Joint Trauma System Research Articles

Joint Trauma System Clinical Practice Guideline: Acute Coronary Syndrome (ACS). 14 May 2021.

Deployed medical providers at all roles of care must be prepared to recognize and manage acute coronary syndrome (ACS). Under optimal conditions, treatment is initiated with medical therapy and may be followed by prompt coronary angiography and revascularization. Emergent percutaneous coronary intervention (PCI) is not available in most deployed locations, however, and the time for such intervention is often dependent on long-range evacuation. This CPG provides guidance on best management for ACS patients in the deployed and resource-constrained environment.

Joint Trauma System Clinical Practice Guideline (JTS CPG): Prehospital Blood Transfusion. 30 October 2020.

This Clinical Practice Guideline (CPG) provides a brief summary of the scientific literature for prehospital blood use, with an emphasis on the en route care environment. Updates include the importance of calcium administration to counteract the deleterious effects of hypocalcemia, minimal to no use of crystalloid, and stresses the importance of involved and educated en route care medical directors alongside at a competent prehospital and en route care providers (see Table 1). With the paradigm shift to use FDA-approved cold stored low titer group O whole blood (CS-LTOWB) along with the operational need for continued use of walking blood banks (WBB) and point of injury (POI) transfusion, there must be focused, deliberate training incorporating the different whole blood options. Appropriate supervision of autologous blood transfusion training is important for execution of this task in support of deployed combat operations as well as other operations in which traumatic injuries will occur. Command emphasis on the importance of this effort as well as appropriate logistical support are essential elements of a prehospital blood program as part of a prehospital/en route combat casualty care system.

An Analysis of Conflicts Across Role 1 Guidelines.

Role 1 care is vital to patient survival and includes many echelons of care from point-of-injury first aid to medical attention at battalion aid stations. Many guidelines are written for Role 1 care providers to optimize care for different scenarios. Differences in the guidelines lead to confusion and discrepancies between the types of treatment medical care providers provide. Although the guidelines were written for different areas of care, uniformity between the guidelines is needed and will lead to a reduced mortality rate. It was determined that the Tactical Combat Casualty Care Guidelines, Prolonged Field Care Guidelines, Joint Trauma System Clinical Practice Guidelines, and Standard Medical Operating Guidelines from medical evacuation were the military medical guidelines most relevant to Role 1 care. These Guidelines were compared side by side to determine the differences between them. Although the guidelines were largely similar, many major differences were found between them. Our online tables contain large inconsistences between guidelines including direct contradictions in conversion of junctional tourniquets and the administration of tranexamic acid. Role 1 care is vital to patient survival, including care from point of injury to battalion aid stations, but the guidelines available to instruct this care and the guidance on which personnel should provide this care are conflicting. This lack of clarity and consistency may adversely impact treatment outcomes. The reduction or elimination of conflicting information across the various guidelines, augmentation of guidance for pediatric care, more specific guidance for unique levels of care, and clearer delineation of the Role 1 phases of care (as well as which guidelines are most appropriate to each) should be considered as urgent priorities within the military medical community.

Time to weigh in on obesity and associated comorbidities in combat-wounded amputees.

The Joint Trauma System database estimates that about 1,200 individuals have sustained a combat-related amputation during the Global War on Terror. Previous retrospective studies have demonstrated that combat-related amputees develop obesity and cardiovascular disease, but the incidence of obesity and associated comorbidities in this population is unknown. The objectives of this study are to determine the prevalence of obesity in the military amputee population and to compare this with the general population. This is a retrospective review of 978 patients who sustained a combat-related amputation from 2003 to 2014. Prevalence of obesity and comorbid conditions were determined. A multivariate logistic regression model was performed to identify risk factors for postamputation obesity. Kaplan-Meier curves were constructed using obesity as the event of interest. A total of 1,233 charts were reviewed with 978 patients included for analysis. The median age of injury was 24 years. Median follow-up time was 8.7 years, ranging from 0.5 years to 16.9 years. The average Injury Severity Score was 23.3. The average body mass index preinjury was 25.6 kg/m2, and the average most recent corrected body mass index was found to be 31.4 kg/m2. Prevalence of comorbidities was higher in the amputee population. Fifty percent of patients who progressed to obesity did so within 1.3 years. There is a notable prevalence of obesity that develops in the amputee population that is much higher than the general population. We determined that the amputee population is at risk, and these patients should be closely monitored for 1 to 2.5 years following injury. This study provides a targeted period for which monitoring and intervention can be implemented. Retrospective, basic science, outcomes analysis, level III/IV.

Military Teleophthalmology in Afghanistan Using Mobile Phone Application

The coronavirus disease 2019 pandemic has highlighted the need to expand telemedicine solutions. To beta test a secure teleophthalmology mobile app at military treatment facilities in Afghanistan. This prospective case series included 16 military treatment facilities at diverse roles of care including forward operating bases in Afghanistan and 1 location outside of Afghanistan. Thirty point-of-care medics and medical professionals were included from September to November 2019. Users placed teleophthalmology consults on their mobile phone using the mobile eye care app, and an expeditionary ophthalmologist stationed at a military hospital in Afghanistan responded. Users graded the mobile app using a rating scale from 1 to 5, with 1 being very dissatisfied and 5 being very satisfied. Mean initial response time, agreement between the teleophthalmology diagnosis and final diagnosis, treatment and management following recommendations outlined in the Joint Trauma System clinical practice guidelines, prevention of the need for aeromedical evacuation, user satisfaction, and security and the Health Insurance Portability and Accountability Act compliance of consult. There were 28 consults placed over 6 weeks by 18 different users that were received by the expeditionary ophthalmologist. The mean (SD) patient age was 30.3 (9.8) years. Most patients were male (26 [93%]) and active duty US military (22 [78%]). The mean initial response time was 3 minutes 58 seconds (95% CI, 2 minutes 30 seconds to 5 minutes 26 seconds). There was agreement between the teleophthalmology diagnosis and final diagnosis in 24 consults (86%; 95% CI, 72%-100%). The treatment and management followed recommendations outlined in the Joint Trauma System Clinical Practice Guidelines for Eye Trauma: Initial Care in 28 consults (100%). Teleophthalmology consultation prevented the need for aeromedical evacuation in 4 consults (14%; 95% CI, 0.7%-28%). The patient returned to duty in 15 consults (54%; 95% CI, 34%-73%). Median overall satisfaction was 5 (minimum, 3; maximum, 5). All 28 consults (100%) were secure and compliant with the Health Insurance Portability and Accountability Act. While only a limited number of consults were evaluated, this study suggests that teleophthalmology mobile phone apps may improve and extend ophthalmic care in combat zones.

Combat Facial Fractures Sustained During Operation Resolute Support and Operation Freedom's Sentinel in Afghanistan.

Facial fractures sustained in combat are generally unrepresentative of those commonly experienced in civilian practice. In the US military, acute trauma patient care is guided by the Joint Trauma System Clinical Practice Guidelines but currently none exists for facial trauma. All casualties that underwent surgery to facial fractures between January 01, 2016 and September 15, 2019 at a US deployed Military Treatment Facility in Afghanistan were identified using the operating room database. Surgical operative records and outpatient records for local Afghan nationals returning for follow-up were reviewed to determine outcomes. 55 casualties underwent treatment of facial fractures; these were predominantly from explosive devices (27/55, 49%). About 46/55 (84%) were local nationals, of which 32 (70%) were followed up. Length of follow-up ranged between 1 and 25months. About 36/93 (39%) of all planned procedures developed complications, with the highest being from ORIF mandible (18/23, 78%). About 8/23 (35%) casualties undergoing ORIF mandible developed osteomyelitis, of which 5 developed nonunion. Complications were equally likely to occur in those procedures for "battlefield type" events such as explosive devices and gunshot wounds (31/68, 46%) as those from "civilian type" events such as falls or motor vehicle collisions (5/11, 45%). Complications Rates from facial fractures were higher than that reported in civilian trauma. This likely reflects factors such as energy deposition, bacterial load, and time to treatment. Load sharing osteosynthesis should be the default modality for fracture fixation. External fixation should be considered in particular for complex high-energy or infected mandible fractures where follow-up is possible.

Predicting the Outcome of Limb Revascularization in Patients With Lower-extremity Arterial Trauma: Development and External Validation of a Supervised Machine-learning Algorithm to Support Surgical Decisions.

Estimating the likely success of limb revascularization in patients with lower-extremity arterial trauma is central to decisions between attempting limb salvage and amputation. However, the projected outcome is often unclear at the time these decisions need to be made, making them difficult and threatening sound judgement. The objective of this study was to develop and validate a prediction model that can quantify an individual patient's risk of failed revascularization. A BN prognostic model was developed using domain knowledge and data from the US joint trauma system. Performance (discrimination, calibration, and accuracy) was tested using ten-fold cross validation and externally validated on data from the UK Joint Theatre Trauma Registry. BN performance was compared to the mangled extremity severity score. Rates of amputation performed because of nonviable limb tissue were 12.2% and 19.6% in the US joint trauma system (n = 508) and UK Joint Theatre Trauma Registry (n = 51) populations respectively. A 10-predictor BN accurately predicted failed revascularization: area under the receiver operating characteristic curve (AUROC) 0.95, calibration slope 1.96, Brier score (BS) 0.05, and Brier skill score 0.50. The model maintained excellent performance in an external validation population: AUROC 0.97, calibration slope 1.72, Brier score 0.08, Brier skill score 0.58, and had significantly better performance than mangled extremity severity score at predicting the need for amputation [AUROC 0.95 (0.92-0.98) vs 0.74 (0.67-0.80); P < 0.0001]. A BN (https://www.traumamodels.com) can accurately predict the outcome of limb revascularization at the time of initial wound evaluation. This information may complement clinical judgement, support rational and shared treatment decisions, and establish sensible treatment expectations.

Practical Considerations for a Military Whole Blood Program.

Prehospital care in the combat environment has always been of great importance to the U.S. military, and trauma resuscitation has remained a cornerstone. More evidence continues to demonstrate the advantages of intervention with early transfusion of blood products at the point of injury. The military has recognized these benefits; as such, the Department of Defense Joint Trauma System and the Committee on Tactical Combat Casualty Care have developed new advanced resuscitation guidelines, which now encourage the use of whole blood (WB) in the prehospital setting. This general review of peer-reviewed journal articles was performed through an extensive electronic search from the databases of PubMed Central (MEDLINE) and the Cochrane Library. Based on this literature search, the current evidence suggests that transfusion with WB is safe and efficacious. Additionally, soldier function is preserved after donating fresh WB in the field. Currently, the collection and implementation of WB is accomplished through several different protocol-driven techniques. WB has become the favored transfusion product as it provides all of the components of blood in a convenient package that is easy to store and transport. Specifically, group O WB containing low titers of anti-A and -B antibodies has become the transfusion product of choice, offering the ability to universally fluid resuscitate patients despite not knowing their blood group. This new ability to obtain low titer group O WB has transformed the approach to the management of hemorrhagic shock in the prehospital combat environment.

Establishing an enduring Military Trauma Mortality Review: Misconceptions and lessons learned.

Under direction from the Defense Health Agency, subject matter experts (SMEs) from the Joint Trauma System, Armed Forces Medical Examiner System, and civilian sector established the Military Trauma Mortality Review process. To establish the most empirically robust process, these SMEs used both qualitative and quantitative methods published in a series of peer-reviewed articles over the last 3 years. Most recently, the Military Mortality Review process was implemented for the first time on all battle-injured service members attached to the United States Special Operations Command from 2001 to 2018. The current Military Mortality Review process builds on the strengths and limitations of important previous work from both the military and civilian sector. To prospectively improve the trauma care system and drive preventable death to the lowest level possible, we present the main misconceptions and lessons learned from our 3-year effort to establish a reliable and sustainable Military Trauma Mortality Review process. These lessons include the following: (1) requirement to use standardized and appropriate lexicon, definitions, and criteria; (2) requirement to use a combination of objective injury scoring systems, forensic information, and thorough SME case review to make injury survivability and death preventability determinations; (3) requirement to use nonmedical information to make reliable death preventability determinations and a comprehensive list of opportunities for improvement to reduce preventable deaths within the trauma care system; and (4) acknowledgment that the military health system still has gaps in current infrastructure that must be addressed to globally and continuously implement the process outlined in the Military Trauma Mortality Review process in the future. LEVEL OF EVIDENCE: Level III.

How the Implementation of a Battlefield Clinical Practice Guideline Affects Documentation Practice and Informs Future Research Initiatives: Spinal Injuries and Cervical Collars

In 2010, the Joint Trauma System published a clinical practice guideline (CPG) for providing care to patients with suspicion of spinal cord injury. The CPG advocated for liberal use of cervical collars and adequate documentation of the practice. This performance improvement project examined C-spine CPG adherence in both the prehospital and military treatment facility (MTF) settings. Understanding challenges in CPG adherence facilitates evaluation of future CPGs and their success at implantation of the clinical guidance. The Department of Defense Trauma Registry was used to identify US Military casualties meeting the criteria for cervical collar placement between January 1, 2007 and December 31, 2018. Criteria for cervical collar placement were defined as any patient who experienced a mechanism of injury relating to an explosion, fall, or motor-vehicle-related injury. Any patients with an AIS severity score greater than 1 to the head or having any ICD injury codes related to either upper spinal cord or head injury were also considered for inclusion. Adherence of cervical collar placement was defined by documented ICD codes or prehospital documentation of cervical collar placement as captured in the registry. A total of 14,837 patients were identified for possible cervical collar placement and 3,317 had verifiable documentation of having a C-collar placed. Documented C-collar placement was higher after the publication of the clinical practice guideline in 2010 (29% vs. 15%, p<0.0001). CPG publication was associated with cervical collar application (odds ratio: 2.50, 95% CI: 2.29-2.72). Application of cervical collars has increased significantly, since the initial publication of the spine injury CPG. Current gaps include valid and reliable identification of patients warranting specific clinical interventions and documentation of patient care. Currently, lack of documentation is reported as nonadherence, but it remains unknown if these missing clinical data accurately portray nonadherence or adherence with lack of documentation. Future research and resources would benefit and expand the results collected in this paper, and cement the importance of CPG publication and adherence.

557 Use of Online Clinical Guidelines for Burn Care in the Deployed Environment: A Model for Care in Rural or Remote Locations

Abstract Introduction During the last decade, our national Joint Trauma System (JTS) has served as the reference body for trauma care throughout our military. The JTS has published 63 Clinical Practice Guidelines (CPGs) on its website to set standards and to provide guidance for deployed providers in the management of challenging clinical scenarios. Given that there is limited burn expertise in the military, the JTS CPGs are a major source of information for most providers. It has been possible to track CPG download activity for over a year. We hypothesized that assessment of download activity would reflect the relative value of JTS CPGs. In particular, we aimed to document the value of burn-related CPGs. Methods Download activity was determined from data pulled for jts.amedd.army.mil, utilizing Google’s Digital Analytics Program (DAP), for 27 Feb 2018 to 3 Sep 2019. After refining results from all of the military down to jts.amedd.army.mil, a search was then launched to determine the top activities on the JTS webpage. An additional refinement was conducted to establish search-date parameters. Data were exported into an Excel spreadsheet for further analysis. The data were analyzed for specific titles and numbers of downloads; those downloads consistently appearing at the top of the download activity were split out and detailed. Results Downloading was consistently the top “event” or tangible action on the site. In 17 months, total CPG downloads from the JTS website were 75,901. Burn-related CPGs and supporting documents (e.g. Lund-Browder chart; resuscitation flowsheet) were downloaded 6,177 times. The next most frequently downloaded CPG was the traumatic brain injury (TBI) CPG, which was downloaded 6,041 times. If each guideline had equal distribution of downloads, they would each be downloaded 1,205 times; burn-related CPGs were download 5 times more frequently than the mean. Conclusions This study emphasizes the importance of burn-related CPGs to providers throughout the global continuum of care. These providers frequently work in expeditionary, remote and austere environments without rapid access to specialty surgical expertise. The use of detailed CPGs can help bridge this gap. Applicability of Research to Practice This model can be used for remote rural areas nationally and internationally. Computer-based tracking of CPG and educational material downloads can, furthermore, be used to identify ongoing educational needs.

Quality Assurance in Tactical Combat Casualty Care for Medical Personnel Training 16 April 2020.

At present, however, there is no systematic, comprehensive quality assurance program for TCCC training throughout the DoD. Individual courses and instructors may or may not use all of the materials in the JTS-approved curriculum; they may or may not add content that is not part of the JTS curriculum; and they may or may not add additional training in the form of advanced simulation, hands-on training with moulaged casualties, graded trauma lanes, or live-tissue training. A recent pilot appraisal of four Tactical Combat Casualty Care for Medical Personnel (TCCC-MP) training courses found that TCCC-MP courses are not presenting all of the course material recommended by the Joint Trauma System (JTS), despite TCCC training having been mandated by the Department of Defense (DoD) for all US military personnel. Some of the omitted material is essential to ensuring that students are fully prepared to perform TCCC on the battlefield. Further, there was incorrect messaging presented in the TCCC-MP courses that were appraised, some of which, if actually reflected in the care provided on the battlefield, would likely result in adverse casualty outcomes. Other aspects of the TCCC messaging presented in the appraised courses that is not at present part of the JTS-approved curriculum might, however, be appropriate for inclusion into the TCCC Guidelines and the course curriculum. Examples of material that should be considered for incorporation into the TCCC curriculum include modifying the method of tranexamic acid (TXA) administration (slow IV push vs the currently recommended 10-minute infusion) and a better technique for securing of the new CAT Generation 7 tourniquets after application. The course appraiser also noted that there were a number of excellent videos of actual TCCC interventions being performed that are not part of the current JTS-approved TCCC-MP curriculum. These videos should be forwarded to CoTCCC staff and the Joint Trauma Education and Training (JTET) branch of the JTS for consideration as potential additions to the TCCC-MP curriculum. Consideration should also be given to the inclusion of additional TCCC training modalities such as advanced simulators, moulaged casualties, graded trauma lanes, autologous blood transfusion training, and the use of live-tissue training (when logistically feasible) for selected course items such as surgical airways. Further, the 16-hour training time currently allotted for TCCC-MP training was found to be insufficient to present all of academic material and testing contained in the existing TCCC-MP curriculum. A 5-day course should be considered to include the entire JTS-recommended curriculum and to add graded trauma lanes and autologous blood transfusion training to the core JTS TCCC-MP curriculum. The post-course written testing also needs to use the standardized TCCC fund of knowledge questions and the TCCC Critical Decision Case Study questions developed by the JTS. Finally, there is a need to establish a systematic and standardized quality assurance program to ensure that TCCC training programs are carried out in accordance with the JTS-recommended TCCC curriculum. This program would best be performed as a new function of the CoTCCC with dedicated TCCC course appraisers.

Airway Management in Prolonged Field Care.

This Role 1, prolonged field care (PFC) clinical practice guideline (CPG) is intended to be used after Tactical Combat Casualty Care (TCCC) Guidelines, when evacuation to higher level of care is not immediately possible. A provider must first and foremost be an expert in TCCC, the Department of Defense standard of care for first responders. The intent of this PFC CPG is to provide evidence and experience-based solutions to those who manage airways in an austere environment. An emphasis is placed on utilizing the tools and adjuncts most familiar to a Role 1 provider. The PFC capability of airway is addressed to reflect the reality of managing an airway in a Role 1 resource-constrained environment. A separate Joint Trauma System CPG will address mechanical ventilation. This PFC CPG also introduces an acronym to assist providers and their teams in preparing for advanced procedures, to include airway management.

Joint Trauma System Clinical Practice Guideline: Austere Resuscitative and Surgical Care - 30 October 2019.

Joint Trauma System Clinical Practice Guideline: Austere Resuscitative and Surgical Care - 30 October 2019.

Application of the Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium in a Combat Support Hospital in Iraq.

The 2017 Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium (JTS CPG) provides an evidence-based framework for managing pain, anxiety, and delirium in combat settings. In this study, we evaluate the use of multimodal analgesia and assess pain outcomes, as indicated by the JTS CPG, at the combat support hospital (CSH). In this quality improvement project, data were collected for all patients, presenting to the CSH in Baghdad, Iraq, who received consultation from the acute pain service from October 10, 2017 to February 27, 2018. Univariate analyses described patient demographic and clinical characteristics. Defense and Veterans Pain Rating Scale (DVPRS) scores, physical therapy completion, and sleep duration were recorded for each patient daily. Correlations assessed relationships between variables, including clinical characteristics and DVPRS scores. 34 patients were included in this study. About 65% of the patients included in this study were Iraqi military, while the other 35% were U.S. or Coalition Forces. Over half received more than one class of analgesic medication. The majority of patients received regional anesthesia, with 17 different techniques utilized. The DVPRS had acceptable internal consistency (Cronbach alpha=0.87, 95% CI 0.80, 0.95). There was a significant difference in median DVPRS pain intensity scores between those who met physical therapy goals and those who did not. Sleep duration was negatively correlated with both the DVPRS pain intensity and sleep scores. This report indicates that acute pain service teams integrated in a CSH can feasibly implement JTS CPGs using a team-based approach. Given the military's emphasis on managing complex pain and disability among survivors beginning in the combat environment, it is imperative that innovations and best practices, like the JTS CPG, be assessed in the combat setting.

Forward Surgical Team Procedural Burden and Non-operative Interventions by the U.S. Military Trauma System in Afghanistan, 2008-2014.

No published study has reported non-surgical interventions performed by forward surgical teams, and there are no current surgical benchmarks for forward surgical teams. The objective of the study was to describe operative procedures and non-operative interventions received by battlefield casualties and determine the operative procedural burden on the trauma system. This was a retrospective analysis of data from the Joint Trauma System Forward Surgical Team Database using battle and non-battle injured casualties treated in Afghanistan from 2008-2014. Overall procedure frequency, mortality outcome, and survivor morbidity outcome were calculated using operating room procedure codes grouped by the Healthcare Cost and Utilization Project classification. Cumulative attributable burden of procedures was calculated by frequency, mortality, and morbidity. Morbidity and mortality burden were used to rank procedures. The study population was comprised of 10,992 casualties, primarily male (97.8%), with a median age interquartile range of 25.0 (22.0-30.0). Affiliations were non-U.S. military (40.0%), U.S. military (35.1%), and others (25.0%). Injuries were penetrating (65.2%), blunt (32.8), and burns (2.0%). Casualties included 4.4% who died and 14.9% who lived but had notable morbidity findings. After ranking by contribution to trauma system morbidity and mortality burden, the top 10 of 32 procedure groups accounted for 74.4% of operative care, 77.9% of mortality, and 73.1% of unexpected morbidity findings. These procedure groups included laparotomy, vascular procedures, thoracotomy, debridement, lower and upper gastrointestinal procedures, amputation, and therapeutic procedures on muscles and upper and lower extremity bones. Most common non-operative interventions included X-ray, ultrasound, wound care, catheterization, and intubation. Forward surgical team training and performance improvement metrics should focus on optimizing commonly performed operative procedures and non-operative interventions. Operative procedures that were commonly performed, and those associated with higher rates of morbidity and mortality, can set surgical benchmarks and outline training and skillsets needed by forward surgical teams.

Antimicrobial Stewardship Challenges in the Deployed Setting.

Up to 34% of combat trauma injuries are complicated by infection with multidrug-resistant organisms. Overutilization of antibiotics has been linked to increased multidrug-resistant organisms in combat-injured patients. Antimicrobial stewardship efforts at deployed medical treatment facilities have been intermittently reported; however; a comprehensive assessment of antimicrobial stewardship practices has not been performed. A survey tool was modified to include detailed questions on antimicrobial stewardship practices at medical treatment facilities. A Joint Service, multidisciplinary team conducted on-site assessments and interviews to assess the status of antimicrobial stewardship best practices, with particular emphasis on antibiotic prophylaxis in combat injured, in the U.S. Central Command operational theaters. Limitations to implementing stewardship to the national standards were explored thematically. Nine Role 1, 2, and 3 medical facilities representing the range of care were assessed on-site. A total of 67% of the sites reported a formal antimicrobial stewardship program and 56% of the sites had an assigned head of antimicrobial stewardship. No military personnel in theater received training on antimicrobial stewardship and laboratory assets were limited. Personnel at these sites largely had access to Joint Trauma System guidelines describing antimicrobial prophylaxis for combat injured (89%), yet infrequently received feedback on their implementation and adherence to these guidelines (11%). Antimicrobial stewardship programs in theater are in the early stages of development in theater. Areas identified for improvement are access to expertise, development of a focus on high-impact lines of effort, laboratory support, and the culture of antimicrobial prescribing. Risks can be mitigated through theater level formalization of efforts, expert mentoring through telehealth, and a focus on implementation and adherence and feedback to national guidelines.

After the Battlefield: Infectious Complications among Wounded Warriors in the Trauma Infectious Disease Outcomes Study.

During recent wars in Iraq and Afghanistan, improved survivability in severe trauma corresponded with a rise in the proportion of trauma-related infections, including those associated with multidrug-resistant organisms (MDROs). Significant morbidity was reported in association with the infections. There is also concern regarding potential long-term impacts of the trauma-related infectious complications. Therefore, to meet the critical need of prospective collection of standardized infection-related data to understand the disease burden and improve outcomes of wounded personnel, the Trauma Infectious Disease Outcomes Study (TIDOS) was developed. Herein, we review accomplishments and key peer-reviewed findings of TIDOS. The TIDOS project is a multicenter observational study of short- and long-term infectious complications following deployment-related trauma. Wounded military personnel medevac'd to Landstuhl Regional Medical Center (LRMC; Germany) before transfer to a participating US military hospital between June 2009 and December 2014 were eligible for inclusion. An infectious disease module to supplement the Department of Defense Trauma Registry by collecting infection-related data from all trauma patients admitted to participating hospitals was developed. Specimens from trauma patients were also collected and retained in a microbiological isolate repository. During the initial hospitalization, patients were given the opportunity to enroll in a prospective follow-up cohort study. Patients who received Department of Veterans Affairs (VA) care were also given the opportunity to consent to ongoing VA follow-up. A total of 2,699 patients transferred to participating military hospitals in the USA, of which 1,359 (50%) patients enrolled in the TIDOS follow-up cohort. In addition, 638 enrolled in the TIDOS-VA cohort (52% of TIDOS enrollees who entered VA healthcare). More than 8,000 isolates were collected from infection control surveillance and diagnostic evaluations and retained in the TIDOS Microbiological Repository. Approximately 34% of the 2,699 patients at US hospitals developed a trauma-related infection during their initial hospitalization with skin and soft-tissue infections being predominant. After discharge from the US hospitals, approximately one-third of TIDOS cohort enrollees developed a new trauma-related infection during follow-up and extremity wound infections (skin and soft-tissue infections and osteomyelitis) continued to be the majority. Among TIDOS cohort enrollees who received VA healthcare, 38% developed a new trauma-related infection with the incident infection being diagnosed a median of 88 days (interquartile range: 19-351 days) following hospital discharge. Data from TIDOS have been used to support the development of Joint Trauma System clinical practice guidelines for the prevention of combat-related infections, as well as the management of invasive fungal wound infections. Lastly, due to the increasing proportion of infections associated with MDROs, TIDOS investigators have collaborated with investigators across military laboratories as part of the Multidrug-Resistant and Virulent Organisms Trauma Infections Initiative with the objective of improving the understanding of the complex wound microbiology in order to develop novel infectious disease countermeasures. The TIDOS project has focused research on four initiatives: (1) blast-related wound infection epidemiology and clinical management; (2) DoD-VA outcomes research; (3) Multidrug- Resistant and other Virulent Organisms Trauma Infections Initiative; and (4) Joint Trauma System clinical practice guidelines and antibiotic stewardship. There is a continuing need for longitudinal data platforms to support battlefield wound research and clinical practice guideline recommendation refinement, particularly to improve care for future conflicts. As such, maintaining a research platform, such as TIDOS, would negate the lengthy time needed to initiate data collection and analysis.

Recommended medical and non-medical factors to assess military preventable deaths: subject matter experts provide valuable insights

IntroductionHistorically, there has been variability in the methods for determining preventable death within the US Department of Defense. Differences in methodologies partially explain variable preventable death rates ranging from 3%...

Fasciotomy Improvement Through Recognition of Errors Course: A Focused Needs Assessment for Error Management Training for Lower Extremity Fasciotomy Performance

Many injuries from recent wars involve extremity trauma secondary to blasts, which predispose patients to developing extremity compartment syndrome. In military studies, 17% of fasciotomies required revision on arrival to a Role 4 hospital, and 41% of these had missed compartments, which is similar to that seen in civilian centers. While training has decreased this rate to 8%, this number is still too high. We conducted a focused needs assessment to guide the development of lower-extremity fasciotomy training. In a predeployment assessment, 42 military surgeons performed a 2-incision, 4-compartment, lower-extremity fasciotomy on simulated lower leg models. Models were assessed for standardized and objectively-assessed major (inadequate skin or fascial incisions, missed compartments) and minor (failure to make an H-shaped incision over the lateral compartments, division of the greater saphenous vein) errors based on joint Trauma System clinical practice guidelines and approved training curricula. Four of 42 (9.5%) models contained no errors. Models averaged 4.3 ± 2.6 major and 0.3 ± 0.5 minor errors. 11 models (26.2%) had at least one missed compartment. The most common missed compartments were the deep posterior (17%) and anterior (14%). 29 (69%) had inadequate or poorly-placed skin incisions, with the most common being inadequate distal extension of the medial (10, 24%) and lateral (14, 33%) incisions, inadequate proximal extension of the lateral incision (6, 14%), medial incision too close to the tibia (7, 17%), and lateral incision over or behind the fibula (12, 29%). A total of 36 (86%) had inadequate fascial incisions. Inadequate fasciotomies were seen in the anterior (57%), lateral (55%), superficial (52%), and deep (34%) posterior compartments CONCLUSIONS: Performance on the models approximates what has been seen in military and civilian settings. This needs assessment will inform development of a simulation curriculum based on error-management and mastery learning theory to reduce the morbidity of lower-extremity compartment syndrome.