DTIC ADA618649: Evaluation of Military Trauma System Practices Related to Damage-Control Resuscitation

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ORIGINAL ARTICLE
Evaluation of military trauma system practices related to
damage-control resuscitation
Keith Palm, RN, Amy Apodaca, PhD, Debra Spencer, RN, George Costanzo, MD, Jeffrey Bailey, MD,
Lorne H. Blackbourne, MD, Mary Ann Spott, and Brian J. Eastridge, MD
BACKGROUND: TheJointTheaterTraumaSystem(JTTS)wasdevelopedwiththevisionthateverysoldier,marine,sailor,andairmaninjured
onthebattlefieldwouldhavetheoptimalchanceforsurvivalandmaximumpotentialforfunctionalrecovery.Inthisanalysis,
we hypothesized that information diffusion through the JTTS, via the dissemination of clinical practice guidelines and
processimprovements,wouldbeassociatedwiththeacceptanceofevidence-basedpracticesanddecreasesintraumapractice
variability.
METHODS: Thecurrentevaluationwasdesignedasasingletime-seriesquasi-experimentalstudyasapreanalysisandpostanalysisrel-
ative to the implementation of clinical practice guidelines and process improvement interventions. Data captured from
patientsadmittedtohospital-level(LevelIII)militarytreatmentfacilitiesinIraqandAfghanistanfrom2003to2010were
retrospectivelyanalyzedfromtheJointTheaterTraumaRegistry(JTTR)todeterminethepotentialimpactofprocessim-
provementinitiativesonclinicalpractice.
RESULTS: TheJTTSclinicalpracticeguidelinesformassivetransfusionledtoincreasedcompliancewithbalancedcomponenttrans-
fusionanddecreasedpracticevariability.Duringthecourseoftheevaluationperiod,hypothermiaonpresentationdecreased
dramaticallyafterthepublicationofthehypothermiapreventionandmanagementclinicalpracticeguideline.
CONCLUSION: Developed metricsdemonstratethatevidence-basedqualityimprovement initiativesdisseminatedthroughthe JTTSwere
associated with improved clinical practice of resuscitation following battlefield injury. (J Trauma Acute Care Surg.
2012;73:S459 S464.Copyright*2012byLippincottWilliams&Wilkins)
LEVELOFEVIDENCE: Therapeutic/caremanagementstudy,levelIV.
KEYWORDS: Military;traumasystem;performanceimprovement;resuscitation;outcomes.
The military trauma system has evolved and matured very The main priorities of the JTTS have been to promote
quickly during the 10 years of war in Afghanistan and system performance improvement and to promote evidence-
Iraq. Civilian trauma systems haveimprovedoutcomes in the basedcombattraumacare.10Thistwo-partevaluationseeksto
United States for decades, but the concept had not been measuretheimpactsonclinicalpracticeandchangeinpatient
adopted by the US military at the time of the invasion of outcomes from information and interventions implemented
Afghanistan.1 Rudimentary elements of a contemporary trau- and disseminated through the JTTS, specifically, clinical
ma system were present in the Vietnam War,2 such as data practice guidelines (CPGs) for hypothermia prevention and
collection and issuance of wartime health policy,3 but formal DCRandestablishmentofaforwarddeployedtraumasystem
establishment of a military trauma system occurred with the team for trauma registry data collection and in-theater per-
creation of the Joint Theater Trauma System (JTTS) in 2004. formance improvement activities. Hypothermia and DCR are
Since that time, the JTTS has been associated with several presented together because they both relate to initial resusci-
traumasystemimprovementsrelatedtohypothermia,damage- tation management and both were implemented early enough
control resuscitation (DCR), compartment syndrome, burn in the 10-year period to allow measurement of long-term
care, hemorrhage, thromboembolic events, interfacility trans- effects on thetrauma system.
fer,andtraining.1,4Y6Themilitarymedicaldepartmentsofthe
UnitedKingdom,Canada,andAustraliahavealsorecognized
Blood Component Ratio Compliance
the value of establishing a trauma system during the wars in
Afghanistan and Iraq.7Y9 In 2011, the Joint Trauma System BloodtransfusionhasbeenapartofUScombatcasualty
care since World War I. Whole-blood transfusion was widely
(JTS) was accepted as the trauma system for the entire US
Departmentof Defense. used among American and British Commonwealth forces by
theendofWorldWarI.11Afteraninitialattempttouseplasma
and albumin, whole-blood transfusion continued to be the
FromtheUSArmyInstituteofSurgicalResearch,FortSamHouston,Texas. primary method of resuscitation during World War II, the
Theopinionsorassertionscontainedhereinaretheprivateviewsoftheauthorand KoreanWar,andtheVietnamWar.Bloodcomponenttherapy,
are not tobe construed asofficial or as reflecting theviewsof the US De- particularly packed red blood cells (pRBCs), became the pri-
partmentoftheArmyortheUSDepartmentofDefense.
mary transfusion method during the Gulf War, Somalia, and
Addressforreprints:BrianJ.Eastridge,MD,ProfessorofSurgery,TraumaMedical
Director,TraumaandEmergencySurgeryUniversityofTexasHealthScience Balkan conflicts.12
CenteratSanAntonio,7703FloydCurlDrive(MC7740),SanAntonio,TX Hemorrhage remains one of the most frequent prevent-
78229;email:[email protected].
able causes of combat death.13,14 In 2004, the US Central
DOI:10.1097/TA.0b013e3182754887 Command’s JTTS published a CPG advocating DCR for
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4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
Evaluation of military trauma system practices related to damage-control
5b. GRANT NUMBER
resuscitation
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6. AUTHOR(S) 5d. PROJECT NUMBER
Palm K., Apodaca A., Spencer D., Costanzo G., Bailey J., Blackbourne L.
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H., Spott M. A., Eastridge B. J.,
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United States Army Institute of Surgical Research, JBSA Fort Sam REPORT NUMBER
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JTraumaAcuteCareSurg
Palmetal. Volume73,Number6,Supplement5
massive transfusions. This CPG describes a balanced resus- effectiveinterventionforseriouslyinjuredpatientsratherthan
citation strategy in which fluids, blood products, and other rewarming uponarrival tothe hospital.38
adjunctive methods are used to reverse or prevent coagulo- Thissecondaryevaluationendpointofthisanalysiswas
pathy and aid in the management of ongoing hemorrhage. tomeasuretheimpactofthemilitarytraumasystemguidance
damage-controlsurgeryisnotanewconcept,15butcombining on the incidence of hypothermia in the Afghanistan and Iraq
it with hemostatic resuscitation to prevent uncontrolled coa- wars. Specifically, it attempts to measure the effect of the
gulopathichemorrhagehasbeenanimportantadvanceduring CPGs and the dedicated performance improvementpersonnel
thecourse of theIraq andAfghanistan wars.16,17 assigned within the trauma system.
Although fresh whole blood (FWB) continues to be a
resuscitation option in theater, it may be less preferable than
PATIENTS AND METHODS
bloodcomponenttherapyforavarietyoflogistical, doctrinal,
and safety issues.18 Although all blood components may not Resuscitation
beavailableatmanyfar-forwardlocations,19theavailabilityof
For this evaluation, the JTS Blood Transfusion Data-
blood components at hospital-level care and fairly equitable
base, maintained at the US Army Institute of Surgical Re-
effectiveness to whole-blood transfusion make blood compo-
search,wasqueriedforselectdemographicandbloodproduct
nent transfusion the current method of choice in the military dataelements.ThepatientpopulationincludedallUSmilitary
trauma system.20
trauma patients admitted to hospital-level treatment facilities
ThisevaluationsoughttomeasuretheeffectoftheDCR who received a massive transfusion in Iraq and Afghanistan
on the combat casualty outcomes in Iraq and Afghanistan. from January 1, 2003, to December 31, 2011. Massive trans-
Aggregate clinical practice was measured by overall compli- fusionwasdefinedas10ormoreunitsofpRBCsand/orFWB
ancewiththe1:1:1(pRBC/plasma/platelets[PLTs])guideline within the first 24 hours following injury. All patients who
recommendations.Inaddition,theuseofFWBovertimewas arrived at Level III facilities whowere coded killed in action
evaluated when compared with 1:1:1 component ratio com- (KIA) were excludedfrom analysis.
plianceoverthesameperiod.Finally,overallcompliancewith Theevaluationanalysiswasdesignedtoincorporateboth
theguidelinewasoverlaidwithmortalityfor thesamepatient epidemiologicandqualityimprovementmeasurestoassessthe
population toassess theeffect onpatientoutcomes. component therapy use and overall JTS impact. All datawere
evaluatedusingSAS9.2software(Cary,NC).Categoricaldata
weresummarizedusingpercentagesorcruderates.Tocompare
Hypothermia Prevention and Management
component therapy compliance with noncompliance, we used
Hypothermia is a major concern in the initial manage- standard W2 tests for analysis when the expected frequencies
ment oftrauma patients. Severalphysiologic processes impor-
were greater than five per group. Furthermore, continuous
tanttotraumacarearesignificantlyaffectedbyhypothermia.21 variables were tested for normality. Means and SDs are re-
Spontaneous hypothermia,22 as opposed to induced hypo- ported as summary statistics for variables that met the criteria
thermia, creates several problems in addition to the under- for normality. Compliance versus noncompliance is compared
lyinginjury,includingcolddiuresis,impaireddrugclearance, byusingindependentStudent’sttests.
decreased cerebral blood flow, pulmonary edema, and multi- System-wide average blood product use for each mas-
organ dysfunction.23Y25 Perhaps most important is the contri- sive transfusion patient was trended over time for individual
bution to coagulopathy.26 Hypothermia can strongly inhibit components by year using basic univariate analysis techni-
the coagulation cascade, affecting both enzyme and PLT ques.SpecificcomponentsanalyzedincludedunitsofpRBCs,
function.27Y30 In addition, hypothermia has been associated fresh frozen plasma (FFP), PLTs,andwholeblood.
with greater operative blood loss as well as a higher rate of In an effort to analyze adherence to the recommended
postoperative wound infection and longer hospital stay.31 componentratiooutlinedintheCPG,wecalculatedtheratiosof
Hypothermiahaspreviouslybeenidentifiedasanindependent FFPtopRBCs,andthatratioofPLTstopRBCswascalculated
predictor of mortality in trauma patients,32,33 but more re- for each patient. A binomial variable was then created to
cently,itwasfoundtobepredictiveasitrelatestoseverityand determine compliance/noncompliance with the recommended
coagulopathy.34 use. If both ratios were within the range of 1:0.5 to 1:1.5,
HypothermiawasidentifiedearlyintheAfghanistanand patientswereconsideredtobeCPGcompliant.Allpatientswho
Iraq wars as having a significant impact on combat trauma fell outside this range were considered noncompliant. The ag-
care.35,36 In 2004, the military deployed its first JTTS team gregatepercentageofcompliancewiththeDCRCPGwasthen
into Iraq, consisting of a trauma physician and six trauma plotted for each year. Crude patient mortality rates were also
nurse coordinators (TNCs). The team deployments have con- plottedtolinkoverallcompliancewithpatientoutcomes.
tinuedonregularrotationssince,growingtoitscurrentsizeof
17 personnel. In 2006, the JTTS published a CPG for hypo- Hypothermia
thermia prevention, monitoring, and management across all This aspect of the evaluation used data from the Joint
echelons of the military trauma system. This was associated Theater Trauma Registry, maintained by the JTS at the US
with a significant decrease in the incidence of hypother- Army Institute of Surgical Research. The patient population
mia a year after the implementation across the trauma sys- includesallUSmilitarytraumapatientsadmittedtoahospital-
tem.37 The CPG heavily emphasizes hypothermia prevention leveltreatmentfacility(USLevelIIIorNATORole3)inIraq
since prehospital mitigation of heat loss might be the most orAfghanistan fromJanuary1,2002,toDecember 31,2011.
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JTraumaAcuteCareSurg
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The temperature used was the initial emergency department
temperature recorded in the trauma registry at the first hospi-
tal-level facility in the chain of evacuation. Hypothermiawas
definedaslessthan36-C,inlinewiththeJTTSCPGandthe
American College of Surgeons guidelines for trauma
patients.39,40 The recorded temperature was not adjusted for
the route taken to remain consistent throughout the entire pe-
riod. All patients who arrived at Level III facilities whowere
coded KIAwere excludedfrom theanalysis.
ThehypothermiasegmentoftheJTSevaluationproject
wasdesignedprimarilytoevaluateannualhypothermiatrends
forthelastdecadeofwarandassesstheoverallimpactofJTS
CPGs regarding patient warming. All data were evaluated
Figure2. Percentageofmassivetransfusionswith1:1:1ratio
usingSAS9.2.Theregistrydataidentified26,068USmilitary adherenceandwhole-bloodutilization.
trauma patients whowere admitted to a US hospital-level fa-
cilityduringthe10-yearperiod.Ofthose,19,970(76.6%)had
CPGwasimplemented,withaflatteningofthetrendbetween
a recorded emergency department temperature. Initial emer-
2005and2009.In2010,averageuseofeachbloodcomponent
gency room temperatures were assessed for all patients and
reached the highest points in the wars, and 2011 showed the
categorized into two binary variables, hypothermic and non-
greatest compliance to the recommended blood component
hypothermic, based on the previously mentioned American
ratio. During the same period (Fig. 2), the percentage of
College of Surgeons guidelines. Annual hypothermia rates
massive transfusion patients receiving whole blood as part of
were calculated as the total number of hypothermic patients
thetransfusiondroppedfrommorethan60%in2003to2004
over the total number of living (non-KIA) trauma admissions
to less than 25% in 2007 to 2010 but increased to 31% in
recordedfor theyear.Theseannualrateswerethencompared
2011. The decrease in whole blood use generally has an in-
withoverallpatientvolumeforthe10-yearperiodstratifiedby
verse association with increased compliance with component
the military theater of operation. In addition, the introduction
therapy until 2009 when whole-blood use levels off, corre-
of the deployedJTTS personnel in 2004 and the introduction
sponding tothe Afghanistan‘‘surge.’’
of the CPG in 2006 were overlaid on the timeline to allow a
Figure 3 displays crude adherence to the CPG’s com-
single time-series analysis.
ponent therapy recommendations overlaid with the mortality
outcomes in the same massive transfusion population. The
clear trend is that as adherence to component therapy in-
RESULTS
creases,mortalitydecreases.Thetrendisinterruptedin2008,
Theimpactevaluationofaggregatebloodcomponentuse however. Overlaying the overall operational efforts on to
shows steady trauma system progress toward the 1:1:1 ratio the chart indicates that the trend is a repeating pattern with
recommendations described in the JTTS DCR CPG. Figure 1 the transition point being 2008, when the Iraq surge ended
shows an aggregate component ratio of 1:0.35:0.05 (RBC/ and the higher proportion of combat operations shifted to
FFP/PLT)in2004,theyearthefirstmassivetransfusionCPG Afghanistan. This second part of the bimodal trend shows
was published, to a ratio of 1:1.09:1.02 in 2011. All compo- continued improvementofthetrauma system toacomponent
nentsseeasteepincreaseinusein2005,thefirstfullyearthis therapy adherence rate of almost 68% and a mortality of less
than 9.5% for massivetransfusion patients in2011.
Figure3. Percentageofmassivetransfusionsadherentto
componenttherapyandpercentageofmassivetransfusions
Figure1. Averagecomponentunitspermassivetransfusion. resultingindeath.
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TABLE2. UnivariateAnalysisofHypothermiaandtheOccurrenceofCoagulopathy(InternationalNormalizedRatio91.5)
TotalPopulation NoCoagulopathy Coagulopathy
(n=19,970) (n=19,718) (n=252)
InitialTemperature n(%) n(%) n(%) p OddsRatio 95%ConfidenceInterval
G36-C 252(1.26) 197(1) 55(21.8) 0.0001 4.9438 3.6432 6.7088
thromboelastographyor rotationthromboelastometry,hasbeen tympanic route temperatures. If low, a core body temperature
in limited use in Iraq and Afghanistan for years. These proce- would be indicated, but that subsequent temperature is un-
duresallowmoreprecisetailoringofbloodcomponenttherapy likely to be recorded in the trauma registry. Many patients,
to patients that might contraindicate the CPG recommended particularly in Afghanistan, will have had initial resuscitation
component ratio. Although some of these patients can be and damage-control surgery at a field site before arriving to
identified in the trauma registry, they were not excluded from hospital-level care. Data from that earlier level of care have
the evaluationsince itwasintendedtomeasure aggregateout- been unreliably collected during the 10-year period, so entry
comesofallUSmilitarymassivetransfusions. into hospital level care was the most consistent data point to
The system evaluation shows that trauma system inter- use as the first temperature. Finally, the Iraq and Afghanistan
ventions affected the rate of hypothermia at emergency de- conflicts have different operational characteristics, and trends
partment admission. Hypothermia prevention was a major that might bedilutedin abroad, systemic evaluation.
focus of the first JTTS team that deployed to Iraq in 2004.
Thereisasignificantreductioninhypothermiafollowingtheir
CONCLUSION
on-site insertion into Iraq. This reduction was sustained for
4yearsafter publicationoftheJTTSCPG,indicatinganinsti- The military trauma system in its ability to affect CPG
tutionalization of the improved care of patients for hypother- and performance improvement substantially affected resusci-
mia. Several factors could contribute to the recent increase in tationpractice,includinghypothermiaprevention,formassive
hypothermic admissions. 2009 was the first year that Afgha- transfusion trauma patients. This change in practice was as-
nistan had more trauma admissions than Iraq since 2002. sociated with improved mortality outcomes for massive
From2003to2008,Afghanistanaccountedforlessthan25% transfusion traumapatients.
of all system trauma admissions. Following the drawdown in
Iraq and the surge in Afghanistan, the percentage of system AUTHORSHIP
trauma admissions from Afghanistan rose to more than 85%
Authorcontributionsareasfollows:K.P.,A.A.,D.S.,G.C.,J.B.,L.H.B.,
forboth2010and2011.Afghanistanhasacolderclimatethan B.J.E.,andM.A.S.contributedinthestudydesign;K.P.andA.A.per
Iraq, and its mountainous terrain makes evacuation more dif- formed the data collection; K.P., A.A., and B.J.E. performed the data
ficult. In addition, the US military conducted large-scale analysis;andK.P.,A.A.,D.S.,G.C.,J.B.,L.H.B.,andB.J.E.preparedthe
article.
combat operations in the winters of 2010 and 2011 in
Afghanistan, increasing the risk of hypothermia compared
DISCLOSURE
with earlier years of thewar. Seasonality has a definite effect
Theauthorsdeclarenoconflictsofinterest.
on the rate of hypothermia in Afghanistan. For those 2 years,
hypothermiaadmissionswereapproximately2%to3%during
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