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

Jeffrey.a.bailey3.mil@mail.mil

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)