Analgesia and Sedation for Tactical Combat Casualty Care: TCCC Proposed Change 21-02.

Analgesia in the military prehospital setting is one of the most essential elements of caring for casualties wounded in combat. The goals of casualty care is to expedite the delivery of life-saving interventions, preserve tactical conditions, and prevent morbidity and mortality. The Tactical Combat Casualty Care (TCCC) Triple Option Analgesia guideline provided a simplified approach to analgesia in the prehospital combat setting using the options of combat medication pack, oral transmucosal fentanyl, or ketamine. This review will address the following issues related to analgesia on the battlefield: 1. The development of additional pain management strategies. 2. Recommended changes to dosing strategies of medications such as ketamine. 3. Recognition of the tiers within TCCC and guidelines for higher-level providers to use a wider range of analgesia and sedation techniques. 4. An option for sedation in casualties that require procedures. This review also acknowledges the next step of care: Prolonged Casualty Care (PCC). Specific questions addressed in this update include: 1) What additional analgesic options are appropriate for combat casualties? 2) What is the optimal dose of ketamine? 3) What sedation regimen is appropriate for combat casualties?

Quantifying Clinical Opportunities at the Navy Trauma Training Center.

INTRODUCTION: Military-Civilian partnerships (MCPs), such as the Navy Trauma Training Center, are an essential tool for training military trauma care providers. Despite Congressional and military leadership support, sparse data exist to quantify participants' clinical opportunities in MCPs. These preliminary data from an ongoing Navy Trauma Training Center outcomes study quantify clinical experiences and compare skill observation to skill performance. MATERIALS AND METHODS: Participants completed clinical logs after each patient encounter to quantify both patients and procedures they were involved with during clinical rotations; they self-reported demographic data. Data analyses included descriptive statistics and chi-square statistics to compare skills observed to skills performed between the first and second half of the 21-day course. RESULTS: A sample of 47 Navy personnel (30 corpsmen, 10 nurses, 3 physician assistants, 4 physicians) completed 551 clinical logs. Most logs (453/551) reflected experiences in the emergency department, where corpsmen and nurses each spent 102.0 hours, and physician assistants and physicians each spent 105.4 hours. Logs completed per participant ranged from 1 to 31, (mean = 8). No professional group was more likely than others to complete the clinical logs. Completion rates varied by cohort, both overall and by clinical role. Of emergency department logs, 39% reflected highest acuity patients, compared with 21% of intensive care unit logs, and 61% of operating room logs. Penetrating trauma was reported on 16.5% of logs. Primary and secondary trauma assessments were the most commonly reported clinical opportunities, followed by obtaining intravenous access and administration of analgesic medications. With few exceptions, logs reflected skill observation versus skill performance, a ratio that did not change over time. CONCLUSION: Prospective real-time data of actual clinical activity is a crucial measure of the success of MCPs. These preliminary data provide a beginning perspective on how these experiences contribute to maintaining a skilled military medical force.

Preliminary Data on Trauma Knowledge, Confidence, and Stress During Navy Trauma Training.

INTRODUCTION: The Navy Trauma Training Center (NTTC) is a military-civilian partnership that provides advanced trauma training for application across the range of military operations while exposing military medical personnel to high-volume and high-acuity trauma. Few published data evaluate the outcomes of military-civilian partnerships, including NTTC. The purpose of this study is to evaluate the knowledge, confidence, and stress of NTTC participants before, at mid-point, and after completion of the program. Participants include corpsmen (HM), nurses (RNs), physician assistants (PAs), and physicians (MDs). MATERIALS AND METHODS: These are preliminary data from an ongoing prospective, observational study with repeated measures. Included are participants that complete NTTC training. Pre-training measures include a demographic questionnaire, trauma knowledge test, Confidence survey, and the Perceived Stress Scale. These same instruments are completed at mid-training and at the conclusion of the NTTC curriculum. Data were analyzed using paired t-tests and linear mixed models. RESULTS: The sample was composed of 83 participants (49 HM, 18 RNs, 4 PAs, and 12 MDs. Knowledge and confidence increased from baseline to post-NTTC for each clinical role (P < .05). Stress for all roles was low and stable over time (P > .05). CONCLUSIONS: These preliminary data suggest that, as expected, trauma-related knowledge and confidence increase significantly with training at NTTC. Stress was low and stable over time. These data from a small sample of participants indicate NTTC training is increasing participants' trauma knowledge and confidence to care for trauma casualties. Continued collection of data in the ongoing study will allow us to determine whether these early findings persist in the overall study sample and may help inform the optimal length of training needed.

A multi-center study of horizontal violence in United States military nursing.

Horizontal violence refers to repeated behaviors over time that intimidate or demean another. These behaviors may negatively impact the nursing workplace. The purpose of this study was to describe horizontal violence occurrence in the United States military nursing workplace and to determine the effectiveness of an educational intervention. Using a one group before-after design, survey data on horizontal violence behaviors, personal effects, perpetrators, job satisfaction and intention to leave were collected before and after a 30-min educational intervention. Reported horizontal violence behaviors and personal effects from horizontal violence averaged once to twice in a three month period. Staff nurses (peers) were the most frequent perpetrators. Job satisfaction and intent to leave significantly correlated with horizontal violence. There were no significant differences in overall horizontal violence before and after the intervention. Within the United States military nursing workplace horizontal violence does occur, although less frequently than in the United States civilian nursing population. Education on horizontal violence may not be sufficient as a sole intervention.

The "Top 10" research and development priorities for battlefield surgical care: Results from the Committee on Surgical Combat Casualty Care research gap analysis.

BACKGROUND: The US Military has achieved the highest casualty survival rates in its history. However, there remain multiple areas in combat trauma that present challenges to the delivery of high-quality and effective trauma care. Previous work has identified research priorities for pre-hospital care, but there has been no similar analysis for forward surgical care. METHODS: A list of critical "focus areas" was developed by the Committee on Surgical Combat Casualty Care (CoSCCC). Individual topics were solicited and mapped to appropriate focus areas by group consensus and review of Eastern Association for the Surgery of Trauma (EAST) and Joint Trauma System guidelines. A web-based survey was distributed to the CoSCCC and the military committees of EAST and the American Association for the Surgery of Trauma. Topics were rated on a Likert scale from 1 (low) to 10 (high priority). Descriptives, univariate statistics, and inter-rater correlation analysis was performed. RESULTS: 13 research focus areas were identified (eight clinical and five adjunctive categories). Ninety individual topics were solicited. The survey received 64 responses. The majority of respondents were military (90%) versus civilians (10%). There was moderate to high agreement (inter-rater correlation coefficient = 0.93, p < 0.01) for 10 focus areas. The top five focus areas were Personnel/Staffing (mean, 8.03), Resuscitation and Hemorrhage Management (7.49), Pain/Sedation/Anxiety Management (6.96), Operative Interventions (6.9), and Initial Evaluation (6.9). The "Top 10" research priorities included four in Personnel/Staffing, four in Resuscitation/Hemorrhage Management, and three in Operative Interventions. A complete list of the topics/scores will be presented. CONCLUSIONS: This is the first objective ranking of research priorities for combat trauma care. The "Top 10" priorities were all from three focus areas, supporting prioritization of personnel/staffing of austere teams, resuscitation/hemorrhage control, and damage-control interventions. This data will help guide Department of Defense research programs and new areas for prioritized funding of both military and civilian researchers. LEVEL OF EVIDENCE: Study design, level IV.

En Route Care Provided by US Navy Nurses in Iraq and Afghanistan.

BACKGROUND: US Navy nurses provide en route care for critically injured combat casualties without having a formal program for training, utilization, or evaluation. Little is known about missions supported by Navy nurses. OBJECTIVES: To characterize the number and types of patients transported and skill sets required by Navy nurses during 2 combat support deployments. METHODS: All interfacility casualty transfers between 2 separate facilities in Iraq and Afghanistan were assessed. Number of patients treated, number transported, en route care provider type, transport priority level and duration, injury severity, indication for critical care transport, en route care interventions, and vital signs were evaluated. RESULTS: Of 1550 casualties, 630 required medical evacuation to a higher level of care. Of those, 133 (21%) were transported by a Navy nurse, with 131 (98.5%) classified as "urgent," accounting for 46% of all urgent transports. The primary indication for en route care nursing was mechanical ventilation of intubated patients (97%). Mean (SD) patient transport time was 29.8 (7.9) minutes (range, 17-61 minutes). The most common en route care interventions were administration of intravenous sedation (80%), neuromuscular blockade (79%), and opioids (48%); transfusions (18%); and ventilation changes (11%). No intubations, cricothyroidotomies, chest tube placements, or needle decompressions were performed en route. No deaths occurred during transport. CONCLUSIONS: US Navy nurses successfully transported critically injured patients without observed adverse events. Establishing en route care as a program of record in the Navy will facilitate continuous process improvement to ensure that future casualties receive optimized en route care.

An Evaluation of Navy En Route Care Training Using a High-Fidelity Medical Simulation Scenario of Interfacility Patient Transport.

INTRODUCTION: Military prehospital and en route care (ERC) directly impacts patient morbidity and mortality. Provider knowledge and skills are critical variables in the effectiveness of ERC. No Navy doctrine defines provider choice for patient transport or requires standardized provider training. Frequently, Search and Rescue Medical Technicians (SMTs) and Navy Nurses (ERC RNs) are tasked with this mission though physicians have also been used. Navy ERC provider training varies greatly by professional role. Historically, evaluations of ERC and patient outcomes have been based on retrospective analyses of incomplete data sets that provide limited insight on ERC practices. Little evidence exists to determine if current training is adequate to care for the most common injuries seen in combat trauma patients. MATERIALS AND METHODS: Simulation technology facilitates a standardized patient encounter to enable complete, prospective data collection while studying provider type as the independent variable. Information acquired through skill performance observation can be used to make evidence-based recommendations to improve ERC training. This IRB approved multi-center study funded through a Congressionally Directed Medical Research Program grant from the Combat Casualty Care Intramural Research Joint En Route Care portfolio evaluated Navy ERC providers. The study evaluated 84 SMT, ERC RN, and physician participants in the performance of critical and secondary actions during an immersive, high-fidelity, patient transport simulation scenario focused on the care during an interfacility transfer. Simulation evaluators with military ERC expertise, blinded to participant training and background, graded each participant's performance. Inter-rater reliability was calculated using Cohen's Kappa to evaluate concordance between evaluator assessments. Categorical data were reported as frequencies and percentages. Performance attempt and accuracy rates were compared with likelihood ratio chi-square or Fisher's exact test where appropriate. Tests were two-tailed and we considered results significant, that is, a difference not likely due to chance exists between groups, if p < 0.05. Confidence intervals were used to present overlap in performance between provider types. RESULTS: Critical and secondary actions were assessed. A majority of providers completed at least one of the critical life-saving actions; only one participant completed all critical actions. Evaluation of critical actions demonstrated that a tourniquet was applied by 64% of providers, blood products administered by 46%, needle decompression performed by 51%, and a complete handoff report performed by 48%. Assessment of secondary actions demonstrated analgesic was accurately administered by 24% of all providers, and 44% reinforced the "hemorrhaging amputation site dressing." CONCLUSION: Over 98% of participants failed to properly perform all critical actions during the interfacility transfer scenario, which in a real-life combat casualty transport scenario could result in a preventable death. Study results demonstrate serious skill deficits among all types of Navy ERC providers. These data can be used to improve the training of Navy ERC providers, ultimately improving care to injured soldiers, sailors, airmen, and marines.

Demographic, Clinical, and Health System Characteristics Associated With Pain Assessment Documentation and Pain Severity in U.S. Military Patients in Combat Zone Emergency Departments, 2010-2013.

Emergency department (ED) pain assessment documentation in trauma patients is critical to ED pain care. This retrospective, cross-sectional study used trauma registry data to evaluate U.S. military combat zone trauma patients injured between 2010 and 2013 requiring ≥ 24-hr inpatient care. Study aims were to identify the frequency of combat zone ED pain assessment documentation and describe pain severity. Secondary aims were to construct statistical models to explain variation in pain assessment documentation and pain severity.Pain scores were documented in 60.5% (n = 3,339) of the 5,518 records evaluated. The proportion of records with ED pain scores increased yearly. Pain assessment documentation was associated with documentation of ED vital signs, comprehensive facility, more recent year, prehospital (PH) heart rate of 60-100 beats/min, ED Glasgow Coma Scale score of 15 vs. 14, blunt trauma, and lower injury severity score (ISS).Pain severity scores ranged from 0 to 10; mean = 5.5 (SD = 3.1); median = 6. Higher ED pain scores were associated with Army service compared with Marine Corps, no documented PH vital signs, higher PH pain score, ED respiratory rate < 12 or >16, moderate or severe ISS compared with minor ISS, treatment in a less-equipped facility, and injury in 2011 or 2012 vs. 2010. The pain severity model explained 20.4% of variance in pain severity.Overall, frequency of pain assessment documentation in combat-zone EDs improved yearly, but remained suboptimal. Pain severity was poorly predicted by demographic, clinical, and health system variables available from the trauma registry, emphasizing the importance of individual assessment.

Prevalence and Predictors of Prehospital Pain Assessment and Analgesic Use in Military Trauma Patients, 2010-2013.

INTRODUCTION: Pain is the most common symptom in patients presenting for prehospital (PH) care. Research in civilian emergency medical systems has shown wide variability in PH pain assessment and analgesic practices, yet a minimal amount is known about pain assessment and analgesic intervention practices in the military, particularly when PH care is delivered in a combat zone. OBJECTIVE: To describe prehospital (PH) pain care practices for U.S. military personnel injured in Iraq and Afghanistan 2010-2013 and explore potential relationships to explain variation. METHODS: An exploratory retrospective, cross-sectional study of Department of Defense Trauma Registry data from 2010 to 2013 was performed. Demographic, clinical, or health system variables for associations with three outcomes: 1) pain assessment documentation; 2) pain severity (0-10 scale); and 3) analgesic administration (yes/no). Including only variables with significant associations, backward stepwise regression was used to develop explanatory models for each outcome. RESULTS: Patient records (n = 3,317) were evaluated for documentation of PH pain assessment and analgesic administration. The prevalence of PH pain score documentation was 37.8% (n = 1,253). Overall, the proportion of records with PH pain scores increased over time: 19.8% (2010), 35.1% (2011), 58.2% (2012), and 62.2% (2013). Severity of pain scores ranged 0-10; mean = 5.5 (SD = 3.1); median = 6 (IQR = 3-8). Analgesics were reported for 50.8% (n = 1,684), of whom 38.3% had a pain severity score documented. The pain assessment documentation model included any documented vital signs, injury year, and mechanism of injury and explained 19.3% of the variance in documentation. The pain severity model included vital signs and injury severity score (ISS) and explained 5.0% of the variance in severity. The analgesic model included any vital signs, pain severity, trauma type, mechanism of injury, ISS, and year. CONCLUSIONS: Pain assessment and treatment documentation improved each year, but remain suboptimal. Available data yielded poor prediction of the outcomes of interest, emphasizing the importance of individual assessment. Analgesic effectiveness could not be evaluated.

A prospective window into medical device-related pressure ulcers in intensive care.

The aim of this study was to determine the prevalence, severity, location, aetiology, treatment and healing of medical device-related pressure ulcers (PUs) in intensive care patients for up to 7 days. A prospective repeated measures study design was used. Patients in six intensive care units of two major medical centres, one each in Australia and the USA, were screened 1 day per month for 6 months. Those with device-related ulcers were followed daily for up to 7 days. The outcome measures were device-related ulcer prevalence, pain, infection, treatment and healing. Fifteen of 483 patients had device-related ulcers and 9 of 15 with 11 ulcers were followed beyond screening. Their mean age was 60·5 years, and most were men, overweight and at increased risk of PU. Endotracheal (ET) and nasogastric (NG) tubes were the cause of most device-related ulcers. Repositioning was the most frequent treatment. Four of 11 ulcers healed within the 7-day observation period. In conclusion, device-related ulcer prevalence was 3·1%, similar to that reported in the limited literature available, indicating an ongoing problem. Systematic assessment and repositioning of devices are the mainstays of care. We recommend continued prevalence determination and that nurses remain vigilant to prevent device-related ulcers, especially in patients with NG and ET tubes.

Differences in the symptom experience of older versus younger oncology outpatients: a cross-sectional study.

BACKGROUND: Mortality rates for cancer are decreasing in patients under 60 and increasing in those over 60 years of age. The reasons for these differences in mortality rates remain poorly understood. One explanation may be that older patients received substandard treatment because of concerns about adverse effects. Given the paucity of research on the multiple dimensions of the symptom experience in older oncology patients, the purpose of this study was to evaluate for differences in ratings of symptom occurrence, severity, frequency, and distress between younger (< 60 years) and older ( ≥ 60 years) adults undergoing cancer treatment. We hypothesized that older patients would have significantly lower ratings on four symptom dimensions. METHODS: Data from two studies in the United States and one study in Australia were combined to conduct this analysis. All three studies used the MSAS to evaluate the occurrence, severity, frequency, and distress of 32 symptoms. RESULTS: Data from 593 oncology outpatients receiving active treatment for their cancer (i.e., 44.4% were < 60 years and 55.6% were ≥ 60 years of age) were evaluated. Of the 32 MSAS symptoms, after controlling for significant covariates, older patients reported significantly lower occurrence rates for 15 (46.9%) symptoms, lower severity ratings for 6 (18.9%) symptoms, lower frequency ratings for 4 (12.5%) symptoms, and lower distress ratings for 14 (43.8%) symptoms. CONCLUSIONS: This study is the first to evaluate for differences in multiple dimensions of symptom experience in older oncology patients. For almost 50% of the MSAS symptoms, older patients reported significantly lower occurrence rates. While fewer age-related differences were found in ratings of symptom severity, frequency, and distress, a similar pattern was found across all three dimensions. Future research needs to focus on a detailed evaluation of patient and clinical characteristics (i.e., type and dose of treatment) that explain the differences in symptom experience identified in this study.

Evidence-based practice in a military intensive care unit family visitation.

BACKGROUND: The dissatisfaction of family members with a restrictive visiting policy in a combined intensive care and step-down unit provides an opportunity for staff to develop better ways to meet the needs of patients and their families. A review of the evidence-based practice (EBP) literature as the measure of significance indicated that less restrictive visitation policies enhance patient and family satisfaction and offer many physiologic and psychological benefits to the patient. OBJECTIVE: The purpose of this study was to determine whether a less restrictive visitation policy could be implemented in the adult critical care department of a naval medical center. METHODS: Staff was educated on the use of EBP, specifically the Iowa-based model, and a less restrictive visitation policy was developed and implemented. RESULTS: Evaluation of the postintervention survey findings revealed higher patient and family satisfaction. CONCLUSIONS: The findings from this EBP project suggest that a more open visitation policy is feasible in adult critical care units, with an increase in overall satisfaction of patients and their families with regard to their stay in the intensive care unit.

Cardiopulmonary resuscitation: how far have we come?

In the 43 years since it was first described, cardiopulmonary resuscitation (CPR) has grown from an obscure medical theory to a basic first aid skill taught to adults and is now the near-universal technique used in CPR instruction. This article provides insight into the history of CPR. We explore the phenomenon of sudden cardiac arrest, the historical roots of CPR, current practice data and recommendations, and the society's role in the development of this life-saving technique. We conclude with a review of CPR's economic impact on the healthcare system and the ethical and policy issues surrounding CPR.

Putting policy theory to work: tobacco control in California.

Policy theory provides a useful lens for nurses evaluating how problems are understood and responded to within the policy arena. This article examines and critiques the agenda-setting model offered by John Kingdon. Furthermore, the theory is applied to the issue of tobacco control in the state of California, suggesting policy solutions and strategies to achieve their placement on the policy agenda. Strategies and techniques that may be useful to nurse policy champions are elucidated.