The Military-Civilian Partnership Quality Improvement Program Concept: A Process to Improve Data Collection and Outcomes Assessment.

INTRODUCTION: Military-Civilian Partnerships (MCPs) are vital for maintaining the deployment readiness of military health care physicians. However, tracking their clinical activity has proven to be challenging. In this study, we introduce a locally driven process aimed at the passive collection of external clinical workload data. This process is designed to facilitate an assessment of MCP physicians' deployment readiness and the effectiveness of individual MCPs. MATERIALS AND METHODS: From March 2020 to February 2023, we conducted a series of quality improvement projects at the Wright Patterson Medical Center (WPMC) to enhance our data collection efforts for MCP physicians. Our methodology encompassed several steps. First, we assessed our existing data collection processes and their outcomes to identify improvement areas. Next, we tested various data collection methods, including self-reporting, a web-based smart phone application, and an automated process based on billing or electronic health record data. Following this, we refined our data collection process, incorporating the identified improvements and systematically tracking outcomes. Finally, we evaluated the refined process in 2 different MCPs, with our primary outcome measure being the collection of monthly health care data. RESULTS: Our examination at the WPMC initially identified several weaknesses in our established data collection efforts. These included unclear responsibility for data collection within the Medical Group, an inadequate roster of participating MCP physicians, and underutilization of military and community resources for data collection. To address these issues, we implemented revisions to our data collection process. These revisions included establishing clear responsibility for data collection through the Office of Military-Civilian Partnerships, introducing a regular "roll call" to match physicians to MCP agreements, passively collecting data each month through civilian partner billing or information technology offices, and integrating Office of Military-Civilian Partnership efforts into regular executive committee meetings. As a result, we observed a 4-fold increase in monthly data capture at WPMC, with similar gains when the refined process was implemented at an Air Force Center for the Sustainment of Trauma and Readiness Skills site. CONCLUSIONS: The Military-Civilian Partnership Quality Improvement Program concept is an effective, locally driven process for enhancing the capture of external clinical workload data for military providers engaged in MCPs. Further examination of the Military-Civilian Partnership Quality Improvement Program process is needed at other institutions to validate its effectiveness and build a community of MCP champions.

Quality of Integration of Air Force Trauma Surgeons Within the Center for Sustainment of Trauma and Readiness Skills, Cincinnati: A Pilot Study.

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.

Implementation of a Multidisciplinary Preoperative Protocol for Geriatric Hip Fractures Improves Time to Surgery at a Level III Trauma Center.

Introduction: Hip fractures are common among the elderly, and delays in time to surgery (TTS) and length of stay (LOS) are known to increase mortality risk in these patients. Preoperative multidisciplinary protocols for hip fracture management are effective at larger trauma hospitals. The purpose of this study is to evaluate the effect of a similar multidisciplinary preoperative protocol for geriatric hip fracture patients at our Level III trauma center. Materials and Methods: In this single-center retrospective study, patients aged 65 and older who were admitted from March 2016 to December 2018 (pre-protocol group, Cohort #1, n = 247) and from August 2021 to September 2022 (post-protocol group, Cohort #2, n = 169) were included. Demographic information, TTS, and LOS were obtained and compared using Student's t-test and Chi-square testing. Results: There was a significant decrease in TTS in Cohort #2 compared to Cohort #1 (P < .001). There was a significant increase in LOS in Cohort #2 compared to Cohort #1 (P < .05), but when comparing a subset of Cohort #2 (Subgroup 2B, patients admitted from May to September 2022 when the effects of COVID-19 were likely dissipated) to Cohort #1, there was no significant difference in LOS (P = .13). For patients admitted to skilled nursing facilities (SNF), LOS in Cohort #2 was significantly longer than in Cohort #1 (P = .001). Discussion: In general, Level III hospitals have fewer perioperative resources compared to larger Level I hospitals. Despite this fact, this multidisciplinary preoperative protocol effectively reduced TTS which improves mortality risk in elderly patients. LOS is a multifactorial variable, and we believe the COVID-19 pandemic was a significant confounder that reduced available SNF beds in our area which prolonged the average LOS in Cohort #2. Conclusion: A multidisciplinary preoperative protocol for geriatric hip fracture management can improve efficiency of getting patients to surgery at Level III trauma centers.

Descriptive Analysis of Intratheater Critical Care Air Transport Team Patient Movements During Troop Drawdown: Afghanistan (2017-2019).

BACKGROUND: The majority of critical care air transport (CCAT) flights are regulated, meaning that a theater-validating flight surgeon has confirmed that the patient is medically cleared for flight and that evacuation is appropriate. If the conditions on the ground do not allow for this process, the flight is unregulated. Published data are limited regarding CCAT unregulated missions to include the period of troop drawdown at the end of the Afghanistan conflict. The objective of our study was to characterize the unregulated missions within Afghanistan during troop drawdown and compare them to regulated missions during the same timeframe. STUDY DESIGN: We performed a retrospective review of all CCAT medical records of patients transported via CCAT within Afghanistan between January 2017 and December 2019. We abstracted data from the records, including mission characteristics, patient demographics, injury descriptors, preflight military treatment facility procedures, CCAT procedures, in-flight CCAT treatments, in-flight events, and equipment issues. Following descriptive and comparative analysis, a Cochran-Armitage test was performed to evaluate the statistical significance of the trend in categorical data over time. Multivariable regression was used to assess the association between vasopressors and preflight massive transfusions, preflight surgical procedures, injury patterns, and age. RESULTS: We reviewed 147 records of patients transported via CCAT: 68 patients were transported in a regulated fashion and 79 on an unregulated flight. The number of patients evacuated increased year-over-year (n = 22 in 2017, n = 57 in 2018, and n = 68 in 2019, P < .001), and the percentage of missions that were unregulated grew geometrically (14%, n = 3 in 2017; 37%, n = 21 in 2018; and 81%, n = 55 in 2019, P < .001). During the time studied, CCAT teams were being used more to decompress forward surgical teams (FST) and, therefore, they were transporting patients just hours following initial damage control surgery in an unregulated fashion. In 2 instances, CCAT decompressed an FST following a mass casualty, during which aeromedical evacuation (AE) crews assisted with patient care. For the regulated missions, the treatments that were statistically more common were intravenous fluids, propofol, norepinephrine, any vasopressors, and bicarbonate. During unregulated missions, the statistically more common treatments were ketamine, fentanyl, and 3% saline. Additional analysis of the mechanically ventilated patient subgroup revealed that vasopressors were used twice as often on regulated (38%) vs. unregulated (13%) flights. Multivariable regression analysis demonstrated that traumatic brain injury (TBI) was the only significant predictor of in-flight vasopressor use (odds ratio = 3.53, confidence interval [1.22, 10.22], P = .02). CONCLUSION: During the troop drawdown in Afghanistan, the number of unregulated missions increased geometrically because the medical footprint was decreasing. During unregulated missions, CCAT providers used ketamine more frequently, consistent with Tactical Combat Casualty Care guidelines. In addition, TBI was the only predictor of vasopressor use and may reflect an attempt to adhere to unmonitored TBI clinical guidelines. Interoperability between CCAT and AE teams is critical to meet mass casualty needs in unregulated mission environments and highlights a need for joint training. It remains imperative to evaluate changes in mission requirements to inform en route combat casualty care training.

Relevance of Deployment Experience and Clinical Practice Characteristics on Military Critical Care Air Transport Team Readiness: A Study of Simulation Construct Validity.

INTRODUCTION: The Critical Care Air Transport Team (CCATT) Advanced course utilizes fully immersive high-fidelity simulations to train CCATT personnel and assess their readiness for deployment. This study aims to (1) determine whether these simulations correctly discriminate between students with previous deployment experience ("experienced") and no deployment experience ("novices") and (2) examine the effects of students' clinical practice environment on their performance during training simulations. MATERIALS AND METHODS: Critical Care Air Transport Team Advanced student survey data and course status (pass/no pass) between March 2006 and April 2020 were analyzed. The data included students' specialty, previous exposure to the CCATT Advanced course, previous CCATT deployment experience, years in clinical practice (<5, 5-15, and >15 years), and daily practice of critical care (yes/no), as well as a description of the students' hospital to include the total number of hospital (<100, 100-200, 201-400, and >400) and intensive care unit (0, 1-10, 11-20, and >20) beds. Following descriptive analysis and comparative tests, multivariable regression was used to identify the predictors of passing the CCATT Advanced course. RESULTS: A total of 2,723 surveys were analyzed: 841 (31%) were physicians (MDs), 1,035 (38%) were registered nurses, and 847 (31%) were respiratory therapists (RTs); 641 (24%) of the students were repeating the course for sustainment training and 664 (24%) had previous deployment experience. Grouped by student specialty, the MDs', registered nurses', and RTs' pass rates were 92.7%, 90.6%, and 85.6%, respectively. Multivariable regression results demonstrated that deployment experience was a robust predictor of passing. In addition, the >15 years in practice group had a 47% decrease in the odds of passing as compared to the 5 to 15 years in practice group. Finally, using MDs as the reference, the RTs had a 61% decrease in their odds of passing. The daily practice of critical care provided a borderline but nonsignificant passing advantage, whereas previous CCATT course exposure had no effect. CONCLUSION: Our primary result was that the CCATT Advanced simulations that are used to evaluate whether the students are mission ready successfully differentiated "novice" from "experienced" students; this is consistent with valid simulation constructs. Finally, novice CCATT students do not sustain their readiness skills during the period between mandated refresher training.

Postinjury treatments to make early tactical aeromedical evacuation practical for the brain after TBI.

BACKGROUND: Traumatic brain injury (TBI) is common in civilians and military personnel. No potential therapeutics have been evaluated to prevent secondary injury induced by the hypobaric hypoxia (HH) environment integral to postinjury aeromedical evacuation (AE). We examined the role of allopurinol, propranolol, adenosine/lidocaine/magnesium (ALM), or amitriptyline administration prior to simulated flight following murine TBI. METHODS: Mice underwent TBI and were given allopurinol, propranolol, amitriptyline, or ALM prior to simulated AE or normobaric normoxia (NN) control. Heart rate (HR), respiratory rate, and oxygen saturation (Spo2) were recorded throughout simulated AE. Mice were sacrificed at 24 hours, 7 days, or 30 days. Serum and cerebral cytokines were assessed by enzyme-linked immunosorbent assay. Motor function testing was performed with Rotarod ambulation. Immunohistochemistry was conducted to examine phosphorylated tau (p-tau) accumulation in the hippocampus at 30 days. RESULTS: While all treatments improved oxygen saturation, propranolol, amitriptyline, and allopurinol improved AE-induced tachycardia. At 24 hours, both propranolol and amitriptyline reduced tumor necrosis factor alpha levels while allopurinol and ALM reduced tumor necrosis factor alpha levels only in NN mice. Propranolol, amitriptyline, and ALM demonstrated lower serum monocyte chemoattractant protein-1 7 days after AE. Both amitriptyline and allopurinol improved Rotarod times for AE mice while only allopurinol improved Rotarod times for NN mice. Propranolol was able to reduce p-tau accumulation under both HH and NN conditions while ALM only reduced p-tau in hypobaric hypoxic conditions. CONCLUSION: Propranolol lowered post-TBI HR with reduced proinflammatory effects, including p-tau reduction. Amitriptyline-induced lower post-TBI HR and improved functional outcomes without affecting inflammatory response. Allopurinol did not affect vital signs but improved late post-TBI systemic inflammation and functional outcomes. Adenosine/lidocaine/magnesium provided no short-term improvements but reduced p-tau accumulation at 30 days in the HH cohort. Allopurinol may be the best of the four treatments to help prevent short-term functional deficits while propranolol may address long-term effects. LEVEL OF EVIDENCE: Basic science article.

Efficacy of Noninvasive Technologies in Triaging Traumatic Brain Injury and Correlating With Intracranial Pressure: A Prospective Study.

BACKGROUND: There is interest in methods of measuring noninvasive intracranial pressure (ICP), including pupillometry, ultrasonographic transcranial Doppler (TCD), and optic nerve sheath diameter (ONSD), for diagnosing traumatic brain injury (TBI) in limited resource environments. Whether these technologies have diagnostic agreement is unknown. We hypothesized that ONSD, pupillometry, and TCD could both distinguish severe TBI and correlate with ICP. METHODS: A prospective study of 135 patients was conducted at a level 1 trauma center. Four test groups were established: nontrauma patients with ICP monitoring, trauma patients without TBI, trauma patients with mild TBI, and trauma patients with severe TBI with ICP monitoring. All patients underwent daily measurements of ONSD, pupillometry, and TCD with both CX50 Sonosite and the Spencer ST3 Yi Pencil probe. RESULTS: ONSD differed significantly in patients with severe TBI compared with patients with mild and no TBI, but did not correlate with ICP. Pupillometric constriction velocity, dilation velocity, and percent change in pupil diameter were significantly different in patients with severe TBI, but also did not correlate with ICP. TCD did not differ among TBI severities, but middle cerebral artery peak systolic velocity, middle cerebral artery flow velocity, and carotid flow velocity correlated with ICP. CONCLUSIONS: This is a novel study of four noninvasive tests to screen for severity of TBI and measure ICP. Our analysis indicates that no single device can do both. However, ONSD and pupillometry may be used as a supplementary screening tool for severe TBI, whereas TCD could be used to estimate and follow ICP in patients with severe TBI.

Surgical management of post-traumatic transvaginal herniation of small intestine in a third-world country.

We present a case of a 26-year-old woman with a small bowel herniating from her vagina following traumatic injury from a road traffic accident. The patient was taken immediately to operating theatre for repair of her uterine defect and small bowel resection. The patient required eventual return to theatre for subtotal hysterectomy and recovered well after her surgeries. She was discharged home without any further complications and in good condition.

Surgical management of compound skull fracture with exposed brain matter in a third-world country.

We hereby present a case of a 6-year-old boy with exposed brain matter following traumatic injury from a road traffic accident, in a third-world country with poor healthcare resources. The patient was taken immediately to operating theater where two general surgeons performed an emergent craniotomy and debridement. The patient survived the injury and surgery without neurological deficits or other surgical complications. He was discharged home in good condition.

Surgical management of fungating penile mass in a third-world country.

We present a 82-year-old man who presented with a 3-week history of a fungating penile mass with urinary leakage. Our objectives are to detail our global health experience providing surgical care in a low-resource, third-world environment.

Supplemental oxygen attenuates the increase in wound bacterial growth during simulated aeromedical evacuation in goats.

BACKGROUND: Bacterial growth in soft tissue and open fractures is a known risk factor for tissue loss and complications in contaminated musculoskeletal wounds. Current care for battlefield casualties with soft tissue and musculoskeletal wounds includes tactical and strategic aeromedical evacuation (AE). This exposes patients to a hypobaric, hypoxic environment. In this study, we sought to determine whether exposure to AE alters bacterial growth in contaminated complex musculoskeletal wounds and whether supplemental oxygen had any effect on wound infections during simulated AE. METHODS: A caprine model of a contaminated complex musculoskeletal wound was used. Complex musculoskeletal wounds were created and inoculated with bioluminescent Pseudomonas aeruginosa. Goats were divided into three experimental groups: ground control, simulated AE, and simulated AE with supplemental oxygen. Simulated AE was induced in a hypobaric chamber pressurized to 8,800 feet for 7 hours. Bacterial luminescence was measured using a photon counting camera at three time points: preflight (20 hours postsurgery), postflight (7 hours from preflight and 27 hours postsurgery), and necropsy (24 hours from preflight and 44 hours postsurgery). RESULTS: There was a significant increase in bacterial growth in the AE group compared with the ground control group measured postflight and at necropsy. Simulated AE induced hypoxia with oxygen saturation less than 93%. Supplemental oxygen corrected the hypoxia and significantly reduced bacterial growth in wounds at necropsy. CONCLUSIONS: Hypoxia induced during simulated AE enhances bacterial growth in complex musculoskeletal wounds which can be prevented with the application of supplemental oxygen to the host.

Recurrence of primary breast lymphoma in contralateral breast: case report and review of the literature.

Lymphoma presenting as a breast mass is rare, although well documented. Although recurrence rates can reach approximately 50%, recurrence in the contralateral breast is rare. We report a case of recurrent primary breast lymphoma (PBL), which was discovered on screening mammography after a 5-year disease-free interval from initial diagnosis.