Evaluation of military trauma system practices related to complications after injury

From the US Army Institute of Surgical Research (K.L., A.A., D.S., G.C., J.B., L.H.B., M.A.S., B.J.E.), Fort Sam Houston, Texas
The journal of trauma and acute care surgery 12/2012; 73(6 Suppl 5):S465-71. DOI: 10.1097/TA.0b013e31827548a9
Source: PubMed

ABSTRACT The Joint Theater Trauma System (JTTS) was developed with the vision that every soldier, marine, sailor, and airman injured on the battlefield would have the optimal chance for survival and maximum potential for functional recovery. In this analysis, we hypothesized that injury and complication after injury surveillance information diffusion through the JTTS, via the dissemination of clinical practice guidelines and process improvements, would be associated with improved combat casualty clinical outcomes.
The current analysis was designed to profile different aspects of trauma system performance improvement, including monitoring of frequent posttraumatic complications, the assessment of an emerging complication trend, and measurement of the impact of the system interventions to identify potential practices for future performance improvement. Data captured from the Joint Theater Trauma Registry on patients admitted to military medical treatment facilities as a result of wounds incurred in Iraq and Afghanistan from 2003 to 2010 were retrospectively analyzed to determine the potential impact of complication surveillance and process improvement initiatives on clinical practice.
Developed metrics demonstrated that the surveillance capacity and evidence-based quality improvement initiatives disseminated through the JTTS were associated with improved identification and mitigation of complications following battlefield injury.
The Joint Trauma System enables evidence-based practice across the continuum of military trauma care. Concurrent data collection and performance improvement activities at the local and system level facilitate timely clinical intervention on identified trauma complications and the subsequent measurement of the effectiveness of those interventions.
Epidemiologic study, level III.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Vladimir A. Oppel (1872-1932) was a forefather of military trauma systems. As a surgeon in the Russian Army in World War I, Oppel experienced the challenges and inefficiencies associated with caring for large numbers of combat wounded, the inefficiencies he observed leading to unacceptable morbidity and mortality. As a consequence, Oppel envisioned a coordinated sequence of surgical care on the battlefield and developed the concept of "targeted evacuation." In his work, Oppel was among the first to propose the "right operation for the right patient at the right location at the right time." Central to Oppel's precepts were (1) the forward positioning of surgical care close to the point of injury, (2) the development of a reserve of proficient and deployable military surgeons, and (3) the provision of specialized surgery to optimize survival and reduce morbidity. Oppel's teachings were validated during World War II in the performance of the Soviet casualty evacuation system and in all modern wars modern since. Today, nearly 100 years after the work of Vladimir Oppel, the benefits of a coordinated or "targeted" trauma system, working to optimize survival after trauma, are well recognized around the world.
    04/2013; 74(4):1178-81. DOI:10.1097/TA.0b013e3182858407
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective. Earlier use of plasma and red blood cells (RBCs) has been associated with improved survival in trauma patients with substantial hemorrhage. We hypothesized that prehospital transfusion (PHT) of thawed plasma and/or RBCs would result in improved patient coagulation status on admission and survival. Methods. Adult trauma patient records were reviewed for patient demographics, shock, coagulopathy, outcomes, and blood product utilization from September 2011 to April 2013. Patients arrived by either ground or two different helicopter companies. All patients transfused with blood products (either pre- or in-hospital) were included in the study. One helicopter system (LifeFlight, LF) had thawed plasma and RBCs while the other air (OA) and ground transport systems used only crystalloid resuscitation. Patients receiving PHT were compared with all other patients meeting entry criteria to the study cohort. All comparisons were adjusted in multilevel regression models. Results. A total of 8,536 adult trauma patients were admitted during the 20-month study period, of which 1,677 met inclusion criteria. They represented the most severely injured patients (ISS = 24 and mortality = 26%). There were 792 patients transported by ground, 716 by LF, and 169 on OA. Of the LF patients, 137 (19%) received prehospital transfusion. There were 942 units (244 RBCs and 698 plasma) placed on LF helicopters, with 1.9% wastage. PHT was associated with improved acid–base status on hospital admission, decreased use of blood products over 24 hours, a reduction in the risk of death in the sickest patients over the first 6 hours after admission, and negligible blood products wastage. In this small single-center pilot study, there were no differences in 24-hour (odds ratio 0.57, p = 0.117) or 30-day mortality (odds ratio 0.71, p = 0.441) between LF and OA. Conclusions. Prehospital plasma and RBC transfusion was associated with improved early outcomes, negligible blood products wastage, but not an overall survival advantage. Similar to the data published from the ongoing war, improved early outcomes are associated with placing blood products prehospital, allowing earlier infusion of life-saving products to critically injured patients.
    Prehospital Emergency Care 06/2014; DOI:10.3109/10903127.2014.923077 · 1.81 Impact Factor


Available from
Sep 5, 2014