By Dr. Valecia L. Dunbar, MEDCOM Public Affairs & Adjunct Professor Army-Baylor University MHA/MBA ProgramJune 23, 2015
FORT SAM HOUSTON, Texas (June 23, 2015) -- Trauma care, within the Department of Defense, is a continuous and enduring mission in peacetime or wartime. Recent improvements in the delivery of trauma care in-theater have resulted in a case fatality rate of less than 10 percent.
To put this number in historical perspective, the case fatality rate was 19.1 percent during World War II, 15.8 percent during Vietnam, and approximately 16 percent at the onset of Operation Enduring Freedom. In Vietnam alone, 2,500 service members died solely from extremity injuries.
One DOD organization, which has sought to improve combat casualty care outcomes, is the Joint Trauma System, or JTS, and its multi-service coordinating component, the Joint Theater Trauma System, or JTTS, to provide "the right care, to the right patient, at the right place, and right time," said Col. Kirby Gross, JTS director. "That's the only way optimal combat casualty care can be provided."
Spurred by the events of 9/11, and subsequent combat operations in Iraq and Afghanistan, military clinicians recognized the need for a more structured approach to a system of trauma care for Soldiers wounded in combat.
In 2005, U.S. Central Command, also known as CENTCOM, implemented an inclusive system of trauma care in support of Operation Enduring Freedom, or OEF, and Operation Iraqi Freedom, OIF. This system integrated care from point of injury through Level IV care. Subsequently, the system evolved to include Level V and Veterans Affairs facilities. JTS uses Level IV and V as the highest levels of definitive trauma care.
The JTS was established in 2006 at the U.S. Army Institute of Surgical Research, or USAISR. Since that time, multiple investigators using data from the Department of Defense Trauma Registry, or DODTR, have demonstrated that this system has improved the process of care, minimized-practice variability, and decreased morbidity and mortality in CENTCOM theater of operations. The JTS became an official program of record under the USAISR within DOD in 2010.
Evidence suggests that inclusive systems of trauma care are associated with a reduction in injury-related mortality within a region compared with exclusive systems.
Today, the CENTCOM JTTS, the U.S. Army Ad Hoc JTS, and the DODTR process enable a seamless, multi-service military trauma system developed on the premise that every Soldier, Marine, Sailor, and Airman injured on the battlefield or in the theater of operations has the optimal chance for survival and maximal potential for functional recovery.
The relationship between the JTTS and JTS is one of coordination, knowledge management, and information sharing to ensure data received from the JTTS shared registry are managed in a unified DOD system.
Army Vice Chief of Staff Gen. Daniel Allyn served as a Ranger Battalion commander in 1998. During remarks at the 2014 Association of the United States Army, also known as AUSA, Hot Topic Medical Symposium, Allyn spoke about his vision for "training every Soldier to be as skilled as our combat medics" and referred to the early steps taken to bring tactical combat trauma care to the point of injury and the lessons learned from Somalia.
"During Somalia and Vietnam, seven of 10 battlefield deaths were caused by bleeding in the arms and legs," Allyn said. "Now we have transitioned to the combat application tourniquet and haemostatic dressings that cause immediate blood clotting. We have moved surgeons forward on the battlefield so Soldiers can receive care within minutes of their injury."
The development of a trauma registry supports the system needs, such as performance improvement and research to reduce morbidity and mortality. Critical to the system's success are trauma nurse coordinators who log combat casualty records into JTTS.
"Nurses were using the registry to facilitate performance improvement among providers and ensure care guidelines have consistent results," Gross said. "What the registry needed outside of JTTS, which serves the CENTCOM area of responsibility, was technology and performance improvement subject-matter experts to train trauma nurses and JTTS teams."
The JTS is an enduring organization within the Army and is housed on Fort Sam Houston in San Antonio. Its mission is to improve trauma care delivery and patient outcomes across the continuum of care utilizing continuous performance improvement and evidence-based medicine driven by the concurrent collection and analysis of data maintained in the DODTR, which was formerly named the JTTR.
JTS is one of five directorates at USAISR. Its additional responsibility is to write clinical practice guidelines and provide a source of institutional knowledge to inform future operations. The agency shares a strategic partnership with the American College of Surgeons, or ACS, Committee on Trauma and the Defense Health Agency, DHA, to ensure all surgeries, including trauma surgeries, in civilian and military environments are registered. JTS has also partnered with United Kingdom medical officers to establish data sharing agreements.
"All data has been de-identified," said Gross.
The JTS was recognized by the Oversight Board of the Defense Centers of Excellence in June 2013 as a Defense Center of Excellence. The Center of Excellence recognition is awarded to organizations, which create value by achieving improvement in outcomes through clinical, educational and research activities.