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Remondelli MH, McDonough MM, Remick KN, Elster EA, Potter BK, Holt DB. Refocusing the Military Health System to support Role 4 definitive care in future large-scale combat operations. J Trauma Acute Care Surg 2024; 97:S145-S153. [PMID: 38720205 DOI: 10.1097/ta.0000000000004379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2024]
Abstract
ABSTRACT The last 20 years of sustained combat operations during the Global War on Terror generated significant advancements in combat casualty care. Improvements in point-of-injury care, en route care, and forward surgical care appropriately aligned with the survival, evacuation, and return to duty needs of the small-scale unconventional conflict. However, casualty numbers in large-scale combat operations have brought into focus the critical need for modernized casualty receiving and convalescence: Role 4 definitive care. Historically, World War II was the most recent conflict in which the United States fought in multiple operational theaters, with hundreds of thousands of combat casualties returned to the continental United States. These numbers necessitated the establishment of a "Zone of the Interior," which integrated military and civilian health care networks for definitive treatment and rehabilitation of casualties. Current security threats demand refocusing and bolstering the Military Health System's definitive care capabilities to maximize its force regeneration capacity in a similar fashion. Medical force generation, medical force sustainment and readiness, and integrated casualty care capabilities are three pillars that must be developed for Military Health System readiness of Role 4 definitive care in future large-scale contingencies against near-peer/peer adversaries.
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Affiliation(s)
- Mason H Remondelli
- From the School of Medicine (M.H.R., M.M.M.) and Department of Surgery (K.N.R., E.A.E., B.K.P., D.B.H.), Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Haverkamp FJC, Van Dongen TTCF, Edwards MJR, Boel T, Pöyhönen A, Tan ECTH, Hoencamp R. European military surgical teams in combat theater: A survey study on deployment preparation and experience. Injury 2024; 55:111320. [PMID: 38238119 DOI: 10.1016/j.injury.2024.111320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/27/2023] [Accepted: 01/08/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Adequate (predeployment) training of the nowadays highly specialized Western military surgical teams is vital to ensure a broad range of surgical skills to treat combat casualties. This survey study aimed to assess the self-perceived preparedness, training needs, deployment experience, and post-deployment impact of surgical teams deployed with the Danish, Dutch, or Finnish Armed Forces. Study findings may facilitate a customized predeployment training. METHODS A questionnaire was distributed among Danish, Dutch, and Finnish military surgical teams deployed between January 2013 and December 2020 (N = 142). The primary endpoint of self-perceived preparedness ratings, and data on the training needs, deployment experiences, and post-deployment impacts were compared between professions and nations. RESULTS The respondents comprised 35 surgeons, 25 anesthesiologists, and 39 supporting staff members, with a response rate of 69.7 % (99/142). Self-perceived deployment preparedness was rated with a median of 4.0 (IQR 4.0-4.0; scale: 1 [very unprepared]-5 [more than sufficient]). No differences were found among professions and nations. Skills that surgeons rated below average (median <6.0; scale: 1 [low]-10 [high]) included tropical disease management and maxillofacial, neurological, gynecological, ophthalmic, and nerve repair surgery. The deployment caseload was most often reported as <1 case per week (41/99, 41.4 %). The need for professional psychological help was rated at a median of 1.0 (IQR 1.0-1.0; scale: 1 [not at all]-5 [very much]). CONCLUSIONS Military surgical teams report overall adequate preparedness for deployment. Challenges remain for establishing broadly skilled teams because of a low deployment caseload and ongoing primary specializations. Additional training and exposure were indicated for several specialism-specific skill areas. The need for specific training should be addressed through customized predeployment programs.
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Affiliation(s)
| | | | | | - Thomas Boel
- Danish Armed Forces, Medical Command, DK-8220 Brabrand, Denmark
| | - Antti Pöyhönen
- Finnish Defence Forces Health Services, Centre For Military Medicine, FI-11311 Riihimäki, Finland
| | - Edward C T H Tan
- Department of Surgery, Radboudumc, 6500 HB Nijmegen, Netherlands; Defence Healthcare Organization, Ministry of Defence, 3584 AB Utrecht, Netherlands
| | - Rigo Hoencamp
- Defence Healthcare Organization, Ministry of Defence, 3584 AB Utrecht, Netherlands; Department of Surgery, Alrijne Hospital, 2353 GA Leiderdorp, Netherlands; Division of Surgery, Leiden University Medical Centre, 2333 ZA Leiden, Netherlands; Department of Surgery, Erasmus MC, 3015 GD Rotterdam, Netherlands
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Cant MR, Naumann DN, Swain C, Mountain AJ, Baden J, Bowley DM. Acquisition and retention of military surgical competencies: a survey of surgeons' experiences in the UK Defence Medical Services. BMJ Mil Health 2024; 170:117-122. [PMID: 35649691 DOI: 10.1136/bmjmilitary-2022-002112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/15/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The acquisition and retention of militarily relevant surgical knowledge and skills are vital to enable expert management of combat casualties on operations. Opportunities for skill sustainment have reduced due to the cessation of combat operations in Iraq and Afghanistan and lack of military-relevant trauma in UK civilian practice. METHODS A voluntary, anonymous online survey study was sent to all UK Defence Medical Services (DMS) surgical consultants and higher surgical trainees in Trauma and Orthopaedics, Plastic and Reconstructive, and General and Vascular surgical specialties (three largest surgical specialties in the DMS in terms of numbers). The online questionnaire tool included 20 questions using multiple choice and free text to assess respondents' subjective feelings of preparedness for deployment as surgeons for trauma patients. RESULTS There were 71 of 108 (66%) responses. Sixty-four (90%) respondents were regular armed forces, and 46 (65%) worked in a Major Trauma Centre (MTC). Thirty-three (47%) had never deployed on operations in a surgical role. Nineteen (27%) felt they had sufficient exposure to penetrating trauma. When asked 'How well do you feel your training and clinical practice prepares you for a surgical deployment?' on a scale of 1-10, trainees scored significantly lower than consultants (6 (IQR 4-7) vs 8 (IQR 7-9), respectively; p<0.001). There was no significant difference in scores between regular and reservists, or between those working at an MTC versus non-MTC. Respondents suggested high-volume trauma training and overseas trauma centre fellowships, simulation, cadaveric and live-tissue training would help their preparedness. CONCLUSIONS There was a feeling among a sample of UK DMS consultants and trainees that better preparedness is required for them to deploy confidently as a surgeon for combat casualties. The responses suggest that UK DMS surgical training requires urgent attention if current surgeons are to be ready for their role on deployed operations.
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Affiliation(s)
| | - D N Naumann
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - C Swain
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - A J Mountain
- Department of Military Trauma and Orthopaedics, Royal Centre for Defence Medicine, Birmingham, UK
| | - J Baden
- Department of Military Plastic and Reconstructive Surgery, Royal Centre for Defence Medicine, Birmingham, UK
| | - D M Bowley
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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Lee J, Roberson L, Garner R, Kim E, Glaser J, Choi P, Vicente D. Trauma and Critical Care Military-Civilian Publications Increased After the COVID-19 Pandemic: A Literature Review. J Surg Res 2023; 292:97-104. [PMID: 37603939 DOI: 10.1016/j.jss.2023.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION There continues to be a growing demand for military-civilian partnerships (MCPs) in research collaborations developing medical trauma care in domestic and international affairs. The objective of this comprehensive review is to investigate the difference in the quantity of MCP trauma and critical care publications before and after the COVID-19 pandemic. METHODS A systematic literature review was performed for the calendar years 2018 and 2021 utilizing MEDLINE, Cochrane, and EMBASE databases. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a three-tiered review of 603 English language articles to identify trauma-related military and/or civilian partners and describe the changes in geographical relationships. RESULTS A total of 96 (2018) and 119 (2021) articles met screening criteria for trauma and critical care studies and were used for final data extraction. Ultimately, 59 (2018) and 71 (2021) papers met the inclusion criteria of identifying trauma/critical care MCPs and identified both military and civilian partners. There was also an increase from 10 (2018) to 17 (2021) publications that mentioned advocacy for MCP. Using the author affiliations, four regional MCP types were recorded: of 2018 articles, locoregional (3.4%), US-national (47.5%), single international country (42.4%), and between multiple countries (6.8%); of 2021 articles, locoregional (15.5%), US-national (38%), single international country (29.6%), and between multiple countries (16.9%). There has been an increase in the number of locoregional and multinational MCPs and an overall increase in the number of collaborative trauma publications and MCP advocacy papers. A national geographical heat map was developed to illustrate the changes from 2018 to 2021. CONCLUSIONS There has been an increase in the number of recorded trauma and critical care MCP publications post-pandemic. The growth in the number of manuscripts in more regions post-pandemic suggests an increase in the recognition of collaborations that contribute not only to conflict readiness but also advancements in trauma and surgical care.
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Affiliation(s)
- Joseph Lee
- Department of Surgery, Naval Medical Center San Diego, San Diego, California
| | - Laura Roberson
- Department of Surgery, Naval Medical Center San Diego, San Diego, California
| | - Reid Garner
- Surgery, Uniformed Services University of The Health Sciences, Bethesda, Maryland
| | - Eungjae Kim
- Surgery, Uniformed Services University of The Health Sciences, Bethesda, Maryland
| | - Jacob Glaser
- Surgery, Uniformed Services University of The Health Sciences, Bethesda, Maryland; Surgery, Providence Regional Medical Center, Everett, Washington
| | - Pamela Choi
- Department of Surgery, Naval Medical Center San Diego, San Diego, California; Surgery, Uniformed Services University of The Health Sciences, Bethesda, Maryland
| | - Diego Vicente
- Department of Surgery, Naval Medical Center San Diego, San Diego, California; Surgery, Uniformed Services University of The Health Sciences, Bethesda, Maryland.
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Horn CB, Kopchak MC, Pritts TA, Sams VG, Remick KN, Strilka RJ, Earnest RE. Quality of Integration of Air Force Trauma Surgeons Within the Center for Sustainment of Trauma and Readiness Skills, Cincinnati: A Pilot Study. Mil Med 2023:usad441. [PMID: 37997688 DOI: 10.1093/milmed/usad441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 09/28/2023] [Accepted: 10/31/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION While previous studies have analyzed military surgeon experience within military-civilian partnerships (MCPs), there has never been an assessment of how well military providers are integrated within an MCP. The Center for Sustainment of Trauma and Readiness Skills, Cincinnati supports the Critical Care Air Transport Advanced Course and maintains the clinical skills of its staff by embedding them within the University of Cincinnati Medical Center. We hypothesized that military trauma surgeons are well integrated within University of Cincinnati Medical Center and that they are exposed to a similar range of complex surgical pathophysiology as their civilian partners. MATERIALS AND METHODS After Institutional Review Board approval, Current Procedural Terminology (CPT) codes were abstracted from billing data for trauma surgeons covering University of Cincinnati Hospitals in 2019. The number of trauma resuscitations and patient acuity metrics were abstracted from the Trauma Registry and surgeon Knowledge, Skills, and Abilities clinical activity (KSA-CA) scores were calculated using their CPT codes. Finally, surgeon case distributions were studied by sorting their CPT codes into 23 categories based on procedure type and anatomic location. Appropriate, chi-squared or Mann-Whitney U-tests were used to compare these metrics between the military and civilian surgeon groups and the metrics were normalized by the group's full-time equivalent (FTE) to adjust for varying weeks on service between groups. RESULTS Data were available for two active duty military and nine civilian staff. The FTEs were significantly lower in the military group: military 0.583-0.583 (median 0.583) vs. civilian 0.625-1.165 (median 1.0), P = 0.04. Per median FTE and surgeon number, both groups performed a similar number of trauma resuscitations (civilian 214 ± 54 vs. military 280 ± 13, P = 0.146) and KSA-CA points (civilian 55,629 ± 25,104 vs. military 36,286 ± 11,267; P = 0.582). Although the civilian surgeons had a higher proportion of hernia repairs (P < 0.001) and laparoscopic procedures (P = 0.006), the CPT code categories most relevant to combat surgery (those relating to solid organ, hollow viscus, cardiac, thoracic, abdominal, and tissue debridement procedures) were similar between the surgeon groups. Finally, patient acuity metrics were similar between groups. CONCLUSION This is the first assessment of U.S. Air Force trauma surgeon integration relative to their civilian partners within an MCP. Normalized by FTE, there was no difference between the two groups' trauma experience to include patient acuity metrics and KSA-CA scores. The proportion of CPT codes that was most relevant to expeditionary surgery was similar between the military and civilian partners, thus optimizing the surgical experience for the military trauma surgeons within University of Cincinnati Medical Center. The methods used within this pilot study can be generalized to any American College of Surgeons verified Trauma Center MCP, as standard databases were used.
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Affiliation(s)
- Christopher B Horn
- United States Air Force, Center for Sustainment of Trauma and Readiness Skills, Cincinnati, Cincinnati, OH 45267, USA
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Maura C Kopchak
- University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Timothy A Pritts
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Valerie G Sams
- United States Air Force, Center for Sustainment of Trauma and Readiness Skills, Cincinnati, Cincinnati, OH 45267, USA
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Kyle N Remick
- Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD 20814, USA
| | - Richard J Strilka
- United States Air Force, Center for Sustainment of Trauma and Readiness Skills, Cincinnati, Cincinnati, OH 45267, USA
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Ryan E Earnest
- United States Air Force, Center for Sustainment of Trauma and Readiness Skills, Cincinnati, Cincinnati, OH 45267, USA
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
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Hefley J, Talbot LA, Metter EJ, Lorenz ME, Shattuck H, Romito K, Heyne RE, Bradley DF. Advancing Readiness Through Military Programs: An Evidence-Based Practice Perspective. Mil Med 2023; 189:31-38. [PMID: 37956329 DOI: 10.1093/milmed/usad230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/24/2023] [Accepted: 06/14/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION Military nurses comprise the largest percentage of military health care providers. In the current military health care system, they have two roles: (1) Patient care in military treatment facilities (MTFs) and (2) patient care during combat operations. Although in MTFs, the military nurse's roles are similar to those of their civilian counterpart, their roles are unique and varied in the combat operational environment. These combined roles lead to questions regarding readiness training to ensure that nurses are proficient in both MTFs and combat operational settings where treatment requirements may differ. The purpose of this paper is to (1) present the current state of educational readiness programs to maintain a ready medical force that entail formal teaching programs, military-civilian partnerships, and joint exercises of combat simulations, and (2) identify gaps as presented in an evidence-based practice educational panel. METHODS On March 11, 2022, TriService Nursing Research Program hosted the virtual First Military Evidence-Based Practice Summit from the Uniformed Services University of the Health Sciences in Bethesda, MD. As part of the summit, an evidence-based practice education panel discussed the availability of current evidence-driven military medical readiness programs and identified gaps in the integration of military readiness for nursing personnel into the Defense Health Agency and Armed Services. RESULTS The panel participants discussed the separate requirements for training within the MTFs and in combat operational settings. The available training programs identified by the panel were primarily those developed in local MTF settings to meet local needs. Although these programs support the MTFs' peacetime mission, competing roles, limited time, and limited funds contributed to limited preparation of nursing personnel in skills associated with combat-related injuries and illnesses. Prolonged casualty care has become an important focus for the Department of Defense as greater considerations are directed to wartime operations in austere expeditionary environments. Although there is some training available that is specific for prolonged casualty care, the focus has been the adaptation of combat casualty care during contingency operations. A keynote here was the concept that combat casualty care training must include both development of individual skills and integration of the team since maximal care can be achieved only when the individual and the team operate as a unit. A key point was the utility of central repositories for storing information related to training a ready medical force at individual and unit levels and that these repositories could also be used to collect and facilitate the accession of current evidence-based information. DISCUSSION Optimal patient care at all levels of the military health system requires training that maximizes individual and unit skills specific to the environment at an MTF or in a combat operational setting. Training must be designed to incorporate evidence-driven knowledge in all military settings with guidance that is specific to the environment. CONCLUSION Enhanced communication of evidence-based training and knowledge is an important component of maintaining a ready medical force for broader medical support of combat contingency operations.
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Affiliation(s)
- Justin Hefley
- Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Laura A Talbot
- Department of Neurology, University of Tennessee Health Science Center, College of Medicine, Memphis, TN 38163, USA
| | - E Jeffrey Metter
- Department of Neurology, University of Tennessee Health Science Center, College of Medicine, Memphis, TN 38163, USA
| | - Megan E Lorenz
- Landstuhl Regional Medical Center, Unit 33100, APO, Landstuhl 66849, Germany
| | - Heather Shattuck
- Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Kenneth Romito
- Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Rebecca E Heyne
- Lackland Airforce Base, Science and Technology, Center for Clinical Inquiry, JBSA Lackland, TX 78236, USA
| | - David F Bradley
- Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Ruggero JM, Farnand AW, Roach PB, Starr F, Tadlock MD, Bokhari F. Initial Assessment of a Regional Military-Civilian Partnership on Trauma Surgery Skills Sustainment. Mil Med 2023; 188:e2462-e2466. [PMID: 35880592 DOI: 10.1093/milmed/usac229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/01/2022] [Accepted: 07/21/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Trauma surgery skills sustainment and maintenance of combat readiness present a major problem for military general surgeons. The Military Health System (MHS) utilizes the knowledge, skills, and abilities (KSA) threshold score of 14,000 as a measure of annual deployment readiness. Only 9% of military surgeons meet this threshold. Most military-civilian partnerships (MCPs) utilize just-in-time training models before deployment rather than clinical experiences in trauma at regular intervals (skills sustainment model). Our aim is to evaluate an established skills sustainment MCP utilizing KSAs and established military metrics. MATERIALS AND METHODS Three U.S. Navy active duty general surgeons were embedded into an urban level-1 trauma center taking supervised trauma call at regular intervals prior to deployment. Operative density (procedures/call), KSA scores, trauma resuscitation exposure, and combat casualty care relevant cases (CCC-RCs) were reviewed. RESULTS During call shifts with a Navy surgeon present an average 16.4 trauma activations occurred; 32.1% were category-1, 27.6% were penetrating, 72.4% were blunt, and 33.8% were admitted to the intensive care unit. Over 24 call shifts of 24 hours in length, 3 surgeons performed 39 operative trauma cases (operative density of 1.625), generating 11,683 total KSA points. Surgeons 1, 2, and 3 generated 5109, 3167, and 3407 KSA points, respectively. The three surgeons produced a total of 11,683 KSA points, yielding an average of 3,894 KSA points/surgeon. In total, 64.1% of operations fulfilled CCC-RC criteria. CONCLUSIONS Based on this initial evaluation, a military surgeon taking two calls/month over 12 months through our regional skills sustainment MCP can generate more than 80% of the KSA points required to meet the MHS KSA threshold for deployment readiness, with the majority being CCC-RCs. Intangible advantages of this model include exposure to multiple trauma resuscitations while possibly eliminating just-in-time training and decreasing pre-deployment requirements.
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Affiliation(s)
- John M Ruggero
- Department of Trauma, Cook County Health, Chicago, IL 60612, USA
- Navy Medicine Readiness and Training Command Great Lakes, North Chicago, IL 60064, USA
| | - Alex W Farnand
- Navy Medicine Readiness and Training Command Great Lakes, North Chicago, IL 60064, USA
| | - Paul B Roach
- Navy Medicine Readiness and Training Command Great Lakes, North Chicago, IL 60064, USA
| | - Frederic Starr
- Department of Trauma, Cook County Health, Chicago, IL 60612, USA
| | - Matthew D Tadlock
- 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, CA 92055, USA
| | - Faran Bokhari
- Department of Trauma, Cook County Health, Chicago, IL 60612, USA
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Andreatta P, Bowyer MW, Ritter EM, Remick K, Knudson MM, Elster EA. Evidence-based Surgical Competency Outcomes from the Clinical Readiness Program. Ann Surg 2023; 277:e992-e999. [PMID: 34879053 DOI: 10.1097/sla.0000000000005324] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES 1) Evaluate the value and strength of a competency framework for identifying and measuring performance requirements for expeditionary surgeons; 2) Verify psychometric integrity of assessment instrumentation for measuring domain knowledge and skills; 3) Identify gaps in knowledge and skills capabilities using assessment strategies; 4) Examine shared variance between knowledge and skills outcomes, and the volume and diversity of routine surgical practice. BACKGROUND Expeditionary military surgeons provide care for patients with injuries that extend beyond the care requirements of their routine surgical practice. The readiness of these surgeons to independently provide accurate care in expeditionary contexts is important for casualty care in military and civilian situations. Identifying and closing performance gap areas are essential for assuring readiness. METHODS We implemented evidence-based processes for identifying and measuring the essential performance competencies for expeditionary surgeons. All assessment instrumentation was rigorously examined for psychometric integrity. Performance outcomes were directly measured for expeditionary surgical knowledge and skills and gap areas were identified. Knowledge and skills assessment outcomes were compared, and also compared to the volume and diversity of routine surgical practice to determine shared variance. RESULTS Outcomes confirmed the integrity of assessment instrumentation and identified significant performance gaps for knowledge and skills in the domain. CONCLUSIONS Identification of domain competencies and performance benchmarks, combined with best-practices in assessment instrumentation, provided a rigorous and defensible framework for quantifying domain competencies. By identifying and implementing strategies for closing performance gap areas, we provide a positive process for assuring surgical competency and clinical readiness.
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Affiliation(s)
- Pamela Andreatta
- Department of Surgery, Uniformed Services University of the Health Science & the Walter Reed National Military Medical Center, Bethesda, MD
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Mark W Bowyer
- Department of Surgery, Uniformed Services University of the Health Science & the Walter Reed National Military Medical Center, Bethesda, MD
| | - E Matthew Ritter
- Department of Surgery, Uniformed Services University of the Health Science & the Walter Reed National Military Medical Center, Bethesda, MD
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; and
| | - Kyle Remick
- Department of Surgery, Uniformed Services University of the Health Science & the Walter Reed National Military Medical Center, Bethesda, MD
| | - Mary Margaret Knudson
- Military Health System Strategic Partnership with the American College of Surgeons, Chicago, IL
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Science & the Walter Reed National Military Medical Center, Bethesda, MD
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Building a Sustainable Mil-Civ Partnership to Ensure a Ready Medical Force: A Single Partnership Site’s Experience. J Trauma Acute Care Surg 2022; 93:S174-S178. [DOI: 10.1097/ta.0000000000003632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lee JJ, Hall AB, Carr MJ, MacDonald AG, Edson TD, Tadlock MD. Integrated military and civilian partnerships are necessary for effective trauma-related training and skills sustainment during the inter-war period. J Trauma Acute Care Surg 2022; 92:e57-e76. [PMID: 34797811 DOI: 10.1097/ta.0000000000003477] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Joseph J Lee
- From the Department of Surgery (J.J.L., M.J.C., M.D.T.), Navy Medicine Readiness & Training Command, San Diego, California; 96th Medical Group (A.B.H.), US Air Force Regional Hospital, Eglin AFB, Florida; Uniformed Services University of the Health Sciences (A.G.M.), Bethesda, Maryland; and 1st Medical Battalion (T.D.E.), 1st Marine Logistics Group, Camp Pendleton, California
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11
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Rask DMG, Tansey KA, Osborn PM. Impact of Civilian Patient Care on Major Amputation Case Volume in the Military Health System. Mil Med 2022; 188:usab534. [PMID: 34986247 DOI: 10.1093/milmed/usab534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/07/2021] [Accepted: 12/14/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Sustaining critical wartime skills (CWS) during interwar periods is a recurrent and ongoing challenge for military surgeons. Amputation surgery for major extremity trauma is exceptionally common in wartime, so maintenance of surgical skills is necessary. This study was designed to examine the volume and distribution of amputation surgery performed in the military health system (MHS). STUDY DESIGN All major amputations performed in military treatment facilities (MTF) for calendar years 2017-2019 were identified by current procedural terminology (CPT) codes. The date of surgery, operating surgeon National Provider Identifier, CPT code(s), amputation etiology (traumatic versus nontraumatic), and beneficiary status (military or civilian) were recorded for each surgical case. RESULTS One thousand one hundred and eighty-four major amputations at 16 of the 49 military's inpatient facilities were identified, with two MTFs accounting for 46% (548/1,184) of the total. Six MTFs performed 120 major amputations for the treatment of acute traumatic injuries. Seventy-three percent (87/120) of traumatic amputations were performed at MTF1, with the majority of patients (86%; 75/87) being civilians emergently transported there after injury. Orthopedic and vascular surgeons performed 78% of major amputations, but only 9.7% (152/1,570) of all military surgeons performed any major amputation, with only 3% (52) involved in amputations for trauma. Nearly all (87%; 26/30) of the orthopedic surgeons at MTF1 performed major amputations, including those for trauma. CONCLUSION This study highlights the importance of civilian patient care to increase major amputation surgical case volume and complexity to sustain critical wartime skills. The preservation and strategic expansion of effective military-civilian partnerships is essential for sustaining the knowledge and skills for optimal combat casualty care.
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Affiliation(s)
- Dawn M G Rask
- Business Operations Division, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- Department of Orthopaedic Surgery, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX 78234, USA
| | - Kimberly A Tansey
- Business Operations Division, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Patrick M Osborn
- Business Operations Division, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- Department of Orthopaedic Surgery, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX 78234, USA
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12
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Cant MR, Naumann DN, König TC, Bowley DM. How do deployed general surgeons acquire relevant skill sets and competencies and mitigate skill fade? BMJ Mil Health 2020; 167:209-213. [PMID: 33328277 DOI: 10.1136/bmjmilitary-2020-001641] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/22/2020] [Accepted: 10/27/2020] [Indexed: 12/28/2022]
Abstract
There are recognised difficulties internationally with acquisition and retention of skills among deployed military general surgeons. These are compounded by reduced trauma workload in non-deployed roles or during low tempo or limited activity deployments, and the winding-down of combat operations in Iraq and Afghanistan. We summarise the relevant military-run courses, military-civilian collaborations and potential future strategies that have been used to address skill sets and competencies of deployed surgeons. We use examples from the American, British, Danish, French, German and Swedish Armed Forces. There is variation between nations in training, with a combination of didactic lectures, simulation training and trauma placements in civilian settings at home and overseas. Data regarding effectiveness of these techniques are sparse. It is likely that combat surgical skill-set acquisition and maintenance requires a combination of employment at a high-volume trauma centre during a surgeon's non-deployed role, together with military-specific courses and high-fidelity simulation to fill skill gaps. There are multiple newer modalities of training that require further evaluation if they are to prove effective in the future. We aimed to summarise the current methods used internationally to ensure acquisition and retention of vital skill sets for these surgeons.
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Affiliation(s)
| | - D N Naumann
- Academic Department of Military Surgery and Trauma, Birmingham, UK
| | - T C König
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK.,16 Medical Regiment, Royal Army Medical Corps, Merville Barracks, Colchester, Essex, UK
| | - D M Bowley
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
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Johnson JC, Morey BL, Carroll AM, Strevig MA, Ramirez AR, Mullenix PS, Wozniak CJ, Ricca RL. Cardiothoracic Surgical Volume Within the Military Health System: Fiscal Years 2007 to 2017. Ann Thorac Surg 2020; 111:1071-1076. [PMID: 32693044 DOI: 10.1016/j.athoracsur.2020.05.124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 05/03/2020] [Accepted: 05/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cardiothoracic surgical services have been provided at 7 military treatment facilities over the past decade. Accurate case volume data for adult cardiac and general thoracic surgical service lines in the Military Health System is unknown. METHODS We queried the Military Health System Data Repository for adult cardiac and general thoracic cases performed at military treatment facilities in the Military Health System and surrounding purchased care markets for fiscal years 2007 to 2017. Cases were filtered and classified into major cardiac and major general thoracic categories. Five military treatment facility markets had sufficient cardiac case data to perform cost analysis. RESULTS Institutional major cardiac case volume was low across the Military Health System with less than 100 cardiopulmonary bypass cases per year (range, 17-151 cases per year) performed most years at each military treatment facility. Similarly, general thoracic surgical case volume was universally low, with less than 30 anatomic lung resections (range, 0-26) and fewer than 5 esophageal resections (range, 0-4) performed at each military treatment facility annually. Cost analysis revealed that provision of cardiac surgical services is significantly more expensive at most military treatment facilities compared with their surrounding purchased care markets. CONCLUSIONS Adult cardiac and general thoracic surgical volume within the Military Health System is low across all institutions and inadequate to provide clinical readiness for active-duty surgeons. Recapture of major cases from the purchased care market is unlikely and would not significantly increase military treatment facility or individual surgeon case volume.
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Affiliation(s)
- Jeffery C Johnson
- Directorate of Surgical Services, Naval Medical Center Portsmouth, Portsmouth, Virginia.
| | - Brittany L Morey
- Directorate of Surgical Services, Navy and Marine Corps Public Health Center, Portsmouth, Virginia
| | - Anna M Carroll
- Directorate of Surgical Services, Navy and Marine Corps Public Health Center, Portsmouth, Virginia
| | - Matthew A Strevig
- Directorate of Surgical Services, Navy and Marine Corps Public Health Center, Portsmouth, Virginia
| | - Alfredo R Ramirez
- Department of Cardiothoracic Sugery, Naval Medical Center San Diego, San Diego, California
| | - Philip S Mullenix
- Department of Cardiothoracic Sugery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Curtis J Wozniak
- Department of Cardiothoracic Sugery, David Grant USAF Medical Center, Fairfield, California
| | - Robert L Ricca
- Directorate of Surgical Services, Naval Medical Center Portsmouth, Portsmouth, Virginia
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Hall A, Qureshi I, Glaser J, Bulger EM, Scalea T, Shackelford S, Gurney J. Validation of a predictive model for operative trauma experience to facilitate selection of trauma sustainment military-civilian partnerships. Trauma Surg Acute Care Open 2019; 4:e000373. [PMID: 31897438 PMCID: PMC6924793 DOI: 10.1136/tsaco-2019-000373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/10/2019] [Accepted: 11/04/2019] [Indexed: 11/03/2022] Open
Abstract
Background Trauma readiness is a Department of Defense requirement for military healthcare providers. Surgeons must maintain readiness to optimize surgical care on the battlefield and minimize preventable death. The objective of this study was to validate a predictive model for trauma operative exposure by applying the model prospectively. Methods The predictive model for operative trauma exposure was prospectively applied to predict the number of emergent operative cases that would be experienced over predetermined time periods at four separate trauma sustainment military-civilian partnerships (TS-MCP). Notional courses were designed to be 2 or 4 weeks long and consisting of 5 and 12 overnight call periods, respectively. A total of 51 separate 2-week courses and 49 4-week courses were evaluated using the model. The outcome measure was the number of urgent (occurring within a day of arrival) operative trauma cases. Results Trauma/general surgery case volumes during call periods of notional courses were within the predicted range at least 98% of the time. Orthopedic volumes were more variable with a range of 82%-98% meeting expectation depending on the course length and institution. Conclusion The previously defined model accurately predicted the number of urgent trauma/general surgery cases course participants would likely experience when applied prospectively to TS-MCP; however, the model was less accurate in predicting acute orthopedic trauma exposure. While it remains unknown how many cases need to be performed meet a trauma sustainment requirement, having a model with a predictive capability for case volume will facilitate metric development. This model may be useful when planning for future TS-MCP. Level of evidence Economic and Value Based Evaluations Level II.
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Affiliation(s)
- Andrew Hall
- Department of Surgery, Saint Louis University Hospital, Eglin AFB, Florida, USA
| | - Iram Qureshi
- Department of Biomaterials & Epidemiology, Naval Medical Research Unit San Antonio, San Antonio, Texas, USA
| | - Jacob Glaser
- Department of Biomaterials & Epidemiology, Naval Medical Research Unit San Antonio, San Antonio, Texas, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Thomas Scalea
- Department of Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Stacy Shackelford
- Joint Trauma System, Defense Center of Excellence, San Antonio, Texas, USA
| | - Jennifer Gurney
- Joint Trauma System, Defense Center of Excellence, San Antonio, Texas, USA
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Hall A, Qureshi I, Shackelford S, Glaser J, Bulger EM, Scalea T, Gurney J. Objective model to facilitate designation of military-civilian partnership hospitals for sustainment of military trauma readiness. Trauma Surg Acute Care Open 2019; 4:e000274. [PMID: 31058239 PMCID: PMC6461135 DOI: 10.1136/tsaco-2018-000274] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/15/2019] [Accepted: 01/30/2019] [Indexed: 11/08/2022] Open
Abstract
Background A major dilemma of the military surgeon is the requirement for battlefield trauma expertise without regular exposure to a traumatically injured patient. To solve this problem, the military is partnering with civilian trauma centers to obtain the required trauma exposure. The main objective of this article is to quantify institutional differences and develop a predictive model for estimating the number of 24-hour trauma shifts a surgeon must be on call at civilian centers to experience urgent trauma cases. Methods Trauma databases from multiple institutions were queried to obtain all urgent trauma cases occurring during a 2-year period. A predictive model was used to estimate the number of urgent surgical cases in multiple specialties surgeons would experience over various numbers of 24-hour shifts and the number of 24-hour shifts required to experience a defined number of cases. Results Institution 1 had the lowest number of required 24-hour shifts to experience 10 urgent operative cases for general/trauma surgery (10 calls) and orthopedic surgery (6 calls) and the highest number of predicted cases over 12 days, 18.3 (95% CI 11 to 27), with 95% confidence. The expected trauma cases and 24-hour shifts at Institution 1 were statistically significant (p<0.0001). There were seasonal effects at all institutions except for Institution 3. Discussion There are significant variabilities in trauma center volume and therefore, the expected number of shifts and cases during a specific period of time is significantly different between trauma centers. This predictive model is objective and can therefore be used as an extrapolative tool to help and inform the military regarding placement of personnel in optimal centers for trauma currency rotations. Level of evidence Economic and value-based evaluations, level II.
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Affiliation(s)
- Andrew Hall
- Center for the Sustainment of Trauma and Readiness Skills - St. Louis, Saint Louis University Hospital, Saint Louis, Missouri, USA
| | - Iram Qureshi
- Naval Medical Research Unit San Antonio, San Antonio, Texas, USA
| | - Stacy Shackelford
- Joint Trauma System, Defense Center of Excellence, San Antonio, Texas, USA
| | - Jacob Glaser
- Naval Medical Research Unit San Antonio, San Antonio, Texas, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Thomas Scalea
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Jennifer Gurney
- Joint Trauma System, Defense Center of Excellence, San Antonio, Texas, USA
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