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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8 A Vision for a National Trauma Care System
8 A Vision for a National Trauma Care System
Pages 339-380
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From page 339... ...
This chapter presents the committee's recommendations for a national trauma care system that would simultaneously support a ready military trauma care capability and establish systematic processes for the transfer of knowledge between the military and civilian sectors. THE NEED FOR COORDINATED MILITARY AND CIVILIAN TRAUMA CARE SYSTEMS Trauma care in the military and civilian sectors is a portrait of c ontradiction -- lethal contradiction.
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From page 340... ...
However, the committee found that although many of the individual components of a learning system are in place, the full potential of such a system is not being realized in either the military or the civilian sector, and the contradiction between excellence and striking results in pockets of military and civilian trauma care on the one hand and gaps in consistency, clarity, and leadership on the other has deadly implications. Thousands or more lives could likely be saved over the course of future wars if military trauma care were improved (Eastridge et al., 2012)
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Key decision makers in the line of command lack the knowledge, skills, clarity of responsibility, and perspective to address problems in the trauma care system. • Presently, most military trauma care teams are not ready to provide the highest-quality care to wounded service members.
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A VISION FOR A NATIONAL TRAUMA CARE SYSTEM Given the significant burden of traumatic injury, it is in the nation's best interest to implement a new collaborative paradigm between military and civilian trauma systems, thus ensuring that the lessons learned over the course of the wars in Afghanistan and Iraq are not lost. Though tenuous, there now exists a military trauma system built on a learning system framework and an organized civilian trauma system well positioned to assimilate the recent wartime trauma lessons learned and to serve as a repository and incubator for innovation in trauma care during interwar periods.
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A national trauma care system would need to be grounded in sound learning health system principles (IOM, 2013) applied across the full continuum of care, from point of injury to definitive care, rehabilitation, and beyond.
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Thus, a national approach to trauma care also further readies our civilian trauma and emergency response systems for disasters and other mass casualty incidents. The benefits of a national trauma care system are myriad (see Box 8-1)
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• Economics: Reduced redundancies at multiple levels and opportunities to reduce costs and achieve economies of scale by leveraging each system's resources more effectively, including more effective asset management and identification of shared gaps to target research funding. • Readiness: Promote patriotism among civilian health care stakeholders as they engage with the Military Health System to ensure readiness through the develop ment of shared services (trauma centers in the United States and abroad [e.g., Landstuhl Regional Medical Center]
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and to ensure a national trauma response capability for all intentional and unintentional mass casualty incidents, high-level executive branch leadership will be needed in catalyzing processes for improving civilian trauma care and the exchange of trauma care knowledge between the military and civilian sectors. One key step would be for a presidentially authorized body or process to declare national aims for improving the processes and outcomes of trauma care, and then to support the convening, planning, and monitoring efforts necessary to achieve those aims.
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mass casualty incident; and • strategically communicating the value of a national trauma care system. Military Leadership Military trauma care has made substantial advances, but the committee found that many of these advances have occurred not because of formal leadership, but despite the absence of clear leadership.
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fail to hold service and line leadership accountable for the standards of medical care provided and for combat casualty care outcomes. The result is a military trauma care system that functions largely independently from line understanding and without the stability, standardization, and resources that would allow it to deliver on the nation's promise to its men and women sent into combat: that the trauma care they receive will be the best in the world, regardless of when and where they are injured -- in short, that preventable deaths after injury from combat and military service will be avoided, from the first to the last casualty.
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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, creat ing 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 uni fied 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 im prove the quality of trauma care.
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. During the interwar period, the JTS could function and hone its mission by reviewing and managing the thousands of nonbattle injuries that are seen every year within the Military Health System.
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The committee recommends HHS as the lead actor based on its conviction that the improvement and optimization of civilian trauma systems spanning the continuum of care can be accomplished only if the entire system is organized within a framework of health care delivery. Trauma care is unquestionably linked to the arenas of public safety and emergency management, and DHS and DOT both are important stakeholders engaged in trauma and emergency care; however, their foci are too narrow to encompass trauma care in its entirety.
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, to jointly define a framework for the recommended national trauma care system, including the desig nation of stakeholder roles and responsibilities, authorities, and accountabilities; • developing a national approach to improving care for trauma pa tients, to include standards of care and competencies for prehospi tal 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 tech nology 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 (inten tional 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)
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A beneficial by-product would be immediate continuous innovation in the learning system generated in pursuit of such aims. AN INTEGRATED MILITARY–CIVILIAN FRAMEWORK FOR LEARNING TO ADVANCE TRAUMA CARE As envisioned by the committee, a national trauma care system encompasses both military and civilian trauma care systems -- thus representing a system of systems.
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-- represents an example of a multidisciplinary organizational structure enabling a state-level collaborative approach to addressing all facets of trauma care delivery including systems of care (e.g., interhospital protocols and patient transfer policies) , data collection, quality improvement, education, and research.
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The recommendations that follow detail actions that can be taken to implement a joint framework that facilitates continuous learning and enables stakeholders to act in a coordinated manner to achieve the vision of an integrated national trauma care system. Potential operationallevel strategies for better integrating military and civilian trauma care are included Appendix C
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• 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.
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Such a platform would require formal conduits for the continuous and seamless exchange of knowledge and innovation between the military and civilian sectors. This system would offer the added benefit of facilitating more timely transfer of military lessons learned and innovations to the civilian sector to help address the nation's tremendous burden of trauma.
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Additionally, more formal processes are needed to encourage joint military–civilian discussion of guidelines so as to en hance bidirectional translation of knowledge and innovation between the two sectors. Recommendation 6: To support the development, continuous refine ment, 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.
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The expansion of this best practice beyond surgeons to include other critical members of the trauma team (e.g., emergency medicine physicians, nurses, medics, technicians) presents opportunities for developing stronger links between military and civilian sectors across all disciplines, facilitating deeper integration in the context of a national trauma care system.
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Models for collaborative research, such as the Major Extremity Trauma Research Consortium (see Box 4-5) , have the potential to yield lifesaving and life-changing advances for severely injured patients in both military and civilian settings but require sustained support.
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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 out comes, 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.
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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.
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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)
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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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Given the urgency of the need, this interagency and cross-agency collaboration should be designed to be as efficient and seamless as possible such that lifesaving prod ucts will be accessible as quickly as possible. • Translation of scientific, regulatory, ethical, and policy lessons learned from trauma research in the military context to the civilian context such that the design of trauma-related research and prod uct development will benefit from deliberations and considerations in the military sector.
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enables comparison across trauma centers, no mechanism currently exists to enable comparison across systems for prehospital care or regional trauma systems as a whole. Conclusion: The absence of a comprehensive, standardized process by which the military and civilian sectors engage in system-level trauma care quality improvement impedes learning, continuous improvement, and the bidirectional translation of best practices and lessons learned.
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Conclusion: A national system-based and patient-centered approach to prehospital trauma care is needed in the civilian sector to incentiv ize improved care delivery, the rapid broad translation of military best practices, reduced provider and system variability, uniform data col lection and performance improvement, and integration with hospital 3 As the VA is a major provider of rehabilitative care for veteran service members who sustained injuries during combat operations, it is important for VA hospitals to participate in trauma system quality improvement processes.
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as a seamless component of health care delivery rather than merely a transport mechanism. 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.
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This investment also must extend to include the education and training of senior line and medical leaders on trauma system concepts as well as the importance of sustaining and continuously improving the military trauma system. When the next military conflict inevitably transpires, there will be little time to reconstruct an optimal combat casualty care capability from a d iminished state of readiness.
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An expert military trauma workforce needs to be developed and sustained to achieve trauma care capabilities defined by DoD -- specifically, the Joint Capabilities Integration and Development System -- as necessary to the success of its wartime mission. Meeting this need will require traumaspecific career paths with defined standards for competency and increased integration of the Military Health System and civilian trauma systems.
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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 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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Further, the selected MTFs should submit data to the American College of Surgeons' National Trauma Data Bank (NTDB) and participate in TQIP,5 thereby ensuring the highest quality of care for all DoD trauma patients, as well as making military trauma data more available for registry-based research in the civilian sector, including cross-sector comparisons.
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The aims of such partnerships would be both to bolster trauma care capacity in those centers during peacetime and to ensure that the embedded trauma teams would be fully ready to function at an expert level at the time of future deployment. To overcome the current lack of standardized training requirements, a joint readiness program could be developed to replace current service-specific training centers, placing military trauma care teams in local civilian trauma centers.
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and is currently developing a needs-based assessment tool that can be used by those regions struggling with this issue.7 The ation n will need to further address this threat if the network of civilian Level I trauma centers is to be successful in training future generations of military trauma care providers. Implications for Prehospital Providers The necessary trauma focus of military medics serves service members on the battlefield well, but during interwar periods, military medics may be assigned to nonmedical duties.
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Permanently assigning military medical per sonnel to civilian trauma centers would remove this barrier.8 5. Brief "just-in-time" rotations usually mean that nurses and physi cians can observe clinical care but not actually perform it.
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7. During interwar periods, the civilian trauma system is the reposi tory of trauma knowledge, expertise, research, and advancement that could be freely exchanged by having military teams embedded at multiple civilian centers, thereby ensuring the highest-quality care at the onset of hostilities.
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Paper presented to the Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector, Meeting Three, Sep tember 16-17, Washington, DC. Branas, C
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Paper commissioned by the Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector. nationalacademies.org/TraumaCare.
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2006. Outcomes after ruptured abdominal aortic aneurysms: The "halo effect" of trauma center designation.
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