Global assessment of military and civilian trauma systems integration: a scoping review

BACKGROUND

The global burden of trauma disproportionately affects low-income countries and middle-income countries (LMIC), with variability in trauma systems between countries. Military and civilian healthcare systems have a shared interest in building trauma capacity for use during peace and war. However, in LMICs it is largely unknown if and how these entities work together. Understanding the successful integration of these systems can inform partnerships that can strengthen trauma care. This scoping review aims to identify examples of military-civilian trauma systems integration and describe the methods, domains, and indicators associated with integration including barriers and facilitators.

METHODS

A scoping review of all appropriate databases was performed to identify papers with evidence of military and civilian trauma systems integration. After manuscripts were selected for inclusion, relevant data was extracted and coded into methods of integration, domains of integration, and collected information regarding indicators of integration, which were further categorized into facilitators or barriers.

RESULTS

Seventy-four studies were included with authors from 18 countries describing experiences in 23 countries. There was a predominance of authorship and experiences from High-Income Countries (91.9 and 75.7%, respectively). Five key domains of integration were identified; Academic Integration was the most common (45.9%). Among indicators, the most common facilitator was administrative support and the lack of this was the most common barrier. The most common method of integration was Collaboration (50%).

CONCLUSION

Current evidence demonstrates the existence of military and civilian trauma systems integration in several countries. High-income country data dominates the literature, and thus a more robust understanding of trauma systems integration, inclusive of all geographic locations and income statuses, is necessary prior to development of a framework to guide integration. Nonetheless, the facilitators identified in this study describe the factors and environment in which integration is feasible and highlight optimal indicators of entry.

The Power of Cooperation: A Quantitative Analysis of the Benefit of Civilian Partnerships on the Academic Output of Military Surgeons

INTRODUCTION

Military-civilian partnerships are crucial to maintaining the skills of active duty surgeons and sustaining readiness. There have been no publications to date that report the quantitative effect of these partnerships on academic research. To address this question, the Hirsch indices (H-indices) of active duty surgeons with a civilian affiliation (CA) were compared to those without. As a secondary outcome, H-indices of military surgeons with and without an appointment to the Uniformed Services University (USU) were similarly compared. We hypothesized that military surgeons with a CA would have a higher H-index as compared to those without.

MATERIALS AND METHODS

Rosters of active duty military surgeons were obtained confidentially through each branch consultant. H-indices were found on Scopus. Graduation dates and hospital affiliations were identified via public Doximity, LinkedIn profiles, and hospital biographies. Rosters were cross-referenced with USU appointments. Stata software was used for final analysis.

RESULTS

Military surgeons without a civilian association have a median H-index of 2 versus 3 in those with such an affiliation (P = .0002). This pattern is also seen in average number of publications, at 3 and 5 articles (P < .0001). When further stratified by branch, Air Force surgeons have median H-indices of 2.5 and 1 with and without a CA, respectively (P = .0007). The Army surgeons follow a similar pattern, with median H-indices of 5 and 3 for those with and without affiliations, respectively (P = .0021). This significance does not hold in the Naval subgroup. Similar results are found for the secondary outcome of USU appointment, with median H-indices of 3 and 2 in those with and without CAs, respectively (P < .0001). In the multivariable negative binomial regression model, both CA and USU appointment significantly increased H-index in the overall cohort, with incidence rate ratios of 1.32 (95% CI = 1.08, 1.61) and 1.56 (95% CI = 1.28, 1.91), respectively.

CONCLUSION

This article provides objective evidence that there is a benefit to military-civilian partnerships on the academic output of military surgeons. These relationships should continue to be fostered and expanded.

Impact of Civilian Patient Care on Major Amputation Case Volume in the Military Health System

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.

Monthly Trauma Training and Simulation Are Associated With Improved Resident Skill and Leadership

BACKGROUND

Training for trauma procedures has been limited to infrequent courses with little data on longitudinal performance, and few address procedural and leadership skills with granular assessment. We implemented a novel training program that emphasized an assessment of trauma resuscitation and procedural skills.

OBJECTIVE

This study aimed to determine whether this program could demonstrate improvement in both skill sets in surgical trainees over time.

METHODS

This was a prospective, observational study at a Level I trauma center between November 2018 and May 2019. A procedural skill and simulation program was implemented to train and evaluate postgraduate year (PGY) 1-5 residents. All residents participated in an initial course on procedures such as tube thoracostomy and vascular access, followed by a final evaluation. Skills were assessed by the Likert scale (1-5, 5 noting mastery). PGY 3s and above were additionally evaluated on resuscitation. A paired t test was performed on repeat learners.

RESULTS

A total of 40 residents participated in the structured procedural skills and simulation program. Following completion of the program, PGY-2 scores increased from a Mdn [interquartile range, IQR] 3.0 [2.5-4.0] to 4.5 [4.2-4.5]. The PGY-3 scores increased from a Mdn [IQR] 3.95 [3.7-4.6] to 4.8 [4.6-5.0]. Eighteen residents underwent repeat simulation training, with Mdn [IQR] score increases in PGY 2s (3.7 [2.5-4.0] to end score 4.47 [4.0-4.5], p = .03) and PGY 3s (3.95 [3.7-4.6] to end score 4.81 [4.68-5.0], p = .04). Specific procedural and leadership skills also increased over time.

Military deployment's impact on the surgeon's practice

BACKGROUND

As the United States withdraws from overseas conflicts, general surgeons remain deployed in support of global operations. Surgeons and surgical teams are foundational to combat casualty care; however, currently, there are few casualty producing events. Low surgical volume and acuity can have detrimental effects on surgical readiness for those frequently deployed. The surgical team cycle of deployment involves predeployment training, drawdown of clinical practice, deployment, postdeployment reintegration, and rebuilding of a patient panel. This study aims to assess these effects on typical general surgeon practices. Quantifying the overall impact of deployment may help refine and implement measures to mitigate the effects on skill retention and patient care.

METHODS

Surgeon case logs of eligible surgeons deploying between January 1, 2017, and January 1, 2020, were included from participating military treatment facilities. Eligible surgeons were surgeons whose case logs were primarily at a single military treatment facility 26 weeks before and after deployment and whose deployment duration, location, and number of deployed cases were obtainable.

RESULTS

Starting 26 weeks prior to deployment, analyzing in 1-week intervals toward deployment time, case count decreased by 4.8% (p < 0.0001). With each 1-week interval, postdeployment up to the 26-week mark, case count increased by 6% (p < 0.0001). Cases volumes most prominently drop 3 weeks prior to deployment and do not reach normal levels until approximately 7 weeks postdeployment. Case volumes were similar across service branches.

CONCLUSION

There is a significant decrease in the number of cases performed before deployment and increase after return regardless of military branch. The perideployment surgical volume decline should be understood and mitigated appropriately; predeployment training, surgical skill retention, and measures to safely reintegrate surgeons back into their practice should be further developed and implemented.

LEVEL OF EVIDENCE

Economic/Decision, Level III.

Variability of Value of Trauma Centers to General Surgery Combat Casualty Care Skill Sustainment

OBJECTIVE

Military-civilian partnerships for the maintenance of trauma readiness skills will be required to maintain skills in preparation for future combat casualty care operations. There is little data describing relative worth of potential partnerships. This study aims to demonstrate that quantitative and qualitative differences are prevalent between trauma centers.

DESIGN

A combat casualty care relevant case (CCC-RC) was determined to be one that was open, urgent, and required a blood transfusion. Total number of urgent trauma cases and number of cases requiring transfusions between January 1, 2017 and January 1, 2019 were tallied at Saint Louis University Hospital (ACS Level 1), San Antonio Military Medical Center (ACS Level 1), Madigan Army Medical Center (Washington Level 2), and William Beaumont Army Medical Center (Texas Level 3). At the participating level 1 trauma centers, cases were segregated by surgeon.

SETTING

Saint Louis University Hospital (SLU), San Antonio Military Medical Center (SAMMC), Madigan Army Medical Center (MAMC), and William Beaumont Army Medical Center (WBAMC).

PARTICIPANTS

All general surgery/trauma cases at participating hospitals between January 1, 2017 and January 1, 2019.

RESULTS

A total of 267 of 721 trauma cases performed by trauma/general surgeons at SAMMC were CCC-RCs, at SLU 213 of 342, MAMC, 5 of 13, and at WBAMC 1 of 33. While SAMMC had the most cases, SLU had the highest ratio of cases that were CCC-RC (p < 0.0001). The average number of CCC-RCs of the top 5 surgeons at each level 1 institutions were 15.7 cases/year (60.5%) at SLU and 10.3 cases/year (33.6%) at SAMMC (p < 0.0001).

CONCLUSIONS

The CCC-RC definition is easily used to distinguish the value and relevancy of trauma centers to general surgeon combat casualty care readiness. The volume and proportions of relevant trauma are significantly different between trauma centers. The military trauma designated hospitals are currently inadequate to support all general surgeon readiness needs. Embedding surgeons at centers with high volumes or relevant cases is the optimum solution.

Quantifying Clinical Opportunities at the Navy Trauma Training Center

INTRODUCTION

Military-Civilian partnerships (MCPs), such as the Navy Trauma Training Center, are an essential tool for training military trauma care providers. Despite Congressional and military leadership support, sparse data exist to quantify participants' clinical opportunities in MCPs. These preliminary data from an ongoing Navy Trauma Training Center outcomes study quantify clinical experiences and compare skill observation to skill performance.

MATERIALS AND METHODS

Participants completed clinical logs after each patient encounter to quantify both patients and procedures they were involved with during clinical rotations; they self-reported demographic data. Data analyses included descriptive statistics and chi-square statistics to compare skills observed to skills performed between the first and second half of the 21-day course.

RESULTS

A sample of 47 Navy personnel (30 corpsmen, 10 nurses, 3 physician assistants, 4 physicians) completed 551 clinical logs. Most logs (453/551) reflected experiences in the emergency department, where corpsmen and nurses each spent 102.0 hours, and physician assistants and physicians each spent 105.4 hours. Logs completed per participant ranged from 1 to 31, (mean = 8). No professional group was more likely than others to complete the clinical logs. Completion rates varied by cohort, both overall and by clinical role. Of emergency department logs, 39% reflected highest acuity patients, compared with 21% of intensive care unit logs, and 61% of operating room logs. Penetrating trauma was reported on 16.5% of logs. Primary and secondary trauma assessments were the most commonly reported clinical opportunities, followed by obtaining intravenous access and administration of analgesic medications. With few exceptions, logs reflected skill observation versus skill performance, a ratio that did not change over time.

CONCLUSION

Prospective real-time data of actual clinical activity is a crucial measure of the success of MCPs. These preliminary data provide a beginning perspective on how these experiences contribute to maintaining a skilled military medical force.