualty care and JTS guidelines); best civilian trauma care practices, outcomes, and data; and professional organizations representing the full spectrum of the military trauma care workforce. The JTS should validate these curricula, skill sets, and competencies.

CONCLUSION

In studying the performance of the military trauma care system and its learning capacity, the committee found a cup far more than half full. Indeed, other sectors of care, military and civilian alike, would do well to take lessons from the extraordinary history of progress in combat casualty care—but also its failures. It is time for the nation to improve its approach to trauma care. If the current course of trauma care continues, the consequences will be dire for tens of thousands of trauma patients who deserve, and could have, better outcomes (Hashmi et al., 2016; Kwon et al., 2014).

In its work on learning health systems (IOM, 2013), the IOM has provided a useful template for redesign that can enable a much better trauma care system. In its albeit-isolated examples of success in the field, the Military Health System has shown not only what is possible, but also how it can be accomplished. The next steps recommended by the committee would replace these isolated examples with a comprehensive learning system. The key requirements for doing so are known: stronger and more consolidated leadership; clearer, bolder aims; much more comprehensive and more usable data and information systems; support for innovation through increased research investment; continuing emphasis on local knowledge and capacity; and much higher and more consistent levels of cooperation within the military, between the military and civilian sectors, and across the nation. Of

Suggested Citation:"Summary." 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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key importance to the military’s readiness mission, progress will require a paradigm shift that entails seeing military and civilian trauma care as tightly interconnected—not two systems, but one.

The problem is of such magnitude and the current systems are so fragmented that the committee believes action and leadership are needed at the highest levels of the White House, as well as across HHS, DoD, the VA, DOT, and DHS. History has shown that anything less will fail to realize the goal—ambitious but achievable—articulated by the committee during the course of this study: zero preventable deaths after injury and minimal trauma-related disability for those the nation sends into harm’s way in combat and indeed, for every American.

REFERENCES

Chiarelli, P. W. 2015. MCRMC health care recommendations summary. Paper presented at the Committee on Military Trauma Care’s Learning Health System and Its Translation to the Civilian Sector, Meeting Two, July 23-24, Washington, DC.

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Suggested Citation:"Summary." 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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Suggested Citation:"Summary." 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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Suggested Citation:"Summary." 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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Suggested Citation:"Summary." 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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Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 8
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 9
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 10
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 11
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 12
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 13
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 14
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 15
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 16
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 17
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 18
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 19
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 20
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 21
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 22
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 23
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 24
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 25
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 26
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 27
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 28
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 29
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 30
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 31
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 32
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 33
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. doi: 10.17226/23511.
×
Page 34
Next: Part I: Introduction, Overview, and Framework »
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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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