As highlighted throughout this report, analysis of the cases presented in Appendix A assisted the committee in identifying those factors that have supported and gaps that have impeded learning and continuous improvement in the military trauma care system. The incremental improvements in patient care and outcomes observed over the course of the conflicts in Afghanistan and Iraq were the result of a multitude of practices—many of which align with the components of a learning trauma care system (see Table B-1)—that include the implementation of lessons learned from previous conflicts and high-performing civilian trauma systems, digital data capture, performance improvement, requirements-driven research, and the dissemination of best practices.

TABLE B-1

Strengths and Gaps Demonstrated by the Case Studies, by Learning Trauma Care System Component.

One cross-cutting theme evident throughout the case studies is the extent to which the military's trauma care system adapted to the difficult conditions, austere environments, and high burden of injury that characterized U.S. engagement in the Middle East. This adaptation is exemplified by the military's use of focused empiricism as a nimble approach to evidence generation, particularly in those instances in which high-quality data were not available to inform clinical practice changes, including the development and refinement of clinical practice guidelines (CPGs). This approach is highlighted by the dismounted complex blast injury (DCBI) case. These devastating injuries—rarely seen in the civilian trauma experience—required innovation in the field and spurred the appointment of a task force to study the injury pattern's causation, prevention, protection, treatment, and long-term care options. The task force emphasized the importance and implementation of existing guidelines, including the prompt application of tourniquets and packing to control blood loss, prevention of hypothermia, and prevention of coagulopathy by tranexamic acid administration and whole blood transfusion. A Joint Trauma System (JTS) CPG on invasive fungal infections (a complication associated with DCBI) was subsequently developed, with supporting evidence based on retrospective analysis of registry data. Similarly, JTS CPGs on burn care and severe traumatic brain injury (TBI) are based on registry data and retrospective analyses and, in the case of pediatric burn care, even “rules of thumb.”

A crucial feature of focused empiricism is the continuous refinement and improvement of CPGs until high-quality data can be generated. Through its performance improvement program, the JTS collects data on and monitors the effects of focused empiricism-based interventions. As discussed in Chapter 4, however, a balanced approach to focused empiricism is essential. Hypothesis-driven research is a necessary complement to and check on evidence generated through experiential learning. The damage control resuscitation approach utilized in the DCBI case, for example, was continuously refined over time and later validated through prospective research undertaken with civilian collaborators. Similarly, although the use of tranexamic acid is included in military prehospital guidelines, the U.S. Department of Defense has funded several randomized controlled trials to study its role, efficacy, and safety given continued concern regarding its potential adverse effects. Other cases reveal gaps in knowledge and demonstrate the need for further research. The military's aggressive approach to severe TBI, for example, while developed through focused empiricism and associated with improved outcomes, requires prospective research to validate the application of military practices in the civilian sector.

Throughout these case studies, it is apparent that the military, building from its excellent systems for developing and refining CPGs, has utilized a variety of mechanisms to provide near-real-time access to knowledge of best trauma care practices. The weekly video teleconference, an e-mail-based teleconsultation program, and the Burn Resuscitation Decision Support System highlighted in the cases all facilitate learning and represent efforts to ensure that providers have the information needed to deliver the best care possible, particularly in circumstances in which predeployment training has failed to provide the necessary expertise (e.g., fasciotomy, pediatrics, burn care). At the same time, however, the committee notes limitations in training, equipment, and infrastructure necessary to support the timely dissemination of knowledge and widespread adoption of best practices. For example, the military currently has no system that enables trauma care providers to access data on their performance (e.g., CPG compliance) relative to that of their peers in near real time.

A lack of accountability contributed to many of the suboptimal outcomes presented in the case studies. The first soldier's death in the extremity hemorrhage case due to lack of tourniquet application was a seminal event and led to the recognition that deaths due to limb exsanguination were common, preventable, and unacceptable. At the time of this incident, however, tactical combat casualty care (TCCC) guidelines had already indicated that the use of tourniquets should be a priority, and the Pentagon had initiated efforts to equip every soldier with a tourniquet. Unfortunately, military line and medical leadership—particularly in the early years of the wars—did not embrace, incorporate, and hold its members accountable for TCCC practices. In an effort to provide some level of accountability, the military has developed the capacity to monitor compliance with many CPGs. The JTS weekly teleconference discussed in the blunt trauma with vascular injury case proved to be a highly effective way to provide feedback on CPG compliance. This represents progress; however, broader accountability and transparency are required.

The committee has identified patient-centered trauma care as one of the critical components of a learning trauma care system. The coordinated and comprehensive care received by the soldier in the DCBI case, including efforts to provide early pain control, reflects positively on the military and its progress in improving communication, patient transfers, and holistic care that includes psychological and spiritual support. Yet while ensuring seamless care across the trauma continuum is an important aspect of patient-centered trauma care, there are other areas in which the military has made less progress, such as consideration of special populations. This latter gap is particularly evident in the pediatric burn case. Despite a foreseeable need to provide pediatric care in wartime, the military was largely unprepared (in training and equipment) to care for injured children, who accounted for more than 10 percent of all bed days. Even after more than a decade of war, “military doctrine has still not evolved to ensure critical care availability for pediatric combat casualties.”

Apparent in many of the cases is the critical importance of knowledge translation, both to and from the civilian sector. The Department of Defense Trauma Registry (DoDTR), modeled after the civilian-sector National Trauma Data Bank, has allowed the military to rapidly detect, analyze, and mitigate devastating injury patterns (e.g., DCBI). Data captured in the DoDTR support performance improvement initiatives, including the development of CPGs, and help identify priorities for clinical research (e.g., the development of a junctional tourniquet). The cases also highlight the extent to which trauma care in the civilian sector has advanced as a result of the translation of best practices and lessons learned from the military. A notable example is the civilian sector's widespread adoption of a 1:1:1 transfusion ratio, which mimics the military whole blood transfusion paradigm and has been shown to decrease trauma-induced coagulopathy, total blood use, and exsanguination. While the civilian sector's implementation of best practices regarding tourniquet use has lagged behind that of the military, the successful use of tourniquets on the battlefield has translated to their incorporation into civilian prehospital care. This was clearly evident in the aftermath of the Boston Marathon bombings, when tourniquets were applied to prevent deaths from isolated extremity hemorrhage.

In summary, the case studies offer insight as to how the military has dealt with the many challenges to trauma care faced on the battlefield, highlight opportunities for improvement, and support the committee's conclusion that the military and civilian trauma systems are symbiotic.