Improved survival in critically injured combat casualties treated with fresh whole blood by forward surgical teams in Afghanistan.

BACKGROUND: The objective of this study was to assess transfusion strategies and outcomes, stratified by the combat mortality index, of casualties treated by small surgical teams in Afghanistan. Resuscitation that included warm fresh whole blood (FWB) was compared to blood component resuscitation. STUDY DESIGN AND METHODS: Casualties treated by a Role 2 surgical team in Afghanistan from 2008 to 2014 who received 1 or more units of red blood cells (RBCs) or FWB were included. Patients were excluded if they had incomplete data or length of stay less than 30 minutes. Patients were separated into two groups: 1) received FWB and 2) did not receive FWB; moreover, both groups potentially received plasma, RBCs, and platelets. The analysis was stratified by critically versus noncritically injured patients using the prehospital combat mortality index. Kaplan-Meier plot, log-rank test, and multivariable Cox regression were performed to compare survival. RESULTS: In FWB patients, median units of FWB and total blood product were 4.0 (interquartile range [IQR], 2.0-7.0) and 16.0 (IQR, 10.0-28.0), respectively. The Kaplan-Meier plot demonstrated that survival was similar between FWB (79.1%) and no-FWB (74.5%) groups (p = 0.46); after stratifying patients by the combat mortality index, the risk of mortality was increased in the no-FWB group (hazard ratio, 2.8; 95% confidence interval, 1.2-6.4) compared to the FWB cohort. CONCLUSION: In forward-deployed environments, where component products are limited, FWB has logistical advantages and was associated with reduced mortality in casualties with a critical combat mortality index. Additional analysis is needed to determine if these effects of FWB are appreciable in all trauma patients or just in those with severe physiologic derangement.

Analysis of Pediatric Trauma in Combat Zone to Inform High-Fidelity Simulation Predeployment Training.

OBJECTIVES: The military uses "just-in-time" training to refresh deploying medical personnel on skills necessary for medical and surgical care in the theater of operations. The burden of pediatric care at Role 2 facilities has yet to be characterized; pediatric predeployment training has been extremely limited and primarily informed by anecdotal experience. The goal of this analysis was to describe pediatric care at Role 2 facilities to enable data-driven development of high-fidelity simulation training and core knowledge concepts specific to the combat zone. SETTING AND PATIENTS: A retrospective review of the Role 2 Database was conducted on all pediatric patients (< 18 yr) admitted to Role 2 in Afghanistan from 2008-2014. INTERVENTIONS: Three cohorts were determined based on commercially available simulation models: Group 1: less than 1 year, Group 2: 1-8 years, Group 3: more than 8 years. The groups were sub-stratified by point of injury care, pre-hospital management, and Role 2 facility medical/surgical management. MEASUREMENTS AND MAIN RESULTS: Appropriate descriptive statistics (chi square and Student t test) were utilized to define demographic and epidemiologic characteristics of this population. Of 15,404 patients in the Role 2 Database, 1,318 pediatric subjects (8.5%) were identified. The majority of patients were male (80.0%) with a mean age of 9.5 years (± SD, 4.5). Injury types included: penetrating (56%), blunt (33%), and burns (7%). Mean transport time from point of injury to Role 2 was 198 minutes (±24.5 min). Mean Glasgow Coma Scale and Revised Trauma Score were 14 (± 0.1) and 7.0 (± 1.4), respectively. Role 2 surgical procedures occurred for 424 patients (32%). Overall mortality was 4% (n = 58). CONCLUSIONS: We have described the epidemiology of pediatric trauma admitted to Role 2 facilities, characterizing the spectrum of pediatric injuries that deploying providers should be equipped to manage. This analysis will function as a needs assessment to facilitate high-fidelity simulation training and the development of "pediatric trauma core knowledge concepts" for deploying providers.

Chapter 2 evolution of burn management in the u.s. Military: impact on nursing.

As the only burn center in the Department of Defense, the U.S. Army Institute of Surgical Research is the primary location for care of service members with burn injuries. The combat operations in Iraq and Afghanistan during the past decade have caused an increase in burn patients. As a result of this increased need, advancements in care were developed. The speed and precision of transporting patients from the battlefield to the burn center has improved over previous conflicts. Technological advancements to support treating complications of burn wound healing were leveraged and are now integrated into daily practice. Clinical decision support systems were developed and deployed at the burn center as well as to combat support hospitals in combat zones. Technology advancements in rehabilitation have allowed more service members to return to active duty or live productive civilian lives. All of these advancements were developed in a patient-centered, interdisciplinary environment where the nurses are integrated throughout the research process and clinical practice with the end goal of healing combat burns in mind.

A Descriptive Analysis of Blood Products Utilized by a Forward Deployed Surgical Team in Syria.

INTRODUCTION: Traumatically injured combat casualties urgently need both blood and surgery. Forward Surgical Teams (FSTs) or Role 2 (R2) surgical teams were created to minimize the time-space distance from point of injury to damage control surgery. Our goal is to describe the use of blood products from a Split FST deployed to Green Village from July 2018 to April 2019. MATERIALS AND METHODS: A retrospective review of a collection of patients treated by a single R2 was conducted following institutional regulatory approval. De-identified data were input into the study database and were then retrospectively reviewed for patients who presented to and received treatment at the R2 facility. RESULTS: Of the 470 total patients treated in 10 months: 226 (48%) received blood products and 132 (28%) underwent operative procedures. The patients were 98% male; 74% Host Nationals (HN), 24% North American Treaty Organization members. Mechanism of injury was 75% explosive and 98% penetrating. Documented Injury Severity Scores (n = 214) were: <9 (n = 57/27%), 9 to 15 (n = 34/16%), 16 to 25 (n = 64/30%), and >25 (n = 59/28%). In total 1,052 units of blood products were administered: whole blood (n = 495), red blood cells (n = 200), fresh frozen plasma (n = 109), and liquid plasma (n = 248). HN whole blood used was 337/495 (68%) units for 78 patients; walking blood bank was mobilized six times for HN patients. Of the patients seen, >99% who arrived with a pulse survived to be discharged to a higher level of care. CONCLUSIONS: This analysis describes blood usage associated with one high volume forward deployed operative team and demonstrates the vital importance of the R2 split FST to provide coalition forces with surgical care in proximity to the point of injury. Over time, the supply chain has improved with more component therapy available at R2s; however, the need for walking blood bank and innovative solutions to care for all casualties must be part of small team capabilities. Liquid plasma use should be expanded as soon as it is feasible.

Determining Clinical Priorities Using a Clinical Practice Guideline Deconstruction Tool: COVID-19 in Austere Operational Environments.

The Joint Trauma System (JTS) publishes Clinical Practice Guidelines (CPGs) used by military and civilian healthcare providers worldwide. With the expansion of CPG development in recent years, there was a need to collate, sort, and deconflict existing and new guidance using systematic methodology both within and across CPGs. This need became readily apparent at the start of the COVID-19 pandemic when guidelines were rapidly developed and fielded in deployed environments. To meet the needs of deploying units requesting immediate and concise guidance for managing COVID-19, JTS developed the CPG entitled Management of Covid-19 in Austere Operational Environments. By applying a deconstruction process to organize clinical recommendations across multiple categories, JTS was able to present clear clinical recommendations across "role of care" and "scope of practice." The use of a deconstruction process supported the rapid socialization of the CPG and may have improved clinical understanding among deployed medical teams.

A Deeper Dive Into Combat Medic Training.

The recent article by Knisely et al. provides a comprehensive review and summary of recent literature describing simulation techniques, training strategies, and technologies to teach medics combat casualty care skills. Some of the results reported by Knisely et al. align with the findings of our team's work, and these findings may be helpful to military leadership with their ongoing efforts to maintain medical readiness. Accordingly, we provide some additional contextual understanding to the results of Knisely et al. in this commentary. Our team recently published two papers describing the results of a large survey that examined Army medic pre-deployment training. Combining the findings of Knisely et al. along with some of the contextual information from our work, we provide some recommendations for improving and optimizing the pre-deployment training paradigm for medics.

Utilization of the En Route Aeromedical Patient Movement Form by Critical Care Air Transport Teams.

INTRODUCTION: Understanding usage patterns of current paper-based documentation can inform the development of electronic documentation forms for en route care. The primary objective was to analyze the frequency of use of each field within the 3899 L Patient Movement Record documented by en route Critical Care Air Transport Teams. Secondary objectives were to identify rarely utilized form fields and to analyze the proportion of verifiable major events documented within the 3899 L form. MATERIALS AND METHODS: We performed a retrospective review of 3899 L patient movement records for patients transported via Critical Care Air Transport Teams from January 2019 to December 2019. Scanned 3899 L forms were manually transcribed into a Microsoft Access database for evaluation and analysis. Proportions were calculated for completed fields. Major vital sign event frequency was compared for checkbox fields versus the vital sign flow sheet for each patient. We performed descriptive analyses for the proportion of charts with completed documentation in each evaluated field and the proportion of flow sheet events documented in major event fields. RESULTS: We analyzed 130 records. Fourteen of 18 (77.8%) demographic fields had a 75% or greater completion ratio. Sections with the largest proportion of rarely or never utilized fields (<1.5% completed) were procedures (77.8% of fields) and major events (63.9% of fields). Major event checkboxes had low sensitivity for documented events in the flow sheet: Change in heart rate greater than 20% (1 of 28 patients); increase in the fraction of inspired oxygen requirement of greater than 10% (6 of 23 patients); decrease in mean arterial pressure of greater than 20% (1 in 12 patients); and temperature less than 35.6°C (1 in 13 patients). CONCLUSIONS: Many of the current 3899 L fields are highly utilized, but some 3899 L sections contain high proportions of rarely utilized fields. Major event checkboxes did not consistently capture events documented within the in-flight vital sign flow sheet.

An Assessment of Nursing Skills Required for Sustaining a Casualty during Prolonged Casualty Care: Implications for Training and Preparing for the Next Major War.

BACKGROUND: The US military is transitioning rapidly from the Global War on Terrorism in preparation for near-peer combat in a multidomain operations (MDO) and/or large scale combat operations (LSCO) setting. Due to potentially contested freedom of movement in this setting, casualty evacuation may be significantly delayed, resulting in medics and other prehospital medical personnel taking on patient care duties normally performed by nurses in a hospital-based setting. However, the frequency of nursing-type care remains unclear. We seek to determine the nursing interventions typically performed in a facility with patient holding capability during the first 72 hours of care in the deployed setting. MATERIALS AND METHODS: This is a sub-analysis of previously described data from the Department of Defense Trauma Registry of US and North Atlantic Treaty Organization (NATO) military personnel from January 2007 to March 2020 with a focus on relevant nursing procedures identified in current Individual Critical Task Lists (ICTL) for critical care, emergency, medical-surgical nurses, and combat medics. RESULTS: Among all casualties, the most common nursing-related skills performed in the prehospital setting were wound dressing application (33%), administration of parenteral opioids (35%), and administration of ketamine (7%); in the hospital setting were preparation for transfer (60%), managing a post-operative patient (59%), and managing a traumatic brain injury (44%). In the hospital setting, most patients had a blood gas performed (73%), ventilator management occurred for 21% of patients, and administration of packed red blood cells occurred for 21% of patients. CONCLUSIONS: Nursing-type interventions were frequently required during the first 72 hours of casualty care. The frequency of the required interventions demonstrates the need for ongoing nursing skills training for medics supporting casualties in the setting of prolonged casualty care.

Whole blood at the tip of the spear: A retrospective cohort analysis of warm fresh whole blood resuscitation versus component therapy in severely injured combat casualties.

BACKGROUND: Death from uncontrolled hemorrhage occurs rapidly, particularly among combat casualties. The US military has used warm fresh whole blood during combat operations owing to clinical and operational exigencies, but published outcomes data are limited. We compared early mortality between casualties who received warm fresh whole blood versus no warm fresh whole blood. METHODS: Casualties injured in Afghanistan from 2008 to 2014 who received ≥2 red blood cell containing units were reviewed using records from the Joint Trauma System Role 2 Database. The primary outcome was 6-hour mortality. Patients who received red blood cells solely from component therapy were categorized as the non-warm fresh whole blood group. Non- warm fresh whole blood patients were frequency-matched to warm fresh whole blood patients on identical strata by injury type, patient affiliation, tourniquet use, prehospital transfusion, and average hourly unit red blood cell transfusion rates, creating clinically unique strata. Multilevel mixed effects logistic regression adjusted for the matching, immortal time bias, and other covariates. RESULTS: The 1,105 study patients (221 warm fresh whole blood, 884 non-warm fresh whole blood) were classified into 29 unique clinical strata. The adjusted odds ratio of 6-hour mortality was 0.27 (95% confidence interval 0.13-0.58) for the warm fresh whole blood versus non-warm fresh whole blood group. The reduction in mortality increased in magnitude (odds ratio = 0.15, P = .024) among the subgroup of 422 patients with complete data allowing adjustment for seven additional covariates. There was a dose-dependent effect of warm fresh whole blood, with patients receiving higher warm fresh whole blood dose (>33% of red blood cell-containing units) having significantly lower mortality versus the non-warm fresh whole blood group. CONCLUSION: Warm fresh whole blood resuscitation was associated with a significant reduction in 6-hour mortality versus non-warm fresh whole blood in combat casualties, with a dose-dependent effect. These findings support warm fresh whole blood use for hemorrhage control as well as expanded study in military and civilian trauma settings.

An Assessment of Pre-deployment Training for Army Nurses and Medics.

INTRODUCTION: Although military nurses and medics have important roles in caring for combat casualties, no standardized pre-deployment training curriculum exists for those in the Army. A large-scale, survey-based evaluation of pre-deployment training would help to understand its current state and identify areas for improvement. The purpose of this study was to survey Army nurses and medics to describe their pre-deployment training. MATERIALS AND METHODS: Using the Intelink.gov platform, a web-based survey was sent by e-mail to Army nurses and medics from the active and reserve components who deployed since 2001. The survey consisted of questions asking about pre-deployment training from their most recent deployment experience. Descriptive statistics were used to analyze the results, and free text comments were also captured. RESULTS: There were 682 respondents: 246 (36.1%) nurses and 436 (63.9%) medics. Most of the nurses (n = 132, 53.7%) and medics (n = 298, 68.3%) reported that they were evaluated for clinical competency before deployment. Common courses and topics included Tactical Combat Casualty Care, Advanced Cardiac Life Support, cultural awareness, and trauma care. When asked about the quality of their pre-deployment training, most nurses (n = 186; 75.6%) and medics (n = 359; 82.3%) indicated that their training was adequate or better. Nearly all nurses and medics reported being moderately confident or better (nurses n = 225; 91.5% and medics n = 399; 91.5%) and moderately prepared or better (nurses n = 223; 90.7% and medics n = 404; 92.7%) in their ability to provide combat casualty care. When asked if they participated in a team-based evaluation of clinical competence, many nurses (n = 121, 49.2%) and medics (n = 180, 41.3%) reported not attending a team training program. CONCLUSIONS: Most nurse and medic respondents were evaluated for clinical competency before deployment, and they attended a variety of courses that covered many topics. Importantly, most nurses and medics were satisfied with the quality of their training, and they felt confident and prepared to provide care. Although these are encouraging findings, they must be interpreted within the context of self-report, survey-based assessments, and the low response rate. Although these limitations and weaknesses of our study limit the generalizability of our results, this study attempts to address a critical knowledge gap regarding pre-deployment training of military nurses and medics. Our results may be used as a basis for conducting additional studies to gather more information on the state of pre-deployment training for nurses and medics. These studies will hopefully have a higher response rate and better quantify how many individuals received any form of pre-deployment training. Additionally, our recommendations regarding pre-deployment training that we derived from the study results may be helpful to military leadership.

Joint Trauma System Clinical Practice Guideline (JTS CPG): Prehospital Blood Transfusion. 30 October 2020.

This Clinical Practice Guideline (CPG) provides a brief summary of the scientific literature for prehospital blood use, with an emphasis on the en route care environment. Updates include the importance of calcium administration to counteract the deleterious effects of hypocalcemia, minimal to no use of crystalloid, and stresses the importance of involved and educated en route care medical directors alongside at a competent prehospital and en route care providers (see Table 1). With the paradigm shift to use FDA-approved cold stored low titer group O whole blood (CS-LTOWB) along with the operational need for continued use of walking blood banks (WBB) and point of injury (POI) transfusion, there must be focused, deliberate training incorporating the different whole blood options. Appropriate supervision of autologous blood transfusion training is important for execution of this task in support of deployed combat operations as well as other operations in which traumatic injuries will occur. Command emphasis on the importance of this effort as well as appropriate logistical support are essential elements of a prehospital blood program as part of a prehospital/en route combat casualty care system.

Predeployment training of Army medics assigned to prehospital settings.

BACKGROUND: Medics have numerous responsibilities in the combat theater, which include performing lifesaving interventions, providing basic medical and nursing care, and caring for casualties in a variety of scenarios unique to the battlefield. An evaluation of the medic predeployment training paradigm is important and will help to understand its current state and identify areas for improvement. Therefore, the purpose of this study was to perform a focused assessment of Army medic predeployment training to identify patterns that might inform future medic training. METHODS: A web-based survey was created using the Intelink.gov platform and sent by e-mail to Army medics who deployed since 2001. Medics were asked to reflect upon the predeployment training from their most recent deployment experience. There were multiple choice, Likert-type scale, and free-text response questions. Descriptive statistics were used to analyze the results. RESULTS: There were 254 respondents who met the study inclusion criteria. Most of the respondents had their clinical competency evaluated (68.5%, n = 174). Respondents reported several acute trauma, basic nursing, and battlefield medicine skills as being critical but also felt that many of these same skills would have benefited from additional predeployment training. Most of the respondents felt very or fully confident and prepared to provide combat casualty care (74.8%, n = 190 and 74.8%, n = 190). There were 64 respondents (25.2%) who reported feeling not at all, slightly, or moderately confident, and 54 (84.4%) of these respondents described in a free-text question wanting additional training before deployment. CONCLUSION: Respondents reported many skills as being critical to combat casualty care, but several of these skills would have benefited from additional predeployment training. Respondents with more deployment experience or completion of more predeployment training reported feeling more confident and prepared to provide combat casualty care. A common sentiment was the desire for more training of any form before deployment. LEVEL OF EVIDENCE: Epidemiological, level IV.

Challenges Associated with Managing a Multicenter Clinical Trial in Severe Burns.

Managing multicenter clinical trials (MCTs) is demanding and complex. The Randomized controlled Evaluation of high-volume hemofiltration in adult burn patients with Septic shoCk and acUte kidnEy injury (RESCUE) trial was a prospective, MCT involving the impact of high-volume hemofiltration continuous renal replacement therapy on patients experiencing acute kidney injury and septic shock. Ten clinical burn centers from across the United States were recruited to enroll a target sample size of 120 subjects. This manuscripts reviews some of the obstacles and knowledge gained while coordinating the RESCUE trial. The first subject was enrolled in February 2012, 22 months after initial IRB approval and 29 months from the time the grant was awarded. The RESCUE team consisted of personnel at each site, including the lead site, a data coordination center, data safety monitoring board, steering committees, and the sponsor. Seven clinical sites had enrolled 37 subjects when enrollment stopped in February 2016. Obstacles included changes in institutional review boards, multiple layers of review, staffing changes, creation and amendment of study documents and procedures, and finalization of contracts. Successful completion of a MCT requires a highly functional research team with sufficient patient population, expertise, and research infrastructure. Additionally, realistic timelines must be established with strategies to overcome challenges. Inevitable obstacles should be discussed in the pretrial phase and continuous correspondence must be maintained with all relevant research parties throughout all phases of study.

Analysis of Casualties That Underwent Airway Management Before Reaching Role 2 Facilities in the Afghanistan Conflict 2008-2014.

INTRODUCTION: Airway compromise is the second leading cause of potentially survivable death on the battlefield. The purpose of this study was to better understand wartime prehospital airway patients. MATERIALS AND METHODS: The Role 2 Database (R2D) was retrospectively reviewed for adult patients injured in Afghanistan between February 2008 and September 2014. Of primary interest were prehospital airway interventions and mortality. Prehospital combat mortality index (CMI-PH), hemodynamic interventions, injury mechanism, and demographic data were also included in various statistical analyses. RESULTS: A total of 12,780 trauma patients were recorded in the R2D of whom 890 (7.0%) received prehospital airway intervention. Airway intervention was more common in patients who ultimately died (25.3% vs. 5.6%); however, no statistical association was found in a multivariable logistic regression model (OR 1.28, 95% CI 0.98-1.68). Compared with U.S. military personnel, other military patients were more likely to receive airway intervention after adjusting for CMI-PH (OR 1.33, 95% CI 1.07-1.64). CONCLUSIONS: In the R2D, airway intervention was associated with increased odds of mortality, although this was not statistically significant. Other patients had higher odds of undergoing an airway intervention than U.S. military. Awareness of these findings will facilitate training and equipment for future management of prehospital/prolonged field care airway interventions.

Anatomic injury patterns in combat casualties treated by forward surgical teams.

BACKGROUND: Role 2 forward surgical teams provide damage-control resuscitation and surgery for life- and limb-threatening injuries. These teams have limited resources and personnel, so understanding the anatomic injury patterns seen by these teams is vital for providing adequate training and preparation prior to deployment. The objective of this study was to describe the spectrum of injuries treated at Role 2 facilities in Afghanistan. METHODS: Using Department of Defense Trauma Registry data, a retrospective, secondary data analysis was conducted. Eligible patients were all battle or non-battle-injured casualties treated by Role 2 forward surgical teams in Afghanistan from October 2005 to June 2018. Abbreviated Injury Scale (AIS) 2005 codes were used to classify each injury and Injury Severity Score (ISS) was calculated for each patient. Patients with multiple trauma were defined as patients with an AIS severity code >2 in at least two ISS body regions. RESULTS: The data set included 10,383 eligible patients with 45,225 diagnosis entries (range, 1-27 diagnoses per patient). The largest number of injuries occurred in the lower extremity/pelvis/buttocks (23.9%). Most injuries were categorized as minor (39.4%) or moderate (38.8%) in AIS severity, while the largest number of injuries categorized as severe or worse occurred in the head (13.5%). Among head injuries, 1,872 injuries were associated with a cerebral concussion or diffuse axonal injury, including 50.6% of those injuries being associated with a loss of consciousness. There were 1,224 patients with multiple trauma, and the majority had an injury to the extremities/pelvic girdle (58.2%). Additionally, 3.7% of all eligible patients and 10.5% of all patients with multiple trauma did not survive to Role 2 discharge. CONCLUSION: The injury patterns seen in recent conflicts and demonstrated by this study may assist military medical leaders and planners to optimize forward surgical care in future environments, on a larger scale, and utilizing less resources. LEVEL OF EVIDENCE: Epidemiological, Level III.

Forward Surgical Team Procedural Burden and Non-operative Interventions by the U.S. Military Trauma System in Afghanistan, 2008-2014.

INTRODUCTION: No published study has reported non-surgical interventions performed by forward surgical teams, and there are no current surgical benchmarks for forward surgical teams. The objective of the study was to describe operative procedures and non-operative interventions received by battlefield casualties and determine the operative procedural burden on the trauma system. METHODS: This was a retrospective analysis of data from the Joint Trauma System Forward Surgical Team Database using battle and non-battle injured casualties treated in Afghanistan from 2008-2014. Overall procedure frequency, mortality outcome, and survivor morbidity outcome were calculated using operating room procedure codes grouped by the Healthcare Cost and Utilization Project classification. Cumulative attributable burden of procedures was calculated by frequency, mortality, and morbidity. Morbidity and mortality burden were used to rank procedures. RESULTS: The study population was comprised of 10,992 casualties, primarily male (97.8%), with a median age interquartile range of 25.0 (22.0-30.0). Affiliations were non-U.S. military (40.0%), U.S. military (35.1%), and others (25.0%). Injuries were penetrating (65.2%), blunt (32.8), and burns (2.0%). Casualties included 4.4% who died and 14.9% who lived but had notable morbidity findings. After ranking by contribution to trauma system morbidity and mortality burden, the top 10 of 32 procedure groups accounted for 74.4% of operative care, 77.9% of mortality, and 73.1% of unexpected morbidity findings. These procedure groups included laparotomy, vascular procedures, thoracotomy, debridement, lower and upper gastrointestinal procedures, amputation, and therapeutic procedures on muscles and upper and lower extremity bones. Most common non-operative interventions included X-ray, ultrasound, wound care, catheterization, and intubation. CONCLUSIONS: Forward surgical team training and performance improvement metrics should focus on optimizing commonly performed operative procedures and non-operative interventions. Operative procedures that were commonly performed, and those associated with higher rates of morbidity and mortality, can set surgical benchmarks and outline training and skillsets needed by forward surgical teams.

Using the Delphi Technique to Determine Core Components of a Nurse Competency Program.

This modified Delphi study determined consensus on core nurse competency program components that apply across the continuum of transition to initial practice, to new specialty practice, to a new role, or within general nursing orientation. The literature review found no published agreement on support and systems for universal transition programs. This broad-based study addressed this gap by identifying core elements within a competency or transition program and then ranking their importance within program structure.

Characteristics of Iraqi Patients Treated During Operation Inherent Resolve by a Forward Surgical Team.

INTRODUCTION: The combat experience during the re-entry stages of Operation Inherent Resolve was distinct from other recent operations, but there is no published literature regarding these "initial entry operations" experiences among forward surgical teams (FSTs) deployed to Role 2 facilities A descriptive analysis of patients treated by FSTs may provide valuable information for Role 2 surgical teams preparing to deploy in support of initial entry operations. The purpose of this analysis was to describe injury mechanism, wounding patterns and interventions performed by a small FST in the re-entry phase in Iraq. MATERIALS AND METHODS: From July 17, 2015 to January 31, 2016, a split surgical team with two surgeons and an ER physician documented care for all patients treated by their FST located in Iraq. Given their austere environment, FSTs have limited holding capacity, blood supply, and ability to triage and perform advanced procedures. Patients, who arrived to the Role 2 in asystole, were ineligible for the study. The patient population was Iraqi Security Forces as well as Iraqi civilians. No follow-up data were obtained. Using descriptive statistics, we described the basic demographics, health status, blood utilization, injury severity, and injury pattern of the patient population. RESULTS: The final study population included 300 Iraqi casualties. The majority of patients (96%) were discharged alive. Many patients were 16 years or older (96%), male (96%), Iraqi soldiers (86%), and injured during battle (96%). Over one-third of patients (35%) had a form of metabolic acidosis, 7% were hypothermic, and 18% were in shock at admission. The median amount of blood products used was 6 (interquartile ranges (IQR) = 2-12) units, while the median red blood cells:fresh frozen plasma ratio was 1.2:1. Six or more units of blood were given to 67 (22%) patients. The top three diagnoses were laceration (n = 197, 21%), penetrating injury (n = 185, 19%), and fracture (n = 174, 18%). A high number of injuries occurred in the extremities/pelvis and buttocks (n = 360, 38%) and in the abdomen and pelvic contents (n = 145, 15%). Over a quarter of patients (26%) had critical injuries (i.e., military injury severity score ≥25). CONCLUSIONS: Given the Role 2 configuration, these results demonstrate FSTs must be capable of managing critically ill patients with markedly limited resources. This management will include general operations in both adult and pediatric patients, resuscitation with a limited blood supply, and patient assessment with minimal to no diagnostic tools. This analysis can inform resident training, pre-deployment training, as well as sustainment training for surgeons after residency.

An Evidence-Based Approach to Precepting New Nurses.

While developing a standardized approach to orient new staff in the U.S. Army Institute of Surgical Research Burn Center at Fort Sam Houston in Texas, nurse leaders identified the need to also standardize preceptor selection and instruction. A multidisciplinary research team conducted a two-year pilot project based on the evidence-based Vermont Nurses in Partnership Clinical Transition Framework, which provides a structured method for preceptor selection, development, and evaluation. Minimum preceptor qualifications; preceptor validation processes; and modifiable, unit-specific coaching tools were established. The authors previously published a description of the preceptor program implementation process and their findings. In this article, they discuss lessons learned during the project, highlighting the challenges and obstacles encountered when implementing this preceptorship program.