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DoD Joint Trauma System

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The Joint Trauma System (JTS) run by the Department of Defense Center of Excellence (DCoE) for Trauma captures and reports battlefield injury demographics, treatments and outcomes using the DoD Trauma Registry (DoDTR), formerly known as the Joint Theater Trauma Registry.

History[edit]

In 2004, the Assistant Secretary of Defense (ASD), Health Affairs (HA) directed all services to work together to establish a single trauma registry. The ASD (HA) Policy Memorandum 04-03, Coordination of Policy to Establish a Joint Theater Trauma Registry, Dec 22, 2004 was a mandate to collect and aggregate combat casualty care epidemiology, treatments, and outcomes essential to understanding the challenges, successes and failures that the military medical corps faced in providing effective and timely care for combat casualties. JTS was founded to build and manage the DoD Trauma Registry, a resource to scientifically validate and analyze aggregated data.

In fall of 2016, the Office of the Under Secretary of Defense for Personnel and Readiness recommended the DoD “establish the JTS, in its role as the DoD Trauma System as the lead agency for trauma in DoD with authority to establish and assure best-practice trauma care guidelines to the Director of the Defense Health Agency, the Services, and the Combatant Commanders.” [1] Previously, the JTS is located at Joint Base Fort Sam Houston, Texas.

The DoD Trauma Registry[edit]

The DoDTR captures trauma data from battlefield first responders to definitive care stateside, plus en route care for military and civilian personnel treated in US military facilities in wartime and peace-time. As of January 2016, JTS evaluates the DoDTR data abstracted from 131,000 trauma patient records, representing approximately 80,000 unique trauma patients, and from after action reports to develop clinical practice guidelines (CPGs). The CPGs minimize medical practice variations from known evidence-based best practices and help save lives. [2] DoDTR data-driven advancements in the military trauma care are being applied to civilian trauma care. The DoDTR:

  • Captures and reports battlefield injuries.
  • Facilitates movement, collection, and sharing of theater battle trauma patient data across all levels of care, the Services, and supports the Theater Trauma Director and Trauma Coordinators.

The first iteration of the DoDTR was named the Joint Theater Trauma Registry. The data collection tools were diverse paper forms that required validation before entry into a Microsoft Excel spreadsheet. The next generation was standalone software, Store & Forward (S&F), and designed to standardize data collection. The S&F was loaded on a laptop assigned to trauma coordinators selected from each Service and trained by the JTS staff. These coordinators were deployed to Role 1 through Echelon 5 - from forward operating bases and military treatment facilities in Iraq, Afghanistan, Germany, and to military treatment facilities in the U.S. The JTTR was used to identify Operation Iraqi Freedom and Operation Enduring Freedom combat casualties from October 2001 to June 2009 who died from injury after admission to a military MTF. [3] In 2011, the S&F JTTR product was revamped and launched as a real time, web accessible system (DoDTR).

Organization[edit]

The following branches make up the JTS:

Data Acquisition: Responsible for data abstraction and entry of concurrent and retrospective records into DoDTR, as well as the quality assurance of the data. It is responsible for creating and updating the DoDTR data definitions and business rules. Data Acquisition also provides support applications and services to DoDTR users.

Data Analysis (Special Projects): Manages the data sharing agreements process and provides the DoDTR data in response to data requests. It conducts classified and non-classified data analysis for internal and external requests for research purposes.

IT Automation: Supports the information technology needs of the DoDTR and data-related special projects.

Prehospital Care: Tactical Combat Casualty Care (TCCC) is a set of evidence-based, best-practice trauma care guidelines customized for use on the battlefield. TCCC originated as a Special Operations Forces research effort with three objectives: treat the casualty, prevent additional casualties, and complete the mission. TCCC provides lifesaving care to the injured combatant, and limiting the risk of further casualties while helping the unit achieve mission success.

TCCC Guidelines are crafted through a combined effort of trauma subject matter experts, operational physicians and physician assistants, and combat medical providers. TCCC has proven highly successful at saving lives on the battlefield throughout the 14 years of conflict in Iraq and Afghanistan and has been endorsed by the senior leaders of all 4 US armed services. See CoTCCC below for more information.

Performance Improvement (PI): Coordinates the PI activities across the spectrum of trauma care. It helps develop PI course content and training, and reviews trauma system patient-care issues. These reviews, courses are designed to provide an organized approach to improved trauma care at all care levels.

Military Orthopaedic Trauma Registry (MOTR): Manages the MOTR registry which house trauma care information about warriors from all Services who sustain extremity injuries. MOTR seeks to improve functional outcomes of combat casualties by using a systematic approach to determine the acute and long term outcomes of all battlefield injuries, improvement in treatment, and the logistical implications.

Education: Conducts pre-deployment training of the US Central Command, Joint Theater Trauma System (JTTS) teams, DoDTR user training, and JTS staff training. It facilitates the development of educational products for Combatant Command trauma system. The group also coordinates and manages continuing education opportunities and performance improvement courses.

Continuing Education Programs

JTS offers clinicians, nurses and medics the ability to earn Continuing Education (CE) credits to maintain certification and licenses while deployed. Between 30 Mar 2012 and 31 December 2015, JTS provided 8,160 Continuing Medical Education and Continuing Nursing Education credits to physicians and nurses who participated in the multidisciplinary weekly/monthly telemedicine conferences, including the JTS Weekly Theater Combat Casualty Care Curriculum Conference (CCCC) and the JTS/Armed Forces Medical Examiner System Combat Mortality Conference. VTCs keep remote users up to date on the latest techniques, clinical guidelines, policy updates, research initiatives, and meet licensure/board requirements. Annually, 84 CEs credits are available per provider.

Combat Casualty Care Curriculum (CCCC) Conference[edit]

JTS PI teams and Education teams discuss care practices and document those variations at global CCCC teleconferences. JTS has presented over 500 video teleconferences discussing over 3,600 trauma patients. Multiple sites around the globe participate weekly in discussions of recently evacuated casualties from POI through each level of care and follow the selected patients through their rehabilitative phase. Following the clinical discussion, subject matter experts present trauma specific topics to drive advancements and promulgate JTS CPGs. The ability to capture lessons learned on the battlefield for the next generation of trauma surgeons, nurses, pre-hospital providers, and key administrators has contributed to trauma care improvements and military medical readiness.[4]

Research and Data Analysis[edit]

JTS employs a staff of data analysts who support the tri-service military medical community. JTS collaborates with military and civilian personnel serving as principal investigators, research associates and performance improvement specialists. JTS has signed over nearly 140 agreements which support 95 organizations. These organizations include leading military medical research facilities, Congressional committees and educational institutions.

Performance Improvement (PI) for U.S. Military Medical Readiness[edit]

  • Enables evaluation, process improvement and adherence to:
    • JTS CPGs.
    • Capture of injury epidemiology.
    • Assessment of interventions and outcomes.
    • Identification of training items.
    • Support of research initiatives.
    • Efficient allocation of medical resources.
    • Improvement in medical record documentation quality.
  • Retrospective Research Studies.
  • Future Medical Planning.
  • Force Health Protection Projects.

Examples of Outcomes Generated from DoDTR Analyses[edit]

  • Proof the golden hour MEDEVAC policy saves lives. Critically injured who were transported in ≤ 60 minutes had a higher survivability rate. Statically proven to have saved 359 lives.[5]
  • A decreased case fatality rate of less than 9% despite increasing acuity of combat injured patients, show the greatest measurable impact. [5]
  • After broad implementation of tourniquet use, introduction of damage control resuscitation, and implementation of the “Golden Hour,” KIA has been reduced significantly, while DOW remained stable.[5] [6] [7]
  • Reduced mortality in multiple trauma injuries and massively transfused patients. Fatality rates dropped to an average of 8.53% versus the highest case fatality rate of 20% reported in 2005. [5]
  • Design improvements of personal protective equipment.[8]
  • Severity of combat injury increased from 2002 to 2014: the average Military Injury Severity Score from 10.7 to 15.7 however cumulative case fatality rate (CFR) for that period declined from 22% to 10%.[9]
  • Uncontrolled bleeding is a leading cause of early death in trauma and can be prevented by tourniquet use.[10]
  • The White House’s “Stop the Bleed” Forum bases its national first responder program on prehospital clinical measures recommended by the JTS and TCCC. The measures control external hemorrhage to increase an injured person’s chance of survival.[11]
  • The association of Cryoprecipitate and Tranexamic Acid with improved survival. [11]

Military Medicine Community Partners[edit]

The JTS works closely with influential organizations to develop and implement best clinical practices, including the American College of Surgeons, the North Atlantic Treaty Organization (NATO), the Canadian Forces, the Joint Trauma Analysis and Prevention of Injuries in Combat (JTAPIC]), Tactical Combat Casualty Care (TCCC), all three service Surgeons General , Force Health Protection & Readiness Program (FHP&R) (MHS), Theater Functional Management Office of OASD HA, TMDS, Uniformed Services University of Health Sciences (USUHS), Army Special Operations Forces (ARSOF) Medical Skills Training), and U.S. Army Medical Materiel Development Activity (USAMMDA), U.S. Army Medical Research and Materiel Command Office of Research Protections, and The Air War College. The JTS provides its DoDTR data to approved researchers and other registries and Centers of Excellence including Defense and Veterans Brain Injury Center (DVBIC), DoD Embedded Metal Fragment (EMFR), DoD/VA Hearing Center of Excellence (HCE), DoD/VA Vision Center of Excellence (DVEIVR), Telemedicine and Advanced Technology Research (TATRC) mTBI, Uniformed Services University of Health Sciences (USUHS), DoD Trauma Infectious Disease Outcomes Study (TIDOS), and Military Orthopedic Trauma Registry (MOTR). The JTS helps drive the innovation, implementation and adoption of devices and techniques that increase a trauma patient’s chance of survival.[12]

Clinical Practice Guidelines (CPGs) for Combat Casualty Care[edit]

Health data abstracted from patient records and after action reports is analyzed and distilled into globally relevant CPGs and TCCC Guidelines to remove medical practice variations and prevent needless deaths. The CPGs compiled from DoDTR data and used by healthcare providers worldwide are largely responsible for the decreased Case Fatality Rate for the wars in Iraq and Afghanistan. Examples are better transfusion practices, reduced burn morbidity and mortality, near elimination of extremity compartment syndrome, better patient care documentation, and improved communication across the spectrum of care between geographically dispersed facilities.

CPG Development[edit]

The CPGs are developed by clinical Subject Matter Experts (SME) in response to needs identified in the Command (COCOM) Area of Operations. Topics for CPG development or revision may be presented by any DoD clinician to the JTS Director. The proposed topic identifies a perceived gap in care and would drive changes in performance. To the greatest extent possible, JTS CPGs are evidenced-based. The evidence is derived from the published literature or internal JTS analysis of combat casualty data. The JTS leadership evaluates the proposed CPG for relevance to the deployed environment. If a topic is approved, a working group consisting of 10 experts and other key clinical leaders, representing all three U.S. military service medical departments. Input from civilian and foreign military SMEs is permissible. Upon approval by the JTS Director, the final CPGs are published on the JTS website and Army Knowledge Online. JTS sends recently published CPGs to COCOM Surgeon Generals who share it with their teams. Individual COCOMs are welcome to utilize or to modify the JTS CPGs into COCOM-specific CPGs. Routine updates to CPGs occur every five years or as the operational need arises or as new evidence surfaces.[13]

Every CPG has performance improvement metrics. The JTS Performance Improvement (PI) Branch measures CPG adherence through the use of PI indicators which are built into each CPG plan. Each CPG is assigned up to four core measures - quality indicators. Tracking the core measures exposes deficiencies that are addressed by providing education, material solutions or improving processes.

Committee on Tactical Combat Casualty Care[edit]

The TCCC curriculum is based upon the prehospital casualty care recommendations of the DoD Committee on TCCC (CoTCCC.) The CoTCCC was established in 2001 and is part of the U.S. military’s Joint Trauma System. The TCCC program empowers personnel with the knowledge and skills to provide medical care in a combat environment following the principles of trauma life support and the guidelines. The TCCC course introduces evidence-based, life-saving techniques and strategies for providing the best trauma care on the battlefield, under the auspices of the Prehospital Trauma Life Support program. The TCCC curriculum, developed annually by the Joint Trauma System, is used to train all US Military combatants to care for the combat wounded. TCCC is the only set of battlefield trauma care best-practice guidelines that has received the dual endorsement of the American College of Surgeons Committee on Trauma and the National Association of Emergency Medical Technicians.

The TCCC Guidelines are now used by all services in the U.S. military as the standard for training medics to manage combat trauma on the battlefield. TCCC is taught to new Soldiers by the Army Training and Doctrine Command as part of its Combat Lifesaver training program and is used increasingly to train tactical medics in civilian law enforcement agencies.[14] [13] [15] [16]

References[edit]

  1. DoD Instruction 6040.47, Joint Trauma System, Sept 28, 2016
  2. Eastridge BJ, Costanzo G, Jenkins D, et al. Impact of joint theater trauma system initiatives on battlefield injury outcomes. Am J Surg. 2009;198:852– 857.
  3. Holcomb JB, Stansbury LG, Champion HR, Wade C, Bellamy RF. Understanding combat casualty care statistics. J Trauma. 2006;60:397–401.
  4. Eastridge B, Hardin M, Cantrell J, et al. Died of Wounds on the Battlefield: Causation and Implications for Improving Combat Casualty Care, The Journal of Trauma Injury, Infection, and Critical Care, Vol71:1, July 2011 Supplement.
  5. 5.0 5.1 5.2 5.3 Kotwal RS; Howard JT; Orman JA; et al. (2016-01-01). "THe effect of a golden hour policy on the morbidity and mortality of combat casualties". JAMA Surgery. 151 (1): 15–24. doi:10.1001/jamasurg.2015.3104. ISSN 2168-6254.
  6. Kragh, JF (Dec 2011). "Battle casualty survival with emergency tourniquet use to stop limb bleeding". J Emerg Med.
  7. Kotwal, Russ S (Dec 2012). "Death on the battlefield (2001-2011): implications for the future of combat casualty care". J Trauma Acute Care Surg.
  8. "Lessons learnt and battlefield innovations from the Middle East are of operations". jmvh.org. Retrieved 2016-07-27.
  9. Langan, NR (Sep 2014). "Changing patterns of in-hospital deaths following implementation of damage control resuscitation practices in US forward military treatment facilities". JAMA Surg.
  10. Khalili, R. "White House Taps Military Medicine Expertise for Emergency Preparedness Campaign".
  11. 11.0 11.1 Morrison JJ; Ross JD; Dubose JJ; Jansen JO; Midwinter MJ; Rasmussen TE (2013-03-01). "Association of cryoprecipitate and tranexamic acid with improved survival following wartime injury: Findings from the matters ii study". JAMA Surgery. 148 (3): 218–225. doi:10.1001/jamasurg.2013.764. ISSN 2168-6254.
  12. "Trauma registry yields significant increase in traumatic injury survival rates". www.dvidshub.net. Retrieved 2016-07-27.
  13. 13.0 13.1 Butler, Frank K (2012). "Battlefield Trauma Care Then and Now: A Decade of Tactical Combat Casualty Care". Journal of Trauma and Acute Care Surgery. 73 (6). doi:10.1097/TA.0b013e3182754850.
  14. "TCCC Guidelines and Curriculum".
  15. Butler, Frank K (2014). Prehospital Trauma Life Support Manual. Search this book on
  16. Butler, Frank K (2012). "Tactical Combat Casualty Care: From the Battlefields of Afghanistan and Iraq to the Streets of America. The Tactical Edge".


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