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.

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 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 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.