Optimizing wartime en route nursing care in operation Iraqi freedom.
Health care industry (Services)
Medical care (Quality management)
Medical care (Research)
|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 Computer Subject: Health care industry|
|Product:||SIC Code: 8000 HEALTH SERVICES|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
The Combat Healthcare System is a complex mix of interrelated and interdependent systems which provides a continuum of medical treatment from the point of injury (POI) or wounding, through the chain of healthcare delivery to definitive, rehabilitative, and convalescent care in the United States, if needed. Medical evacuation (MEDEVAC) is the system that provides the vital en route patient care during transport between echelons of care, and includes emergency medical interventions to improve patient outcomes, for example, improved prognosis for recovery and/or minimization of potential disabilities.
The intratheater patient movement and en route care during medical evacuation occurs at the battlefront (tactical), between echelons of care (level II and level III) within the theater (operational), and during intertheater transfers (strategic). It requires the synchronization and integration of the Army, Navy, and Air Force medical evacuation resources. The intratheater patient movement system is unlike the intertheater worldwide patient movement and evacuation system, operated by the US Transportation Command, which moves patients to the United States from all combat theaters. Army medical evacuation is a multifaceted program accomplished by a combination of dedicated ground (ambulances/other vehicles) and air (helicopters) evacuation platforms synchronized to provide direct MEDEVAC within the joint operations area. At the tactical level or at the POI, first responders from the organic unit provide the medical evacuation resources to locate, acquire, treat, and evacuate wounded Warriors to an appropriate level II/level III facility. Damage control surgery is often performed by forward surgical teams (FST) in relatively austere environments (level II). The stabilized patients require rapid evacuation by helicopter to a level III combat support hospital (CSH) or theater hospital, since there is no intensive care unit in which to continue the resuscitation. Patients often undergo 2 to 3 damage control surgeries along the way. At the CSH, the goal is to stabilize, prioritize, and, if required, prepare for further evacuation to a higher-level capability, either within the joint operations area, at an overseas facility, or in the United States. The transport of critically ill patients from a CSH to level IV (Landstuhl, Germany) and or level V (medical treatment facility in the United States) is the responsibility of the Air Force Critical Care Aeromedical Transport Team.
The Army's medical evacuation system uses the following principles to guide patient transport1:
* Conformity. Medical evacuation support is arrayed on the battlefield in the right place at the right time, and synchronized across operational commands to maximize responsiveness and effectiveness.
* Continuity. Medical care provided during medical evacuation is effective and continuous to prevent interruptions in the continuum of care.
* Control. Control is exercised over the execution of medical evacuation operations. The medical evacuation system is responsive to changing requirements and tailored to effectively support the forces within an area of operations. The system also complies with the combatant command guidance and intent, and maximizes the use of scarce medical evacuation resources.
* Proximity. The speed with which medical evacuation is initiated is extremely important in reducing morbidity, mortality, and disability.
* Flexibility. The medical evacuation plan must be designed to ensure flexibility and agility as well as enhance the ability to rapidly task-organize and relocate medical evacuation assets to meet changing battlefield requirements.
* Mobility. Mobility and survivability ensures that medical evacuation resources can rapidly respond and that evacuation routes do not become too lengthy.
In mid 2007, MG Patricia Horoho, the new Chief of the Army Nurse Corps, presented her vision for fundamentally transforming the Army Nurse Corps into a force multiplier for both Army Medicine and the Army. That vision eventually evolved into the need to establish an Army Nursing System of Care, now called the Patient CaringTouch System, to transition nursing delivery from an expert-based to a systems-based nursing care model. The 5 major elements that make up the Patient CaringTouch System include:
* Enhanced communication
* Capability building
* Healthy work environment
* Patient-family centered care
Patient-family centered care addressed the need to deliver the highest quality care to those wounded in battle, and to support their families and loved ones back home. MG Horoho and senior leaders of the Army Nurse Corps highlighted en route care in a combat environment as an area that not only needed major improvements, but would have a substantial impact on healthcare delivery to wounded Warriors. In addition to improving the quality of care provided to our Warriors in combat, the Patient CaringTouch System would also promote standards, allow measurement of nurse-sensitive outcomes, and monitor the impact of practice innovations.
In late 2007, the 86th CSH (Task Force 86 (TF86)), located in Baghdad, Iraq, was selected to establish a theater-wide en route care program that would address and meet the combatant commanders' responsibilities of intratheater patient movement in their areas of operations. TF86 was selected not only because of the large number of en route care missions that were originating from that facility, but also because of the high acuity of patients admitted to and transported from it. The surge of combat operations in 2007 vastly increased the number of deployed military members to the ITO. This surge resulted in increased combat operations and resulting casualties and injuries throughout the theater. Being one of the premiere level III trauma facilities in Iraq, with specialized trauma teams, TF86 was heavily involved in supporting the intense combat operations in and around Baghdad. TF86 had inherited a substantial en route care program from the previous deployed task force which had been in theater for 15 months. TF86 was therefore able to influence the much needed changes in the en route care processes and procedures. The need to improve Warrior care delivery in theater also coincided with the theater medical commander's insistence to refocus the task force's mission of providing top notch care for all wounded and ill brought to medical treatment facilities. The en route care program directly supported the commander's major strategic goal of "providing world-class Warrior healthcare to US and Coalition forces," with the end point of optimizing the return of Soldiers to duty and conserving combat power. Initial assessment of the en route care program in Operation Iraqi Freedom (OIF) showed fragmented care delivery and the lack of standards and standardization of the nursing role during en route care missions. However, the assessment also showed that there were examples of excellence at many medical facilities, as was expected in an expert-based care delivery model. The previous task force had left a legacy of a working en route care model, and MG Horoho challenged TF86 to enhance the model to allow both development and dissemination of en route care best practices throughout the ITO. The need to make a deliberate and effective shift towards systems-based care delivery was quickly established. The systems-based delivery model was supported by the development and implementation of clinical practice guidelines, and effective, efficient, outcome-based metrics.
Since the beginning of the ongoing combat operations in early 2003, Army nurses have functioned in their role as en route care providers, transporting patients from level II and level III facilities on MEDEVAC helicopters throughout Iraq and Afghanistan. Although the en route care program discussed in this article was developed in OIF, the challenges of undertaking this mission under rugged and dangerous combat conditions remains the same in OIF, Operation Enduring Freedom (OEF), the current Operation New Dawn in Iraq, and other overseas contingency operations (OCO).
Transfers from the point of injury to level II/level III are primarily provided by Army MEDEVAC units assigned to dedicated geographical sectors. The primary healthcare provider on these transfers are Army (or other service equivalent) flight medics, and/or flight surgeon or a physician's assistant. These healthcare providers are specially trained for providing urgent and routine en route care on helicopters. On the other hand, the nurses selected to perform the en route care mission in the early years of combat operations had minimal or no formal training to function as sole providers in a helicopter. Informal surveys among MEDEVAC flight nurses during the 15 months of OIF 07-09 (2007-2009) indicated that approximately 14% of Army nurses providing en route care in the ITO had received formal military (Joint En Route Care Course) or civilian training to function in the role, while over 96% of the nurses providing en route care self-reported critical care or emergency room training (Table 1). * The patient case-mix of those medically evacuated during OIF 07-09 is presented in Table 2. [[dagger]]
The typical MEDEVAC flight in either combat theater lasted 25 to 60 minutest Besides operating in a dangerous active combat corridor, the en route care nurses also operated in constrained environments with limited to no light, high decibel noise, and severe vibrations that impacted not only basic patient assessment and interventions, but also high to very high equipment failure rates. Regardless of the limitations, both the medical task force and the combatant commanders expected en route medical care to maintain the same standards of nursing care as found in a fixed facility. During OIF 07-09, a period of 15 months, approximately 18% (over 700) of over 3,800 total aeromedical evacuation patients from all level II and level III facilities in the ITO required en route care nurses to provide the higher level of nursing care. ([dagger])
Transport of any critically ill patient begins with a careful consideration of the necessity of the transport, assessment of the patient condition, defining command and control for the process, communication between care teams, preparation and packaging of the patient for transport, premovement equipment checks, transportation and en route care, transfer of care at the staging facility, proper documentation, and consideration for events reporting and process improvement. (2) Considering the complexities of transporting patients, the importance of evidence-based decision making in a resource-constrained combat environment in the delivery of quality healthcare is well understood. The program discussed here focused not only on the problem of lack of indicators to measure en route care nursing workload, but also the lack of benchmarks to measure the quality of en route nursing care in a combat environment.
For the first time in MEDEVAC operations in OIF, a set of 5 metrics were developed to quantify both the workload and the quality of care. The 5 metrics not only allowed the level III facilities to capture the workload, but also allowed the medical treatment facility commanders and nursing leaders to make informed, data-driven decisions to improve en route care processes. To quantify the workload, a new Operational Interfacility Transport Acuity Workload Tool, developed by the Army Medical Department Center and School Directorate of Combat and Doctrine Development, was used by all level II and level III facilities in the ITO. Operational metrics were used to measure, analyze, control, and improve local operations in a process workflow. The qualitative metrics measured those processes that are not easily quantifiable but define the standards of en route care delivered during the en route care missions. In addition the program also supported performance improvements while sustaining efficiencies, allowed appropriate levels of internal controls and incorporated best practices from current and civilian aeromedical evacuation programs. The performance metrics were benchmarked (3) (benchmarking identifies "best-in-class organizational performance") and improved processes were applied to achieve superior results.
The performance metrics developed under the operational category include throughput and patient workload, while the qualitative category includes metrics which measure processes not easily quantifiable but define the standards of en route care. These metrics include nursing/medical interventions during en route care, equipment failure-related interventions; and performance improvement initiatives. Throughput was defined as the output of a process over a specified period of time. with results displayed as a percentage. (3) Patient workload measured the actual workload and reported patient acuities as acuity category (category 1-6). Acuity categories 5 and 6 are considered severely ill, similar to the patient acuity profile provided by the Workload Management System for Nursing at a United States or overseas Army medical treatment facility with inpatient capability. Within qualitative metrics, nursing/medical interventions included all nursing/medical interventions, such as titrating paralytics, sedation, fluids/blood, adjusting oxygenation, etc, during each en route care flight. The interventions included actions such as reversing/supporting hemodynamic changes, ventilator support, manual oxygenation support efforts via the bag-valve method, and medications and blood transfusions among others. Nursing/medical intervention was entered for each patient workload acuity category. Equipment failure interventions (EFI) included patient interventions due to equipment failures, such as failure of ventilators/ventilator settings, Propaq (Skaneateles Falls, NY) monitors, medication infusion pumps, oxygen tanks, and other onboard equipment to maintain patient safety and stability. An EFI was also entered for each patient workload acuity category. Finally, the performance improvement (PI) initiatives at each CSH/level II facility were captured as a metric. Each facility was allowed to improve a site-specific process because of very dissimilar combat and operational environments. For example, patient acuities at level II and level III facilities with head trauma teams would be vastly different and require completely different equipment, as well as different patient en route care protocols. Allowing each facility the leverage to focus on their site-specific deficiencies allowed ownership and added effort. Each facility conducted an assessment of priority of initiatives needed to improve patient care and/or processes. Example of PI results in this study included improved patient outcomes for mechanically ventilated patients and initiatives to reduce hypothermia.
PERFORMANCE METRIC OUTCOMES
The data presented in Figure 1 are site-specific to TF86 in Iraq from September 2007 through September 2008. The data compiled during the 12-month period provided the en route care program officer-in-charge (OIC) an overview of the structure of the en route care processes, including pretransport assessment, and preparation and discharge transportation and documentation processes. In addition, this metric highlighted for the hospital command the quality of triage, registration and care processes, staffing requirements, and specialist and diagnostic availability. Clinical quality management was able to use this metric to assess the emergency medical treatment (EMT) unit, the intensive care unit, the intermediate care ward, the operating room (OR) capacity, bed availability and tracking, and interaction between EMT, OR, and inpatient sections. As a lagging indicator, throughput allowed the leaders to match periods of high intensity combat operations in the areas of operations with the increased need for en route care nursing staff. For example, in May 2008, there was a large spike in the number of en route care missions concurrent with an increase in operations in many parts of Baghdad. The use of this metric as a predictor to adjust staffing based on increases in combat operations requires further investigation.
[FIGURE 1 OMITTED]
Patient workload measures the patient acuities over a period. The Operational Interfacility Transport Acuity Workload Tool was used for the first time in any combat theater to capture the workload data (Figure 2). The workload capture tool was tested for reliability and validity. The inter-rater reliability of the workload tool, tested at 5 facilities in the ITO, was 0.933 and showed a high validity. This metric functioned as an indicator to plan, monitor, and evaluate the en route care nurse's performance, as well as allow the en route care program OIC, the MEDEVAC committee, and senior nurse leaders to monitor variances between patient outcomes and take corrective actions. This was accomplished through documentation that was standardized throughout the ITO.
Prior to this theater-wide program, major variances were noted, not only in what was documented, but also the different forms used to capture the patient care data. The use of standard processes enhances the validity of a workload capture system and a reliable, validated nursing workload capture tool is a key source of information. (4) The results of the workload metric provided the decision makers and researchers a retrospective view of the patient workload in the ITO, something that had not been accomplished since the beginning of the war. The results determined by the metric highlighted the category of patients transferred during en route care missions, with over 30% patients categorized as severely or very severely injured/ill, as shown in Figure 2. Qualitative metrics, nursing interventions, and equipment failure interventions answer the question of the value-added of an en route care nurse operating in a helicopter. All MEDEVAC missions (routine through urgent) include a flight medic, a specially trained crew member capable of providing necessary critical patient care in prehospital settings and in the aviation environment, and is certified in basic trauma life support, advance cardiac life support, and pediatric advanced life support. (5)
However, the majority of patients were either postsurgical stabilized, or had received initial interventions/resuscitation in the emergency rooms. This added complexity of postsurgery medication management or the unstable status of the patient required a higher level of care.
[FIGURE 3 OMITTED]
For example, the management of complex ventilator settings, in addition to the use and management of sedation and paralytics in head trauma patients, clearly required skills that are maintained by nurses and physicians with formal critical and/or emergency room training or experience. As shown in Figure 3, en route care nurses intervened during 40% and 80% of total en route care missions. The EFI highlighted as high as 20% of the en route care missions required the en route care nurse to take corrective actions with patient equipment. The value added of this metric was the evidence of a successful transition to standardize patient equipment in January 2008. Beginning in early 2008, the trend showed a decrease in the number of EFI.
Finally, the last metric measured at TF86 was PI. The PI metric at TF86 measured the number of hypothermia cases per month. Combat trauma patients have a high percentage of penetrating or burn injuries. Hypothermia is a prehospital physiologic marker, and independent contributor to overall mortality.
Prevention of hypothermia could reduce resource use and improve survival. In a study (6) of 2,848 patients in Iraq, 18% were found to be hypothermic with temperatures below 36[degrees]C. Hypothermia was significantly correlated (P <.05) with admission Glasgow Coma Scale, ** tachycardia, hypotension, lower hematocrit, and acidosis. Hypothermic patients had a significantly higher blood product and factor VIIa requirement. Hypothermia was an independent predictor of operative management of injuries, damage control laparotomy, factor VIIa use, and overall mortality (P<.05). Prior to a standardized packaging process at TF86, between 12% and 15% patients had recorded hypothermia during or after medical evacuation. With the implementation of a standardized process, including the use of the Hypothermia Prevention and Management Kit (HPMK) and warmed intravenous fluids prior to the evacuation, the hypothermia cases had dropped to less than 3% during the 12-month period. The HPMK is a NASA-developed, lightweight, strong, and flexible self-heating liner with reflective reinforced shell, designed to maintain temperatures up to 41[degrees]C. These low cost liners were one-time use items, and management of hypothermia was successfully achieved, especially during the low temperatures at night in the Iraq desert.
A number of other structural and process improvements were also documented after the implementation of the theater-wide en route care program. Notably, the success of the program was heavily influenced by the establishment of a multidisciplinary MEDEVAC committee and the use of clinical practice guidelines, developed by the Joint Theater Trauma Registry (JTTS). The MEDEVAC committee, initially established by the preceding task force, was responsible for the oversight of all en route care missions and operations at TF86. The committee also ensured the efficacy of the standardized processes in place for en route care, and reported directly to the TF86 Executive Council. The TF86 Medical Director served as the supervising medical consultant for all en route care issues. The en route care program director (additional duty of intensive care unit and emergency medical treatment clinical nurse OIC), provided direct supervision of the en route care nursing competencies and reported to the deputy commander of nursing. Another role of the committee was to perform periodic risk assessment on 10% of records per month to ensure there was no deviation from en route care policies. This audit role not only ensured standardization of practice during en route care, but also standardized documentation forms and procedures, as well as the equipment and supplies carried by the en route care nurse. Another outcome was the standardization of medications carried by the en route care nurse. Based on the patient's diagnosis, standardized medication packets were carried, including intravenous fluids, sedatives, paralytics, vasoactive/vasopressors, and controlled medications (narcotics). Special focus was also placed on head trauma, considering the limitations and special equipment required during en route care. For example, from a therapeutic perspective, the use of hypertonic saline for hyperosmolar therapy in traumatic brain injury (TBI) is beneficial in disaster and wartime practice, not only because of its ability to effectively lower intracranial pressure, but also due to its ability to preserve or improve hemodynamic parameters in patients who have experienced polytrauma. (7) A 3% Hyperosmolar solution was a standard medication during patient transfers with head trauma/TBI.
The JTTS clinical practice guidelines on the intratheater air transport of patients from a level II facility to a level II or III facility, and from a level III facility to a level III facility provided guidelines for en route care activities during such transport. The JTTS, like civilian trauma systems, was designed to provide a seamless transition in combat casualty care from the point of injury through each echelon of care to further integrate casualty care resources at all echelons among all services, and to ultimately achieve improved combat casualty outcomes. The contributions of the JTTS have resulted in improved combat casualty outcomes through the development of a number of clinical practice guidelines for medical care in a combat theater. In addition, with data collected on over 17,000 combat casualties, the JTTS standardized methods of medical documentation, and supported implementation of a sophisticated performance improvement program. (8)
En route care in an austere environment, such as the battlefields of Iraq and Afghanistan, definitely presents many challenges. The many lessons that were learned in the Iraq theater demonstrate the need for adequate preparation of nurses involved with the en route care missions. The intratheater transport system is a unique and significant part of the Force Health Protection concept for "clearing the battlefield." Medical evacuation is the timely, efficient movement and en route care of patients by medical personnel from the battlefield and/or medical facilities to a higher level of care during the full spectrum of military operations. The goal is to provide every patient who is injured on the battlefield or in the areas of operations with the optimal opportunity for survival and the maximum potential for a functional recovery. Combatant commanders expect clinicians to provide expert care at medical facilities and during transport to a higher level of care. With a standardized approach, we were able to make many structural and process improvements to the program, making it not only robust and flexible to meet the unique challenges in an area of operation, but also easily exportable to any area of combat operations or disaster relief. The new Operational Interfacility Transport Acuity Workload Tool, with a high reliability and validity, can be effectively used in any environment, peacetime or combat. The tactical deployment of clinical practice guidelines resulted in positive patient outcomes throughout the continuum of healthcare delivery. In addition to the outcomes mentioned in the study, strategic implications of the en route care program for senior leaders include the establishment of a process to support decision making based on data driven metrics, improvements in quality of nursing care delivery, and decision making ability of needs-based nurse staffing requirements. Future research could focus on further refinements of the workload capture tool in humanitarian and peacekeeping/peacetime missions, both at home and abroad. Further study is indicated to establish a process to predict increased need for medical assets, both for en route care and to ensure continued healthcare delivery during high-tempo combat operations in the theater of operations.
(1.) Field Manual 4-02.2: Medical Evacuation. Washington, DC: US Dept of the Army; May 8, 2007.
(2.) Pauldine R, Gerold KB. Transport of the critically ill patient. Contemp Crit Care. 2008:5(8):1-11.
(3.) George ML, Rowlands D, Price M, Maxey J. The Lean Six Sigma Pocket Toolbook. New York: McGraw Hill; 2005.
(4.) US Army Office of Business Transformation. Lean Six Sigma. 2011. Available at: http://www.armyobt.army. mil/cpi-kc-tools-lss.html. Accessed April 15, 2011.
(5.) US Army School of Aviation Medicine. Flight Medic Course, Medical Medic Course (300-F6). Available at: http://usasam.amedd.army.mil/fmc.htm#History. Accessed February 2, 2011.
(6.) Arthurs D, Cuadrado D, Beekley A, Grathwohl K, Perkins J, Rush R, Sebesta J. The impact of hypothermia on trauma care at the 31st Combat Support Hospital. Am J Surg. 2006; 191(5):610-614.
(7.) Venticinque SG, Grathwohl KW. Critical care in the austere environment: providing exceptional care in unusual places. Crit Care Med. 2008;36(suppl 7): S284-S289.
(8.) Smith KK. Critical care nursing in an austere environment. Crit Care Med. 2008;36(suppl 7):S297-S303.
MAJ Michael Nagra, AN, USA
* Self-reported to the author during informal surveys in theater.
[[dagger]] Data extracted and compiled by military analysts during deployment, not available to the general public.
** The Glasgow Coma Scale is a quick, practical, standardized system for assessing the degree of consciousness in the critically ill and for predicting the duration and ultimate outcome of coma, primarily in patients with head injuries. The system involves eye opening, verbal response, and motor response, all of which are evaluated independently according to a rank order that indicates the level of consciousness and degree of dysfunction. Source: Mosby's Medical Dictionary. 8th ed. St Louis, MO: Mosby- Year Book, Inc; 2009.
MAJ Nagra is Chief, Clinical Modeling Branch, Manpower Division, Program Analysis and Evaluation, US Army Medical Command, Fort Sam Houston, Texas.
Table 1. Self-reported sources of training of available en route care nurses in Iraq during Operation Iraqi Freedom 07-09 (N=72). * En route Care Training Source No. % N Military trained (Joint En Route Care Course) 8 11% Civilian en route care trained 2 3% Critical care or emergency room trained nurses 69 96% * Informal surveys by the author during deployment. Table 2. The patient case mix of medical evacuees during Operation Iraqi Freedom 07-09. * Combat Injuries >40% Disease and nonbattle injuries 40% Others <20% US casualties (military and civilian) >70% Pediatric 8% Burns 5% * Data sourced and compiled internally by military analysts during deployment, not available to the general public. Figure 2. Distribution of patient acuity categories by percentage of the total number of patients transported on en route care missions in Iraq by TF86 assets from September 2007 through September 2008. Categories represent increasing severity of injury/sickness from 1 (lowest) to 6 (very seriously injured/ill). Source: Data derived and compiled by the author. Patient Acuity Category Percentage of Total Workload CAT 1 0.0% CAT 2 9.1% CAT 3 31.0% CAT 4 29.5% CAT 5 20.4% CAT 6 10.0% Note: Table made from bar graph.
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