A National Trauma Care System Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury (2016) / Chapter Skim
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Pages 5-34
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From page 5... ...
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. T rauma care in the military and civilian sectors is a portrait of c ontradiction -- lethal contradiction.
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From page 6... ...
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.
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From page 7... ...
Military trauma care, despite its laudable successes, is • inconsistent over time, with significant loss during interwar peri ods of clinical competence and hard-won lessons learned on the battlefield; • inconsistent over space, with many of the key, successful innova tions 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 civil ian 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 medi cal 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 com bined responsibility and authority for maintaining the readiness and ensuring the performance of military trauma care teams and of the system as a whole.
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From page 8... ...
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.
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From page 9... ...
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.
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From page 10... ...
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 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)
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From page 11... ...
Coordinated Performance Improvement and Research to Generate EvidenceBased 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 The American College of Surgeons National Trauma rapid-cycle performance improvement has enabled Data Bank and Trauma Quality Improvement evidence-based improvements to patient care Program have enabled evidence-based processes.
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From page 12... ...
MILITARY SECTOR FINDINGS CIVILIAN SECTOR FINDINGS Ensuring the appropriate expertise of the trauma Sharing of new civilian best trauma care care workforce is impeded by reduced caseloads practices/experiences with the military community during interwar periods, competition for resources is not occurring systematically (and vice versa) , with the beneficiary care mission, reliance on and no national framework has been defined just-in-time training, and a lack of standardized for integrating military best practices into training informed by best practices in military skill building, team building, and certification trauma care (e.g., clinical practice guidelines)
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From page 13... ...
MILITARY SECTOR FINDINGS CIVILIAN SECTOR FINDINGS Patient care is fragmented across the trauma care Patient care is fragmented across the trauma care continuum, and trauma systems do not optimally continuum, and trauma systems do not optimally address the holistic needs of the patient. address the holistic needs of the patient.
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From page 14... ...
MILITARY SECTOR FINDINGS CIVILIAN SECTOR FINDINGS Military trauma care providers lack real-time Trauma quality improvement programs exist for access to their own performance data, although trauma centers but there is no common process in a weekly video teleconference is a means of place for benchmarking safety, quality, processes, obtaining feedback in a timely manner. Few prices, costs, and outcomes of prehospital care military treatment facilities submit data to or whole trauma systems, and for making that a trauma quality improvement program for information available for care improvement and benchmarking purposes, limiting transparency and informed decision making by clinicians, patients, performance improvement across DoD military and their families.
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From page 15... ...
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.
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From page 16... ...
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
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From page 17... ...
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.
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From page 18... ...
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 • Secretary of Defense also should ensure the DHA Director has The the responsibility and authority and is held accountable for defin ing the capabilities necessary to meet the requirements specified by the combatant commanders with regard to expert combat casualty care personnel and system support infrastructure.
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From page 19... ...
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 under resourced for the magnitude of the task: • The Emergency Care Coordination Center (ECCC)
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From page 20... ...
• 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.
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From page 21... ...
. 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.
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From page 22... ...
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 longterm 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.
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From page 23... ...
• 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 incorpo rating long-term outcomes (e.g., patient-centered functional out comes, mortality data at 1 year, cost data)
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From page 24... ...
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.
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From page 25... ...
Ultimately, to close critical gaps in knowledge of optimal trauma care practices and delivery systems, the United States needs a coordinated m ilitary–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.
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From page 26... ...
, 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.
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From page 27... ...
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 misinterpre tation of the regulations through policy statements (i.e., guidance documents)
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From page 28... ...
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, includ ing discussion of appropriate governance and oversight specific to trauma care (e.g., the continuum of combat casualty care, and prehospital and mass casualty settings)
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From page 29... ...
The following steps should be taken to enable learning and improve ment 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)
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From page 30... ...
• Supporting and appropriately resourcing an EMS needs assessment to determine the necessary EMS workforce size, location, compe tencies, 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.
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From page 31... ...
The results of a needs assessment should inform the selection of these military treatment facilities, and these new centers should partici pate 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 as signment of military trauma teams representing the full spectrum of providers of prehospital, hospital, and rehabilitation-based care to civilian trauma centers.
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From page 32... ...
; best civilian trauma care practices, outcomes, and data; and professional organizations representing the full spec trum of the military trauma care workforce. The JTS should vali date these curricula, skill sets, and competencies.
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From page 33... ...
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. DCAS (Defense Casualty Analysis System)
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From page 34... ...
Paper presented to the Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector, Meeting One, May 18-19, Washington, DC. Rasmussen, T
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