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Abstract
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Since antiquity, with respect to advancing the care of the injured, “war has been a very efficient schoolmaster.” Innovation in trauma care has once again accelerated, spurred by the significant burden of injury from more than a decade of war in Afghanistan and Iraq.
During those recent wars, the percentage of wounded service members who died of their injuries reached the lowest point in recorded wartime history—9.3% in Afghanistan and Iraq compared with 23% during the Vietnam War. Effective bleeding-control measures, improved resuscitation techniques, and aggressive neurocritical care interventions are among many advances that saved lives on the battlefield that otherwise would have been lost. For example, an estimated 1000 to 2000 lives were saved by widespread use of tourniquets.
Military medical forces did not begin the recent wars with these capabilities. These interventions developed in response to the urgency from increasing numbers of US service members who died of potentially survivable injuries. That urgency was inconsistent with reliance on slow and costly clinical trials to inform improvements in trauma care practices. It drove the Military Health System and its nascent Joint Trauma System to embrace, instead, a culture of continuous performance improvement and a more agile approach to advancing combat casualty care.
The Military Health System calls this pragmatic, more rapid model for learning “focused empiricism.” Focused empiricism is aligned with the characteristics of a learning health system articulated in the 2012 Institute of Medicine report Best Care at Lower Cost. For example, the Joint Trauma System digitally captures and routinely uses patient care data from its registry to identify trends and answer clinical questions, enabling care practices to evolve incrementally based on the best available evidence until higher-quality data can be generated. In effect, military medicine put the learning health system framework into practice before the Institute of Medicine described it.
However, questions have arisen as to how the military’s learning trauma system can be improved, sustained, and expanded across the US Department of Defense. In addition, there are questions about how thoroughly and rapidly wartime trauma lessons learned can be applied in the civilian sector, where the need, if not the sense of urgency, is at least as great. In Afghanistan and Iraq, approximately 6850 service member lives have been lost over the last 15 years. In the United States there are nearly 150 000 deaths from trauma each year, and injury is the third leading cause of death, accounting for more years of life lost than any other cause.
A new report* from the National Academies of Sciences, Engineering, and Medicine, of which the former Institute of Medicine is now part, clarifies the components of a learning health system necessary to ensure continuous improvement in military and civilian trauma care. The report also provides recommendations on how lessons from the military’s experiences in Afghanistan and Iraq can be sustained and built on for future combat operations and translated more effectively into the civilian care system.
The report concludes that military and civilian trauma systems are inextricably linked, even if leaders sometimes seem unaware of that. It asserts that continued progress in trauma care capability and learning capacity will require better conduits for the continuous and seamless exchange of knowledge between the 2 sectors. Military and civilian trauma care and learning will be optimized together, or not at all.
The committee recommends that a national strategy and a joint military-civilian approach for improving trauma care be developed to ensure the delivery of optimal trauma care to save the lives of Americans injured both within the United States and on the battlefield. To guide such an approach, the committee identified strengths and gaps in progress in the military and civilian sectors, using the following elements of a learning trauma care system as a diagnostic lens.
*National Academies of Sciences, Engineering, and Medicine. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: National Academies Press; 2016. A summary is available: http://www.safetylit.org/citations/index.php?fuseaction=citations.viewdetails&citationIds[]=citreport_264_28&sha=1
Language: en |