Operational patient care pathway: building pragmatic medical interoperability through health engagements.

The future operational demand for medical support in Western militaries will likely outstrip available resources, necessitating burden-sharing through medical interoperability with allies and partners. However, the current North Atlantic Treaty Organization (NATO) model of interoperability through standardisation, while achieving high levels of commonality and integration along the operational patient care pathway (OPCP), is high-cost and resource-intensive. We have termed this model assured interoperability. Assured interoperability, while applicable to well-established partnerships with high-resource nations, is unlikely to be feasible when working with resource-limited partners or, potentially, when in a sustained conflict with a near-peer adversary. In these circumstances, there will be a requirement to develop a far less resource-intensive model of medical interoperability with lower levels of commonality, assurance and standardisation than assured interoperability, but that provides a 'good enough' OPCP for the operational context. We have termed this pragmatic interoperability. By considering these two types of interoperability, the complete continuum of medical interoperability can be mapped with the full spectrum of partners demonstrating increasing levels of interoperability from pragmatic through to assured interoperability, integrateability and interchangeability, reducing the gap between demand and provision of medical support for operations, increasing operational resilience. This is a paper commissioned as a part of the Defence Engagement special issue of BMJ Military Health.

Medics as influencers: a historical analysis of British Army military medical exercises in Kenya over two decades.

INTRODUCTION: Annual British Army medical training exercises have run in Kenya since the early 1990s, initially with a dual purpose-to deliver the Kenyan Extended Programme of Immunisation (in remote locations) and to undertake austere training. This provided a specific response to a capability gap request from the partner nation, but as this gap closed, the exercise changed in various ways. This study aimed to qualitatively explore the impact of these exercises on the Kenyan healthcare system and the influence and relationships between the nations. METHODS: Semistructured interviews were conducted for 10 former senior commanders and medical officers who had deployed in key command and clinical positions from 1993 to 2019. Three researchers conducted thematic content analysis on the key-informant interviews. RESULTS: Five domains with 18 subdomains formed the study's analysis framework. 16 recurring themes were identified and placed into four categories that denote if they were of benefit to the engagement, enabled success, had the potential to cause harm or were a barrier to successful engagement. Three distinct phases of the exercise were identified: supporting Kenyan vaccinations, direct clinical care, training and education. CONCLUSIONS: This is the first qualitative analysis of the impact of a British Defence Engagement (Health) on the partner nation and UK influence gained through it. It has identified factors which may improve outcomes, namely, ensuring sustainability and continuity between iterations; maintaining enduring stakeholder relationships; responding to a capability gap request; intelligence-led planning with incorporated assessment, monitoring and evaluation; adapting to changes in needs or contextual settings; while ensuring mutual benefit in objective setting. These may be used as the basis for a conceptual framework supporting the planning and execution of high-quality, mutually beneficial Defence Engagement (Health) activities in future. This framework and future research would also benefit from gaining perspectives from the partner nation.

Defence context for the UK's Defence Engagement (Health).

Defence Engagement (DE) has been a core UK Defence task since 2015. DE (Health) is the use of military medical capabilities to achieve DE effects within the health sector to achieve security and defence objectives. DE (Health) practitioners must understand the underlying defence context that shapes these objectives. The strategic context is becoming more uncertain with the return of great power competition layered on enduring threats from non-state actors and transnational challenges. The UK response has been to develop the Integrated Review, outlining four national security and international policy objectives. UK Defence has responded by developing the integrated operating concept, differentiating military activity between operating and warfighting. Engage is one of the three functions of operate activity, which is complementary to the other operate functions of protect and constrain. DE (Health) can play a unique role in engagement, given its ability to develop new partnerships through health-related activity. DE (Health) may be an enabler for other engagements or to enable the protect and constrain functions. This will be dependent on delivering improvement in health outcomes. Therefore, the DE (Health) practitioner must be conversant with both the contemporary defence and global health contexts to deliver effective DE (Health) activities. This is an article commissioned for the DE special issue of BMJ Military Health.

Fellowships and defence engagement: from clinical niches to strategic impact.

Medical fellowships have traditionally developed the individual rather than furthering military or national strategic objectives. This paper describes a medical fellowship with the British Antarctic Survey to illustrate the benefits to the individual, to the military and to wider international defence engagement efforts.By rebranding such fellowships as Defence Healthcare Engagement and by treating international organisations on a par with partner nations, the humble fellowship can facilitate enduring, mutually beneficial healthcare engagement at low cost and with minimal additional resources.

Personal view: security sector health systems and global health.

In many countries the security sector is a major contributor to the healthcare system. The role and transformation of a state's security health system within the universal health coverage is important, in that it sits at the interface of the United Nations Sustainable Development Goals 3 (ensure healthy lives and promote well-being) and 16 (promote just, peaceful and inclusive societies). The paper describes the breadth of the security sector and outlines the potential beneficiaries, clinical services and macro-organisation of a security sector health system from the perspective of its contribution to wider government health services and crisis response. It examines the characteristics of the security sector compared with other providers of health services, including those generic to the sector and unique to a given service. Understanding civil-security relationships is a critical facet of effective Defence Healthcare Engagement (DHE), which includes the use of defence medical assets in support of capacity-building overseas. The analytical process described may form the basis of DHE planning. It may have even greater importance in the near future as countries review national resilience and global health diplomacy after the COVID-19 crisis.

Prehospital emergency care in a humanitarian environment: an overview of the ethical considerations.

Recent history has demonstrated that UK Defence personnel can be used, potentially with little notice, in humanitarian disaster zones. The provision of prehospital emergency care (PHEC) in a humanitarian environment requires an innovative approach to overcome the technical challenges of a resource-limited setting. In addition to technical challenges, prehospital practitioners working in a humanitarian environment can expect to be faced with ethically testing situations that they are not familiar with in their usual practice. The organisational and individual ethical decision-making burden can result in significant harms. Therefore, the aim of this paper is to discuss the ethical considerations relevant to providing PHEC during a humanitarian disaster in order that personnel can be more prepared to optimally deliver care. This is a paper commissioned as a part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

Comparison between Defence Healthcare Engagement and humanitarian assistance.

Humanitarian assistance and Defence Healthcare Engagement have traditionally both been taught on the Medical Humanitarian Stabilisation Operations Course. However, the two activities are distinct. This paper outlines the critical differences between them, focusing on their specific purposes, scope, timescales and ethics. Humanitarian assistance will remain a distinct activity with a focus on the relief of suffering, guided by international norms, while Defence Healthcare Engagement will encompass a broader range of activities, less constrained by internationally agreed principles. This presents an opportunity for the Defence Medical Services to directly contribute to projecting UK influence, preventing conflict and building stability. However, it requires the Defence Medical Services to take responsibility for the ethical issues that Defence Healthcare Engagement raises. This paper recommends the development of an ethical framework that reconciles the strategic aims of Defence Healthcare Engagement with maximising patient welfare at the tactical level. This is a paper commissioned as a part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

Changes in NHS Major Incident management and their relevance to the Defence Medical Services.

High-profile Major Incidents in the UK civilian setting in the last few years have appropriately raised awareness of the principles and frameworks involved in the design of reliable response systems. The introduction of the Joint Emergency Services Interoperability Principles in tandem with increased investment in Major Incident Planning has supported practitioners to successfully respond to high numbers of incidents.Defence Medical Services personnel are increasingly being asked to deploy to resource-limited 'contingency' settings where much of the established guidance relating to Major Incident response requires reconsideration and modification in the face of severely constrained space, manpower and equipment.This editorial seeks to review contemporary theories and principles of Major Incident response and discuss how military medical personnel may need to adapt these to address the various Major Incident challenges that they may face on operations.

Triage and the Modified Physiological Triage Tool-24 (MPTT-24).

Major incidents occur on a regular basis. So far in 2017, England has witnessed five terrorism-related major incidents, resulting in approximately 40 fatalities and 400 injured. Triage is a key principle in the effective management of a major incident and involves prioritising patients on the basis of their clinical acuity. This paper describes the limitations associated with existing methods of primary major incident triage and the process of developing a new and improved triage tool-the Modified Physiological Triage Tool-24 (MPTT-24). Whilst the MPTT-24 is likely to be the optimum physiological method for primary major incident triage, it needs to be accompanied by an appropriate secondary triage process. The existing UK military and civilian secondary triage tool, the Triage Sort, is described, which offers little advantage over primary methods for identifying patients who require life-saving intervention. Further research is required to identify the optimum method of secondary triage.

A family with Classical Ehlers-Danlos Syndrome (cEDS), mild bone fragility and without vascular complications, caused by the p.Arg312Cys mutation in COL1A1.

The Ehlers-Danlos syndromes (EDS) are heritable disorders of connective tissue (HDCT) with joint hypermobility, skin hyperextensibility and tissue fragility, which were recently re-classified (2017 International Classification). Most patients (>90%) with Classical Ehlers-Danlos syndrome (cEDS) have a mutation in the COL5A1 or COL5A2 genes encoding type V procollagen. A small number of patients with the p.Arg312Cys mutation in COL1A1 have been reported with overlapping features of both cEDS and vascular EDS (vEDS). In this report, we describe two patients from a large family with this mutation and clinical features consistent with cEDS without vascular complications. The proband presented with congenital hip dislocation (previously reported in one patient), the mother of the proband with multiple fractures in childhood, and dental defects (novel findings). The small number of patients reported with this mutation and proportion with vascular complications suggests that vascular surveillance should still be recommended.

Medical Civil-Military Relationships: A Feasibility Study of a United Kingdom Deployment in South Sudan.

OBJECTIVES: Civil-military relationships are necessary in humanitarian emergencies but, if poorly managed, may be detrimental to the efforts of humanitarian organizations. Awareness of guidelines and understanding of risks relating to the relationship among deployed military personnel have not been evaluated. METHODS: Fifty-five military and 12 humanitarian healthcare workers in South Sudan completed questionnaires covering experience, training and role, agreement with statements about the deployment, and free text comments. RESULTS: Both cohorts were equally aware of current guidance. Eight themes defined the relationship. There was disagreement about the benefit to the South Sudanese people of the military deployment, and whether military service was compatible with beneficial health impacts. Two key obstacles to the relationship and 3 areas the relationship could be developed were identified. CONCLUSION: This study shows that United Kingdom military personnel are effectively trained and understand the constraints on the civil-military relationship. Seven themes in common between the groups describe the relationship. Current guidance could be adapted to allow a different relationship for healthcare workers.

Acetoacetate and ethyl acetoacetate as novel inhibitors of bacterial biofilm.

Acetoacetate (AAA) was identified as a biofilm inhibitor in a previous study, where the effect of 190 carbon and nitrogen sources on biofilm amounts by Escherichia coli O157:H7 was determined. With this study, we tested the effect of AAA on growth and biofilm amounts of Cronobacter sakazakii, Serratia marcescens and Yersinia enterocolitica. AAA reduced growth and biofilm amounts of the three pathogens, albeit at rather high concentrations of 10 to 35 mg ml-1 . Acetoacetate at a concentration of 5 mg ml-1 reduced Y. enterocolitica mRNA transcripts of the flagellar master regulator operon flhD, the invasion gene inv, and the adhesion gene yadA. Transcription of the regulator of plasmid-encoded virulence genes virF, the plasmid-encoded virulence gene yopQ, and ymoA were largely unaffected by AAA. Importantly, AAA did not cause an increase in transcription of any of the tested virulence genes. As a more cost efficient homologue of AAA, the effect of ethyl acetoacetate (EAA) was tested. EAA reduced growth, biofilm amounts and live bacterial cell counts up to 3 logs. IC50 values ranged from 0·31 mg ml-1 to 5·6 mg ml-1 . In summary, both AAA and EAA inhibit biofilm, but EAA appears to be more effective. SIGNIFICANCE AND IMPACT OF THE STUDY: Bacterial biofilms are communities of bacteria that form on surfaces and are extremely difficult to remove by conventional physical or chemical techniques, antibiotics or the human immune system. Despite advanced technologies, biofilm still contributes to 60 to 80% of human bacterial infections (NIH and CDC) and cause problems in many natural, environmental, bioindustrial or food processing settings. The discovery of novel substances that inhibit biofilm without increasing the virulence of the bacteria opens doors for countless applications where a reduction of biofilm is desired.

Enhanced case management can be delivered for patients with EVD in Africa: Experience from a UK military Ebola treatment centre in Sierra Leone.

BACKGROUND: Limited data exist describing supportive care management, laboratory abnormalities and outcomes in patients with Ebola virus disease (EVD) in West Africa. We report data which constitute the first description of the provision of enhanced EVD case management protocols in a West African setting. METHODS: Demographic, clinical and laboratory data were collected by retrospective review of clinical and laboratory records of patients with confirmed EVD admitted between 5 November 2014 and 30 June 2015. RESULTS: A total of 44 EVD patients were admitted (median age 37 years (range 17-63), 32/44 healthcare workers), and excluding those evacuated, the case fatality rate was 49% (95% CI 33%-65%). No pregnant women were admitted. At admission 9/44 had stage 1 disease (fever and constitutional symptoms only), 12/44 had stage 2 disease (presence of diarrhoea and/or vomiting) and 23/44 had stage 3 disease (presence of diarrhoea and/or vomiting with organ failure), with case fatality rates of 11% (95% CI 1%-58%), 27% (95% CI 6%-61%), and 70% (95% CI 47%-87%) respectively (p = 0.009). Haemorrhage occurred in 17/41 (41%) patients. The majority (21/40) of patients had hypokalaemia with hyperkalaemia occurring in 12/40 patients. Acute kidney injury (AKI) occurred in 20/40 patients, with 14/20 (70%, 95% CI 46%-88%) dying, compared to 5/20 (25%, 95% CI 9%-49%) dying who did not have AKI (p = 0.01). Ebola virus (EBOV) PCR cycle threshold value at baseline was mean 20.3 (SD 4.3) in fatal cases and 24.8 (SD 5.5) in survivors (p = 0.007). Mean national early warning score (NEWS) at admission was 5.5 (SD 4.4) in fatal cases and 3.0 (SD 1.9) in survivors (p = 0.02). Central venous catheters were placed in 37/41 patients and intravenous fluid administered to 40/41 patients (median duration of 5 days). Faecal management systems were inserted in 21/41 patients, urinary catheters placed in 27/41 and blood component therapy administered to 20/41 patients. CONCLUSIONS: EVD is commonly associated life-threatening electrolyte imbalance and organ dysfunction. We believe that the enhanced levels of protocolized care, scale and range of medical interventions we report, offer a blueprint for the future management of EVD in resource-limited settings.

The prospective validation of the Modified Physiological Triage Tool (MPTT): an evidence-based approach to major incident triage.

INTRODUCTION: Triage is a key principle in the effective management of major incidents. There is limited evidence to support existing triage tools, with a number of studies demonstrating poor performance at predicting the need for a life-saving intervention. The Modified Physiological Triage Tool (MPTT) is a novel triage tool derived using logistic regression, and in retrospective data sets has shown optimum performance at predicting the need for life-saving intervention. MATERIALS AND METHODS: Physiological data and interventions were prospectively collected for consecutive adult patients with trauma (>18 years) presenting to the emergency department at Camp Bastion, Afghanistan, between March and September 2011. Patients were considered priority 1 (P1) if they received one or more interventions from a previously defined list. Patients were triaged using existing triage tools and the MPTT. Performance was measured using sensitivity and specificity, and a McNemar test with Bonferroni calculation was applied for tools with similar performance. RESULTS: The study population comprised 357 patients, of whom 214 (59.9%) were classed as P1. The MPTT (sensitivity: 83.6%, 95% CI 78.0% to 88.3%; specificity: 51.0%, 95% CI 42.6% to 59.5%) outperformed all existing triage tools at predicting the need for life-saving intervention, with a 19.6% absolute reduction in undertriage compared with the existing Military Sieve. The improvement in undertriage comes at the expense of overtriage; rates of overtriage were 11.6% higher with the MPTT than the Military Sieve. Using a McNemar test, a statistically significant (p<0.001) improvement in overall performance was demonstrated, supporting the use of the MPTT over the Military Sieve. DISCUSSION AND CONCLUSIONS: The MPTT outperforms all existing triage tools at predicting the need for life-saving intervention, with the lowest rates of undertriage while maintaining acceptable levels of overtriage. Having now been validated on both military and civilian cohorts, we recommend that the major incident community consider adopting the MPTT for the purposes of primary triage.

Predictors of massive blood transfusion: a Delphi Study to examine the views of experts.

BACKGROUND: Trauma patients requiring massive blood transfusion (MBT) have high morbidity and mortality: early and aggressive use of blood products during immediate resuscitation may improve survival. There is currently a lack of evidence to guide initial identification of these patients which is especially important in areas where plasma may need to be thawed. In the absence of this evidence, this study aimed to robustly evaluate expert opinion by using a Delphi process to identify predictors of massive transfusion. This process can be used to ensure that decision rules include variables that have clinical validity, which may improve translation of rules into clinical practice. METHODS: An international panel of 35 experts was identified through expert advice against specific criteria. Military and civilian experts from the fields of emergency medicine, critical care, anaesthesia, prehospital care, haematology and general/trauma surgery were included. The Delphi Study was carried out over three rounds. Consensus level was predefined at 80%. RESULTS: 195 statements were generated by the panel of which 97 (49.7%) achieved consensus at the 80% level by the end of round 3. Strikingly no clinical observations reached consensus individually. Metabolic acidosis of a base excess of -5.0 or worse, lactate >5 mmol/L and a low haematocrit on arrival were all considered predictive. Some patterns of injury, but few mechanisms of injury, were considered highly predictive of the need of MBT. CONCLUSIONS: This Delphi process has produced a list of parameters that expert clinicians felt were predictive for MBT. This list can be used to inform the generation of decision rules. It is of note that many factors used in current decision rules were not valued by clinical experts-this may be a cause for poor uptake of those rules.