Validation of the Nelson Tool: A Scoring Tool for Nonsurgical Service Admission of Injured Patients.

BACKGROUND: Trauma performance improvement programs are required by the American College of Surgeons to review all nonsurgical admissions if the annual rate exceeds 10%. These reviews can have varying consistency between reviewers, are time consuming, and the consequent aggregate data are difficult to evaluate for trends. OBJECTIVE: This study set forth to standardize nonsurgical admission review through validation of the Nelson tool, which is a published objective scoring tool to determine the appropriateness of nonsurgical admissions. We hypothesized that implementation of this tool would facilitate earlier identification of events resulting in meaningful intervention and a reduction of inappropriate nonsurgical admissions. METHODS: The Nelson tool and scoring was integrated into the nonsurgical admission review process. A customized audit filter and report were built in the trauma registry. Data were reviewed with respect to scores and admitting service. Statistical analysis included using analysis of variance and t tests to examine differences between admitting services, χ2 test of independence or Fisher's exact to test the association of categorical variables, and ordinal logistic regression to test the ability of the total Nelson tool to predict appropriateness of admission. RESULTS: Using the Nelson tool, scores resulted in appropriate admission service in over 90% of cases. Implementation of the tool resulted in a decreased performance improvement workload with a 78% reduction in nonsurgical admission cases required to go to secondary level of review. CONCLUSIONS: Utilization of a validated scoring tool decreases performance improvement workload without compromising patient safety.

Overseas organ donation during wartime operations: Benchmarking military performance against civilian practice.

BACKGROUND: Over the past 15 years of war, eligible U.S. military members donated organs overseas in Germany. Our hypothesis was that outcomes at a military treatment facility were comparable to a civilian cohort. METHODS: Military donors were matched 1:3 with a donor cohort from the U.S. United Network for Organ Sharing. Data were compared using univariate and multivariate analysis. Significance set at p < 0.05. RESULTS: Forty military organ donors were compared with 116 civilian matched donors. The military cohort conversion rate was 75.5% and recovered more organs per donor (4.6 vs. 4.0, p = 0.02) with more transplants (4.2 vs 3.5, p = 0.01). Multivariate analysis controlling for sex, age, and type of organ donation showed no difference in odds of total organs donated in the military versus civilian cohort (odds ratio 2.1, 95% CI 0.87-5.24, p = 0.10). CONCLUSIONS: Organ donation at a military treatment facility overseas can be accomplished successfully.

A review of the first 10 years of critical care aeromedical transport during operation iraqi freedom and operation enduring freedom: the importance of evacuation timing.

IMPORTANCE: Advances in the care of the injured patient are perhaps the only benefit of military conflict. One of the unique aspects of the military medical care system that emerged during Operation Iraqi Freedom and Operation Enduring Freedom has been the opportunity to apply existing civilian trauma system standards to the provision of combat casualty care across an evolving theater of operations. OBJECTIVES: To identify differences in mortality for soldiers undergoing early and rapid evacuation from the combat theater and to evaluate the capabilities of the Critical Care Air Transport Team (CCATT) and Joint Theater Trauma Registry databases to provide adequate data to support future initiatives for improvement of performance. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of CCATT records and the Joint Theater Trauma Registry from September 11, 2001, to December 31, 2010, for the in-theater military medicine health system, including centers in Iraq, Afghanistan, and Germany. Of 2899 CCATT transport records, those for 975 individuals had all the required data elements. EXPOSURE: Rapid evacuation by the CCATT. MAIN OUTCOMES AND MEASURES: Survival as a function of time from injury to arrival at the role IV facility at Landstuhl Regional Medical Center. RESULTS: The patient cohort demonstrated a mean Injury Severity Score of 23.7 and an overall 30-day mortality of 2.1%. Mortality en route was less than 0.02%. Statistically significant differences between survivors and decedents with respect to the Injury Severity Score (mean [SD], 23.4 [12.4] vs 37.7 [16.5]; P < .001), cumulative volume of blood transfused among the patients in each group who received a transfusion (P < .001), worst base deficit (mean [SD], -3.4 [5.0] vs -7.8 [6.9]; P = .02), and worst international normalized ratio (median [interquartile range], 1.2 [1.0-1.4] vs 1.4 [1.1-2.2]; P = .03) were observed. We found no statistically significant difference between survivors and decedents with respect to time from injury to arrival at definitive care. CONCLUSIONS AND RELEVANCE: Rapid movement of critically injured casualties within hours of wounding appears to be effective, with a minimal mortality incurred during movement and overall 30-day mortality. We found no association between the duration of time from wounding to arrival at Landstuhl Regional Medical Center with respect to mortality.

A concluding after-action report of the Senior Visiting Surgeon program with the United States Military at Landstuhl Regional Medical Center, Germany.

BACKGROUND: The Senior Visiting Surgeon (SVS) program at Landstuhl Regional Medical Center (LRMC), Germany, was developed during the wars in Afghanistan and Iraq as a measure to build military-civilian interaction in trauma care and research. The objective of this study was to provide a summary of the program including workload and experiences. An additional objective was to identify factors needed for sustainment of this program during an interwar period. METHODS: An electronic, 34-question survey was distributed to 192 surgeons who participated in the SVS program at LRMC, either through the American Association for the Surgery of Trauma or the Society of Vascular Surgery between 2005 and 2012. The survey was composed of multiple-choice and open-ended questions. RESULTS: The response rate was 61% (n = 118), with 24% (n = 28) indicating previous military service. These 117 respondents provided 24.5 months of volunteer coverage at LRMC, with 22% (n = 26) performing multiple, 2-week rotations. Visiting surgeons participated in two to five operative cases per week, with the majority of operations related to the management of soft tissue wounds and burns followed by abdominal and vascular procedures, conducted daily multidisciplinary intensive care unit rounds, and collaborated with military surgeons in research projects resulting in 22 publications. More than half (n = 59) of the respondents maintained contact with military colleagues during the 12 months following the rotation. The majority of surveyed surgeons support continuation of the SVS at military facilities in the United States and hosting military surgeons at their civilian trauma center. CONCLUSION: This study is the first to quantify the SVS program during the wars in Afghanistan and Iraq. Visiting surgeons provided more than 2 years of combat casualty care during these, the longest wars in US history. Continuation of this program will require expanded military-civilian interaction in trauma care, training, and research during any interwar period.

Combat-associated drowning.

BACKGROUND: The purpose of this article is to describe the clinical course and outcome of drowning cases related to current US military combat operations. METHODS: This retrospective case series spans December 2002 to January 2009 of survivors transferred to an echelon IV military trauma center in Europe serving as the primary evacuation hub for ongoing combat operations. Patient demographics and the situational and clinical findings at the initial drowning scene were reviewed. A comprehensive analysis of care as each patient transitioned through the combat theater to the echelon IV trauma center in Europe was performed. RESULTS: Overall, mortality was 37.5% mortality rate (3 of 8 patients). Advanced modes of respiratory support such as high-frequency ventilation, airway pressure release ventilation, and extracorporeal membrane oxygenation were required in a majority of the cohort (6 of 8 patients). Limited-duration vasopressor infusions (7 of 8 patients) were also required to ensure adequate end-organ perfusion. Glasgow Coma Scale (GCS) scores and the need for cardiopulmonary resuscitation (CPR) at the scene of injury were associated with eventual patient mortality (100% mortality for an initial GCS score of 3 and 75% mortality for on-scene CPR). Survivor long-term morbidity was often related to the sequelae of acute respiratory distress syndrome and hypoxic encephalopathy. CONCLUSION: Drowning associated with combat operations was associated with severe acute respiratory distress syndrome and cardiovascular shock. GCS score and the need for CPR at the scene of injury were associated with eventual mortality because of anoxic brain injury in all cases.

Rewards and challenges of nursing wounded warriors at Landstuhl Regional Medical Center, Germany.

Since the beginning of the Overseas Contingency Operation, more than 45,000 ill and wounded service members have been evacuated from the battlefield to Landstuhl Regional Medical Center (LRMC) in western Europe. LRMC is a stopover for these service members, where they are further assessed, treated, and stabilized before they return to the United States. This process requires coordination between different military services, health care teams, and modes of transportation. These processes can be complicated given the severity of the wounded. Nurses at LRMC have learned how to streamline services, providing efficient, comprehensive care for wounded service members and their families.

Nurses' role in the Joint Theater Trauma System.

Nurses' role within the Joint Theater Trauma System's trauma performance improvement program spans the entire trauma continuum. Nurses serve as trauma nurse coordinators at combat zone medical treatment facilities, flight nurses within the US Air Force Aeromedical Evacuation system, multidisciplinary trauma teams at overseas and stateside military and Veterans Affairs healthcare organizations, and members on trauma video teleconferences. Many of the trauma performance improvement initiatives that have occurred since the Joint Theater Trauma System inception have been led by nurses serving within the trauma continuum and resulted in successful outcomes for patients with polytrauma.

Performance improvement on the battlefield.

The Joint Theater Trauma System (JTTS) is a formal system of trauma care designed to improve the medical care and outcomes for combat casualties of Operation Iraqi Freedom and Operation Enduring Freedom. This article describes the JTTS Trauma Performance Improvement Plan and how JTTS personnel use it to facilitate performance improvement across the entire continuum of combat casualty care.

Implementation of a combat casualty trauma registry.

The Joint Theater Trauma Registry is a standardized, retrospective data collection system for all echelons of combat casualty care. Military-specific data elements include expanded demographic data to include military branch, service, rank, military occupation, and personal protective equipment. Varying data from each echelon are entered into the Joint Theater Trauma Registry, version 3. The Joint Theater Trauma Registry, version 3 at the echelon 4 medical treatment facility requires routine collection of 367 data elements for each casualty, but casualties sustaining burns, deaths, or those with performance improvement issues may have more than 450 data elements recorded. Trauma registries are powerful tools for process improvement. Collaboration between civilian and military trauma programs may foster improvements in registry design and data collection for both groups.

Trauma advanced practice nurses: implementing the role.

The need for advanced practice nurses (APN) has expanded over the past several decades as a result of the changing healthcare environment. Increased patient acuity and decreased resident work hours have lead to a need for additional clinical expertise at the bedside. APNs are becoming an integral part of the acute care delivery team in many trauma programs and intensive care units. To date little has been published regarding the role of the APN in Trauma Centers. This article outlines the wide variety of responsibilities and services provided by a select group of nurse practitioners who work in trauma centers throughout the United States.