Optimizing performance in the combat casualty continuum.
Article Type: Report
Subject: Continuum of care (Research)
Trauma centers (Services)
Authors: Martin, Kathleen D.
Spott, Mary Ann
Schell, Elizabeth
Neal, Sheryl
Pub Date: 10/01/2011
Publication: Name: U.S. Army Medical Department Journal Publisher: U.S. Army Medical Department Center & School Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 U.S. Army Medical Department Center & School ISSN: 1524-0436
Issue: Date: Oct-Dec, 2011
Topic: Event Code: 310 Science & research; 360 Services information Canadian Subject Form: Trauma centres
Geographic: Geographic Scope: Germany Geographic Code: 4EUGE Germany
Accession Number: 274955764

Participation in the trauma center verification process almost invariably results in significant improvements in patient care, along with enhancement of institutional pride and commitment to care of the injured patient. (1) Further, implementation of trauma systems in the civilian sector has long been known for the resulting impact on decreased morbidity, hospital mortality, length of stay, and costs, with correlating improved contribution margin. (2,3) Wounded combatants of today's conflicts suffer a variety of injuries not encountered in the civilian sector, specifically related to improvised explosive devices where primary, secondary, and tertiary blast and blast overpressure phenomena produce devastating injuries. Therefore, implementation of the trauma model in the military medical system was sought on the premise that trauma care within the military is constant and long-term, whether during war or peace. No one is more deserving of this enhanced care than our Soldiers, Marines, Sailors, and Airmen.


Landstuhl Regional Medical Center, the US military echelon IV medical treatment facility (MTF) in Germany, was a low acuity, low volume institution before Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). A surge in patient volume with increasing complexity in treatments required multiple resources and expertise to enhance care, which is typically available at civilian trauma centers. Landstuhl is the evacuation hospital and main referral center for casualties coming from OIF and OEF and, consequently, now is the center of the largest trauma system in the world. The facility receives patients from echelon III MTFs in Iraq, Afghanistan, Africa, and Europe. After restabilization, further surgery, and preparation for flight, combat casualties are transferred to the United States. Landstuhl has been described as the "prism," centered in the evacuation chain which takes in a chaotic, complex compilation of nationalities, diagnoses, medical records, and damage control care processes from combat theaters, as represented in Figure 1. The output is a stable group of patients with consistent, clinical practice-guided evaluations and complete and organized medical records who are evacuated to facilities throughout the world.


Army leadership committed to level II trauma center verification in 2005. As shown in Figure 2, key positions such as trauma medical director, trauma nurse director, trauma performance improvement nurse coordinator, trauma nurse coordinator, and trauma registrar were then created. The trauma program nurse director position has responsibility for multiple aspects of the trauma program, such as trauma-related performance improvement, registry, injury prevention, research, publications, consultation, and involvement in national trauma organizations. The key responsibility of the trauma performance improvement coordinator is to assist nurses and other associated services in the coordination of a plan of care. This is accomplished through collaboration with physicians, nurses, and other associated services in developing a comprehensive plan of care and identifying variances in that plan of care, thus enhancing outcomes for combat casualties. Key to the continuum of care of military trauma patients is feedback to both referring (combat theater) and receiving (United States) military treatment facilities.


The education and trauma multidisciplinary committees were implemented in early 2006, and the timeline shown in Figure 3 was established. A comprehensive gap analysis was undertaken in November 2006, outlining areas of noncompliance with the criteria of the American College of Surgeons Committee on Trauma. (4) Additional facility capabilities were harnessed, including the development of a web-based joint patient tracking application and an all-encompassing case management system, creation of a Deployed Warriors Medical Management Center, and establishment of a distinct trauma program. A comprehensive military trauma registry, the Joint Theater Trauma Registry, and performance improvement processes were then implemented. The trauma program was enhanced by the creation of a weekly clinical video teleconference (VTC) to discuss specific patient issues and provide feedback across the continuum of care (Iraq, Afghanistan, Germany, and the United States) and establishment of a monthly worldwide trauma VTC to quickly identify and resolve common system issues. Care was enhanced with the development of combat-related clinical practice guidelines, development of critical capabilities (including dialysis), and implementation of an acute lung team including critical care transport nurses who are able to treat and transport patients with catastrophic pulmonary injury. (5) Additional education and clinical practicum were undertaken to train Landstuhl providers and critical care nurses at a German facility (Regensburg Hospital) in use of portable extra-corporeal membrane oxygenation which can be used enroute from theater to Landstuhl.

Resulting improvements in care and outcomes, examples of which are shown in the Table, are reflected in a system-wide standardization of care coupled with a robust concurrent performance improvement process, which led to further improvements in care.


Early in both Operation Enduring Freedom and Operation Iraqi Freedom, collection of combat casualty data was independently completed via spreadsheets or home-grown databases at multiple MTFs worldwide. In an effort to improve care throughout the trauma care continuum, especially the battlefield, the Joint Theater Trauma System (JTTS) was developed. The Joint Theater Trauma Registry (JTTR), the data depository collecting and hosting all US military trauma casualty related data, is a component of the JTTS. This unique trauma registry allows for direct data input from all echelons of combat casualty care, and is used for data abstraction and analysis by Active and Reserve nurses of the Army, Air Force, and the Navy.

The first JTTS team, consisting of a trauma medical director (trauma surgeon) and 6 trauma nurse coordinators, deployed in 2004. The JTTR was implemented at Landstuhl in January 2007, and fielded in theater with the trauma nurse coordinators the following July. (10) Expansion of the JTTS trauma coordinators to allow enhanced coverage in Afghanistan, and at coalition sites such as Kandahar and Bastion, began in 2009. In addition, JTTS nurses have taken responsibility for the growth of medical evacuation (MEDEVAC) data acquisition and MEDEVAC performance improvement with a specific focus on improvements in transport times following combat casualty injuries.

Currently, data is directly input by echelon II mobile surgical teams deployed throughout the Iraq and Afghanistan theaters, more permanently based echelon III combat support hospitals, a sustaining echelon IV medical center in Germany (Landstuhl), and established echelon V military treatment facilities in the United States. The information in the JTTR also draws data abstracted from multiple electronic datasets, including the US Transportation Command Regulating and Command & Control Evacuation System, the Theater Medical Data Storage, the Composite Health Care System, and Essentris (CliniComp, International, San Diego, CA), the electronic medical record system. Information is also abstracted from paper medical records.

Military specific data elements within the JTTR include expanded demographic data, including military branch, rank, and military occupation. Casualties may have been treated in as many as 4 distinct MTFs before arrival at the echelon IV facility in Landstuhl. Varying data from each echelon along the combat casualty's route of evacuation are entered into the JTTR.

In addition to ICD-9 * and standard Abbreviated Injury Scale (AIS) codes, all injuries are coded using a military version of the AIS. The military version of the AIS was developed through a collaboration of military physicians and the Association for the Advancement of Automotive Medicine in order to better represent the compound injuries from improvised explosive devices. It allows for a heavier weighting of lower extremity injuries, penetrating head injuries, and calculation of the abbreviated injury score from the 3 worst injuries. The traditional injury severity score allows you to take only the worst injury in each region, which greatly underserves penetrating injury and blast injury.

A robust performance improvement tracking system is integrated into the JTTR to allow clinical providers and trauma coordinators to concurrently track 55 user defined audit filters and 61 specific complications, as well as document primary, secondary, and tertiary case reviews. The JTTR at the echelon IV MTF requires routine collection of 367 data elements for each casualty. Despite the high number of required data elements, the need to access multiple widespread data sources worldwide, and a short inpatient length of stay, data abstraction is still routinely completed within 7 days of discharge. The data is validated and closed within 2 weeks of discharge in more than 90% of cases. The national benchmark is to close charts within 6 weeks of abstraction. The strength of the trauma registry program at Landstuhl has earned the praise of the American College of Surgeons Committee on Trauma.


Based upon the positive accomplishments of the deployed JTTS trauma coordinators in theater, the Army Nurse Corps resolved to assign a colonel to the JTTS leadership in the Joint Trauma System structure in San Antonio to ensure the capture of lessons learned. The objective is to transition the lessons learned into data and evidenced-based clinical practice guidelines, which would drive the composition and design of training at the US Army Nursing Leader Academy. **


Trauma performance improvement is a continuous multidisciplinary effort to measure, evaluate, and improve both the process of care and the outcomes. The American College of Surgeons Committee on Trauma defines it as "the continuous evaluation of a trauma system and trauma providers through structured review of the process of care as well as the outcome."4 The trauma performance improvement program at Landstuhl was developed with the goals of monitoring the process and outcome of patient care, to ensure the quality and timely provision of such care, to improve the knowledge and skills of military trauma care providers, and to provide the institutional structure and organization to promote improved outcomes for wounded Warriors. The focus of the development of the program began with structure, which included staffing, equipment, education, and the physical space. The second phase centered on development of a system-wide clinical practice guideline which was implemented both in the theaters of operations and Landstuhl. As the program matured, the focus shifted more to outcomes such as morbidity, mortality, process parameters, and compliance with clinical practice guidelines. The primary purpose of the trauma performance improvement program is the delivery of optimal care to injured Warriors treated at Landstuhl. The care of injured patients depends on a complex network of people working together as a team. (11) The urgent nature of trauma care relies on each member of the team to perform well on a regular basis, with the goal of optimal communication which results in improvements in clinical care and patient outcome (Figure 4).

The performance improvement program is designed to monitor the system and determine ways in which it can be improved. In order to sustain effectiveness, the performance improvement process must be inclusive, drawing from the expertise of each individual member of the trauma care team. In addition, the performance improvement program must always maintain certain principles so that it can function in a fair, autonomous way. These principles include objectivity; efficiency; effectiveness; and a process that is care-directed, data-driven, issue-oriented, education-oriented, and nonpunitive.

The mature trauma performance improvement plan was integrated into the overall hospital performance improvement plan to support the institutional mission, vision, and goals. The plan was inclusive of the trauma scope of care, which includes all echelons of care from the battlefield through return to the United States, and captured all-encompassing system events, nursing care events, provider issues, and variances from established clinical practice guidelines. Landstuhl uses institution-specific audit filters and a selection of pertinent American College of Surgeons audit filters which are continually assessed. Intensive care unit nursing staff monitor ventilator associated pneumonia bundles, which include elevation of head of bed, sedation holidays, peptic ulcer prophylaxis, and oral care. Central line bundle is also monitored by nursing, which includes hand hygiene, barrier precaution on insertion, Chlorhexidine use, optimal site selection, and prompt removal of unnecessary lines. Landstuhl has also developed institution-specific audit filters unique to combat casualty care. Primary review of performance occurs concurrently with data abstraction and collection by trauma nurse coordinators while the care is still being delivered. Issues are identified and validated as they occur. This information may be gleaned during morning report, patient care rounds, chart review, and direct staff/patient interaction. Daily patient rounds are multidisciplinary, and include the charge nurse, bedside nurse, trauma nurse coordinators, infectious diseases, air evacuation team members, and nutrition, and are lead by the trauma surgeons and intensivists. Daily goals are identified by using input from all disciplines. Changes in a patient's plan of care or implementation of clinical practice guidelines may be influenced immediately. Prompt feedback to providers will occur concurrently. A rounding tool was formatted to enhance all disciplines' participation, and is tracked by the trauma nurse coordinators for compliance. Secondary review of identified events may require additional analysis, input from a variety of providers, and/or review by the trauma nurse director, trauma medical director or intensive care unit nursing leadership. Issues are validated, supplementary information collected and analyzed In some situations the case may be closed. If peer review is indicated, the case is forwarded to the Trauma Conference or Trauma Multidisciplinary Peer Review. Criteria for determining which cases go to these committees are: all deaths, selected complications, unique patient populations, focused reviews, and all referred cases. Cases are reviewed, factor determinations made, preventability established, surgical grading defined, corrective actions developed, and loop closure, if indicated at the time. Systems issues are reviewed in the Trauma Operational Process Performance Committee.



Landstuhl Regional Medical Center strives continually to provide world class comprehensive and compassionate care to our Warriors, their Families, retirees, and all other directed beneficiaries, while maintaining unit and personal readiness to meet the demands of our nation. Establishment of a verified trauma center, with a concurrent performance improvement process coupled with implementation of the JTTR has resulted in improved outcomes for our combat casualties and increased identification and closure of performance improvement events. Contributions of trauma nurses to care of combat casualties have focused on the unique and complex care of our wounded Warriors in order that they attain, maintain, or recover optimal health and quality of life. Because trauma nurses work as part of a team along the combat casualty continuum, they are able to assess, plan, implement, and concurrently evaluate care. Army nursing must continue to focus on nursing as a science, and a field of knowledge based on evidence.


(1.) Ehrlich PF, Rockwell S, Kincaid S, Mucha P Jr. American College of Surgeons, Committee on Trauma Verification review: does it really make a difference?. J Trauma. 2002;53(5):811-816.'

(2.) Piontek FA, Coscia R, Marselle CS, Korn RL, Zarling EJ. Impact of American College of Surgeons verification on trauma outcomes. J Trauma. 2003;54 (6):1041-1046.

(3.) DiRusso S, Holly C, Kamath R, et al. Preparation and achievement of American College of Surgeons level I trauma verification raises hospital performance and improves patient outcome. J Trauma. 2001;51(2):294-299.

(4.) American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons; 2006.

(5.) Fecura SE Jr, Martin CM, Martin KD, et al. Nurses role in the Joint Theater Trauma System. J Trauma Nurs. 2008;15(4):170-173.

(6.) Chung LL, Blackbourne LH, Wolf SE, et al. Evolution of burn resuscitation in Operation Iraqi Freedom. J Burn Care Res. 2006;27(5):606-611.

(7.) Joint Theater Trauma System Clinical Practice Guideline: Burn Care. US Army Institute of Surgical Research Web site. Available at: http://www.usaisr. amedd.army.mil/cpgs/Burn_CPG_20_Dec_10.pdf. Accessed August 31, 2011.

(8.) Dempsey K, Dorlac W, Martin K, et al. Landstuhl Regional Medical Center: traumatic brain injury screening program. J Trauma Nurs. 2009;16(1):6-12.

(9.) Steele N, Ketz A, Martin K, Garcia D, Womble S, Wright H. Rewards and challenges of nursing wounded warriors at Landstuhl Regional Medical Center, Germany. Nurs Clin North Am. 2010;45 (2):205-218.

(10.) Glenn MA, Martin KD, Monzon D, et al. Implementation of a combat casualty trauma registry. J Trauma Nurs. 2008;15(4):181-184.

(11.) De Jong MJ, Martin JD, Huddleson M, et al. Performance improvement on the battlefield. J Trauma Nurs. 2008;15(4):174-180.

Kathleen D. Martin, RN, MSN

Mary Ann Spott, MPA, MSIS

Elizabeth Schell, RN, MSN

Sheryl Neal, RN, MBA

Ms Martin is the Trauma Program Nurse Director, Landstuhl Regional Medical Center, Germany.

Ms Spott is Deputy Director, Joint Trauma System, Army Institute of Surgical Research, Fort Sam Houston, Texas.

Ms Schell is the Trauma Performance Improvement Coordinator, Landstuhl Regional Medical Center, Germany.

Ms Neal is the Trauma Data Informatics Coordinator, Landstuhl Regional Medical Center, Germany.

* International Classification of Diseases, 9th Revision

** See "Designing and Implementing the Army Nursing Leader Academy" on page 18.
Examples of improvements in care and outcomes realized from the
implementation of level II trauma center capability at the
Landstuhl Regional Medical Center.

Category             Outcome/Lessons Learned

Burn care            Implementation of the burn flowsheet
                     with documentation of continuous fluid
                     resuscitation decreased morbidity and
                     mortality from burn wounds. (6)

Compartment          ALARACT (all Army action) memo mandated
syndrome             a high index of suspicion for
                     compartment syndrome and a standardized
                     approach to guide providers in the
                     evaluation and treatment of patients
                     with extremity war wounds, including the
                     role of prophylactic and therapeutic
                     fasciotomy. (7)

Infection control/   Early recognition of Mucor and
prevention           Aspergillus fungal infection, which
                     allowed initiation of a clinical
                     practice guideline designed to combat
                     angioinvasive fungal infections.

Mild traumatic       Development of a comprehensive screening
brain injury         process of all Warriors for incidence of
                     traumatic brain injury before they are
                     returned to duty or manifested to the
                     United States. (8)

Nutrition            Optimization of nutritional status with
                     early initiation and ongoing nutritional
                     support of the critically ill or injured
                     patient. (7)

Post-splenectomy     Implementation of a clinical practice
immunization         guideline which ensured that all
                     post-splenectomy wounded warriors
                     receive appropriate vaccination and
                     nursing documentation of its
                     administration. (7)

Skin integrity       Implementation of clinical guidance in
                     the assessment and management of skin
                     integrity in order to assess patients
                     for risk of pressure ulcers, prevent
                     pressure ulcers, and treat pressure
                     ulcers using standards of nursing
                     practice guidelines. (9)
Gale Copyright: Copyright 2011 Gale, Cengage Learning. All rights reserved.