Summary

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.

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.

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).

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).

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).

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).

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

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.

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.

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.

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.

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.

• 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.

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

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.

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-

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.

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

federal agencies to coordinate their efforts in the absence of a funded congressional mandate.

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

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.

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

mechanisms in place to enable comparison across systems for prehospital care or regional trauma systems.

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.

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:

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.

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

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.

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