Military-civilian Partnership Research Articles

Do Fellowship-educated Military Orthopaedic Oncologists Who Practice in Military Settings Treat a Sufficient Volume of Patients to Maintain Their Oncologic Expertise?

Fellowship-trained orthopaedic oncologists in the US military provide routine clinical care and also must maintain readiness to provide combat casualty care. However, low oncologic procedure volume may hinder the ability of these surgeons to maintain relevant surgical expertise. Other low-volume specialties within the Military Health System (MHS) have established partnerships with neighboring civilian centers to increase procedure volume, but the need for similar partnerships for orthopaedic oncologists has not been examined. The purpose of this study was to characterize the practice patterns of US military fellowship-trained orthopaedic oncologists. We asked the following questions: (1) What are the diagnoses treated by US military fellowship-trained orthopaedic oncologists? (2) What are the procedures performed by US military fellowship-trained orthopaedic oncologists? We queried the Military Data Repository, a centralized repository for healthcare data for all healthcare beneficiaries (active duty, dependents, and retirees) within the Defense Health Agency using the MHS's Management and Reporting Tool for all international common procedure taxonomy (CPT) codes and ICD-9 and ICD-10 codes associated with National Provider Identifier (NPI) numbers of active duty, military fellowship-trained orthopaedic oncologists. Fellowship-trained orthopaedic oncologists were identified by military specialty leaders. Then, we identified all procedures performed by the orthopaedic oncologist based on NPI numbers for fiscal years 2013 to 2022. We stratified the CPT codes by top orthopaedic procedure categories (such as amputation [performed for oncologic and nononcologic reasons], fracture, arthroplasty, oncologic) based on associated ICD codes. These were then tabulated by the most common diagnoses treated. Thirteen percent (796 of 5996) of the diagnoses were oncologic, of which 45% (357 of 796) were malignant. Forty-four percent (158 of 357) of the malignancies were primary and 56% (199 of 357) were secondary; this translates to an average of 2 patients with primary and 2.5 patients with secondary malignancies treated per surgeon per year. During the study period, nine orthopaedic oncologists performed 5996 orthopaedic procedures, or 74 procedures per surgeon per year. Twenty-one percent (1252 of 5996) of the procedures were oncologic; the remaining procedures included 897 arthroplasties, 502 fracture-related, 275 amputations for a nononcologic indication, 204 infections, 142 arthroscopic, and 2724 other procedures. Although military orthopaedic oncologists possess expert skills that are directly translatable to combat casualty care and operational readiness, within MHS hospitals they treat relatively few patients with oncologic diagnoses, and less than one-half of those involve malignancies. Despite postgraduation procedure volume raining stable over the last decade, it is unknown how many new patient visits for oncologic diagnoses and how many corresponding tumor procedures are necessary to maintain competence or build confidence after musculoskeletal oncology fellowship training. It is important to note that there are no military orthopaedic oncology fellowships, and all active duty orthopaedic oncologists undergo training at civilian institutions. Military-civilian partnerships with high-volume cancer centers may enable military orthopaedic oncologists to work at civilian cancer centers to increase their oncologic volume to ensure sustainment of operationally relevant knowledge, skills, and abilities and improve patient care and outcomes.

Using a Military-Civilian Partnership to Enhance Clinical Readiness and Sustainment for Air Force Critical Care Nurses.

Decreases in size, capability, clinical volumes, case mixes, and complex care opportunities in military treatment facilities contribute to the atrophy of clinical skills among medical professionals in these facilities. The COVID-19 pandemic resulted in a 39% decline in admissions to a military critical care unit. The decrease in patient census contributed to skill sustainment challenges. To identify methods to combat skill atrophy, the CINAHL and PubMed databases were searched using the terms peacetime effect, military-civilian partnership, and skill sustainment. Active-duty critical care nurses stationed at a military treatment facility implemented a military-civilian partnership with a civilian medical facility for clinical skill sustainment. One year after implementation, 39 critical care nurses had completed 511 shifts, gaining clinical experiences seldom achieved at the military facility. A survey of these nurses demonstrated that 8 of 17 (47%) gained experience treating patients requiring intra-aortic balloon pumps or continuous renal replacement therapy, 6 of 17 (36%) gained experience with patients requiring a ventricular assist device, 12 of 17 (71%) acquired hands-on experience with intracranial pressure monitoring, and 14 of 17 (82%) reported vasoactive intravenous infusion manipulation. This article highlights the importance of evaluating clinical practice within the military health system, developing military-civilian partnerships, and removing military-civilian partnership barriers for nurses and other health care professionals. Failure to implement military-civilian partnerships may adversely affect the clinical competency of the military nurse force.

Military-Civilian Partnership to Improve Combat Casualty Care Readiness Among Non-physician Providers.

Military-civilian partnerships (MCP) provide a bidirectional exchange of information and trauma best practices. In 2021, Penn Presbyterian Medical Center and the U.S. Navy signed a 3-year memorandum of understanding to embed active duty trauma providers into the Trauma Division to facilitate the training and sustainment of combat casualty care (CCC) skills. To date, there is little evidence to demonstrate the efficacy of military-civilian partnerships in maintaining combat casualty readiness in non-physician trauma providers. We evaluated the impact of combat casualty readiness for non-physician providers by mapping clinical experiences in an urban Level I trauma center against the Defense Health Agency's Joint Trauma Systems (JTS) Clinical Practice Guidelines (CPG). The JTS CPGs provide best practices for CCCand highlight the critical skills providers need to know before deploying to an austere environment. Patient acuity data and specific JTS CPG skills performed by a non-physician providers were collected in their respective specialties for each patient seen between January 2023 to January 2024. Analyses were performed using descriptive statistics via Redcap. A sample of 6 Navy personnel in different specialties: 1 Physician Assistant, 3 Registered Nurses (emergency medicine, perioperative, critical care), and 2 corpsmen (scrub tech and search & rescue/prehospital medic) completed 1299 records on patients treated. In all, 685 (52.7%) were trauma patients and 614 (47.3%) were non-trauma patients. Categories of injuries seen, listed from the most frequent to the least, were as follows: Other (764), Falls (250), Motor Vehicle Crashes (164), Gunshot Wound (126), Stab-related injuries (41). Category 1 skills, defined as "essential to know," were performed in 921 (36.1%) of the patients treated. In Category 2, skills described as "important to know" were performed in 889 (34.8%) of the patients treated. Category 3 skills, identified as "less urgent" as they are rare among trauma patients, were performed in 486 (19.0%) of the patients treated, and 252 (9.8%) required none of the JTS CPG skills. These categories were further broken down based on the frequency of the skills performed. Analysis revealed strengths and identified opportunities to direct clinical experience for underperforming skills. Military-civilian partnerships support CCC readiness. The data presented and the continuation of mapping personnel's clinical experience to military CPGs can gauge readiness in non-physician trauma providers. Notably, several skills in each category were identified as opportunities to modify the clinical exposure of the military provider. These findings indicate that modifications in clinical assignments could enhance active duty combat casualty readiness in these critical skills.

Quality ofIntegration ofAir Force Trauma Surgeons Within the Center forSustainment ofTrauma andReadiness Skills, Cincinnati: A Pilot Study.

While previous studies have analyzed military surgeon experience within military-civilian partnerships (MCPs), there has never been an assessment of how well military providers are integrated within an MCP. The Center for Sustainment of Trauma and Readiness Skills, Cincinnati supports the Critical Care Air Transport Advanced Course and maintains the clinical skills of its staff by embedding them within the University of Cincinnati Medical Center. We hypothesized that military trauma surgeons are well integrated within University of Cincinnati Medical Center and that they are exposed to a similar range of complex surgical pathophysiology as their civilian partners. After Institutional Review Board approval, Current Procedural Terminology (CPT) codes were abstracted from billing data for trauma surgeons covering University of Cincinnati Hospitals in 2019. The number of trauma resuscitations and patient acuity metrics were abstracted from the Trauma Registry and surgeon Knowledge, Skills, and Abilities clinical activity (KSA-CA) scores were calculated using their CPT codes. Finally, surgeon case distributions were studied by sorting their CPT codes into 23 categories based on procedure type and anatomic location. Appropriate, chi-squared or Mann-Whitney U-tests were used to compare these metrics between the military and civilian surgeon groups and the metrics were normalized by the group's full-time equivalent (FTE) to adjust for varying weeks on service between groups. Data were available for two active duty military and nine civilian staff. The FTEs were significantly lower in the military group: military 0.583-0.583 (median 0.583) vs. civilian 0.625-1.165 (median 1.0), P = 0.04. Per median FTE and surgeon number, both groups performed a similar number of trauma resuscitations (civilian 214 ± 54 vs. military 280 ± 13, P = 0.146) and KSA-CA points (civilian 55,629 ± 25,104 vs. military 36,286 ± 11,267; P = 0.582). Although the civilian surgeons had a higher proportion of hernia repairs (P < 0.001) and laparoscopic procedures (P = 0.006), the CPT code categories most relevant to combat surgery (those relating to solid organ, hollow viscus, cardiac, thoracic, abdominal, and tissue debridement procedures) were similar between the surgeon groups. Finally, patient acuity metrics were similar between groups. This is the first assessment of U.S. Air Force trauma surgeon integration relative to their civilian partners within an MCP. Normalized by FTE, there was no difference between the two groups' trauma experience to include patient acuity metrics and KSA-CA scores. The proportion of CPT codes that was most relevant to expeditionary surgery was similar between the military and civilian partners, thus optimizing the surgical experience for the military trauma surgeons within University of Cincinnati Medical Center. The methods used within this pilot study can be generalized to any American College of Surgeons verified Trauma Center MCP, as standard databases were used.

113 The Effect of Civilian Purchased Care on Military Neurosurgery Wartime Readiness

INTRODUCTION: The current landscape of military neurosurgery reflects the relative peacetime for the US-World relationship - a problem of intrinsically low case volume compounded by patients being deferred away from Military Treatment Facilities (MTFs). TRICARE is the healthcare program of the US Department of Defense Military Health Care System, in which ‘Purchased Care’ or civilian based health care, is used to supplement healthcare needs when services are not readily available to TRICARE beneficiaries. Within military neurosurgery, case volume and complexity continue to be diverted via purchased case pathways, greatly affecting wartime readiness. Neurosurgery wartime readiness can be measured through the Knowledge, Skills and Abilities (KSA) metric based on case complexity and volume. METHODS: We analyzed case counts and KSA values of active-duty military neurosurgery capable MTFs and purchased care counterparts using the CarePoint Access portal. Residents, civilian contractors, and retirees were excluded. RESULTS: In 2022, the KSA total for 16 MTFs was 139005, a result of 2286 cases and 47 surgeons. The average KSA/surgeon/month was 393.8, extrapolating to 4725.5/surgeon/year - 59% of the KSA goal of 8000/surgeon/year. The purchased care KSA of 10 MTFs totaled 301535 in 2022 from 7324 cases. Purchased care out-performed MTF case volume by over 300%. Recovering full purchased care volume would increase the individual MTF neurosurgeon KSA by 135%. CONCLUSIONS: The military neurosurgical community cannot maintain wartime readiness as defined by the KSA metric with current trends in military neurosurgery case volume and high incidence of purchased care. The solution lies in either recovering purchased care patients or expanding military-civilian partnerships to base military neurosurgeons at local academic hospitals and trauma centers.

The Military-Civilian Partnership Quality Improvement Program Concept: A Process to Improve Data Collection and Outcomes Assessment.

Military-Civilian Partnerships (MCPs) are vital for maintaining the deployment readiness of military health care physicians. However, tracking their clinical activity has proven to be challenging. In this study, we introduce a locally driven process aimed at the passive collection of external clinical workload data. This process is designed to facilitate an assessment of MCP physicians' deployment readiness and the effectiveness of individual MCPs. From March 2020 to February 2023, we conducted a series of quality improvement projects at the Wright Patterson Medical Center (WPMC) to enhance our data collection efforts for MCP physicians. Our methodology encompassed several steps. First, we assessed our existing data collection processes and their outcomes to identify improvement areas. Next, we tested various data collection methods, including self-reporting, a web-based smart phone application, and an automated process based on billing or electronic health record data. Following this, we refined our data collection process, incorporating the identified improvements and systematically tracking outcomes. Finally, we evaluated the refined process in 2 different MCPs, with our primary outcome measure being the collection of monthly health care data. Our examination at the WPMC initially identified several weaknesses in our established data collection efforts. These included unclear responsibility for data collection within the Medical Group, an inadequate roster of participating MCP physicians, and underutilization of military and community resources for data collection. To address these issues, we implemented revisions to our data collection process. These revisions included establishing clear responsibility for data collection through the Office of Military-Civilian Partnerships, introducing a regular "roll call" to match physicians to MCP agreements, passively collecting data each month through civilian partner billing or information technology offices, and integrating Office of Military-Civilian Partnership efforts into regular executive committee meetings. As a result, we observed a 4-fold increase in monthly data capture at WPMC, with similar gains when the refined process was implemented at an Air Force Center for the Sustainment of Trauma and Readiness Skills site. The Military-Civilian Partnership Quality Improvement Program concept is an effective, locally driven process for enhancing the capture of external clinical workload data for military providers engaged in MCPs. Further examination of the Military-Civilian Partnership Quality Improvement Program process is needed at other institutions to validate its effectiveness and build a community of MCP champions.

Comparison of military and civilian surgeon outcomes with emergent trauma laparotomy in a mature military-civilian partnership

IntroductionMedical readiness is of paramount concern for active-duty military providers. Low volumes of complex trauma in military treatment facilities has driven the armed forces to embed surgeons in high-volume civilian...

Advancing Readiness Through Military Programs: An Evidence-Based Practice Perspective.

Military nurses comprise the largest percentage of military health care providers. In the current military health care system, they have two roles: (1) Patient care in military treatment facilities (MTFs) and (2) patient care during combat operations. Although in MTFs, the military nurse's roles are similar to those of their civilian counterpart, their roles are unique and varied in the combat operational environment. These combined roles lead to questions regarding readiness training to ensure that nurses are proficient in both MTFs and combat operational settings where treatment requirements may differ. The purpose of this paper is to (1) present the current state of educational readiness programs to maintain a ready medical force that entail formal teaching programs, military-civilian partnerships, and joint exercises of combat simulations, and (2) identify gaps as presented in an evidence-based practice educational panel. On March 11, 2022, TriService Nursing Research Program hosted the virtual First Military Evidence-Based Practice Summit from the Uniformed Services University of the Health Sciences in Bethesda, MD. As part of the summit, an evidence-based practice education panel discussed the availability of current evidence-driven military medical readiness programs and identified gaps in the integration of military readiness for nursing personnel into the Defense Health Agency and Armed Services. The panel participants discussed the separate requirements for training within the MTFs and in combat operational settings. The available training programs identified by the panel were primarily those developed in local MTF settings to meet local needs. Although these programs support the MTFs' peacetime mission, competing roles, limited time, and limited funds contributed to limited preparation of nursing personnel in skills associated with combat-related injuries and illnesses. Prolonged casualty care has become an important focus for the Department of Defense as greater considerations are directed to wartime operations in austere expeditionary environments. Although there is some training available that is specific for prolonged casualty care, the focus has been the adaptation of combat casualty care during contingency operations. A keynote here was the concept that combat casualty care training must include both development of individual skills and integration of the team since maximal care can be achieved only when the individual and the team operate as a unit. A key point was the utility of central repositories for storing information related to training a ready medical force at individual and unit levels and that these repositories could also be used to collect and facilitate the accession of current evidence-based information. Optimal patient care at all levels of the military health system requires training that maximizes individual and unit skills specific to the environment at an MTF or in a combat operational setting. Training must be designed to incorporate evidence-driven knowledge in all military settings with guidance that is specific to the environment. Enhanced communication of evidence-based training and knowledge is an important component of maintaining a ready medical force for broader medical support of combat contingency operations.

Trauma and Critical Care Military-Civilian Publications Increased After the COVID-19 Pandemic: A Literature Review

IntroductionThere continues to be a growing demand for military-civilian partnerships (MCPs) in research collaborations developing medical trauma care in domestic and international affairs. The objective of this comprehensive review is to investigate the difference in the quantity of MCP trauma and critical care publications before and after the COVID-19 pandemic. MethodsA systematic literature review was performed for the calendar years 2018 and 2021 utilizing MEDLINE, Cochrane, and EMBASE databases. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a three-tiered review of 603 English language articles to identify trauma-related military and/or civilian partners and describe the changes in geographical relationships. ResultsA total of 96 (2018) and 119 (2021) articles met screening criteria for trauma and critical care studies and were used for final data extraction. Ultimately, 59 (2018) and 71 (2021) papers met the inclusion criteria of identifying trauma/critical care MCPs and identified both military and civilian partners. There was also an increase from 10 (2018) to 17 (2021) publications that mentioned advocacy for MCP. Using the author affiliations, four regional MCP types were recorded: of 2018 articles, locoregional (3.4%), US-national (47.5%), single international country (42.4%), and between multiple countries (6.8%); of 2021 articles, locoregional (15.5%), US-national (38%), single international country (29.6%), and between multiple countries (16.9%). There has been an increase in the number of locoregional and multinational MCPs and an overall increase in the number of collaborative trauma publications and MCP advocacy papers. A national geographical heat map was developed to illustrate the changes from 2018 to 2021. ConclusionsThere has been an increase in the number of recorded trauma and critical care MCP publications post-pandemic. The growth in the number of manuscripts in more regions post-pandemic suggests an increase in the recognition of collaborations that contribute not only to conflict readiness but also advancements in trauma and surgical care.

Answering Our Nation's Call: A Solution for Military Neurosurgery Wartime Readiness Through Civilian Collaboration.

Military-civilian partnerships have built the foundation for US neurosurgery as we see it today. Each conflict throughout history has led to expansion within the field of neurosurgery, benefiting civilian patients and those in uniform. Despite the field's growth during wartime, military neurosurgical case volume declines during peacetime, and as a result, important knowledge gained is at risk of being lost. The current landscape of military neurosurgery reflects the relative peacetime for the US-World relationship. Because of this peacetime, the surgical case volume and experience of the military neurosurgeon are declining rapidly. In addition to providing a history of military-civilian partnerships in neurosurgery, we have analyzed the declining case volume trends at a single military treatment facility with neurosurgical capabilities. We compared the case volume of a military neurosurgeon at a civilian partnered location with their previous volume at a military treatment facility and analyzed current trends in wartime readiness by Neurosurgery Knowledge, Skills and Abilities metrics. We believe that military civilian partnerships hold the key to scaffolding the experience to maintain the wartime readiness in the military neurosurgical community.

Beyond Trauma: High-Volume Critical Care Medicine ina Military Medical Center-Based Military-Civilian Partnership.

Critical Care Internal Medicine (CCIM) is vital to the U.S. Military as evidenced by the role CCIM played in the COVID-19 pandemic response and wartime operations. Although the proficiency needs of military surgeons have been well studied, this has not been the case for CCIM. The objective of this study was to compare the patient volume and acuity of military CCIM physicians working solely at Military Treatment Facilities (MTFs) with those at MTFs also working part-time in a military-civilian partnership (MCP) at the University Medical Center of Southern Nevada (UMC). We analyzed FY2019 critical care coding data from the Military Health System and UMC comparing the number of critical care encounters, the number of high-acuity critical care encounters, and the Abilities/Activity component of the Knowledge, Skills, and Abilities/Clinical Activity (KSA) score. This analysis was restricted to critical care encounters defined by Current Procedural Terminology codes for critical care (99291 and 99292). A critical care encounter was considered high acuity if the patient had ICD-10 codes for shock, respiratory failure, or cardiac arrest or had at least three codes for critical care in the same episode. The five AF CCIM physicians in the MCP group performed 2,019 critical care encounters in 206 days, with 63.1% (1,273) being defined as high acuity. The total number of MTF critical care encounters was 16,855 across all providers and services, with 28.9% (4,864) of encounters defined as high acuity. When limited to CCIM encounters, MTFs had 6,785 critical care encounters, with 32.0% being high acuity (2,171). Thus, the five AF CCIM physicians, while working 206 days at the UMC, equated to 12.0% (2,019/16,855) of the total critical care MTF encounters, 27.2% (1,273/4,684) of the total high-acuity MTF critical care encounters, and 29.8% (2,019/6,785) of the MTF CCIM encounters, with 58.6% (1,273/2,171) of the MTF CCIM high-acuity encounters.The USAF CCIM physicians in the MCP group performed 454,395 KSAs in 206 days, with a KSA density per day of 2,206. In the MTF group, CCIM providers generated 2,344,791 total KSAs over 10,287 days, with a KSA density per day of 227.9. Thus, the five CCIM physicians at the UMC accounted for 19.38% of the MTF CCIM KSAs, with a KSA density over 10 times higher (2,206 vs. 227.9). The volume and acuity of critical care at MTFs may be insufficient to maintain CCIM proficiency under the current system. Military-civilian partnerships are invaluable in maintaining clinical proficiency for military CCIM physicians and can be done on a part-time basis while maintaining beneficiary care at an MTF. Future CCIM expeditionary success is contingent on CCIM physicians and team members having the required CCIM exposure to grow and maintain clinical proficiency.Limitations of this study include the absence of off-duty employment (moonlighting) data and difficulty filtering military data down to just CCIM physicians, which likely caused the MTF CCIM data to be overestimated.

Initial report on special operations clinical training at a civilian academic medical center.

Military-civilian partnerships for combat casualty care skills training have mostly focused on traditional, combat surgical team training. We sought to better understand US Special Forces (SF) Medics' training at West Virginia University in Morgantown, West Virginia, a Level 1 trauma center, via assessments of medical knowledge, clinical skills confidence, and technical performance. Special Forces Medics were evaluated using posttraining medical knowledge tests, procedural skills confidence surveys (using a 5-point Likert scale), and technical skills assessments using fresh perfused cadavers in a simulated combat casualty care environment. Data from these tests, surveys, and assessments were analyzed for 18 consecutive SF medic rotations from the calendar years 2019 through 2021. A total of 108 SF Medics' tests, surveys, and assessments were reviewed. These SF Medics had an average of 5.3 years of active military service; however, deployed experience was minimal (73% never deployed). Review of knowledge testing demonstrated a slight increase in mean test score between the precourse (80% ± 14%; range, 50-100%) when compared with the postcourse (82% ± 14%; range, 50-100%). Skills confidence scores increased between courses, specifically within the point of injury care ( p = 0.09) and prolonged field care ( p < 0.001). Technical skills assessments included cricothyroidotomy, chest tube insertion, and tourniquet placement. This study provides preliminary evidence supporting military-civilian partnerships at an academic Level 1 trauma center to provide specialty training to SF Medics as demonstrated by increase in medical knowledge and confidence in procedural skills. Additional opportunities exist for the development technical skills assessments. Therapeutic/Care Management; Level IV.

Drive-Through Mass Vaccination Center Operations in a Rural, Medically Underserved Area Using Military Civilian Partnership During the COVID-19 Pandemic.

During the coronavirus disease (COVID-19) pandemic, mass vaccination centers became an essential element of the public health response. This drive-through mass vaccination operation was conducted in a rural, medically underserved area of the United States, employing a civilian-military partnership. Operations were conducted without traditional electronic medical record systems or Internet at the point of vaccination. Nevertheless, the mass vaccination center (MVC) achieved throughput of 500 vaccinations per hour (7200 vaccinations in 2 days), which is comparable with the performance of other models in more ideal conditions. Here, the study describes the minimum necessary resources and operational practicalities in detail required to implement a successful mass vaccination event. This has significant implications for the generalizability of our model to other rural, underserved, and international settings.

Initial Assessment of a Regional Military-Civilian Partnership on Trauma Surgery Skills Sustainment.

Trauma surgery skills sustainment and maintenance of combat readiness present a major problem for military general surgeons. The Military Health System (MHS) utilizes the knowledge, skills, and abilities (KSA) threshold score of 14,000 as a measure of annual deployment readiness. Only 9% of military surgeons meet this threshold. Most military-civilian partnerships (MCPs) utilize just-in-time training models before deployment rather than clinical experiences in trauma at regular intervals (skills sustainment model). Our aim is to evaluate an established skills sustainment MCP utilizing KSAs and established military metrics. Three U.S. Navy active duty general surgeons were embedded into an urban level-1 trauma center taking supervised trauma call at regular intervals prior to deployment. Operative density (procedures/call), KSA scores, trauma resuscitation exposure, and combat casualty care relevant cases (CCC-RCs) were reviewed. During call shifts with a Navy surgeon present an average 16.4 trauma activations occurred; 32.1% were category-1, 27.6% were penetrating, 72.4% were blunt, and 33.8% were admitted to the intensive care unit. Over 24 call shifts of 24 hours in length, 3 surgeons performed 39 operative trauma cases (operative density of 1.625), generating 11,683 total KSA points. Surgeons 1, 2, and 3 generated 5109, 3167, and 3407 KSA points, respectively. The three surgeons produced a total of 11,683 KSA points, yielding an average of 3,894 KSA points/surgeon. In total, 64.1% of operations fulfilled CCC-RC criteria. Based on this initial evaluation, a military surgeon taking two calls/month over 12 months through our regional skills sustainment MCP can generate more than 80% of the KSA points required to meet the MHS KSA threshold for deployment readiness, with the majority being CCC-RCs. Intangible advantages of this model include exposure to multiple trauma resuscitations while possibly eliminating just-in-time training and decreasing pre-deployment requirements.

Improving Care During Peacetime, War, and Disasters: A Call for Agile Military Civilian Strategic Alliances.

Improving Care During Peacetime, War, and Disasters: A Call for Agile Military Civilian Strategic Alliances.

Data-driven readiness: A preliminary report on cataloging best practices in military civilian partnerships.

Between conflicts, many of the combat casualty care lessons learned are lost as the nation shifts priorities and providers leave the military. Solutions are needed to bridge the knowledge gap created by interwar periods. One of the foremost solutions is partnerships between civilian trauma centers and the military health system. Over the past two decades, a myriad of military-civilian partnerships (MCPs), which vary in their composition, duration, and focus, was created. The objective of this report is to describe the initial attempt of the Department of Defense to catalog existing MCPs to inform both civilian and military stakeholders. This initial catalog is intended as a reference to aid in future MCP development and facilitate the synchronization of efforts to improve trauma care delivery and readiness. Using methodology from the Institute of Defense Analysis, the total number of eligible trauma centers in the United States was determined. The Institute of Defense Analysis determined eligibility-based American College of Surgeons Trauma Center verification or state trauma center designation. Each military service provided their list of MCPs, which were categorized. Military-civilian partnerships were cataloged by various characteristics and program components. Key variables include number and type of personnel trained, duration of training, and focus, for example, team versus individual focused and training versus maintaining proficiency focused. A total of 1,139 hospitals in the United States are potentially eligible for MCPs. There are at least 87 unique partnerships; the majority are part-time sustainment MCPs. The Air Force has the largest number of providers in MCPs. There are many challenges to maintain accurate and up to date data on MCPs. With the collated information, the Defense Health Agency, military services, special operations community, and civilian partners will be better empowered to optimize the readiness value of their programs and better prepare our military medical providers for the nation's and military's future needs.

The Las Vegas military-civilian partnership: An origin story and call to action.

Military-civilian partnerships (MCPs) in urban American trauma centers have existed for more than 60 years to assist in the development and maintenance of wartime skills of military medical professionals. In the last 5 years, MCPs have gained congressional support, and their number and variety have grown substantially. The historical impact of these flagship trauma MCPs is well documented, with bidirectional benefit in the advancement of trauma care during the wars in Iraq and Afghanistan both deployed and stateside, and the future aim of MCPs lies primarily in mitigating the "peacetime effect." The majority of data regarding MCPs; however, focus on trauma care and are biased toward surgeons specifically. The Las Vegas (LV) MCP began in 2002 with the similar goal of sustaining Air Force (AF) expeditionary medical skills by embedding AF medics from nearby Nellis Air Force Base (AFB) into University Medical Center of Southern Nevada (UMC), the only Level 1 Trauma Center in Nevada. Over nearly 20 years, the LV-MCP has evolved into an innovative market-based collaboration composed of numerous relationships and programs that are designed to develop and sustain critical skills for military medical personnel in all aspects of expeditionary medicine. This includes AF medical personnel providing care to federal beneficiaries as well as civilian patients in a variety of medical settings. The partnership's central coordinating authority, the Office of Military Medicine-Las Vegas (OMM-LV), brings together military and civilian organizations with distinct and intersecting missions to support the greater LV population and the DoD mission of readiness. The LV-MCP is presented here as a model for the future of MCPs within the integrated local and national trauma and medical systems.

Complete and Partial Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhagic Shock.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) devices grew out of a military-civilian partnership to develop new capabilities for hemorrhage control. With the advent of purpose-built devices, REBOA has become increasingly common in civilian trauma and acute care settings. Currently available REBOA catheters were designed as complete aortic occlusion devices. However, the therapeutic window for complete aortic occlusion is time-limited due to ischemia-reperfusion injury. The partial procedure allows blood flow past the level of occlusion while maintaining targeted proximal pressure, which has been shown to reduce distal ischemia and adjunctive resuscitation requirements in preclinical studies with prolonged occlusion times as compared to traditional complete occlusion. pREBOA-PRO is the first catheter designed to enable partial and complete aortic occlusion and is currently in limited market release at seven Level I trauma centers in North America. This paper will focus on procedural considerations for REBOA, including patient selection criteria and a comparison of complete and partial aortic occlusion in a simulator, along with highlighting critical steps to improve clinical outcomes. Additionally, this paper reviews a contrast-enhanced CT scan from a trauma patient that shows distal perfusion after 2 h of partial aortic occlusion using this newly designed catheter and discusses representative results from the limited market release to highlight the profound effect of technological innovation on outcomes in vascular emergencies.

Complete and Partial Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhagic Shock

Resuscitative endovascular balloon occlusion of the aorta (REBOA) devices grew out of a military-civilian partnership to develop new capabilities for hemorrhage control. With the advent of purpose-built devices, REBOA has become increasingly common in civilian trauma and acute care settings. Currently available REBOA catheters were designed as complete aortic occlusion devices. However, the therapeutic window for complete aortic occlusion is time-limited due to ischemia-reperfusion injury. The partial procedure allows blood flow past the level of occlusion while maintaining targeted proximal pressure, which has been shown to reduce distal ischemia and adjunctive resuscitation requirements in preclinical studies with prolonged occlusion times as compared to traditional complete occlusion. pREBOA-PRO is the first catheter designed to enable partial and complete aortic occlusion and is currently in limited market release at seven Level I trauma centers in North America. This paper will focus on procedural considerations for REBOA, including patient selection criteria and a comparison of complete and partial aortic occlusion in a simulator, along with highlighting critical steps to improve clinical outcomes. Additionally, this paper reviews a contrast-enhanced CT scan from a trauma patient that shows distal perfusion after 2 h of partial aortic occlusion using this newly designed catheter and discusses representative results from the limited market release to highlight the profound effect of technological innovation on outcomes in vascular emergencies.

Military-civilian partnerships and the clinical readiness mission: A preliminary study from the Military Health System and the American College of Surgeons.

The Blue Book , published in conjunction with the Military Health System Strategic Partnership with the American College of Surgeons, serves as a reference manual for institutions wishing to establish a military-civilian partnership (MCP). To evaluate the applicability of the criteria contained in the Blue Book , we created a survey to be distributed to MCP military surgeons and their civilian host champions. E-mail surveys were sent to MCP military surgeons and civilian host champions. Military surgeons were queried about basic demographic information and aspects of the MCP including type, duration of assignment, onboarding, malpractice coverage, and billing for services. We gathered information on the role of military surgeons at the MCP, workload information, and trauma cases. The civilian host champions survey focused on institutional activities including trauma surgical volume, clinical and educational opportunities for the military surgeons, and exposure to research. Military-civilian partnership military surgeons and civilian host champions were questioned on program attributes: administrative support, budget, and profile of the program within the institution. Ten MCP military surgeons and 7 host champions completed surveys. The majority of military surgeons were assigned to the MCP for a 3-year instructor role (90%), and most were trauma surgeons (80%). Clinical activities for the military surgeon were where 60% spent ≥13 weeks annually on trauma. Military surgeons identified host program support in academic growth, deployment preparation, and sense of value at the MCP as positive attributes. Civilian host champions unanimously reported that exposure to research, opportunities to lead trauma teams, dedicated intensive care unit time, and patient volume were positive program attributes. This preliminary survey demonstrates that the criteria put forth in the Blue Book align with experiences of MCP military surgeons and host champions. Continued development of this survey and others like it may be useful in the MCP program selection and evaluation process. Therapeutic/care management; Level V.