Military Health System Strategic Partnership with the American College of Surgeons

Refocusing the Military Health System to support Role 4 definitive care in future large-scale combat operations

ABSTRACT

The last 20 years of sustained combat operations during the Global War on Terror generated significant advancements in combat casualty care. Improvements in point-of-injury care, en route care, and forward surgical care appropriately aligned with the survival, evacuation, and return to duty needs of the small-scale unconventional conflict. However, casualty numbers in large-scale combat operations have brought into focus the critical need for modernized casualty receiving and convalescence: Role 4 definitive care. Historically, World War II was the most recent conflict in which the United States fought in multiple operational theaters, with hundreds of thousands of combat casualties returned to the continental United States. These numbers necessitated the establishment of a "Zone of the Interior," which integrated military and civilian health care networks for definitive treatment and rehabilitation of casualties. Current security threats demand refocusing and bolstering the Military Health System's definitive care capabilities to maximize its force regeneration capacity in a similar fashion. Medical force generation, medical force sustainment and readiness, and integrated casualty care capabilities are three pillars that must be developed for Military Health System readiness of Role 4 definitive care in future large-scale contingencies against near-peer/peer adversaries.

Case Volume and Readiness to Deploy: Clinical Opportunities for Active-Duty Surgeons Outside of Military Hospitals

BACKGROUND

The Military Health System (MHS) uses a readiness program that identifies the knowledge, skills, and abilities (KSAs) necessary for surgeons to provide combat casualty care. Operative productivity is assigned an objective score based on case type and complexity and totaled to assess overall readiness. As of 2019, only 10.1% of surgeons met goal readiness threshold. At one tertiary military treatment facility (MTF), leadership has taken an aggressive approach toward increasing readiness by forming military training agreements (MTAs) and allowing Off Duty Employment (ODE). We sought to quantify the efficacy of this approach.

STUDY DESIGN

Operative logs from 2021 were obtained from surgeons assigned to the MTF. Operations were assigned CPT codes and processed through the KSA calculator (Deloitte; London, UK). Each surgeon was then surveyed to identify time away from clinical duties for deployment or military training.

RESULTS

Nine surgeons were present in 2021 and spent an average of 10.1 weeks (19.5%) abroad. Surgeons performed 2,348 operations (Average [Avg] 261 ± 95) including 1,575 (Avg 175; 67.1%) at the MTF, 606 (Avg 67.3; 25.8%) at MTAs, and 167 (Avg 18.6, 7.1%) during ODE. Adding MTA and ODE caseloads increased KSA scores by 56% (17,765 ± 7,889 vs 11,391 ± 8,355). Using the MHS threshold of 14,000, 3 of 9 (33.3%) surgeons met the readiness threshold from MTF productivity alone. Including all operations, 7 of 9 (77.8%) surgeons met threshold.

CONCLUSIONS

Increased use of MTAs and ODE significantly augments average caseloads. These operations provide considerable benefit and result in surgeon readiness far exceeding the MHS average. Military leadership can maximize the chances of meeting readiness goals by encouraging clinical opportunities outside the MTF.

Evidence-based Surgical Competency Outcomes from the Clinical Readiness Program

OBJECTIVES

1) Evaluate the value and strength of a competency framework for identifying and measuring performance requirements for expeditionary surgeons; 2) Verify psychometric integrity of assessment instrumentation for measuring domain knowledge and skills; 3) Identify gaps in knowledge and skills capabilities using assessment strategies; 4) Examine shared variance between knowledge and skills outcomes, and the volume and diversity of routine surgical practice.

BACKGROUND

Expeditionary military surgeons provide care for patients with injuries that extend beyond the care requirements of their routine surgical practice. The readiness of these surgeons to independently provide accurate care in expeditionary contexts is important for casualty care in military and civilian situations. Identifying and closing performance gap areas are essential for assuring readiness.

METHODS

We implemented evidence-based processes for identifying and measuring the essential performance competencies for expeditionary surgeons. All assessment instrumentation was rigorously examined for psychometric integrity. Performance outcomes were directly measured for expeditionary surgical knowledge and skills and gap areas were identified. Knowledge and skills assessment outcomes were compared, and also compared to the volume and diversity of routine surgical practice to determine shared variance.

RESULTS

Outcomes confirmed the integrity of assessment instrumentation and identified significant performance gaps for knowledge and skills in the domain.

CONCLUSIONS

Identification of domain competencies and performance benchmarks, combined with best-practices in assessment instrumentation, provided a rigorous and defensible framework for quantifying domain competencies. By identifying and implementing strategies for closing performance gap areas, we provide a positive process for assuring surgical competency and clinical readiness.

Upper-Extremity Vascular Exposures for Trauma: Comparative Performance Outcomes for General Surgeons and Orthopedic Surgeons

INTRODUCTION

As combat-related trauma decreases, there remains an increasing need to maintain the ability to care for trauma victims from other casualty events around the world (e.g., terrorism, natural disasters, and infrastructure failures). During these events, military surgeons often work closely with their civilian counterparts, often in austere and expeditionary contexts. In these environments, the primary aim of the surgical team is to implement damage control principles to avert blood loss, optimize oxygenation, and improve survival. Upper-extremity vascular injuries are associated with high rates of morbidity and mortality resulting from exsanguination and ischemic complications; however, fatalities may be avoided if hemorrhage is rapidly controlled. In austere contexts, deployed surgical teams typically include one general surgeon and one orthopedic surgeon, neither of which have acquired the expertise to manage these vascular injuries. The purpose of this study was to examine the baseline capabilities of general surgeons and orthopedic surgeons to surgically expose and control axillary and brachial arteries and to determine if the abilities of both groups could be increased through a focused cadaver-based training intervention.

METHODS

This study received IRB approval at our institution. Study methods included the use of cadavers for baseline assessment of procedural capabilities to expose and control axillary and brachial vessels, followed by 1:1 procedural training and posttraining re-assessment of procedural capabilities. Inferential analyses included ANOVA/MANOVA for within- and between-group effects (P < .05). Effect sizes were calculated using Cohen's d.

RESULTS

Study outcomes demonstrated significant differences between the baseline performance abilities of the two groups, with general surgeons outperforming orthopedic surgeons. Before training, neither group reached performance benchmarks for overall or critical procedural abilities in exposing axillary and brachial vessels. Training led to increased abilities for both groups. There were statistically significant gains for overall procedural abilities, as well as for critical procedural elements that are directly associated with morbidity and mortality. These outcomes were consistent for both general and orthopedic surgeons. Effect sizes ranged between medium (general surgeons) and very large (orthopedic surgeons).

CONCLUSION

There was a baseline capability gap for both general surgeons and orthopedic surgeons to surgically expose and control the axillary and brachial vessels. Outcomes from the course suggest that the methodology facilitates the acquisition of accurate and independent vascular procedural capabilities in the management of upper-extremity trauma injuries. The impact of this training for surgeons situated in expeditionary or remote contexts has direct relevance for caring for victims of extremity trauma. These outcomes underscore the need to train all surgeons serving in rural, remote, expeditionary, combat, or global health contexts to be able to competently manage extremity trauma and concurrent vascular injuries to increase the quality of care in those settings.

A Novel Paradigm for Surgical Skills Training and Assessment of Competency

Importance

Sustainment of comprehensive procedural skills in trauma surgery is a particular problem for surgeons in rural, global, and combat settings. Trauma care often requires open surgical procedures for low-frequency/high-risk injuries at a time when open surgical experience is declining in general and trauma surgery training.

Objective

To determine whether general surgeons participating in a 2-day standardized trauma skills course demonstrate measurable improvement in accuracy and independent performance of specific trauma skills.

Design, Setting, and Participants

General surgeons in active surgical practice were enrolled from a simulation center with anatomic laboratory from October 2019 to October 2020. Differences in pretraining/training and posttraining performance outcomes were examined using (1) pretraining/posttraining surveys, (2) pretraining/posttraining knowledge assessment, and (3) training/posttraining faculty assessment. Analysis took place in November 2020.

Interventions

A 2-day standardized, immersive, cadaver-based skills course, developed with best practices in instructional design, that teaches and assesses 24 trauma surgical procedures was used.

Main Outcomes and Measures

Trauma surgery capability, as measured by confidence, knowledge, abilities, and independent performance of specific trauma surgical procedures; 3-month posttraining skill transfer.

Results

The study cohort included 65 active-duty general surgeons, of which 16 (25%) were women and 49 (75%) were men. The mean (SD) age was 38.5 (4.2) years. Before and during training, 1 of 65 participants (1%) were able to accurately perform all 24 procedures without guidance. After course training, 64 participants (99%) met the benchmark performance requirements for the 24 trauma procedures, and 51 (78%) were able to perform them without guidance. Procedural confidence and knowledge increased significantly from before to after the course. At 3 months after training, 37 participants (56%) reported skill transfer to trauma or other procedures.

Conclusions and Relevance

In this study, direct measurement of procedural performance following standardized training demonstrated significant improvement in skill performance in a broad array of trauma procedures. This model may be useful for assessment of procedural competence in other specialties.

Clinical Readiness Program: Refocusing the Military Health System

INTRODUCTION

The Military Health System serves to globally provide health services and trained medical forces. Military providers possess variable levels of deployment preparedness. The aim of the Clinical Readiness Program is to develop and assess the knowledge, skills, and abilities (KSAs) needed for combat casualty care.

METHODS

The Clinical Readiness Program developed a KSA metric for general and orthopedic surgery. The KSA methodology underwent a proof of concept in six medical treatment facilities.

RESULTS

The KSA metric feasibly quantifies the combat relevance of surgical practice. Orthopedic surgeons are more likely than general surgeons to meet the threshold. Medical treatment facilities do not provide enough demand for general surgery services to achieve readiness.

CONCLUSION

The Clinical Readiness Program identifies imbalances between the health care delivery and readiness missions. To close the readiness gap, the Military Health System needs to recapture high KSA value procedures, expand access to care, and/or partner with civilian institutions.

An evaluation of bariatric surgery in all military treatment facilities

BACKGROUND

Multiple bariatric databases have been formed, but there have been no comprehensive assessments of military treatment facilities (MTFs). MTFs have unique patients and coverage policies by Tricare insurance.

METHODS

MHS Mart (M2) was used to review the outpatient medical record, AHLTA, from October 2013 to December 2018 for type of bariatric procedure, demographics, military-specific data, comorbidities, and complications, which were identified by ICD code and CPT code, including a robotic modifier. MTFs were classified by volume as high (HV) with > 50 cases annually, moderate (MV) with 25 to 50 cases, and low (LV) with < 25 cases, as well as by the presence of surgical residencies.

RESULTS

Patients at MTFs were slightly younger and more female than by other database studies. The Army was the most common branch of service, and dependents of retirees were the most common beneficiary population. MTFs with residencies had slightly older patients and fewer Army patients. HV, MV, and LV MTFs had similar patients except for branch of service. Over time, the proportion of open gastric bypasses increased, biliopancreatic diversions with duodenal switches decreased, and robotic assistance increased 744%. MTFs with residencies performed more procedures than those without residencies, and with the exception of procedures utilizing robotic assistance, procedures were overall similar to those without residencies. HV MTFs performed most of the procedures annually, and their procedures were proportionately similar to MV and LV MTFs, with the exception of HV MTFs having a higher proportion of laparoscopic bypasses and robotic assistance.

CONCLUSION

MTFs largely perform similar procedures on similar patients relative to MBSAQIP and NSQIP studies. Robotic assistance increased significantly over time. Except for laparoscopic bypasses and procedures with robotic assistance, HV MTFs performed similar proportions of procedures to MV and LV MTFs. MTFs with residencies performed similar procedures to those without residencies.

Dutch combat operation experiences in Iraq and Afghanistan: The conundrum of low surgical workload deployments

INTRODUCTION

The Combined Joined Task Force - Operation Inherent Resolve is the military intervention of Iraq and Coalition Forces in the battle against Islamic State of Iraq and Syria (ISIS). Al Assad Airbase (AAAB) is one of the key airbases. It contains a Role 2 Medical Treatment Facility, primarily to perform Damage Control Surgery in Coalition Forces, Iraqi National Security Forces and Local Nationals. We present a six month medical exposure in order to provide insight into the treatment of casualties and to optimize medical planning of combat operations and (pre-/post-) deployment training.

PATIENTS AND METHODS

This is a cohort study of casualties that were admitted to the Role 2 Medical Treatment Facility AAAB from November 2017 to April 2018. Their mechanisms and types of injury are described and compared to those sustained in Uruzgan, Afghanistan between 2006-2010. Additionally, they are compared to the caseload in the Dutch civilian medical centers of the medical specialist team at AAAB.

RESULTS

There were significant differences in both mechanism and type of injury between Coalition Forces and Iraqi Security Forces (p = 0.0001). Coalition Forces had 100% disease and non-battle injuries, where Iraqi Security Forces had 86% battle injuries and 14% non-battle casualties. The most common surgical procedures performed were debridement of wounds (38%), (exploratory) laparotomy (10%) and genital procedures (7%). The surgical caseload in Uruzgan, Afghanistan was significantly different in aspect and quantity, being 4.1 times higher. When compared to the workload at home all team members had at least a tenfold lower workload than in their civilian hospitals.

DISCUSSION

The deployed surgical teams were scarcely exposed to casualties at AAAB, Iraq. These low workload deployments could cause a decline in surgical skills. Military medical planning should be tailormade and should include adjusting length of stay, (pre-/post-)deployment refresher training and early consultation of military medical specialists. Future research should focus on optimizing this process by investigating fellowships in combat matching trauma centers, regional and international collaboration and refresher training possibilities to maintain the expertise of the acute military care provider.