Pneumococcal Perplexity: Improving Awareness of Updated Pneumococcal Vaccination Recommendations in Two Large Military Treatment Facilities.

INTRODUCTION: Vaccinations are an essential aspect of preventive medicine. In October 2021, the pneumococcal conjugate vaccine-20 (PCV-20) and PCV-15 were authorized for use in adults by the U.S. FDA. In 2022, the Advisory Committee on Immunization Practices (ACIP) subsequently published updated pneumococcal vaccination recommendations that incorporate both PCV-20 and PCV-15. Pneumococcal vaccination is effective in reducing pneumococcal disease, particularly in high-risk patient groups such as those with chronic lung disease; however, the updated dosing schedule for pneumococcal vaccinations can be quite confusing, especially if patients have previously received "older" vaccinations, such as pneumococcal polysaccharide vaccine-23 or PCV-13. The purpose of this quality improvement project was to increase providers' knowledge of current ACIP pneumococcal vaccination recommendations, including indications and dosing schedule, and to improve pneumococcal vaccination rates among eligible adults and children. MATERIALS AND METHODS: Focused education sessions were presented to primary care and subspecialty residents, fellows, and staff at Brooke Army Medical Center and Wilford Hall Ambulatory Surgical Center regarding current ACIP pneumococcal vaccination recommendations. Sessions included information about PCV-15 and PCV-20 vaccines, indications for vaccination, and dosing schedules. Subjective knowledge of updated ACIP pneumococcal vaccination recommendations was assessed among primary care and subspecialty residents, fellows, and staff via an anonymous survey both pre- and post-intervention. Number of PCV-20 vaccinations given and estimated vaccination rates of patients aged 19 to 64 years with asthma were assessed pre- and post-intervention over a 6 month time span. RESULTS: Of surveyed providers, only 9% discussed vaccinations at every visit and 11% did not discuss vaccinations at all. There was a statistically significant increase in providers' knowledge of pneumococcal vaccination guidelines for children post-intervention (P = .01) but no statistically significant increase in knowledge for guidelines for adults, for patients that have received prior pneumococcal vaccines, or in overall confidence in recommending pneumococcal vaccines. There was a 17% increase in the number of PCV-20 vaccinations given post-intervention (198 pre-intervention, 232 post-intervention). The estimated PCV-20 vaccination rate for adults aged 19 to 64 years with asthma increased from 14.9% pre-intervention to 19.5% post-intervention (P = .33). CONCLUSIONS: There is a significant knowledge gap regarding ACIP pneumococcal vaccination recommendations among military providers and a low pneumococcal vaccination rate for adults aged 19 to 64 years with asthma at Joint Base-San Antonio MTFs. Focused education sessions were effective in increasing providers' knowledge of updated pneumococcal vaccination recommendations, confidence in recommending vaccines, total number of pneumococcal vaccinations given, and estimated pneumococcal vaccination rate for adults with asthma. The validity of conclusions drawn from our data were limited because of discordant numbers of survey respondents as well as potentially inaccurate estimates of pneumococcal vaccination rates pre- and post-intervention. Despite this, the results warrant continued education of pneumococcal vaccines, indications, and dosing schedules.

Concept of error and nature of nursing error detectors in military hospitals: a qualitative content analysis.

BACKGROUND AND OBJECTIVES: Nursing errors can cause irreparable consequences. Understanding the concept of error and the nature of nursing error detectors can significantly reduce this type of errors. The present study was conducted to explain the concept of error and the nature of nursing error detectors in military hospitals. MATERIALS AND METHODS: The present study was conducted on eight nurses working in different wards of military hospitals using a qualitative approach to content analysis proposed by Graneheim and Lundman. Data were collected through in-depth semistructured interviews. FINDINGS: 'The concept of error' and 'the nature of error detectors' in military hospitals were the two main categories extracted from data analysis. The present findings showed that the nature of errors in military hospitals is inevitable, a threat to job position and bipolar. Nurses use different resources to identify errors, including personal, environmental and organisational factors of detection. DISCUSSION AND CONCLUSION: Given the military nature of the study hospitals, organisational factors of detection played a key role in identifying errors. Moreover, given the perception of military nurses of errors, they were not inclined to personal detectors. The managers of military hospitals are therefore recommended to pursue a justice-oriented and supportive culture to help nurses play a more active role in identifying errors.

Challenges of implementing the accreditation model in military and university hospitals in Iran: a qualitative study.

BACKGROUND: The aim of this study was to present challenges of implementing the accreditation model in university and military hospitals in Iran. METHODS: In this qualitative study, purposive sampling was used to select hospital managers and implementers of the model working in 3 hospitals affiliated to Kerman University of Medical Sciences and in 3 military hospitals in Kerman, Iran. A total of 39 participants were interviewed, and semi-structured questionnaires and thematic analysis were used for data collection and analysis, respectively. RESULTS: In this study, 5 major codes and 17 subcodes were identified: (1) perspectives on accreditation model with 5 subcodes: a difficult and time-consuming model, less attention to the patient, accreditation as a way of money acquisition, not being cost-effective, and accreditation means incorrect documentation; (2) absence of appropriate executive policy, with 3 subcodes: lack of financial funds and personnel, disregarding local conditions in implementation and evaluation, and absence of the principle of unity of command; (3) training problems of the accreditation model, with 2 subcodes: absence of proper training and incoordination of training and evaluation; (4) human resources problems, with 3 subcodes: no profit for nonphysician personnel, heavy workload of the personnel, and physicians' nonparticipation; (5) evaluation problems, with 4 subcodes: no precise and comprehensive evaluation, inconformity of authorities' perspectives on evaluation, considerable change in evaluation criteria, and excessive reliance on certificates. CONCLUSIONS: This study provided useful data on the challenges of implementing hospitals' accreditation, which can be used by health policymakers to revise and modify accreditation procedures in Iran and other countries with similar conditions. The accreditation model is comprehensive and has been implemented to improve the quality of services and patients' safety. The basic philosophy of hospital accreditation did not fully comply with the underlying conditions of the hospitals. The hospital staff considered accreditation as the ultimate goal rather than a means for achieving quality of service. The Ministry of Health and Medical Education performed accreditation hastily for all Iranian hospitals, while the hospitals were not prepared and equipped to implement the accreditation model.

El Hospital Central de la Defensa en la crisis de la COVID-19 / The Spanish Central Defense Hospital in COVID-19 Crisis

En este trabajo se exponen los cambios efectuados en el Hospital Central de la Defensa durante la crisis de la COVID-19. Se efectúa una descripción de las capacidades previas al comienzo de la pandemia, y como se han adaptado los diferentes departamentos, el servicio de Urgencias, las plantas de hospitalización y la Unidad de Cuidados Intensivos a una situación nueva, y de súbita aparición. Así mismo, se exponen los apoyos logísticos recibidos, tanto desde el punto de vista de recursos humanos y materiales

In this paper, we present the changes made at the Central Defense Hospital «Gomez Ulla» to face the COVID-19 crisis. A description on the available capabilities prior to the pandemic outbreak is made, and how they had to adapt to a suddenly established new situation, regarding departments such as Emergency, Hospitalization and Intensive Care Units. Support received, both in personal and material resources will also be mentioned

Balancing Patient Care and Force Protection at Military Medical Treatment Facilities.

OBJECTIVES: This study aimed to identify delays of care due to base access security protocols at a stateside military medical treatment facility (MTF) for patients with a time-sensitive medical condition who are seeking emergency medical care at the MTF. METHODS: We retrospectively analyzed emergency medical services (EMS) run reports from January 1, 2017 to November 12, 2017 to hospital access points to assess patients who were initially denied access to the MTF. Time from EMS activation until patient delivery at the emergency department, number of time-sensitive complaints, number of time-sensitive conditions, and number of unauthorized access attempts are reported. RESULTS: During the 11-month period of review, 42 delays of care related to EMS activation by the sentry at hospital access points were identified. Of the 42, 14 were associated with a time-sensitive complaint, 2 with time-sensitive conditions, and none were unauthorized access attempts. CONCLUSION: We identify the potential for patient harm due to delays in care resulting from the security protocols at our MTF. A review of force protection requirements with consideration for their impact on patient safety, especially in cases of time-sensitive conditions, has been conducted.

The Royal Navy Operating Department Practitioner: Perioperative care on land and sea.

Royal Navy Operating Department Practitioners are employed in a number of different roles, during peacetime, humanitarian aid operations and periods of war. In recent times, Royal Navy Operating Department Practitioners have deployed on active operations in addition to working in NHS hospitals at home in the United Kingdom. This article will explore the different avenues and experiences of Operating Department Practitioners who are currently serving in the Royal Navy. The reader will then also gain an insight into the different echelons of care provided by the Defence Medical Services to the United Kingdom Armed Forces and Allied Nations. The article will then consider the unique experiences available to Royal Navy Operating Department Practitioners in this multi-faceted role which offers the opportunity to explore work patterns in different environments.

A Collaborative To Evaluate And Improve The Quality Of Surgical Care Delivered By The Military Health System.

In an effort to improve surgical quality and reduce clinical variability, the Military Health System (MHS) expanded its participation in the National Surgical Quality Improvement Program to all military hospitals beginning in 2015. This expansion and a partnership with the American College of Surgeons laid the foundation for a surgical quality collaborative in the MHS. We review the history of the program in the MHS and the activities that have contributed to developing the collaborative. We also report promising trends in surgical outcomes at hospitals that were already participating in the program in 2014, when a critical MHS review identified areas for improvement in surgical care. We conclude with a discussion of possible lessons for other health systems and challenges ahead for the MHS, now that full enrollment in the program has been completed.

How do I get an emergency civilian walking blood bank running?

The shift toward using a transfusion strategy in a ratio to mimic whole blood (WB) functionality has revitalized WB as a viable option to replace severe blood loss in civilian health care. A military-civilian collaboration has contributed to the reintroduction of WB at Haukeland University Hospital in Bergen, Norway. WB has logistical and hemostatic advantages in both the pre- and in-hospital settings where the goal is a perfectly timed balanced transfusion strategy. In this paper, we describe an event leading to activation of our emergency WB collection strategy for the first time. We evaluate the feasibility of our civilian walking blood bank (WBB) to cover the need of a massive amount of blood in an emergency situation. The challenges are discussed in relation to the different stages of the event with the recommendations for improvement in practice. We conclude that the use of pre-screened donors as a WBB in a civilian setting is feasible. The WBB can provide platelet containing blood components for balanced blood resuscitation in a clinically relevant time frame.

Capacidades sanitarias del buque de proyección estratégica L-61 Juan Carlos I. Lecciones médicas identificadas tras las maniobras FLOTEX-17 / Health capacity of the strategic projection warship Juan Carlos I. Medical lessons identified after the FLOTEX-17 maneouvers

El Buque de Proyección Estratégica L-61 Juan Carlos I (L-61 JC I) es el buque de mayores dimensiones que ha tenido la Armada española en toda su historia. Puede desarrollar cuatro perfiles de misión: anfibio, portaviones, transporte estratégico y ayuda humanitaria. En todos ellos su capacidad sanitaria Role 2 juega un papel determinante gracias a las importantes prestaciones médicas con las que cuenta el buque. Las maniobras FLOTEX-17 realizadas en el Mar Mediterráneo en junio de 2017 en las que participaron 29 buques y más de 3500 efectivos fue la primera vez que embarcó un Role 2 en el L-61 JC I. El objetivo de este artículo es describir las características técnicas y sanitarias del buque, las lecciones identificadas obtenidas tras las maniobras navales y analizar las semejanzas y diferencias de buques similares de marinas de guerra aliadas

Strategic Projection Ship L-61 Juan Carlos I (L-61 JC I) is the largest ship that the Spanish Navy has had in its history. This warship can develop four mission profiles: amphibian, aircraft carrier, strategic transport and humanitarian aid. In all of them, Role 2 medical capacity and capability plays a decisive role thanks to the important medical benefits available in the ship. FLOTEX-17 maneuvers carried out in the Mediterranean Sea in June 2017 with the participation of 29 warships and more than 3,500 navy members was the first time that a Role 2 was shipped in the L-61 JC I. The purpose of this article is to describe warship technical and medical characteristics, lessons identified after the naval maneuvers and analyze the similarities and differences of similar warships of allied navies

Review of an emergency general surgery process improvement program at a verified military trauma center.

INTRODUCTION: Decreasing combat-based admissions to our military facility have made it difficult to maintain a robust trauma process improvement (PI) program. Since emergency general surgery (EGS) and trauma patients share similarities, we merged the care of our EGS and trauma patients into one acute care surgery (ACS) team. An EGS PI program was developed based on trauma PI principles to facilitate continued identification of opportunities for improvement despite our decline in trauma admissions. Analysis of the first 18 months of combined ACS PI data is presented. METHODS: EGS registry inclusion criteria was based on published Association for the Surgery of Trauma's recommendations. Program components and PI categories were based on our existing trauma PI program. Dedicated coordinators actively reviewed and cataloged patient care and outcomes. Deviations from standard practice patterns, unplanned interventions, and other complications were abstracted, categorized, and evaluated through levels of review similar to accepted trauma PI principles. Data for the first six quarters were collated and trends were analyzed. RESULTS: Over 18 months, 696 EGS patients met registry inclusion criteria, with 468 patients (67%) undergoing operative intervention. Over the same time, 353 trauma patients were admitted with 158 undergoing operative intervention (56.4%). Of the 696 EGS patients and 353 trauma patients, 226 (32%) and 243 (69%) PI events were identified, respectively. Common events included unplanned therapies, re-admissions, and unplanned ICU admissions. Based on analysis of all events, four new areas for improvement initiatives were identified. Results of these initiatives included implementation of a multi-disciplinary EGS PI committee, consensus protocols, and departmental and hospital-wide actions. CONCLUSION: In an 18-month period, integration of our EGS patients into a novel, combined ACS PI program facilitated recognition of an additional 226 PI events and provided a substrate for continued improvements in patient care.

Factors affecting sentinel events in hospital emergency department: a qualitative study.

Purpose A sentinel event is an unexpected occurrence resulting in death or serious physical or psychological injury or the risk thereof. The purpose of this paper is to investigate the influencing factors of sentinel events in the emergency department of a military hospital in Tehran to find out some of the effective solutions. Design/methodology/approach In this qualitative study with content analysis approach, 20 hospital healthcare personnel participated as participants from the fields of medicine and nursing. Purposive random sampling and semi-structured interviews were used for data collection. Atlas.ti software version 5.2 was used for data analysis. Findings Four themes and 32 subthemes were identified by numerous revisions and combining the codes. The four main themes of sentinel events were: causes, incidence barriers, cause prevention solutions, and barriers' improvement solutions. Moreover, these main factors were related to these issues: staff and patients' education, communication, assessment, patients and their companions, employee rights, leadership, care continuum, human factors, physical environment, information management and medication use. Some solutions were also suggested according to these factors and a policy was recommended. Practical implications Hospital managers and authorities should try to find the main causes of sentinel events by periodical analysis to find ways to prevent them in the future, using logical and reasonable solutions. Originality/value This study confirms that strategies to reduce the sentinel events in emergency departments should focus on empowerment of all staff.

Processing of Bulk Nanocrystalline Metals at the US Army Research Laboratory.

Given their potential for significant property improvements relative to their large grained counterparts, much work has been devoted to the continued development of nanocrystalline metals. Despite these efforts, the transition of these materials from the lab bench to actual applications has been blocked by the inability to produce large scale parts that retain the desired nanocrystalline microstructures. Following the development of a method proven to stabilize the nanosized grain structure to temperatures approaching that of the melting point for the given metal, the US Army Research Laboratory (ARL) has progressed to the next stage in the development of these materials - namely the production of large scale parts suitable for testing and evaluation in a range of relevant test environments. This report provides a broad overview of the ongoing efforts in the processing, characterization, and consolidation of these materials at ARL. In particular, focus is placed on the methodology used for producing the nanocrystalline metal powders, in both small and large-scale amounts, that are at the center of ongoing research efforts.

Validation of knowledge and adherence assessment tools among patients on warfarin therapy in a Saudi hospital anticoagulant clinic.

Background Although it can result in serious complications due to its narrow therapeutic index, warfarin is widely used in the treatment and prevention of thromboembolic disorders. However, patients' adherence and knowledge are determinants of therapeutic success. Objective We sought to validate instruments to provide a reliable means of identifying gaps in patient understanding and nonadherence to inform targeted pharmacists' interventions to improve these measures. Methods A cross-sectional survey was conducted. Patients' knowledge about warfarin was rated using an Arabic-language tool. Medication adherence was assessed using the eight-item Morisky Medication Adherence Scale (MMAS-8). The international normalized ratio (INR) control was quantified by the Rosendaal Method. Setting At the Security Forces hospital anticoagulant clinic (ACC), Riyadh. Main outcome measure Validity of a Knowledge and adherence tool. Results Totally, 101 patients completed the questionnaires. Interestingly, the knowledge tool demonstrated good internal consistency (total Cronbach's alpha = 0.75) and significant concurrent validity with adherence levels. Fifty-two patients were classified as having unsatisfactory knowledge. Deficiency in knowledge was most obvious with respect to the consequences of missing a dose and when to seek immediate medical attention. The MMAS-8 had moderate reliability (Cronbach's alpha = 0.65); however, its concurrent validity with good INR control was not demonstrated. Conclusions This study revealed high prevalence of nonadherence and poor knowledge in the population visiting the ACC. Given that available knowledge and adherence tools seemed to have little validity in predicting clinical outcomes, structured tools should be designed, considering progression in clinical outcomes with future pharmacists' interventions.

Maintaining Quality in Lower Volume Cardiac Surgery: A Blueprint From a Military Program.

Although there is a clear volume-outcome relationship in the field of cardiac surgery, the existence of high-performing programs with relatively low case volumes is well established. This report describes the programmatic and institutional processes in place at a lower volume cardiac surgery center in a US military hospital, which have been executed to optimally leverage available resources in the delivery of exemplary patient care. By implementing a highly collaborative practice, rigorous outcomes review, evidence-based standardized care pathways, consistent attending surgeon oversight for care delivery, careful case selection, and a mechanism for support from highly experienced outside cardiac surgeons, the cardiac surgery program at the authors' institution delivers care on par with its higher volume counterparts. A review of these practices and available supporting evidence may provide a model for other programs seeking success in this setting.

Comparative Survival Analysis of Invasive Breast Cancer Patients Treated by a U.S. Military Medical Center and Matched Patients From the U.S. General Population.

OBJECTIVE: Many differences between U.S. military beneficiaries and the U.S. general population, including differences in health care access, are known factors affecting invasive breast cancer outcomes. Thus, comparing the two populations for any outcome differences and their contributing factors may provide insights to breast cancer prognosis. METHODS: Using a marginal Cox proportional hazards regression model, we compared disease-specific survival (DSS) and 5-year DSS rates between 418 patients from the Clinical Breast Care Project at the Walter Reed National Military Medical Center (CBCP-WR) and a set of 1:5 randomly matched patients from the Surveillance, Epidemiology, and End Results program. Patients were compared in the "demographic model" (adjusted by diagnosis year, age, and race) and the "overall model" (further adjusted by estrogen receptor, progesterone receptor, stage, and grade). RESULTS: In the "overall model," CBCP-WR patients were less likely overall to die from breast cancer (hazard ratio [HR] = 0.631, 95% confidence interval [CI] = 0.437-0.911; p = 0.014). This increase in survival was also significant in African American patients (HR = 0.524, 95% CI = 0.277-0.992; p = 0.047) and patients older than 50 (HR = 0.511, 95% CI = 0.306-0.854; p = 0.010). The advantage in 5-year DSS rate for CBCP-WR patients was 5.3% (93.1% vs. 87.8%; p < 0.001) in the "demographic model" and 3.4% (91.3% vs. 87.9%; p = 0.018) in the "overall model." CONCLUSION: CBCP-WR patients demonstrated significantly better DSS over matched SEER patients. Although a portion of the outcome disparity, i.e., 36% of the 5.3% DSS rate difference, could be explained by differences in tumor characteristics, the cause(s) behind the majority of the disparity has yet to be identified. Identification and further analysis of contributing factors to survival differences have the potential to improve clinical practice and outcomes for invasive breast cancer patients.

Being Prepared for the Next Conflict: A Case Analysis of a Military Level I Trauma Center.

BACKGROUND: As we transition to an interwar period, combat-related injuries are at their lowest levels in over a decade, yet we must continue to maintain our surgical skills and train new surgeons. During the recent wars, the importance of the treatment and care for amputations and complex extremity injuries became apparent. This study compares the number of these procedures performed during the treatment of civilian and military orthopaedic trauma patients at a Department of Defense Level I trauma center over the past 9 years. The need to evaluate this unique system is further highlighted by the recent recommendation from the National Academies of Sciences, Engineering, and Medicine's to combine civilian and military trauma systems. METHODS: Data derived through a retrospective review of electronic health records were charted and evaluated for statistically unique periods. RESULTS: There were significant fluctuations in the number of procedures performed within the military cohort, with peaks centered around 2007 and 2011-2012, whereas the number of civilian cases remained relatively steady. On average, the civilian cohort also produced a more consistent and greater number of tibia fractures than the military cohort. For the past 3 years, the civilian cohort has produced 22 more tibia fractures per quarter than the military cohort. Furthermore, although type III open tibia fractures were the most common classification within the military cohort, the civilian cohort provided comparable numbers of type III open fractures despite only being the second most common fracture classification in the civilian cohort. In fact, the civilian volume outpaced the military cohort the past 3 years in this metric. More importantly, the military cohort produced 6 type III fractures in 2013, and 3 in 2014, whereas the civilian cohort produced 14 and 25, respectively, during those years. DISCUSSION/IMPACT/RECOMMENDATIONS: Fluctuations in the military cohort's data mirrors surges in operational activity, whereas the civilian cohort demonstrates a higher and more predictable number of tibia fractures; with reliability and numbers being important factors in training new surgeons and maintaining surgical skills. Although this study focused on specific orthopaedic trauma cases deemed essential to combat casualty care, it highlights the universal reality facing U.S. Military Medicine: as combat trauma continues to decline, military medicine as a whole will have to look elsewhere for critical trauma experience. This study confirmed military case volumes fluctuate with operational demands and evaluated one method of supplementing the declining combat trauma volumes with a local civilian trauma mission. This indicates not only the need for a system that is able to quickly adapt to the increased patient load, but also depicts how little reliability there is within the system in terms of perpetuating physician experience when the civilian trauma mission is not considered.

Multimedia Campaign Enhances Orthopaedic Patient Perceptions of Health Care Quality: A Prospective Analysis of Effect at a Military Treatment Facility.

BACKGROUND: The importance of patient satisfaction as a measure of quality has grown with initiatives intended to enhance demand for services, refocus reimbursement paradigms, encourage health care efficiencies, and ultimately improve clinical outcomes. The purpose of our performance improvement project was to (1) characterize the effect of a two-pronged multimedia initiative on patient perceptions of health care quality and satisfaction as assessed by the Army Provider Level Satisfaction Survey (APLSS) and (2) assess for differences in APLSS scores between the surgeons that did and did not participate in the program. METHODS: Baseline APLSS data for our Department of Orthopaedic Surgery were collected and subsequently compared to APLSS results 3 months after the implementation of a department-wide multimedia campaign. The multimedia initiative consisted of two concurrently implemented interventions to the orthopaedic surgery outpatient clinics. One intervention involved placing large-framed posters about the orthopaedic clinic waiting areas on which were written, "We helped write the book," and included pictures of various orthopaedic textbooks of which attending surgeons and/or residents had contributed to as authors. The other intervention provided patients with surgeon "face sheets" upon arrival to their clinic appointments. These sheets included a picture of their attending surgeon, contact information for the surgeon's nurse care coordinator, and a brief biographical sketch of the surgeon's training, clinical interests and expertise, and other information at each surgeon's discretion. FINDINGS: Among APLSS survey results for the orthopaedic surgery clinic including all surgeons, significant increases were observed between baseline data and 3-month data for Top 1 and Top 2 responses to the questions, "How satisfied do you feel about your visit?" and "Did your surgeon listen to you carefully about your concerns and questions?" (p = 0.003 and p = 0.004, respectively). IMPACT: The implementation of a multimedia campaign resulted in significant improvements among indices of orthopaedic patient satisfaction. We believe this model could be used at other military or nonmilitary treatment facilities as a means to engender patients' familiarity with their surgeon and prompt an appreciation for his/her expertise and enhance overall patient perceptions of department-wide health care quality.

Improving Surgical Complications and Patient Safety at the Nation's Largest Military Hospital: An Analysis of National Surgical Quality Improvement Program Data.

INTRODUCTION: The U.S. Military Health System cares for over 9 million patients and encompasses 63 hospitals and 413 clinics worldwide. Military medicine balances the simultaneous tasks of caring for those patients wounded in military engagements, treating large numbers of families of service men and women, and training the next generation of health care providers and ancillary staff. Similar to civilian health care delivery in the United States, military medicine has also seen increased scrutiny in the areas of cost and quality. In 2014, the U.S. military medical health care system was criticized for higher than average surgical complication rates and concerns regarding patient safety, quality of care, lack of transparency, and compartmentalized leadership. The San Antonio Military Medical Center was specifically cited as having "a perennial problem with surgical infection control…the infection rate of surgical wounds was 77% higher than expected given the mix of cases, according to a Pentagon-ordered comparison with civilian hospitals." To determine the scope of complication rates, data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) were analyzed. The goal of this article is to describe the NSQIP surgical outcome data for the U.S. Military's largest medical center from 2009 to 2014 and compare national averages in the areas of mortality, morbidity, cardiac occurrences, pneumonia, unplanned intubation, ventilator use greater than 48 hours, infections, readmissions, and return to operating room. MATERIALS AND METHODS: Retrospective data analysis of NSQIP data from 2009 to 2014 at the San Antonio Military Medical Center, a level I trauma center for military members and eligible dependents along with civilian trauma patients. Observed event rates were compared with expected event rates for each year with the 2-tail Fisher's exact test to determine if rates were significantly different from each other. Cochran-Armitage Trend Test was performed to compare trends in time for the observed event rates. This study was exempt from institutional review board Approval. RESULTS: Complication rates remained stable or decreased over the 5 years studied. Significant improvement in morbidity and surgical site infections were observed during the observation period. All other variables except urinary tract infections were within expected range or decreased during this time. Urinary tract infection rates, although decreasing, remain above the expected value. CONCLUSIONS AND RELEVANCE: NSQIP data at the Department of Defense's largest hospital reveals complication rates similar to civilian hospitals. The majority of areas studied revealed improving or stable complication rates. The ACS NSQIP is a nationally validated, risk-adjusted, outcomes program that is widely used by many leading hospital institutions. Similar to most quality data reporting articles, a weakness of our study may have been collection of all complications. Yet, we are confident that the majority of complications were captured as we have dedicated personnel monitoring the adverse events measured by ACS NSQIP. Future areas of study should focus on continued analysis of surgical quality improvement within the entire military system.

An Orthopedic Performance Improvement Initiative at a Small Military Treatment Facility.

OBJECTIVES: The scientific literature demonstrates a cost-benefit associated with early access to physical therapy. The purpose of this case study is to report the results of an orthopedic performance improvement initiative (OPII) at a small military treatment facility (approximately 4.5K active duty beneficiaries). The OPII was introduced to (1) limit variation by ensuring that all active duty orthopedic consults were audited ensuring proper timing of appropriate services and (2) establish contractual agreement for shared resources with the U.S. Naval Jacksonville Orthopedic Department. METHODS: OPII was accomplished through consensus development and strong leadership support. All orthopedic referrals (n = 260) were audited for 6 months. Appropriate recommendations were provided to either continue with orthopedic care or to redirect to a physical therapy first approach. RESULTS: Orthopedic referrals decreased 27% with concomitant 32% increase in physical therapy referrals producing overall savings of $462K (33%). Meanwhile, surgical throughput improved 45%. Seventy percent of the savings were attributed to improved utilization translating to a relative value unit savings per beneficiary of $17.64 (23.7%). CONCLUSION: Our results support the value of a conservative physical therapy first approach for musculoskeletal conditions and shared mil-to-mil resourcing agreements. Success requires an iterative audit/feedback process balanced with stakeholder consensus.