Elizabeth Cornett

A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury

Topic Area Research Priorities Prevention and epidemiology • Develop data-driven strategies for mitigating morbidity and mortality due to potentially preventable injury. • Determine the epidemiology of preventable deaths after injury in the United States (adults and children). Resuscitation • Develop and clinically evaluate the efficacy and safety of dried or frozen blood products. • Evaluate the efficacy and safety of new devices and drugs for controlling lifethreatening extremity, junctional, and truncal hemorrhage. • Determine whether measuring prehospital shock and coagulopathy would improve outcomes in the prehospital environment. • Develop safe and effective oxygen carriers. • Determine whether whole blood resuscitation is clinically superior to component therapy. • Determine the safety of low-titer Group O whole blood as a universal donor. • Determine the clinical and cost-effectiveness of pathogen reduction technology for blood products. • Develop methodology, training, and equipment to improve the ability of farforward medical personnel to transfuse whole blood and blood products. • Determine how various endpoints of resuscitation affect clinical outcomes in patients with traumatic brain injury, hemorrhagic shock, or both. • Develop fail-safe methods for ensuring establishment of a casualty’s airway. • Determine the efficacy and safety of permissive hypotensive strategies with blood product resuscitation and for prolonged prehospital transport times. Prehospital care • Develop predictive prehospital algorithms for early identification of prehospital and hospital life-saving interventions. • Fund the addition of prehospital and hospital blood product data to existing trauma registries. • Develop methods for and implement accurate automated meshing of prehospital trauma care, hospital, autopsy, fire, police, and rehabilitation data registries. Burn care • Develop novel methods for rapid skin replacement, minimizing scar formation. Pain management • Develop and test battlefield/prehospital analgesia techniques. • Develop strategies for optimizing perioperative pain management.

A National Trauma Care System to Achieve Zero Preventable Deaths After Injury: Recommendations From a National Academies of Sciences, Engineering, and Medicine Report.

Since antiquity, with respect to advancing the care of the injured, “war has been a very efficient schoolmaster.” Innovation in trauma care has once again accelerated, spurred by the significant burden of injury from more than a decade of war in Afghanistan and Iraq. During those recent wars, the percentage of wounded service members who died of their injuries reached the lowest point in recorded wartime history—9.3% in Afghanistan and Iraq compared with 23% during the Vietnam War. Effective bleeding-control measures, improved resuscitation techniques, and aggressive neurocritical care interventions are among many advances that saved lives on the battlefield that otherwise would have been lost. For example, an estimated 1000 to 2000 lives were saved by widespread use of tourniquets. Military medical forces did not begin the recent wars with these capabilities. These interventions developed in response to the urgency from increasing numbers of US service members who died of potentially survivable injuries. That urgency was inconsistent with reliance on slow and costly clinical trials to inform improvements in trauma care practices. It drove the Military Health System and its nascent Joint Trauma System to embrace, instead, a culture of continuous performance improvement and a more agile approach to advancing combat casualty care. The Military Health System calls this pragmatic, more rapid model for learning “focused empiricism.” Focused empiricism is aligned with the characteristics of a learning health system articulated in the 2012 Institute of Medicine report Best Care at Lower Cost. For example, the Joint Trauma System digitally captures and routinely uses patient care data from its registry to identify trends and answer clinical questions, enabling care practices to evolve incrementally based on the best available evidence until higher-quality data can be generated. In effect, military medicine put the learning health system framework into practice before the Institute of Medicine described it. However, questions have arisen as to how the military’s learning trauma system can be improved, sustained, and expanded across the US Department of Defense. In addition, there are questions about how thoroughly and rapidly wartime trauma lessons learned can be applied in the civilian sector, where the need, if not the sense of urgency, is at least as great. In Afghanistan and Iraq, approximately 6850 service member lives have been lost over the last 15 years. In the United States there are nearly 150 000 deaths from trauma each year, and injury is the third leading cause of death, accounting for more years of life lost than any other cause. A new report* from the National Academies of Sciences, Engineering, and Medicine, of which the former Institute of Medicine is now part, clarifies the components of a learning health system necessary to ensure continuous improvement in military and civilian trauma care. The report also provides recommendations on how lessons from the military’s experiences in Afghanistan and Iraq can be sustained and built on for future combat operations and translated more effectively into the civilian care system. The report concludes that military and civilian trauma systems are inextricably linked, even if leaders sometimes seem unaware of that. It asserts that continued progress in trauma care capability and learning capacity will require better conduits for the continuous and seamless exchange of knowledge between the 2 sectors. Military and civilian trauma care and learning will be optimized together, or not at all. The committee recommends that a national strategy and a joint military-civilian approach for improving trauma care be developed to ensure the delivery of optimal trauma care to save the lives of Americans injured both within the United States and on the battlefield. To guide such an approach, the committee identified strengths and gaps in progress in the military and civilian sectors, using the following elements of a learning trauma care system as a diagnostic lens. *National Academies of Sciences, Engineering, and Medicine. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: National Academies Press; 2016. A summary is available: http://www.safetylit.org/citations/index.php?fuseaction=citations.viewdetails&citationIds[]=citreport_264_28&sha=1 Language: en