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2 Overview of Contemporary Civilian and Military Trauma Systems
Pages 73-118

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From page 73...
... This chapter provides an overview of civilian and military trauma systems in the United States, focusing on structure, process, and variability in patient outcomes. As the structure, organization of services, and capabilities 73
From page 74...
... Furthermore, each system is a dynamic entity, evolving in response to lessons learned, critical review, and changes in the population. As a result, trauma care delivery in the civilian sector occurs in the context of a "system of systems." Although every regional trauma system is unique, certain essential elements should be in place in any civilian or military trauma system to optimize efficiency and effectiveness.
From page 75...
... . The public health approach ensures that a regional trauma system is not merely a cluster of emergency services, but a comprehensive, organized structure for care of all injured patients within a defined geographic region.
From page 76...
... This approach ensures that all system components meet or exceed predescribed standards of care and adhere to evidence-based clinical practice guidelines. Absent statutory authority or rules, there would be nothing to prevent a hospital -- any hospital -- from calling itself a trauma center, nor would there be any means of ensuring that an ambulance can bypass a closer hospital in favor of direct transport to a center with all the resources needed to provide a patient with immediate and effective trauma care (Eastman et al., 2013)
From page 77...
... , and advocacy (e.g., American Trauma Society, Trauma Center Association of America) .1 Trauma System Plan The trauma system, as defined in statute, is best outlined in a trauma system plan that is developed in accordance with the needs of the popula 1  The societies named here are offered as examples and are not intended as a comprehen sive list.
From page 78...
... The sense of system is strong. A tight bond also exists between prehospital personnel and those who work in the trauma centers.
From page 79...
... NHTSA: NHTSA was created in 1966 following passage of the Highway Safety Act and was given the authority to fund improvements to emergency medical services (EMS)
From page 80...
... Periodic evaluation and adjustment of the size and scope of practice of the workforce need to be part of the system-level performance improvement and verification process. Coordinated Injury Prevention Efforts Approximately half of all trauma deaths occur at the scene of the injury or during transport to a hospital (Demetriades et al., 2005)
From page 81...
... Prehospital and En Route Care Trauma centers are at the core of any trauma system, but have limited value in the absence of a strategy for ensuring timely access to the appropriate level of care. Emergency medical services (EMS)
From page 82...
... These linkages are particularly important in coordinating the medical response system with the incident command system in the case of disasters or mass casualty incidents. Definitive Care Facilities At the heart of the trauma system is a network of hospitals or trauma centers that are equipped and staffed to provide definitive care for injuries across the spectrum of severity.
From page 83...
... . Guidelines for establishing the appropriate number, level, and location of trauma centers should be included in the trauma plan, and the lead agency should have the authority to designate trauma centers according to the plan.
From page 84...
... . The committee's discussions with several experts suggested that developing strategies for ensuring the appropriate number and configuration of trauma centers based on population needs may be one of the most important challenges facing trauma systems in the next 5 years.
From page 85...
... Rehabilitation specialists should play a leadership role to ensure that rehabilitation issues are integrated into the overall trauma system plan. Trauma Management Information Systems and Quality Improvement Activities Data on the processes and outcomes of care within a system are critical to ensuring that the system evolves and improves over time.
From page 86...
... Information such as injury patterns, geographic locations of injury, and frequency of injuries identified by a state trauma registry can help target resources for regional and statewide injury prevention programs and special populations, identifying, for example, the need for pediatric trauma centers or burn centers. The National Trauma Data Bank (NTDB)
From page 87...
... . Linking state-level EMS data with the state trauma registry can assist in performance reviews, such as determining time from 911 calls to arrival at appropriate trauma centers, transfer times, and tracking of patients who are transferred more than once or are transferred out of the region or state because of limited resources.
From page 88...
... Early efforts in trauma system development in the United States focused on establishing exclusive networks of highly specialized trauma centers, primarily in urban environments, for treatment of the most severely injured patients. Less attention was paid to integrating into the system other acute care facilities that could care adequately for the majority of less severe injuries.
From page 89...
... The goal of such a system is to serve the population by matching the needs of the injured to the appropriate levels of care, ensuring that the most severely injured are treated in a limited number of specialty centers with sufficient patient volume to maintain quality while minimizing duplication of expensive resources across the system. The American College of Surgeons Committee on Trauma has played a key role in catalyzing the development of inclusive trauma systems, developing a series of documents -- Resources for Optimal Care of the Injured Patient -- that set forth the characteristics and resources that represent the minimal expectations for verification of hospitals as trauma centers at varying levels of care (ACS, 2014)
From page 90...
... found that immediate transport to a Level I trauma center reduced morbidity and mortality for severely injured patients. A greater d ­ egree of integration and involvement of all acute care facilities also benefits patients, being associated with a significantly lower injury-related mortality (Utter et al., 2006)
From page 91...
... Variability in Trauma System Access Nearly 2,000 trauma centers exist nationwide; 2013 estimates from the American Trauma Society suggest there are 213 Level I, 313 Level II, 470 Level III, and 916 Level IV or V centers (Eastman et al., 2013)
From page 92...
... as the accrediting body for trauma centers in Pennsylvania. The PTSF is governed by a multidisciplinary board of stakeholders from state government, hospitals, and emergency medical services (EMS)
From page 93...
... These three elements have guided the PTSF in optimizing care of injured patients throughout Pennsylvania in partnership with trauma centers and other organizations. The PTSF has been successful in ensuring that trauma care is a constant focus of those responsible for delivering health and emergency care in Pennsylvania.
From page 94...
... . These criteria represent an attempt to balance both under- and overtriage, so that patients are taken to an appropriate trauma center, while higher-level trauma centers are not over ­ whelmed with minimally injured patients (Barnett et al., 2013; Newgard et al., 2013)
From page 95...
... The five trauma centers they studied varied dramatically in the level of compliance, from a low of 12 percent to a high of 94 percent. Interhospital variation in risk-adjusted outcomes among trauma patients indicates that the quality of care provided across trauma centers varies as well (Shafi et al., 2009b, 2010)
From page 96...
... When an individual patient received all of the recommended care, he or she was 58 percent less likely to die than a patient who did not. Variability in Emergency Medical Services Systems Like access to and care provided at trauma centers in the United States, the organization and outcomes of the estimated 21,283 EMS systems nationwide vary significantly (FICEMS, 2011)
From page 97...
... emergency medical technicians (EMTs) , the basic level of ambulance provider, who provide comprehensive basic life support care and expertise in extrication, patient lifting and handling, and transportation; (3)
From page 98...
... OVERVIEW OF THE MILITARY'S TRAUMA CARE SYSTEM Just as the sophisticated civilian trauma systems in the United States emerged from the successes and lessons of military trauma care during the wars in Korea and Vietnam, the military has contemporized, expanded, and improved upon principles of civilian trauma system design that evolved over more than 25 years in the period between the end of the Vietnam War and the wars in Afghanistan and Iraq. This section describes the development and features of the military's contemporary system for trauma care delivery -- the Joint Trauma System (JTS)
From page 99...
... There are, however, some basic operational and environmental differences between military and civilian trauma care that impact the way that care is delivered. In the context of military trauma, for example, it is frequently necessary for a patient to receive care at multiple facilities after being wounded, with "life- and limb-preserving care" being provided far forward on the battlefield and at military treatment facilities (MTFs)
From page 100...
... . Depending on the nature of 9  While the American College of Surgeons uses Level I as the highest level of definitive care in the civilian sector, the military uses Role 5 as its highest level of care.
From page 101...
... Army Institute for Surgical Research (Bailey et al., 2012a) , where it provides for ongoing development and maintenance of the military trauma system's support infrastructure, including the DoDTR and performance improvement processes (see Figure 2-7)
From page 102...
... , continued coordination between the JTS and JTAPIC is essential. The JTS is also closely linked to the DoD's combat casualty care research program, informing research priorities based on registry-driven performance improvement data and, on the
From page 103...
... . Distribution of Responsibility for Trauma Care in the Military Mirroring the distribution of leadership across numerous local, state, and federal agencies in the civilian sector, responsibility for the delivery of military trauma care is spread across multiple entities and actors within the DoD (see Figure 2-8)
From page 104...
... NOTE: ASD(HA) = Assistant Secretary of Defense for Health Affairs; DHA = Defense Health Agency; MTF = military treatment facility; USD(P&R)
From page 105...
... Although the DHA has been designated a combat support agency for health and medical operations, the complex overlapping and conflicting authorities among the combatant commands, the Joint Staff, the Secretary of Defense, and the military departments make it extremely difficult to establish reliable joint combat casualty care processes and systems; set and allocate funding for readiness, research, and staffing priorities; and establish a single point of accountability for delivering quality medical services across all combatant commands. Variability in Trauma Systems Across the Military As mentioned previously, the Joint Theater Trauma System is limited to the CENTCOM theater of operations.
From page 106...
... Training Pipeline and Practice at Military Trauma Centers The vast majority of military surgeons, nurses, and medics receive their medical training in the civilian sector. Following graduation, the surgeons undertake residencies in the military or continue their postgraduate training in the civilian sector.
From page 107...
... . Currently, three MTFs are verified as trauma centers by the American College of Surgeons: San Antonio Military Medical Center (SAMMC)
From page 108...
... While SAMMC has the capacity to train only a small percentage of military medical personnel, the training it provides has clear benefits over training in civilian trauma centers or in non-trauma center MTFs. SAMMC's verification as a Level I trauma center and its integration into the regional civilian trauma system enables military physicians, nurses, and medics to attain and sustain expertise in trauma care and to interact, conduct research, and collaborate with civilian trauma care providers -- for example, through the Southwest Texas Regional Advisory Council and the South Texas Research Organizational Network Studies on Trauma and Resilience (STRONG STAR)
From page 109...
... Recognizing this fact, military and civilian leaders in trauma care have developed two collaborative platforms -- the Federal Interagency Committee on Emergency Medical Services (FICEMS) and the Military Health System American College of Surgeons (MHS/ACS)
From page 110...
... MHS/ACS Strategic Partnership The concept behind this partnership, launched in December 2014, emerged from the shared recognition by DoD and the American College of Surgeons of the need for a synergistic and collaborative relationship between the military and civilian sectors to ensure that the next generation of surgeons would be adequately prepared to deliver optimal trauma care to patients (Hoyt, 2015a,c)
From page 111...
... As highlighted in this chapter, however, there is room for improvement in both the military and civilian trauma systems. The implementation of inclusive systems and patient outcomes vary dramatically across both sectors.
From page 112...
... 2005. Access to trauma centers in the United States.
From page 113...
... Paper commissioned by the Committee on Military Trauma Care's Learning Health System and Its Translation to the Civilian Sector. nationalacademies.org/TraumaCare.
From page 114...
... trauma centers. Prehospital Emergency Care 16(2)
From page 115...
... Army surgeons: Another call for collaborative training in civilian trauma centers. Military Medicine 161(3)
From page 116...
... 2010. The North Carolina EMS data system: A comprehensive integrated emergency medical services quality improvement program.
From page 117...
... 2013. The cost of overtriage: More than one-third of low-risk injured patients were taken to major trauma centers.
From page 118...
... 2014. Compliance with recommended care at trauma centers: ­ Association with patient outcomes.


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