battle scars lessons learned from modeling and developing ... · test presented at: southwest texas...
TRANSCRIPT
Test
Presented at:
Southwest Texas Regional Advisory Council
First Annual Regional Emergency Healthcare Systems Conference
Presented by:
Col Jeff Bailey, MD, FACS
Director, Joint Trauma System
Defense Center of Excellence
6 May 2014
Right Patient, Right Care, Right Place, Right Time
“Battle Scars: Lessons Learned from Modeling and
Developing the Military Trauma System”
Disclosure and Disclaimer
• Nothing to disclose
• “The opinions or assertions contained herein
are the private views of the author and are not
to be construed as official or as reflecting the
views of the Department of the Army or the
Department of Defense.”
“Battle Scars”
Vision
That every Soldier, Marine,
Sailor, or Airman injured on
ANY battlefield or in ANY
theater of operations has
the optimal chance for
survival and maximal
potential for functional
recovery.
OEF CUMULATIVE ROLLING MONTHLY AVERAGES: %KIA, %DOW, CFR
AND AVG. MISS, Nov 2003 – Mar 2013
5
0
2
4
6
8
10
12
14
16
0%
5%
10%
15%
20%
25%
30%
Cum KIA% Cum DOW% Cum CFR% Cum Avg mISS
Injury Severity
Mortality
Right Patient, Right Care, Right Place, Right Time
Advances in Combat Casualty Care
DATA ANALYSIS
DOD
TRAUMA
REGISTRY
TRAUMA
CARE
DELIVERY
PERFORMANCE
IMPROVEMENT
Operational Cycle
BOLD, RESPONSIBLE PRACTICE OF BATTLEFIELD MEDICINE
Joint Trauma System
• Near concurrent and continuous performance improvement and best-evidence based best practice in combat casualty care
BAS
Role 1
Forward Surgical Teams
Role 2
CSH, EMEDS, EMF
Role 3
Definitive Care
Level 4
OCONUS
POI
1 Hour
TACTICAL
MEDEVAC
1-24 Hours
STRATEGIC AE
24-72 Hours
72 Hours Plus
Level 4
CONUS
Post Acute Care
VA
Trauma System:
Global Continuum of Care
Prevention
DOW
KIA
Battlefield Survival Non-preventable
Death � Prevention
PRIMARY:
PREVENT THE INJURY
INCIDENT
FROM OCCURING
SECONDARY:
MITIGATE
THE EXTENT
OF
INJURY
TACTICS, TECHNIQUES &
PROCEDURES
PERSONAL
PROTECTIVE
EQUIPMENT
(PPE)
TERTIARY:
OPTIMIZE
PATIENT CARE
AND
OUTCOMES
TRAUMA SYSTEMS
&
THERAPEUTIC
INTERVENTIONS
DOW
KIA
TERTIARY:
OPTIMIZE
PATIENT CARE
AND
OUTCOMES
TRAUMA SYSTEMS
&
THERAPEUTIC
INTERVENTIONS
Casualty Card and AAR collection of point-of-injury data at near-real time for timely
unit-based PHTR command-level reports and feedback in order to:
1. Improve Command visibility of casualties
2. Augment Commander’s decision-making process
3. Validate and refine casualty response system and TCCC treatment strategies
4. Refine medical & non-medical personnel, training, and equipment requirements
5. Reduce morbidity/mortality,force protection modifications, directed procurement
Medic Enters Casualty Data Data Populates Graphs, Shows Trends, Depicts Wounding Patterns
Prehospital Trauma Registry
Tactical Evacuation and En Route Care
Right Patient, Right Care, Right Place, Right Time
0
50
100
150
200
250
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 - 9 10 - 19 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 80 - 89 90 - 99 100 -
109
110 -
119
120 -
129
130 +
Time of Injury --> Time of Death (mins)
Cnt All Deaths (N = 748) Total Body Destruction (n = 129) Severe Brain Injury (n = 151)
Truncal Hem (n = 265) Junctional Hem (n = 59) Extremity Hem (n = 144)
Golden Hour Directive: Cumulative % of All Deaths
by Time and Dominant Injury Pattern (n = 748)
Note: The total number of deaths here includes both KIAs and DOWs.
Additionally, there are ≈ 250 cases under review from the UK Trauma
Registry waiting inclusion.
Forward
LSI
DCR
Observed versus the predicted mortality for the MERT
platform per ISS groupings
* Statistic significant
Pre-Hospital SI Admission SI P
ISS 1 - 9
MERT 0.84 ± 0.28 0.66 ± 0.24 < 0.001
PEDRO 0.76 ± 0.25 0.64 ± 0.20 < 0.001
DUSTOFF 0.78 ± 0.26 0.66 ± 0.28 0.001
ISS 10 - 25
MERT 1.10 ± 0.48 0.91 ± 0.43 < 0.001
PEDRO 0.86 ± 0.35 0.78 ± 0.40 0.013
DUSTOFF 0.82 ± 0.26 0.88 ± 0.41 0.805
ISS 26 +
MERT 1.39 ± 0.62 1.09 ± 0.42 0.001
PEDRO 0.88 ± 0.37 1.02 ± 0.43 0.440
DUSTOFF 0.94 ± 0.30 0.86 ± 0.17 0.898
Table 3: Pre-hospital shock index compared to admission shock
index per FAME platform by ISS bin.
FAME TRISS Analysis
Forward
LSI
DCR En Route CC Providers
0.0%
1.6%
4.8%
9.8%
1.2%2.2%
5.6%
20.0%
0%
5%
10%
15%
20%
25%
< 9 9 - 15 16 - 24 25 +
Un
ad
just
ed
Mo
rta
lity
Ra
te (
%)
Injury Severity Score Bins
Unadjusted Mortality Rate (%) Comparison by Injury Severity and
Provider (n=778)
Advanced Care Providers Non Advanced Care Providers
Role 3Role 2
Evidence based best practicesClinical Practice Guidelines LIST OF CURRENT CPGs
01_CPG Index_1_Nov_12.pdf
02_CENTCOM_JTTS_CPG_Process - 2_Apr_2012
Acoustic_Trauma_and_Hearing_Loss - 9_Mar_2012
Amputation - 2_Apr_2012
Battle_Non-Battle_Injury_Documentation_Resuscitation_Record_20_Sep_12
Blunt_Abdominal_Trauma - 27_Sept_2012
Burn_Care - 25_June_2012
Catastrophic_Care - 7_Mar_2012
Cervical_Spine_Evaluation - 19_Mar_2012
Cervical_and_Thoracolumbar_Spine_Injury - 9_Mar_2012
Clinical_Mgmt_of_Military_Working_Dogs_Combined - 19_Mar_2012
Clinical_Mgmt_of_Military_Working_Dogs_Zip - 19_Mar_2012.zip
Compartment_Syndrome_and_Fasciotomy - 9_Mar_2012
Damage_Control_Resuscitation - 11_Oct_2012
DoD Policy Guidance for Management of Mild Traumatic Brain Injury/Concussion in the Deployed Setting
Emergent_Resuscitative_Thoracotomy - 11_June_2012
Fresh_Whole_Blood_Transfusion_24_Oct_12
Frozen_Blood - 2_Apr_2012
High_Bilateral_Amputations - 7_Mar_2012
Hypothermia_Prevention - 20_Sept_2012
Infection_Control - 2_Apr_2012
Inhalation_Injury_and_Toxic_Industrial_Chemicals - 7_June_2012
Initial_Care_of_Ocular_and_Adnexal_Injuries - 7_Mar_2012
Intratheater_Transfer_and_Transport - 19_Nov_2008
Invasive_Fungal_Infection_in_War_Wounds - 1_Nov_12
Management_of_Pain_Anxiety_and_Delirium - 23_Nov_2010
Mgmt_of_Patients_with_ Severe_Head_Trauma - 7_Mar_2012
Management_of_War_Wounds - 25_April_2012
Neurosurgical_Management - 7_Mar_2012
Nutrition - 11_June_2012
Pelvic_Fracture_Care_2 - Apr_2012
Post_Splenectomy_Vaccination - 7_Mar_2012
Prevention_of_Deep_Venous_Thrombosis - 24_April_2012
Trauma_Airway_Management - 11_Jun_2012
Unexploded_Ordnance_Management - 7_Mar_2012
Urologic_Trauma_Management - 2_Apr_2012
Use_of_Electronic_Documentation - 5_Jun_2012
Use_of_MRI_in_Mgmt_of_mTBI_in_the_Deployed_Setting - 11_June_2012
Ventilator_Associated_Pneumonia - 17_Jul_2012
Wartime_Vascular_Injury - 7_June_2012
Operational Cycle
JTS Operational Cycle
ISR Research Philosophy
JTS and Research:
� Identify Injury Prevention & Care Gaps
� Establish Research Priorities
JTS is optimally positioned both physically and
operationally at BHTR I/SAMMC:
���� Support and infrastructure well
established and highly productive
���� A center of mass for combat casualty
care research
���� Clinical center of excellence: Level I
Trauma Center, Burn Center, Center
for the Intrepid
Battlefield Health and
Trauma Research Institute
DATA ANALYSIS
DOD
TRAUMA
REGISTRY
TRAUMA
CARE
DELIVERY
PERFORMANCE
IMPROVEMENT
Operational Cycle
BOLD, RESPONSIBLE PRACTICE OF BATTLEFIELD MEDICINE
Test
Right Patient, Right Care, Right Place, Right Time
Col Jeffrey A. Bailey, MD, FACS
Director, Joint Trauma System
COMM 210-539-9174
Discussion
Theater Land & Maritime
First Responder/TCCC
(DCR)
Theater Land & Maritime
Forward Resuscitative Care
(DCR & DCS)
PREVENTION
Tactics, Techniques, Procedures & PPE
TCCC Guidelines
Role 4: DEFINITIVE CARE PRACTICES
JTTS CPGs
Definitive Care
Rehabilitation
CONTINUUM
OF
TRAUMA
CARE
DELIVERY
What is a Trauma System?
�Organized and coordinated effort to deliver full range of trauma care for a population and/or within a region
� Improves patient transition between phases of care
�System coordination improves patient outcomes
�Reduces mortality by 15 - 20%
�Reduces morbidity
Joint Theater Trauma System
� Mar 04: 2nd MED BDE directed LTC Brian Eastridge to develop trauma system in Iraq
� Nov 04: Service SGs coordinated with Health Affairs on Joint Theater Trauma System (JTTS) & Joint Theater Trauma Registry (JTTR)
Dec 04: OSD/HA directed services to implement JTTR & 44th MEDCOM CG directed implementation of JTTS in Iraq
Mar 05: CENTCOM SG established JTTS for entire AOR
Joint Trauma System
Prior to 1 Oct 2012
�JTS initially operated at USAISR as contingency
activity to support CENTCOM JTTS
Joint Trauma System
Prior to 1 Oct 2012
� DoD trauma system capability risked
significant degradation post conflict:
�JTTS region/contingency specific
� No enduring Joint lead agent to sustain Global
DoD trauma system capability beyond conflict
Joint Trauma System
Prior to 1 Oct 2012
� JTS designated as DoD Program of Record in
USAISR 2010
� CONOPS to support DHP POM beyond conflict
completed 2011
� Funded in DHP O&M Oct 2012
� Tri-Service supported
�37 Core GS staff + 6 US Military minimum requirement to maintain a
trauma system
�Augmentation CTR capability scaled to global operational tempo
�JTS Core GS positions assigned to USAISR (JTS operating based on
legacy relationship as USAISR Directorate)
� JTTR re-designated as DoD Trauma Registry (DoDTR)
� JTS re-configured to support full continuum of care
�Added Trauma Care Delivery Division organized to interface with full
continuum of care (Pre-Hospital, En Route Care, Facility Based Care)
Joint Trauma System
After 1 October 2012
DoD
Trauma
Registry
Data
Automation
Data
AnalysisData
Acquisition
Performance
Improvement
EducationPI
Primary/Secondary
Prevention (JTAPIC)
Trauma Care
Delivery
Facility
Based En Route Care
CPGs
Pre-Hospital
Projects
Forums
DMRTI
Office of the Director COCOM SGs
JTTS
Service SGs
Joint Surgeon
Casualty Care
Research
Joint Trauma System Directorate
CoTCCC
Where do the data come from?
Camp Bastion KAF BAF
MEDEVAC TEAMPre-Hospital Team
In Hospital Team
“S&F”
“Web”
IV V
WISPR
TMDS
DEERS
TRAC2ES
ISR Archive
10% QA
� As of Jan 22, 2014:
�Total Records = 128,267
�Total Theater Hospital (level 3) records = 79,172
�Total Level 3 US Mil = 32,887
�Total Level 3 Non-US Mil = 46,285
�Total Level 3 OIF/OND = 46,608
�Total Level 3 OEF = 32,546
�Total Level 3 BI = 56,851
�Total Level 3 NBI = 20,130
DoD Trauma Registry (DoDTR)