Military Sector

In the military, the challenges associated with fragmented data repositories and the abstraction process—discussed in more detail in Chapter 4—limit the extent to which timely individual provider performance improvement is possible. A 2011 assessment of the military's trauma system included the following observations about performance improvement processes in theater:

• The trauma performance improvement and patient safety process is fragmented. The awareness, implementation and integration of structured [performance improvement] processes vary by level of care, branch of service and coalition partners. This less than desirable state results in a loss of transparency and creates difficulty in performing concurrent, multidisciplinary [performance improvement] and stifles the communication and learning between and amongst levels of care.
• Efforts to implement rudimentary trauma related [performance improvement] were present at each military trauma facility. Morbidity and mortality review varied widely from no review, to an exclusionary physician only review with little documented analysis or corrective actions, to a casual multidisciplinary verbal debriefing with no recorded corrective actions or loop closure documented in any of these observed systems. (Rotondo et al., 2011, pp. 11-12)

The JTS holds weekly teleconferences to review the treatment and outcomes for all casualties across the continuum of care. In the absence of easily accessible data on provider performance, this exercise fosters communication among the various providers for a single casualty, providing the opportunity to receive feedback (Bailey et al., 2013; Eastridge et al., 2009). System-wide, however, DoD lacks a codified and standardized approach to performance improvement, which results in a lack of transparency and hinders learning. To improve transparency and learning, it is important for deployed hospitals to conduct weekly morbidity and mortality conferences, with patient-specific information flowing between hospitals and across levels of care. These reports could be collated by the JTS and lessons learned rapidly distributed back to all providers in the system.

Military participation in national collaboratives such as TQIP is severely limited. At this time, only a single military hospital (Carl R. Darnall Army Medical Center) participates in the ACS TQIP Level III pilot benchmarking program.² This lack of transparency at the organization level highlights an opportunity to improve the learning system for military trauma care through adoption of civilian best practices. Although only trauma centers are eligible to participate in TQIP, military treatment facilities (MTFs) that are not trauma centers may still be able to participate in Vizient's quality improvement program.

Civilian Sector

In the civilian sector, the trauma performance improvement process—supported by a trauma registry—is a hallmark function of trauma centers, second only to trauma patient care. This process entails monitoring compliance with evidence-based practice, care delivered, and system performance to ensure that opportunities for improvement are quickly identified and addressed, optimizing patient outcomes. The ACS Committee on Trauma requires that all verified trauma centers have a performance improvement and patient safety program that demonstrates a process of monitoring, assessment, and management to continuously improve care (ACS, 2014). This process helps identify unnecessary variation in care and adverse events that can subsequently be addressed through corrective actions, but it does not ensure that providers have access to timely and continuous information on their performance relative to that of their peers.

At the hospital level, ACS-verified and state-designated trauma centers are eligible to participate in TQIP. Currently more than 350 Level I and II centers are participating, and a program for Level III centers was launched in July 2016 (ACS, 2015e). Starting in January 2017, all centers seeking ACS verification or reverification must be TQIP participants.³ During a pilot study of 23 Level I and II trauma centers, 90 percent of survey respondents said they found the performance data report useful, and 63 percent indicated that they would take action based on the information it provided (Hemmila et al., 2010).

Although the ACS has been successful in establishing a system for performance improvement across trauma centers, an equivalent national program is notably lacking for prehospital care (challenges to benchmarking whole trauma systems are discussed in the next section). The problem has been largely cultural. While some success has been achieved at the state and regional levels in establishing programs to support the quality improvement of EMS care (see Box 7-2), a culture of continuous improvement has not yet been uniformly embraced by the EMS community.

Box 7-2

A QUALITY PROGRAM FOR EMERGENCY MEDICAL SERVICES (EMS): THE EMS PERFORMANCE IMPROVEMENT CENTER'S PREHOSPITAL MEDICAL INFORMATION SYSTEM.

An ongoing National Highway Traffic Safety Administration Office of EMS-funded initiative, EMS Compass, is developing measures for civilian prehospital care (see Box 7-3). The establishment of evidence-based measures through EMS Compass could enable benchmarking of EMS performance, serving as the first step toward the creation of a program similar to TQIP for comparing and assessing EMS systems. However, because EMS systems vary considerably in structure across the United States and their regulation is based at the state and local levels, enacting such a national program could be difficult. State EMS agencies could facilitate a national benchmarking program by requiring licensed agencies to use and report on the EMS Compass measures (Gainor, 2015).

Box 7-3

EMS COMPASS.

Benchmarking Across the Military and Civilian Systems

The ability to benchmark performance across trauma systems is comparatively undeveloped, if not altogether lacking. TQIP's Collaborative Initiative enables a health system, region, or state to be evaluated as a single entity, comparing its outcomes with those at the national level as well as those of other similar collaboratives (Nathens et al., 2012). Trauma systems encompassing the entire continuum of care, however, cannot compare their outcomes against one another. Thus the military cannot compare its trauma system with those found in the civilian sector and vice versa. In addition, civilian trauma systems cannot compare their performance with that of other civilian systems. This lack of transparency at the regional and state levels inhibits the transfer of best practices from high-performing systems.

The absence of standard, national metrics for trauma care is a barrier to greater transparency and benchmarking at the system level. The National Quality Forum, which grew out of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, has reviewed and endorsed numerous sets of measures, including those for hospital care, home health care, nursing home care, cardiac surgery, diabetes care, and emergency care (NQF, 2005, 2006, 2009, 2010, 2011). Currently, however, it has endorsed no measures of trauma care quality.

Public Reporting of Performance Data

Public dissemination of data on trauma system performance (both military and civilian) currently represents a notable gap in transparency. The reason is likely multifaceted, including a lack of data and quality measures for trauma care, competition among provider organizations, and tort concerns. Reports from national-level quality improvement programs, including those offered by ACS and Vizient, are not made publicly available. Although research has been conducted to demonstrate variability in trauma center performance, such information is publicized largely through journal articles, a channel unlikely to reach the public. The lack of public reporting may contribute to the documented misalignment of Americans' perception that they will receive the best possible care after injury and the reality regarding variability in regional trauma care capabilities and patient outcomes across the nation (Champion et al., 2006). Given the nature of traumatic injury, increased public reporting likely would not guide individual choice of where to receive care, but it could raise awareness of the overall burden of injury and lead to greater public engagement in and advocacy for trauma system development, quality improvement, and research. Similarly, public reporting would inform community and policy leaders regarding geographic differences and potential gaps in the care and outcomes among trauma patients.

Military Sector

Military trauma care providers are driven to improve first and foremost by the desire to help their fellow service members achieve the best possible outcomes after injury. While financial incentives (e.g., variable reimbursement) are a powerful driver of change in the civilian sector, they have a much lesser role in the military. The military essentially functions as a single-payer system, which in theory should help align financial incentives across the continuum of care. However, a large budget for health care coupled with little financial accountability may encourage spending rather than pushing the system to reduce waste and reward high-quality care (Haut et al., 2016).

The backbone of the U.S. military is its system of rank and chain of command. Recognition in the form of promotions serves as one of the strongest incentives for military personnel who value the authority and prestige associated with a higher rank (Baker et al., 1988). Merit-based promotions in the military have received increasing attention in recent years. Defense Secretary Ash Carter has proposed a major overhaul of the way the military evaluates and promotes its service members, stressing merit over seniority (Tilghman, 2015). For line officers, promotions based on merit depend on evaluation of service members' readiness for their combat mission. For medical personnel, however, promotions are not based on readiness for their combat medical mission. Therefore, while promotion serves as a strong incentive for line and infantry personnel to perform optimally and make readiness a priority, promotion incentives for medical personnel are misaligned. The absence of a clear measure by which line and medical leaders can be held accountable for the trauma system's performance and casualty outcomes (Rotondo et al., 2011) is a barrier to leveraging this incentive mechanism to drive improvement.

In some cases, requirements for promotion can act as a disincentive. The committee heard, for example, that experienced nurses must shift from patient care to administrative positions in order to obtain the experience necessary for continued promotion⁴ (Wilmoth, 2016). Physicians face similar pressures (LaFraniere, 2014). Current promotion structures thus do not encourage or reward the growth of clinical trauma-focused expertise, reducing the pool of senior-level clinicians available at the point of care to shepherd continuous performance improvement efforts.

Civilian Sector

In the civilian sector, measures and financial incentives play a large role in current health care reform initiatives. For decades, the civilian sector operated under a largely fee-for-service payment system. Fee-for-service, however, leads to increased costs by rewarding providers for the complexity and number of medical services provided (James, 2012). Unsurprisingly, more intense care does not necessarily equate to better outcomes, and can even prove harmful to patients (Chen et al., 2010; Fisher et al., 2003).

In the face of widespread recognition of serious deficiencies in the U.S. health care system, highlighted in the landmark IOM (2001) report Crossing the Quality Chasm: A New Health System for the 21st Century, policy makers and private and public payers have encouraged pay-for-performance initiatives as a way to realign the system's incentive structure to encourage improvement in the quality, efficiency, and value of care (Miller, 2009). As a result, experimentation with a variety of financial incentives is under way. Payment-based strategies include incentive payments for processes (e.g., care coordination), penalties for unwanted outcomes (e.g., hospital-acquired infections), and shared accountability payment methods (e.g., bundled payment) (IOM, 2013). However, the evidence base is not yet robust enough to demonstrate the effectiveness of current strategies, and further investigation of different care delivery and financing approaches (e.g., through pilots) is needed and is under way to gauge impacts on health and cost measures and identify unintended consequences. Although pilots are being conducted on a small scale by private payers, the Center for Medicare & Medicaid Innovation at the Centers for Medicare & Medicaid Services (CMS) was established to identify, test, and diffuse new payment and service delivery models to reduce expenditures while maintaining or improving quality of care for CMS beneficiaries. If innovative care delivery models demonstrate evidence of cost reductions and/or improvements in outcomes, the U.S. Department of Health and Human Services (HHS) has the authority to expand those models without congressional action (CMS, 2015).

Trauma care is not encompassed within current health care reform efforts. CMS, as the nation's largest payer organization for trauma care,⁵ has significant influence over how such care is delivered through the use of health care payment policies, and thus is well positioned to lead the development of innovative approaches to improving trauma care while lowering costs. However, the distribution of trauma care across the prehospital, hospital, and outpatient (post-acute care) settings raises some challenges to the use of financial incentives to drive changes in trauma care practice. As discussed above, there is currently no standard set of quality measures (e.g., National Quality Forum measures) that can be used to evaluate the performance of trauma systems. One can imagine a shared savings model applied to trauma care—for example, with a bundled payment to a region's EMS organizations, emergency departments, and trauma center or centers—that would entail measuring the contribution of the system in the aggregate and each provider type to patient outcomes. However, given the current state of data capture and integration across the trauma care continuum (see Chapter 4), implementing regional measures, although optimal, is currently not feasible. In the face of these challenges, an alternative to pay-for-performance incentives that has been piloted as a means of improving trauma care is the pay-for-participation model, a minimal-risk method of encouraging engagement in regional quality initiatives (see Box 7-4).

Box 7-4

A PAY-FOR-PARTICIPATION MODEL FOR TRAUMA CARE QUALITY IMPROVEMENT.

Beyond bundled payment, another particularly powerful lever available to CMS for effecting change is its “conditions of participation” for designated provider types.⁶ To qualify for Medicare certification and reimbursement, health services providers must comply with these minimum health and safety standards, which are considered baseline requirements. Trauma system elements critical to continuous quality improvement (data collection systems, performance improvement programs) could be considered conditions of participation for all components of the care continuum. For the prehospital care component of the continuum, however, use of this approach would require including EMS as a provider type through legislative changes to the Social Security Act. EMS is currently considered a supplier of transportation under the Social Security Act and therefore is not subject to conditions of participation for providers.

The EMS reimbursement model used by CMS reimburses on the basis of transport to a medical facility (miles traveled to an emergency department and the level of service provided while en route). This “fee-for-transport” model, emulated by many other payers, ignores the increasingly complex care and lifesaving interventions performed by EMS providers at the point of injury and while en route (IOM, 2007a). This model thus represents an extreme misalignment of incentives. The fact that payers will deny reimbursement should transport not occur discourages EMS agencies from making determinations regarding the need for transport to a hospital, and as many as 11 to 61 percent of EMS transports to emergency departments are medically unnecessary (Gratton et al., 2003). These unnecessary transports add costs to the health care system, further burden hospital-based providers, limit the ability to respond to disasters, and hinder the implementation of processes that would allow EMS providers to transport patients to a more appropriate setting or treat and release (IOM, 2007a). Present EMS reimbursement practices thus act in direct opposition to the committee's vision of a learning trauma care system. As national efforts to link health care to quality proceed, EMS is being left behind.

Military Sector

The gains in military trauma care made over the past two decades are significant. The refinement of a joint and successful tiered system of battlefield care and transport required learning, innovation, and attention to details of logistics and design. Similarly, advances in technical, clinical trauma care—such as new fluid resuscitation methods and tourniquet use—arose from agility, knowledge management, and the use of focused empiricism (described in Chapter 4) as an invaluable learning method. Many of these advances could not have occurred without assistance and encouragement (or at least tacit permission) from military leaders, but many appear to have come in fact from rather informal, entrepreneurial, emergent bottom-up activities by people at various levels of seniority and without official guidance or direction. In effect, with respect to improvement in military trauma care, deep commitment from individuals has substituted in some ways for formal programs, systems, and command structures. This bottom-up change is an integral component of a learning system.

At the same time, a result of this process for change is that structures and offices that have emerged report to entities that may not have the ability to effect change, and they appear to have a somewhat ambiguous status and uncertain longevity within DoD's Military Health System. The JTS, for example, has produced measureable success in advancing trauma care and saving lives on the battlefield over the past decade, yet despite this success, its influence, its scope, and even its very existence are threatened at present, given its lack of doctrinal authority,⁷ resources, and reporting structure (DHB, 2015; Rotondo et al., 2011). Although it was conceptually designed to serve as a consulting agency, the JTS's impact is limited largely to Central Command (CENTCOM) because DoD has neither formalized its role nor developed any requirements for it to take part in or help develop a DoD-wide trauma system. With the exception of the Pacific Command, which is working proactively with the JTS to establish a Joint Theater Trauma System, the efforts of the JTS to engage other combatant commands have received limited response (Gross, 2015). Thus, the committee sees a paradox: creditable and necessary gains in trauma care during both wars in Afghanistan and Iraq, but weak or nonexistent formal joint structures to ensure that those gains are perpetuated (particularly during the interwar period), stable, and distributed uniformly across the combatant commands and services.

In the absence of standardization of a formal trauma system across all combatant commands, the many lessons learned over the course of the wars in Afghanistan and Iraq and the improvements made in combat casualty care may be lost. Maintaining these advances and a state of readiness will require continuous investment and commitment from the highest levels of DoD leadership. Otherwise, capabilities and outcomes will remain the same or deteriorate, instead of improving (Hoyt, 2015a; Winchell et al., 2015). This capability gap could be addressed if the Joint Requirements Oversight Council utilized the Joint Capabilities Integration and Development System process (see CJCSI, 2015) and made an all-of-DoD approach to trauma care a priority.

Ambiguity in trauma care ownership and instability of the nascent trauma system infrastructure are especially consequential with regard to an essential role of the Military Health System: readiness to deliver trauma care in support of the full range of military operations. Evidence of suboptimal trauma care and outcomes at the start of the wars in Afghanistan and Iraq—including a high rate of preventable battlefield deaths—testifies to gaps in trauma care readiness and a workforce inadequately trained to ensure that expert trauma care would be available for the very first (and last) casualty on the battlefield. As discussed in Chapter 5, it is not difficult to see why: the Military Health System lacks a sufficient volume of trauma cases to train and preserve expertise in a mission-ready trauma care workforce. Briefly put, line commanders assume Military Health System leaders will deliver providers expert in trauma care, while Military Health System leaders' priority is beneficiary care, and they have limited financial resources and personnel to develop programs that would create a robust cadre of multidisciplinary trauma experts.

This conundrum is pervasive across the military, yet no single agent or agency appears to be responsible for addressing this gap. Despite several recent evaluations (summarized in Table 7-1) recommending the establishment of a unified medical command or the designation of a senior medical leader, directorate, or division solely responsible for combat casualty care, DoD continues to lack a unifying lead agency with the authority, oversight, and resources to lead all aspects of combat casualty care and readiness (DHB, 2015; Mabry, 2015; Maldon et al., 2015; Rotondo et al., 2011). Responsibility for the training and delivery of combat casualty care remains widely distributed across the Assistant Secretary of Defense for Health Affairs, the Defense Health Agency, the services, and the combatant commands (see Box 7-5), with the consequence that no single organization or agency official “owns” or is accountable for DoD's medical readiness mission (Butler et al., 2015). With respect to the assurance of continuous practice improvement, learning, and readiness in battlefield trauma care, no one is in charge—a reality at odds with a military system known and revered for the integrity and quality of its command and control methods.

TABLE 7-1

Recent Recommendations on the Need for a Single Point of Accountability Responsible for Combat Casualty Care and Military Medical Readiness.

Box 7-5

DIFFUSION OF MILITARY LEADERSHIP RESPONSIBILITY FOR THE DELIVERY OF COMBAT CASUALTY CARE.

This diffusion of responsibility is especially poignant on the battlefield. While the surgeons general have oversight over policy within their respective services, final authority and responsibility for the delivery of combat casualty care—including control over budget, personnel, training, and equipment—is assigned to combatant commanders (Mabry, 2015). These line leaders are highly focused on mission (national defense) and lack medical expertise, while medical leaders are focused on maximizing fitness and health and optimizing ways to reduce health risks. Although combatant commanders are structurally tasked with delivering optimal health and trauma care, they lack the numbers of trained personnel needed to deliver expert trauma care at all levels across the battlefield. While medical risks are considered, mission needs appropriately take precedence over medical concerns (e.g., diversion of helicopters from operations for casualty evacuation). Thus there is an ongoing tension between the medical and combat missions that, in some cases, can be resolved only with commitment and a clear message from the highest level, as exemplified by Secretary Gates's Golden Hour Policy (see Box 7-6). The critical importance of direction originating from the Secretary of Defense has been recognized from within DoD itself—without it, “there is no assurance that advances in trauma care will be implemented consistently throughout the various components of the U.S. Military” (Butler et al., 2015, p. 323).

Box 7-6

359 LIVES: IMPACTS OF SECRETARY GATES'S GOLDEN HOUR POLICY.

The consequences of the lack of ownership for combat casualty care include ineffective investment in trauma readiness and variation within and across combatant commands. Successful combat casualty care is a blend of both tactics and medicine, and it thus ideally would have the attention and support of combatant commanders (Kotwal et al., 2013). The successful history of the 75th Ranger Regiment, summarized previously, offers a compelling and informative counterexample of the unsurpassed outcomes that can emerge when the line commander takes full responsibility for the vitality and aims of a combat casualty care system: lives are saved. Equally compelling are the results when line leadership does not take this responsibility (see Box 7-7).

Box 7-7

CASE STUDY: TOURNIQUET USE AND THE LIFE-OR-DEATH DECISIONS OF MILITARY LINE LEADERSHIP.

There have been efforts by some Military Health System leaders to change the current situation. However, structures and culture need to change if this deficit is to be addressed. Initially, greater clarity will be necessary to identify who in the military is responsible, in the final analysis, for the quality, learning processes, and readiness of military trauma care both in peacetime and during conflicts. As always, with that responsibility must come the relevant authorities and resources—when those are unlinked, the responsibility lacks relevance. Further, as exemplified by the 75th Ranger Regiment, the culture of accountability will have to shift such that there is widespread understanding and acceptance among medical and nonmedical leadership that line commanders have a primary role in and must be engaged in the readiness of their forces to deliver optimal combat casualty care.

Civilian Sector

Since 1966, civilian trauma systems have developed in many areas of the country to varying degrees of maturity, resulting in varying levels of outcomes. This variation is due largely to a lack of national leadership, policy guidance, standardization, coordination, and metrics and incentives tied to outcomes. As discussed in Chapter 2, no single federal entity is accountable for trauma care or trauma system development in the United States. Most trauma systems are regional, coordinated at the state level through respective department of health or EMS offices. Consequently, the role of local, state, and federal government in U.S. civilian trauma care systems is variable and inconsistent, leaving authority and accountability for trauma capabilities fragmented and varying from location to location. Government leadership at the state and federal levels is highly variable with respect to knowledge of the need for and the value and function of a trauma system. Other critical constituents, including academic health systems, the insurance industry, professional societies, and private industry, may have divergent values, contributing further to fragmentation. The result of this patchwork of systems for trauma care is mortality that varies twofold between the best and worst trauma centers in the nation (Hashmi et al., 2013). Mechanisms for examining variability across entire trauma systems do not even exist.

As in the military, the civilian trauma care sector appears to be ill equipped at present to set bold aims, as counseled by the IOM (2013) report Best Care at Lower Cost in its description of a learning health system. Advances do unquestionably occur, but it would be difficult under current circumstances to imagine anyone with the authority to declare, for example, that “zero preventable deaths after injury” ought to become a national goal. This represents a loss for the nation, since trauma deaths that could be averted with uniform best practices certainly number in the tens of thousands every year (Hashmi et al., 2016). Strong and capable civil society organizations⁸ do what they can to improve the quality of trauma care, but none has the authority to require the pursuit of this improvement.

In principle, the gaps in civilian trauma care practice and learning highlighted throughout this report suggest that clearer and more cogent leadership is needed, supported by a framework that defines national aims and system designs and includes trauma care in health care delivery reform efforts. As noted, this leadership appointment needs to be accompanied by responsibility, funding, and authority. This need for leadership is exemplified at present by the proliferation of trauma centers in some geographic areas, driven by business opportunities rather than true regional needs (Johnson, 2015). In some areas, the number of Level I and II trauma centers exceeds the number needed to concentrate the patient volumes shown to correlate with improved trauma care quality and outcomes (ACS, 2015b; Eastman et al., 2013). Absent leadership in planning at the national, state, and regional levels, this costly and disruptive trend may proceed unabated, with unfavorable implications for public health, costs, and safety. To determine the future course of trauma care in the United States, the following question must be answered: Is the American public willing to accept that, after a severe injury, where one lives may determine whether one lives? If the nation's expectation is that variability in quality and outcomes based purely on geography is unacceptable, current systems for accountability need to be reexamined.

As in the military, the trauma care system in the civilian sector has witnessed a strong record of inaction or inadequate action in response to widespread calls for more national-level leadership. The National Highway Traffic Safety Administration's Trauma System Agenda for the Future, released in 2004, envisions a National Trauma System Leadership Council “to advocate for system development, serve as the locus for policy development and support, and coordinate the work of Federal agencies and professional organizations with injury-related programs” (NHTSA, 2004). However, no such council has been established. Likewise, the IOM's Future of Emergency Care series recommends that Congress establish a lead federal agency for trauma and emergency care⁹ (inclusive of prehospital care) to be housed within HHS. The IOM Committee on the Future of Emergency Care in the United States deemed this lead federal agency necessary to

• serve as a federal advocate for trauma and emergency care, increasing its visibility within the government and among the public;
• move existing fragmented systems toward improved integration;
• provide unified and consistent federal leadership on policy development and funding;
• represent all providers and settings (to include the entire continuum of care); and
• create unified accountability for the performance of the trauma and emergency care system (IOM, 2007b).

Other individuals and organizations have called for the establishment of a federal home for emergency care within the federal government, but again, no such entity has emerged. While executive action did prompt the creation of the Emergency Care Coordination Center, this center is unfunded and thus extremely limited in its effect (Carr, 2015). Lacking authority and resources, by no means does this center approach the intent of the lead agency envisioned 10 years ago by the IOM Committee on the Future of Emergency Care in the United States. The present committee agrees with and supports previous assessments regarding the need for defined leadership for trauma and emergency care within HHS that serves to promote the integration of services across the continuum of care, from prehospital to rehabilitation and post-acute care.

Military–Civilian Leadership Partnerships

From the viewpoint of the committee, given its charge, the one inescapable conclusion about the need for stronger trauma system leadership and accountability at the national level relates to the core trauma care readiness mission of the military. As discussed in Chapter 5, the Military Health System lacks sufficient volumes of trauma patients within MTFs to train and maintain a mission-ready trauma care workforce. Consequently, the military needs to work with the civilian sector to advance best trauma care practices through collaborative research initiatives (see Chapter 4). Through its research and deliberations for this study, the committee determined that the only feasible solution is to forge a significant and ambitious partnership between the military and civilian sectors such that the civilian sector can serve as a reservoir and innovative engine for trauma care knowledge and a training platform for the military trauma care workforce during the interwar period. In addition, the integration of military and civilian trauma care is necessary to ensure the full transfer of lessons learned between the two sectors and thereby improve civilian trauma care outcomes. This latter point is important, since (as discussed in Chapter 1) the burden of trauma in the civilian sector (approximately 148,000 deaths per year) numerically dwarfs the burden among military personnel (approximately 6,850 deaths over a decade of war); thus ensuring that the best conceivable civilian trauma care can avert tremendous morbidity and mortality.

The committee discovered a number of formal and informal pathways through which the military and civilian trauma care systems currently exchange ideas and knowledge (as discussed in Chapter 2). Instances of formalized leadership-level collaboration have emerged, for example, in the prehospital setting with the Federal Interagency Committee on EMS (FICEMS, 2013; IOM, 2007a) and, for trauma surgery, the Military Health System/ACS Strategic Partnership (Hoyt, 2015b). However, where successful collaboration has occurred, it has depended largely on the drive, good will, and personal investment of key individuals in leadership positions. As a result, the sustainability of collaborative efforts is threatened when changes in personnel take place (IOM, 2007b).

As yet, a durable collaborative effort encompassing the entire continuum of trauma care with representation of all stakeholders, military and civilian, does not exist. Consequently, diffusion of knowledge across sectors is slow and incomplete, care is not optimal, and lives are placed in jeopardy. As discussed in Chapter 4, for example, tourniquet use in civilian trauma care is growing, but its penetration is far from complete (Haider et al., 2015). The absence of such all-encompassing collaboration does not signal that this task is impossible and not worth attempting. Successful examples of the emergence of defined leadership and national collaboration on related aspects of trauma care (e.g., hemorrhage control) or on specific subsets of traumatic injury (e.g., traumatic brain injury) demonstrate that this type of collaboration is possible and impactful. The obstacle has not been the good will of individuals, but the institutional lack of will among leadership.

The enormous burden of trauma and the importance of an optimally functioning national trauma system to the nation's health and national security make the need for national leadership that cuts across both military and civilian sectors all the more pressing and relevant. National leadership would help unify and ensure collaboration among existing efforts and points of authority spread not just across federal agencies but among state and local governments and professional organizations as well. The success of the hemorrhage control and traumatic brain injury movements suggests strategies and mechanisms for encouraging effective collaborative action as well as national leadership on trauma care in its entirety (see Box 7-8 for an overview of these positive examples).

Box 7-8

EXAMPLES OF SUCCESSFUL WHITE HOUSE–LED MILITARY–CIVILIAN COLLABORATION TO IMPROVE TRAUMA CARE.