Part 5: The Time Is Now: Creating and Sustaining a Unified, Learning Trauma System

Great strides have been made in developing an optimal trauma system in many areas of the U.S, with particular focus on trauma centers. Based in part on the work done in the civilian sector, there have been significant advances in the military’s trauma system—advances that could, in turn, greatly benefit the civilian trauma system.

Despite these achievements, the full potential of a national trauma system featuring seamless sharing of data, best practices and continuous improvement within and across the military and civilian systems has yet to be realized. In fact, the nation’s developing trauma systems remain a patchwork of care with limited federal ownership, according to David B. Hoyt, MD, FACS, Executive Director of the American College of Surgeons (ACS).¹

The unfortunate truth is that in the U.S., where you are injured may very well determine if you live or die.

“At least one of three Americans live in a region without a complete trauma system offering immediate responder support, an EMS system that arrives quickly and takes the patient to the right hospital, appropriate hospital care, and effective rehabilitation,” said Ronald M. Stewart, MD, FACS, Chair, ACS Committee on Trauma. “Tens of thousands of lives could be saved if advances in military and civilian trauma care reach all injured patients. Today, trauma is the leading health problem facing our military service members during times of war, and the leading cause of death and disability for Americans age 45 and younger.”

Reports suggest one of five civilian trauma deaths and one of four military trauma deaths could be prevented if advances in trauma care reach all Americans.² Since anyone can become injured at any time, all Americans have a stake in this debate. In addition, our national trauma system is critical to our national and homeland security and a backbone for disaster preparedness.

A 2016 report by the National Academies of Science, Engineering, and Medicine (NASEM) outlines 11 recommendations for completing the nation’s trauma system, including federal leadership, coordination and integration between military and civilian health leaders, stronger collaboration between states, steps to address gaps in trauma care, and a national trauma research plan with dedicated funding for clinical research.

The ultimate goal of this unified, integrated, strengthened trauma system is to achieve maximum survival and maximal return to normal function following injury. This goal helps to drive the system. As legendary improvement expert W. Edwards Deming once wrote: “A system must have an aim. Without an aim, there is no system.”³

The ultimate vision is to make our trauma system a continuously learning health care system, one in which science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral byproduct of the delivery experience.

This national trauma care system would feature patient-centered care with timely access to high-quality prehospital, definitive, and rehabilitative care, along with seamless transitions between each phase of care to ensure that patient needs are met. It is a system grounded in sound learning health care system principles applied across the delivery of care from point of injury to hospitalization, rehabilitation, and beyond.

Above all, achieving this vision depends upon the establishment of policy and supporting agency structures at the highest levels of the Federal government. Implementation will require a systems approach in which committed leaders from both sectors integrate military and civilian trauma care. In addition, it will require a strategy that defines common standards, interoperable frameworks, and points of accountability to reduce variation in care and outcomes while supporting continuous learning and innovation at the point of care delivery.

The 75th Ranger Regiment, part of the U.S. Army Special Operations Command, exemplifies how a commitment to the principles of a learning system can significantly reduce and even eliminate deaths from potentially survivable wounds.

Rangers were provided with the knowledge, training, and equipment to render immediate care, and there were coordinated evacuation sequences and patient handoffs across the trauma care continuum. The regiment also developed a Ranger Casualty Card and prehospital trauma registry to capture patient data that can be difficult to collect, providing the continuous feedback necessary for performance improvement throughout the unit.⁴

The result was an unprecedented reduction in preventable deaths and the greatest survival record in the history of war.⁵ From 2001 to 2010, the 75th achieved markedly better outcomes than the Department of Defense overall. In fact, while the entire U.S. military population faced a preventable death rate of up to 25 percent, the 75th Ranger Regiment documented only one potentially survivable fatality in the hospital setting and no preventable deaths in the prehospital setting.⁶

Up to 20 percent of civilian trauma deaths occur in patients with potentially survivable injuries.⁷

If these injured patients had access to optimal trauma care, the lives of nearly 30,000 Americans might have been saved in 2014 alone.

The 75th Ranger Regiment demonstrates that zero preventable deaths is an achievable goal when leadership takes ownership of trauma care and data are used for continuous reflection and improvement.

Advances in trauma care provided to service members during the conflicts in Iraq and Afghanistan have led to remarkable achievements in medicine, resulting in more lives saved on the battlefield than ever before. In fact, service members injured today have a better chance of surviving than during any previous war in history. But if past is prologue, as our nation unwinds from its longest period of armed conflict, those advances in care are at risk of being lost.

To prevent this loss, military and civilian trauma systems must integrate and share innovations to ensure military trauma providers maintain their skills and readiness. Ultimately, the civilian and military trauma systems should be part of one unified system. Such a system would not only improve performance, but it would also support national defense and homeland security, serving as a framework for disaster preparedness and response.

“One nation, one system,” said Air Force Col. Jeff Bailey, MD, FACS, a former director of the Joint Trauma System.⁸

Work on this mission is already underway by the American College of Surgeons (ACS) and a broad coalition of trauma stakeholders, who are translating the lessons of war into civilian trauma care and helping service members maintain their readiness to deploy in the future.

Their efforts were aided by the recently signed National Defense Authorization Act, which requires all major military treatment facilities to participate in the U.S. trauma system. Efforts are underway to support this integration of military medical teams in civilian trauma centers to optimize training.

To further initiatives such as these, in 2014, ACS and the U.S. Department of Defense Military Health System created the Military Health System Strategic Partnership American College of Surgeons (MHSSPACS) to strengthen ties between civilian and military health systems, share trauma innovations, and expand education and training opportunities by partnering civilian and military surgeons and care teams at some of the busiest trauma centers in the nation. The partnership’s goal is to expand pre-deployment training opportunities for military surgeons, provide disaster response training for civilian surgeons, partner on surgical practice guideline development and quality improvement, and develop an “optimal resources” manual specific to the needs of the Joint Trauma System.

Through the Military Health System Strategic Partnership and existing military partnerships within the COT, collaborative efforts aimed at improving both civilian and military trauma care are making significant progress. The success of Stop the Bleed

Related legislation currently before Congress, called the Mission Zero Act (H.R. 880), would provide $40 million in funding to facilitate partnerships between military trauma care teams/providers, and high-volume civilian Level I trauma facilities.

“Military and civilian trauma care will be optimized together or not at all,” said Donald Berwick, MD, MPP, who chaired the NASEM committee.⁹

There have been numerous reports through the years that have urged significant improvements to the trauma system, starting with the 1966 National Research Council report, “Accidental Death and Disability: The Neglected Disease of Modern Society.” Although much progress has been achieved in the last 50 years, a new national trauma action plan is desperately needed.

Initiatives to close gaps in trauma care have been driven largely by the private sector, including ACS, with insufficient involvement from the federal government, Dr. Berwick said.

“There was far more inaction than action,” he said.

In order to prevent this history from being repeated, the ACS has joined with a broad coalition of trauma stakeholders, such as the National Highway Traffic Safety Administration (NHTSA), the U.S. Department of Defense, NASEM, and the National Institutes of Health, to develop a National Trauma Action Plan. The specific aim is to provide a framework to enable implementation of the recommendations in the NASEM report. In addition, ACS has strengthened collaboration with trauma system specialists including EMS, nursing, orthopedic surgeons, neurosurgeons, and emergency physicians, whose associations sponsored the NASEM report and were members of the NASEM committee.

The National Trauma Action Plan outlines steps to establish federal leadership to integrate military and civilian trauma into one national trauma system, identify and close the gaps in trauma care in the United States, reduce unnecessary deaths, encourage data sharing and system-wide performance improvement, and increase trauma research funding commensurate with trauma’s heavy burden for our society. It must allow for flexibility for the states and regional systems to optimize implementation. Specific areas of focus in the plan are discussed in more detail in the paragraphs that follow.

The National Academies’ Zero Preventable Deaths report recommends that authority for the national trauma system should be housed at the highest executive level, as a White House directive. At an operational level, the report recommends that the military system be housed in the Defense Health Agency and that leadership of the civilian system should be housed within the Department of Health and Human Services (HHS). The operational leadership role should include coordination with governmental (federal, state, and local), academic, and private-sector partners and should address care from the point of injury to rehabilitation and post-acute care.¹⁰

Though easily expressed in a few simple recommendations, the establishment of an over-arching Federal policy and the agency-level governance structures to support it is a large-scale project that will require broad political support and strong leadership from within the government itself. As such, this work may well be the greatest challenge put forward by the NASEM report.

Given the complexities of the civilian health care system and the lack of an existing governance structure within HHS that has responsibility for injury, it has been argued that HHS may not be the best solution. An alternative solution would be to house the leadership of the system within the Department of Homeland Security (DHS), based on the critical role that trauma systems play in national preparedness for disaster and mass casualty response.

Regardless of the exact home, there should be an overarching federal umbrella that ensures state and regional trauma systems cover the entire United States, that a basic set of uniform standards are met, and that trauma research funding disparities are addressed.

For the most seriously injured patients, life or death is determined by the immediate responders and the EMS system. After all, patients who have uncontrolled bleeding do not have a “Golden Hour” to get to appropriate care – they may have just minutes to live. About half of trauma deaths occur before the patient ever gets to definitive care. Turning bystanders into immediate responders and making high quality EMS care uniformly available regardless of location are critical.

One of the most effective changes made by the military, as exemplified by the 75th Ranger Regiment, was to train all soldiers, not just medics, to learn the basics of bleeding control. The DoD provides tourniquets to every soldier in a combat zone.

In the wake of the 2012 shootings at Sandy Hook Elementary in Newtown, CT, ACS and other organizations organized the Hartford Consensus expert panel to determine how we could better respond to mass casualty incidents. Inspired by the success of the military’s bleeding control efforts, the Hartford Consensus recommended that the public be trained to act as immediate responders by learning the basics of bleeding control techniques. The resulting Stop the Bleed® program, which was developed and supported by ACS, the Department of Defense and the National Association of EMTs, uses bleeding control techniques developed and honed for tactical combat casualty care. The campaign has already been a springboard to improved community dialog and community preparedness. The recent mass shootings make it clear that all must be trained in basic bleeding control.

Besides delivering immediate aid to the injured, there is also the need to reduce variability in the EMS systems across the nation. The absence of standard, national quality metrics for trauma care and present reimbursement practices for civilian EMS (i.e., pay-for-transport) are major impediments to the integration of prehospital care into the trauma care continuum. All too often, injured patients do not receive the care they need on the way to definitive care, or face dangerous delays in getting to the most appropriate level of care. Just as with trauma centers, universal availability of professional EMS is highly variable.

EMS must become a seamless and essential component of health care delivery. Some of the recommendations include identifying EMS as a provider subject to health and safety standards; linking CMS reimbursement to the quality of prehospital care; and ensuring EMS systems have the workforce size, location, competencies, training, and equipment necessary for optimal prehospital medical care.

Injury prevention is an equally important prehospital trauma issue that was not addressed in the National Academies report and that we have only briefly discussed in this series. The ACS COT has worked and partnered with other health care and public health organizations to make injury prevention a critical pillar of the modern trauma system. For example, prevention efforts are essential for ACS Trauma Center Verification. Still, there are substantial opportunities for improvement in the prevention of injuries. The ACS COT has made significant progress with a trauma system/public health approach aimed at achieving a consensus on the best steps to reducing injuries from violence and firearms.

One out of three Americans lives in a region that does not have adequate trauma care. In large areas of the country, trauma centers are too few and far between, making it more difficult to get injured patients to the right level of care. Paradoxically, many urban and suburban areas may well have too many trauma centers, potentially leading to duplication of expensive resources, increased costs, and decreased volume at individual centers that could compromise patient outcomes and the training of future generations of trauma providers.

“Simply having more trauma centers does not necessarily improve patient access or patient outcomes, and may in fact destabilize systems that currently function at a high level,” according to Robert J. Winchell, MD, FACS, Chair, ACS Trauma Systems Evaluation and Planning Committee. “Rather than just adding more trauma centers without pre-planning, we instead must focus on the ensuring there are an appropriate number and level of trauma centers distributed based upon the needs of the population served.”

The distribution of trauma centers within a region should be based on a trauma system plan that accounts for the needs of the population and takes an inventory of services and their geographic distribution.¹¹ The plan should be developed and maintained by a multidisciplinary group of stakeholders that includes trauma surgeons, emergency physicians, nurses, trauma program managers, prehospital personnel, rehabilitation providers, information system personnel, hospital administrators, and prevention experts.¹²

Due to a lack of Federal direction, lead agencies at the state and local level are often challenged to resolve difficult decisions regarding trauma center distribution, and as a result, the decisions are left to external market forces. One of the key elements of the National Trauma Action Plan is the establishment of local authority to implement regulations that designate trauma centers based on need as part of an inclusive national system.

Research is a critical component to a successful learning health care system – it is the feedback loop that drives continuous improvement. Unfortunately, for many years trauma research has not received the attention and funding it deserves, and its future remains uncertain.

To facilitate trauma research, work needs to be done to expand and integrate data on trauma patients, who are now difficult to track across the continuum of care or between civilian and military patients.

Although ACS led the creation of trauma registries and improvement programs that have contributed significantly to improved care at trauma centers, such as the Trauma Quality Improvement Program (ACS TQIP), data gaps exist for patients before they get to the trauma center and after they leave it. That’s why metrics and performance improvement programs should be established for EMS and prehospital care. In addition, more work needs to be done to integrate rehabilitation, now arguably the weakest link in the trauma care continuum, with other phases of trauma care.¹³

Meanwhile, data gathered on military trauma patients remains separate from data gathered on civilian trauma patients. HHS, DoD, and others need to work together to create a unified trauma data system that spans the continuum of trauma care and includes all injured patients.¹⁴

If data are necessary for research, so is funding. For years, funding for trauma research has been dramatically low. For example, even though injury is a leading cause of death and disability, especially among young people, trauma research accounts for a disproportionately small portion of the National Institute of Health’s overall research budget compared to its burden.¹⁵ And unlike many major diseases, there is no centralized institute dedicated to trauma and emergency care research. Looking forward, civilian investment in trauma research is limited and the sustainment of DoD’s trauma research program is threatened.¹⁶ This must be addressed if we are to maximize survival and functional recovery of trauma patients.

The United States needs a coordinated trauma research program with defined objectives, a focus on high-priority needs across the continuum of trauma care (from prehospital to rehabilitation), and adequate resourcing from both the military and civilian sectors. To get there, the National Trauma Research Action Plan calls for a resourced, coordinated, joint approach to trauma care research across the relevant federal organizations, academic institutions, professional societies and foundations.

Even if we get a plan, however, the question is: Who will fund trauma research?

Most agree that the best solution would be to create a NIH Institute for Trauma research that would include a steady, reliable source of funding, which would be less subject to political influence.

But under the current administration, the White House and the NIH are unlikely to be big supporters of increased trauma research funding, said Timothy Fabian, MD, FACS, a trauma surgeon from Memphis. After all, President Trump proposed reducing National Institutes of Health funding by $5.8 billion to $25.9 billion in his budget, Dr. Fabian said.

Likewise, the Department of Defense, whose own trauma research program is in doubt¹⁷, does not appear to be a likely source for increased funding either, according to Jerry Jurkovich, MD, FACS, chief of surgery of the Denver Health Medical Center.

A third possibility, at least in the short run, is industry, such as car manufacturers, and philanthropic foundations, Dr. Fabian said.

“Even in regions of the country with world-class trauma care, greater research can help us continue to improve outcomes for trauma patients,” said Eileen Bulger, MD, FACS, Chair-Elect of the ACS COT. “Research is critical to saving more lives and improving recovery for all trauma patients.”

The latest National Academies report was far from the first to urge improvements for our trauma system. Over the past 50 years, similar task forces and committees have called for consolidated leadership, strong system designs, dramatic increases in support for research, and clear lines of responsibility. These calls have not been heeded, and much work remains to be done.

But this time, there are many factors driving the need to improve:

• The urgency to better prepare for mass casualty events and disasters;
• The short-lived chance to preserve hard-earned advances in military trauma care derived from the conflicts in Iraq and Afghanistan;
• The need to unify military and civilian trauma systems in order to provide sustainable systems to maintain the skills of military trauma providers;
• The opportunity to significantly improve pre-hospital care and empower bystanders as first responders;
• And the irrefutable need to optimize and coordinate trauma data and research.

“The time is now to make the recommendations of the NASEM report a reality,” said Dr. Stewart. “There are obstacles, but we must have the will to overcome these obstacles. With strong leadership, we can make these changes and achieve the goal of zero preventable deaths and disability after injury. By doing so, we will save tens of thousands of American lives every single year.”

References

1. https://www.facs.org/quality-programs/trauma/trauma-series/part-i
2. https://www.facs.org/media/press-releases/2016/zero-preventable-101816
3. Deming, W. Edwards Deming. “The New Economics for Industry, Government, Education.” 1993.
4. Blackbourne, L. H., D. G. Baer, B. J. Eastridge, F. K. Butler, J. C. Wenke, R. G. Hale, R. S. Kotwal, L. R. Brosch, V. S. Bebarta, M. M. Knudson, J. R. Ficke, D. Jenkins, and J. B. Holcomb. 2012. Military medical revolution: Military trauma system. Journal of Trauma and Acute Care Surgery 73(6 Suppl. 5):S388-S394.
5. http://www.nationalacademies.org/hmd/Reports/2016/A-National-Trauma-Care-System-Integrating-Military-and-Civilian-Trauma-Systems.aspx
6. Kotwal, R. S., H. R. Montgomery, B. M. Kotwal, H. R. Champion, F. K. Butler, Jr., R. L. Mabry, J. S. Cain, L. H. Blackbourne, K. K. Mechler, and J. B. Holcomb. 2011. Eliminating preventable death on the battlefield. Archives of Surgery 146(12):1350-1358.
7. Kwon, A., N. Garbett, and G. Kloecker. 2014. Pooled preventable death rates in trauma patients.
   European Journal of Trauma and Emergency Surgery 40(3):279-285.
8. Bailey J. Integrating Military Treatment Facilities into a Civilian Trauma System. 2017. https://www.facs.org/~/media/files/quality%20programs/trauma/Zero Preventable Deaths%20conf/38_bailey.ashx
9. http://tetaf.org/wp-content/uploads/2014/08/National-Trauma-System-Berwick.Downey.pdf
10. http://www.nationalacademies.org/hmd/Reports/2016/A-National-Trauma-Care-System-Integrating-Military-and-Civilian-Trauma-Systems.aspx
11. ACS Statement on trauma center designation based upon system need. ACS Bulletin, Jan. 1, 2015. http://bulletin.facs.org/2015/01/statement-on-trauma-center-designation-based-upon-system-need
12. http://www.nationalacademies.org/hmd/Reports/2016/A-National-Trauma-Care-System-Integrating-Military-and-Civilian-Trauma-Systems.aspx
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14. http://www.nationalacademies.org/hmd/Reports/2016/A-National-Trauma-Care-System-Integrating-Military-and-Civilian-Trauma-Systems.aspx
15. http://www.nationalacademies.org/hmd/Reports/2016/A-National-Trauma-Care-System-Integrating-Military-and-Civilian-Trauma-Systems.aspx
16. http://www.nationalacademies.org/hmd/Reports/2016/A-National-Trauma-Care-System-Integrating-Military-and-Civilian-Trauma-Systems.aspx
17. http://www.nationalacademies.org/hmd/Reports/2016/A-National-Trauma-Care-System-Integrating-Military-and-Civilian-Trauma-Systems.aspx