Trauma Governance in the UK Defence Medical Services

Counterfactual reasoning using causal Bayesian networks as a healthcare governance tool

BACKGROUND

Healthcare governance (HG) is a quality assurance processes that aims to maintain and improve clinical practice. Clinical decisions are routinely reviewed after the outcome is known to learn lessons for the future. When the outcome is positive, then practice is praised, but when practice is suboptimal, the area for improvement is highlighted. This process requires counterfactual reasoning, where we predict what would have happened given both what happened and the possible different decisions. Causal models that capture the mechanisms that generate events can support counterfactual reasoning.

OBJECTIVE

This study is an initial attempt to show how counterfactual reasoning with causal Bayesian networks (CBNs) can be used as a HG tool to assess what would have happened if treatments other than those occurred had been selected.

METHODS

Motivated by the Defence Medical Services (DMS) mortality and morbidity (M&M) review meeting, in this paper we (1) extended the use of counterfactual reasoning in CBNs to review decisions, where the alternative treatment strategies and its effect belong to different stages of care, (2) placed counterfactual reasoning in a specific clinical context to examine how it can be used as a HG tool.

RESULTS

Using three realistic examples, we demonstrated how the proposed counterfactual reasoning can be used to assist the DMS M&M review meetings.

CONCLUSIONS

Useful lessons can be learned by assessing decisions after they are made. M&M review meetings are fruitful ground for counterfactual reasoning. The use of a clinical decision support tool that can assist clinicians in assessing counterfactual probabilities will be beneficial.

Injuries in Fatalities of Dismounted Blast: Identification of Four Mechanisms of Head and Spine Injury

Blast is the most common injury mechanism in conflicts of this century due to the widespread use of explosives, confirmed by recent conflicts such as in Ukraine. Data from conflicts in the last century such as Northern Ireland, the Falklands, and Vietnam up to the present day show that between 16% and 21% of personnel suffered a traumatic brain injury. Typical features of fatal brain injury to those outside of a vehicle (hereafter referred to as dismounted) due to blast include the presence of hemorrhagic brain injury alongside skull fractures rather than isolated penetrating injuries more typical of traditional ballistic head injuries. The heterogeneity of dismounted blast has meant that analysis from databases is limited and therefore a detailed look at the radiological aspects of injury is needed to understand the mechanism and pathology of dismounted blast brain injury. The aim of this study was to identify the head and spinal injuries in fatalities due to dismounted blast. All UK military fatalities from dismounted blast who suffered a head injury from 2007-2013 in the Iraq and Afghanistan conflicts were identified retrospectively. Postmortem computerized tomography images (CTPMs) were interrogated for injuries to the head, neck, and spine. All injuries were documented and classified using a radiology brain injury classification (BIC) tool. Chi-squared (χ2) and Fisher's exact tests were used to investigate correlations between injuries, along with odds ratios for determining the direction of correlation. The correlations were clustered. There were 71 fatalities from dismounted blast with an associated head injury with a CTPM or initial CT available for analysis. The results showed the heterogeneity of injury from dismounted blast but also some potential identifiable injury constellations. These were: intracranial haemorrhage, intracranial deep haemorrhage, spinal injury, and facial injury. These identified injury patterns can now be investigated to consider injury mechanisms and so develop mitigation strategies or clinical treatments. Level of Evidence: Observational. Study type: cohort observational.

Defining capabilities in deployed UK military prehospital emergency care

The UK military prehospital emergency care (PHEC) operational clinical capability framework must be updated in order that it retains its use as a valid operational planning tool. Specific requirements include accurately defining the PHEC levels and the 'Medical Emergency Response Team' (MERT), while reinforcing PHEC as a specialist area of clinical practice that requires an assured set of competencies at all levels and mandatory clinical currency for vocational providers.A military PHEC review panel was convened by the Defence Consultant Advisor (DCA) for PHEC. Each PHEC level was reviewed and all issues which had, or could have arisen from the existing framework were discussed until agreement between the six members of this panel was established.An updated military PHEC framework has been produced by DCA PHEC, which defines the minimum requirements for each operational PHEC level. These definitions cover all PHEC providers, irrespective of professional background. The mandatory requirement for appropriate clinical exposure for vocational and specialist providers is emphasised. An updated definition of MERT has been agreed.This update provides clarity to the continually evolving domain of UK military PHEC. It sets out the PHEC provider requirements in order to be considered operationally deployable in a PHEC role. There are implications for training, manning and recruitment to meet these requirements, but the processes required to address these are already underway and well described elsewhere.

Advanced bleeding control in combat casualty care: An international, expert-based Delphi consensus

BACKGROUND

Hemorrhage from truncal and junctional injuries is responsible for the vast majority of potentially survivable deaths in combat casualties, causing most of its fatalities in the prehospital arena. Optimizing the deployment of the advanced bleeding control modalities required for the management of these injuries is essential to improve the survival of severely injured casualties. This study aimed to establish consensus on the optimal use and implementation of advanced bleeding control modalities in combat casualty care.

METHODS

A Delphi method consisting of three rounds was used. An international expert panel of military physicians was selected by the researchers to complete the Delphi surveys. Consensus was reached if 70% or greater of respondents agreed and if 70% or greater responded.

RESULTS

Thirty-two experts from 10 different nations commenced the process and reached consensus on which bleeding control modalities should be part of the standard equipment, that these modalities should be available at all levels of care, that only trained physicians should be allowed to apply invasive bleeding control modalities, but all medical and nonmedical personnel should be allowed to apply noninvasive bleeding control modalities, and on the training requirements for providers. Consensus was also reached on the necessity of international registries and guidelines, and on certain indications and contraindications for resuscitative endovascular balloon occlusion of the aorta (REBOA) in military environments. No consensus was reached on the role of a wound clamp in military settings and the indications for REBOA in patients with chest trauma, penetrating axillary injury or penetrating neck injury in combination with thoracoabdominal injuries.

CONCLUSION

Consensus was reached on the contents of a standard bleeding control toolbox, where it should be available, providers and training requirements, international registries and guidelines, and potential indications for REBOA in military environments.

Department of Defense Trauma Registry Infectious Disease Module Impact on Clinical Practice

BACKGROUND

The Joint Trauma System (JTS) is a DoD Center of Excellence for Military Health System trauma care delivery and the DoD's reference body for trauma care in accordance with National Defense Authorization Act for Fiscal Year 2017. Through the JTS, evidence-based clinical practice guidelines (CPGs) have been developed and subsequently refined to standardize and improve combat casualty care. Data are amassed through a single, centralized DoD Trauma Registry to support process improvement measures with specialty modules established as the registry evolved. Herein, we review the implementation of the JTS DoD Trauma Registry specialty Infectious Disease Module and the development of infection-related CPGs and summarize published findings on the subsequent impact of the Infectious Disease Module on combat casualty care clinical practice and guidelines.

METHODS

The DoD Trauma Registry Infectious Disease Module was developed in collaboration with the Infectious Disease Clinical Research Program (IDCRP) Trauma Infectious Disease Outcomes Study (TIDOS). Infection-related information (e.g., syndromes, antibiotic management, and microbiology) were collected from military personnel wounded during deployment June 1, 2009 through December 31, 2014 and medevac'd to Landstuhl Regional Medical Center in Germany before transitioning to participating military hospitals in the USA.

RESULTS

To support process improvements and reduce variation in practice patterns, data collected through the Infectious Disease Module have been utilized in TIDOS analyses focused on assessing compliance with post-trauma antibiotic prophylaxis recommendations detailed in JTS CPGs. Analyses examined compliance over three time periods: 6 months, one-year, and 5 years. The five-year analysis demonstrated significantly improved adherence to recommendations following the dissemination of the 2011 JTS CPG, particularly with open fractures (34% compliance compared to 73% in 2013-2014). Due to conflicting recommendations regarding use of expanded Gram-negative coverage with open fractures, infectious outcomes among patients with open fractures who received cefazolin or expanded Gram-negative coverage (cefazolin plus fluoroquinolones and/or aminoglycosides) were also examined in a TIDOS analysis. The lack of a difference in the proportion of osteomyelitis (8% in both groups) and the significantly greater recovery of Gram-negative organisms resistant to aminoglycosides or fluoroquinolones among patients who received expanded Gram-negative coverage supported JTS recommendations regarding the use of cefazolin with open fractures. Following recognition of the outbreak of invasive fungal wound infections (IFIs) among blast casualties injured in Afghanistan, the ID Module was refined to capture data (e.g., fungal culture and histopathology findings, wound necrosis, and antifungal management) needed for the TIDOS team to lead the DoD outbreak investigation. These data captured through the Infectious Disease Module provided support for the development of a JTS CPG for the prevention and management of IFIs, which was later refined based on subsequent TIDOS IFI analyses.

CONCLUSIONS

To improve combat casualty care outcomes and mitigate high-consequence infections in future conflicts, particularly in the event of prolonged field care, expansion, refinement, and a mechanism for sustainability of the DoD Trauma Registry Infectious Disease Module is needed to include real-time surveillance of infectious disease trends and outcomes.

Injury scoring systems for blast injuries: a narrative review

Injury scoring systems can be used for triaging, predicting morbidity and mortality, and prognosis in mass casualty incidents. Recent conflicts and civilian incidents have highlighted the unique nature of blast injuries, exposing deficiencies in current scoring systems. Here, we classify and describe deficiencies with current systems used for blast injury. Although current scoring systems highlight survival trends for populations, there are several major limitations. The reliable prediction of mortality on an individual basis is inaccurate. Other limitations include the saturation effect (where scoring systems are unable to discriminate between high injury score individuals), the effect of the overall injury burden, lack of precision in discriminating between mechanisms of injury, and a lack of data underpinning scoring system coefficients. Other factors influence outcomes, including the level of healthcare and the delay between injury and presentation. We recommend that a new score incorporates the severity of injuries with the mechanism of blast injury. This may include refined or additional codes, severity scores, or both, being added to the Abbreviated Injury Scale for high-frequency, blast-specific injuries; weighting for body regions associated with a higher risk for death; and blast-specific trauma coefficients. Finally, the saturation effect (maximum value) should be removed, which would enable the classification of more severe constellations of injury. An early accurate assessment of blast injury may improve management of mass casualty incidents.

Pattern of upper limb amputation associated with lower limb amputation: the UK military experience from Iraq and Afghanistan

INTRODUCTION

The conflicts in Iraq and Afghanistan resulted in large numbers of personnel sustaining extremity injuries. In the context of polytrauma, partial hand amputation is often unrecorded. The aim of this work was to quantify the burden of upper limb (UL) amputation at any level occurring concurrently with a major (ankle and proximal) lower limb (LL) amputation. Knowledge of this cohort could aid in prosthetic modification to further improve quality of life outcomes in a population with dexterity loss.

METHOD

A trauma database search was undertaken for all UK military LL amputees from the conflicts in Iraq and Afghanistan. A manual search method was employed to identify from the major LL amputees those who had a concurrent UL amputation at any level (including isolated finger amputation). Demographics, level of amputation, and injury profile data were recorded.

RESULTS

Sixty-eight individuals were identified; the most prevalent population was bilateral LL with a unilateral UL amputation (60%). Most UL amputations were partial hand (75%). The was no statistically significant difference between left or right side (p=0.13). On the left side, correlation was found between amputation of the thumb and third digit (rho=0.34; p=0.005) not seen on the right.

CONCLUSION

We have determined the rate of UL amputation at any level, in combination with LL amputation as a result of blast injury. Knowledge of these combinations enables further research to support anecdotal evidence that there is a need for tailored prosthetics in the context of potential dexterity loss making donning and doffing problematic.

Primary Blast Lung Injury: The UK Military Experience

INTRODUCTION

Primary blast lung injury occurs when an explosive shock wave passes through the thorax and transits through tissues of varying densities. It requires close proximity to an explosion and presents quick with respiratory distress in survivors.

MATERIALS AND METHODS

The Joint Theatre Trauma Registry and the Defence Statistics (Health) Database were interrogated for casualties injured as a result of an explosion during the conflict in Afghanistan. The case notes and imaging of casualties meeting the criteria for diagnosis were reviewed. Demographic and clinical data on casualties with primary blast lung injury were analyzed.

RESULTS

848 blast-exposed casualties survived to discharge from intensive care, and 238 blast-exposed casualties were killed in action. Following exclusions, 111 case notes and all postmortem reports were reviewed in detail. About, 25 casualties had isolated primary blast lung injury (2.9% of casualties surviving to discharge from intensive care) and 31 nonsurvivors (13% of nonsurvivors) had the disease documented at postmortem. Severe cases of primary blast lung injury required an estimated average of 4.5 days of conventional mechanical ventilation.

CONCLUSIONS

8.1% of blast exposed casualties suffered primary blast lung injury. It was a less severe disease than other nontraumatic forms of acute lung injury and did not cause deaths once a casualty had reached a combat support hospital. It was well managed with a relatively brief period of conventional mechanical ventilation.

Pelvic injury patterns in blast: Morbidity and mortality

BACKGROUND

Pelvic trauma has emerged as one of the most severe injuries to be sustained by the victim of a blast insult. The incidence and mortality due to blast-related pelvic trauma is not known, and no data exist to assess the relative risk of clinical or radiological indicators of mortality.

METHODS

The UK Joint Theater Trauma Registry was interrogated to identify those sustaining blast-mediated pelvic fractures during the conflicts in Iraq and Afghanistan, from 2003 to 2014, with subsequent computed tomography image analysis. Casualties that sustained more severe injuries remote to the pelvis were excluded.

RESULTS

One hundred fifty-nine casualties with a 36% overall mortality rate were identified. Pelvic vascular injury, unstable pelvic fracture patterns, traumatic amputation, and perineal injury were higher in the dismounted fatality group (p < 0.05). All fatalities sustained a pelvic vascular injury. Pelvic vascular injury had the highest relative risk of death for any individual injury and an associated mortality of 56%. Dismounted casualties that sustained unstable pelvic fracture patterns, traumatic amputation, and perineal injury were at three times greater risk (relative risk, 3.00; 95% confidence interval, 1.27-7.09) to have sustained a pelvic vascular injury than those that did not sustain these associated injuries. Opening of the pubic symphysis and at least one sacroiliac joint was significantly associated with pelvic vascular injury (p < 0.001), and the lateral displacement of the sacroiliac joints was identified as a fair predictor of pelvic vascular injury (area under the receiver operating characteristic curve, 0.73).

CONCLUSION

Dismounted blast casualties with pelvic fracture are at significant risk of a noncompressible pelvic vascular injury. Initial management of these patients should focus upon controlling noncompressible pelvic bleeding. Clinical and radiological predictors of vascular injury and mortality suggest that mitigation strategies aiming to attenuate lateral displacement of the pelvis following blast are likely to result in fewer fatalities and a reduced injury burden.

LEVEL OF EVIDENCE

Prognostic, level III.

The impact of ‘unofficial trauma’ on a Major Trauma Centre: A service evaluation of accident and emergency department trauma team activations

Introduction

Trauma remains a leading cause of death worldwide. In the UK, data for trauma patients are prospectively collected locally and collated by the Trauma Audit and Research Network. This study assesses and describes the subgroup of patients who triggered a trauma call but who subsequently did not meet criteria for Trauma Audit and Research Network.

Methods

A single centre, retrospective observational study of trauma calls between 1 June 2012 and 31 August 2018 was performed, determining which trauma calls had been submitted to Trauma Audit and Research Network by cross referencing with the submission database. Data were tested for normality (Shapiro–Wilk test) and appropriate statistical tests employed to determine differences between inclusion and non-inclusion groups. For categorical data, we used Chi-squared tests to examine for differences.

Results

There were 6529 trauma calls and over half (3837 (58.8%)) were not registered on Trauma Audit and Research Network. Patients excluded were significantly younger (mean 42.4 years SD 19.2) than those who met inclusion criteria (mean 50.3 years, SD 21.8), p < 0.001 and were significantly more likely to suffer from penetrating trauma (18.6% versus 8.2%, p < 0.001), the majority (77.8%, 553/713) caused by stabbings. Patients excluded were less likely to be involved in a road traffic accident (31.1% versus 35.3%, p < 0.001), less likely to have fallen downstairs (15.2% versus 18.7%, p < 0.001) and less likely to have fallen from a height > 2 m (8.1% versus 12.7%, p < 0.001).

Discussion

Patients who trigger a trauma call but who subsequently do not meet the criteria for Trauma Audit and Research Network inclusion place a significant burden on healthcare provision. To our knowledge this is the first investigation to specifically explore this group of at-risk patients. To enable medical planners a more accurate view of activity on the ‘shop floor’, particularly in reference to knife crime injuries we ask the question as to whether a separate database should now be held of trauma calls?

Innovating at pace during crisis—military lessons for the COVID environment

The challenges of innovating at pace in recent conflicts has encouraged military medical lessons to be codified into an integrated model of innovation, with generic application for the wider healthcare sector and the COVID environment specifically. This ‘Toolset for innovation and change’ emphasises the need to first understand and frame the problem using external (STEEPLE) and internal (TEPID COIL) factor analysis. The conditions that support exemplar innovation adoption by an organisation are described (ADOPTER—Agile, Decisive, Outcome focused, Politically aware, Tolerant of Risk, Empowered and Rewarded) as are the conditions that are necessary for successful innovation translation to another organisation (TRANSL8—Transformational leadership, Relevance, Adaptability/Acceptability, Networks, Simplicity, Life enhancing change, 8-steps of complex change). The obstructions to innovation, or ‘innovation constipation’, are highlighted and remembered as B-OWELS. The toolset was first developed by the author in 2015 from sustained experience of innovation at pace and has been successfully applied to messy problems requiring complex change in both the military and civilian healthcare sectors.

Trauma registry implementation and operation in low and middle income countries: A scoping review

Injury is a major public health crisis contributing to more than 4.48 million deaths annually. Trauma registries have proven highly effective in reducing injury morbidity and mortality rates in high income countries. They are a critical source of information for injury prevention, benchmarking care, quality improvement, and resource allocation. Historically, low and middle income countries (LMICs) have largely been excluded from trauma registry development due to limited resources. Recently, this has begun to change with low-resource hospitals adopting innovative strategies to implement trauma registries. Nonetheless, dissemination of these strategies remains fragmented. Hospitals looking to develop their own trauma registries have no current, comprehensive resource that summarises the implementation decisions of other registries in similar contexts. This scoping review aims to identify where trauma registries are located in LMICs, bringing up to date previous estimates, and to identify the most common approaches to registry implementation and operation in these settings.

Refining the Trauma and Injury Severity Score (TRISS) to Measure the Performance of the UK Combat Casualty Care System

INTRODUCTION

The Trauma and Injury Severity Score (TRISS) methodology is used in both the UK and US Military trauma registries. The method relies on dividing casualties according to mechanism, penetrating or blunt, and uses different weighting coefficients accordingly. The UK Military Joint Theatre Trauma Registry uses the original coefficients devised in 1987, whereas the US military registry uses updated civilian coefficients, but it is not clear how either registry analyzes explosive casualties according to the TRISS methodology. This study aims to use the UK Military Joint Theatre Trauma Registry to calculate new TRISS coefficients for contemporary battlefield casualties injured by either gunshot or explosive mechanisms. The secondary aim of this study is to apply the revised TRISS coefficients to examine the survival trends of UK casualties from recent military conflicts.

MATERIALS AND METHODS

The Joint Theatre Trauma Registry was searched for all UK casualties injured or killed in Iraq and Afghanistan by explosive or gunshot mechanisms between January 1, 2003 and December 31, 2014. Details of these casualties including injuries and vital signs were reviewed. Logistic regression analysis was performed to devise new TRISS coefficients; these were then used to examine survival over the 12 yr of the study.

RESULTS

Comparing the predictions from the gunshot TRISS model to the observed outcomes, it demonstrates a sensitivity of 98.1% and a specificity of 96.8% and an overall accuracy of 97.8%. With respect to the explosive TRISS model, there is a sensitivity of 98.6%, a specificity of 97.4%, and an overall accuracy of 98.4%. When this updated and mechanism-specific TRISS methodology was used to measure changes in survival over the study period, survival following these injuries improved until 2012 when performance was maintained for the last 2 yr of the study.

CONCLUSION

This study for the first time refines the TRISS methodology with coefficients appropriate for use within combat casualty care systems. This improved methodology reveals that UK combat casualty care performance appears to have improved until 2012 when this standard was maintained.

Clinical activity at the UK military level 2 hospital in Bentiu, South Sudan during Op TRENTON from June to September 2017

Introduction

Diseases and non-battle injuries (DNBIs) are common on UK military deployments, but the collection and analysis of clinically useful data on these remain a challenge. Standard medical returns do not provide adequate clinical information, and clinician-led approaches have been laudable, but not integrated nor standardised nor used long-term. Op TRENTON is a novel UK military humanitarian operation in support of the United Nations Mission in South Sudan, which included the deployment of UK military level 1 and level 2 medical treatment facilities at Bentiu to provide healthcare for UK and United Nations (UN) personnel.

Methods

A service evaluation of patient consultations and admissions at the UK military level 2 hospital was performed using two data sets collected by the emergency department (ED) and medicine (MED) teams.

Results

Over a three-month (13-week) period, 286 cases were seen, of which 51% were UK troops, 29% were UN civilians and 20% were UN troops. The ED team saw 175 cases (61%) and provided definitive care for 113 (40%), whereas the MED team saw and provided definitive care for 128 cases (45%). Overall, there were 75% with diseases and 25% with non-battle injuries. The most common diagnoses seen by the ED team were musculoskeletal injuries (17%), unidentified non-malarial undifferentiated febrile illness (UNMUFI) (17%), malaria (13%), chemical pneumonitis (13%) and wounds (8%). The most common diagnoses seen by the MED team were acute gastroenteritis (AGE) (56%), UNMUFI (12%) and malaria (9%). AGE was due to viruses (31%), diarrhoeagenic Escherichia coli (32%), other bacteria (6%) and protozoa (12%).

Conclusion

Data collection on DNBIs during the initial phase of this deployment was clinically useful and integrated between different departments. However, a standardised, long-term solution that is embedded into deployed healthcare is required. The clinical activity recorded here should be used for planning, training, service development and targeted research.

Environment at the time of injury determines injury patterns in pelvic blast

The use of explosives by terrorists, or during armed conflict, remains a major global threat. Increasingly, these events occur in the civilian domain, and can potentially lead to injury and loss of life, on a very large scale. The environment at the time of detonation is known to result in different injury patterns in casualties exposed to blast, which is highly relevant to injury mitigation analyses. We describe differences in pelvic injury patterns in relation to different environments, from casualties that presented to the deployed UK military hospitals in Iraq and Afghanistan. A casualty on foot when injured typically sustains an unstable pelvic fracture pattern, which is commonly the cause of death. These casualties die from blood loss, meaning treatment in these should focus on early pelvic haemorrhage control. In contrast, casualties injured in vehicle present a different pattern, possibly caused by direct loading via the seat, which does not result in pelvic instability. Fatalities in this cohort are from injuries to other body regions, in particular the head and the torso and who may require urgent neurosurgery or thoracotomy as life-saving interventions. A different strategy is therefore required for mounted and dismounted casualties in order to increase survivors.

The ‘Walker dip’

Throughout recent history there has been a pattern whereby military medical care improves in wartime and these advances are lost by the time the next conflict occurs. This dip in medical performance potentially represents lives that may be lost and recovery that may be impaired for our young servicemen and women at the start of every new conflict. When reviewing the wars of the last two centuries, three themes emerge. Firstly, post-war military cuts fall disproportionately on medical services, leaving a mismatch between the size of forces that can be deployed and the ability to care for them when injured. Secondly, insufficient medical representation in military operational planning results in the neglect of medical logistics; and finally, technical and procedural lessons are not adequately captured and incorporated into training and doctrine.

The burden of gunshot wounding of UK military personnel in Iraq and Afghanistan from 2003-14

INTRODUCTION

Gunshot wounding (GSW) is the second most common mechanism of injury in warfare after explosive injury. The aim of this study was to define the clinical burden of GSW placed on UK forces throughout the recent Iraq and Afghanistan conflicts.

METHODS

This study was a retrospective review of data from the UK Military Joint Theatre Trauma Registry (JTTR). A JTTR search identified records within the 12 year period of conflict between 19 Mar 2003 and 27 Oct 2014 of all UK military GSW casualties sustained during the complete timelines of both conflicts. Included cases had their clinical timelines and treatment further examined from time of injury up until discharge from hospital or death.

RESULTS

There were 723 casualties identified (177 fatalities, 546 survivors). Median age at the time of injury was 24 years (range 18-46 years), with 99.6% of casualties being male. Most common anatomical locations for injury were the extremities, with 52% of all casualties sustaining extremity GSW, followed by 16% GSW to the head, 15% to the thorax, and 7% to the abdomen. In survivors, the rate of extremity injury was higher at 69%, with head, thorax and abdomen injuries relatively lower at 5%, 11% and 6% respectively. All GSW casualties had a total of 2827 separate injuries catalogued. A total of 545 casualties (523 survivors, 22 fatalities) underwent 2357 recorded surgical procedures, which were carried out over 1455 surgical episodes between admission to a deployed medical facility and subsequent transfer to the Royal Centre for Defence Medicine (RCDM) in the UK. This gave a median of 3 (IQR 2-5) surgical procedures within a median of 2 (IQR 2-3) surgical episodes per casualty. Casualties had a combined length of stay (LoS) of 25 years within a medical facility, with a mean LoS in a deployed facility of 1.9 days and 14 days in RCDM.

CONCLUSION

These findings define the massive burden of injury associated with battlefield GSW and underscore the need for further research to both reduce wound incidence and severity of these complex injuries.

From Northern Ireland to Afghanistan: half a century of blast injuries

Introduction

Throughout the last half century, blast injuries have been a common occurrence to UK military personnel during combat operations. This study investigates casualty data from three different military operations to determine whether survivability from blast injuries has improved over time and whether the tactics used could have influenced the injuries sustained.

Methods

Casualty data from operations in Northern Ireland, Iraq and Afghanistan were reviewed and found to contain a total of 2629 casualties injured by improvised explosive devices. The injury severities were examined and the suitability of comparison between conflicts was considered.

Results

The case fatality rate and mean severity score sustained remained consistent among the operations included in this study. Using the New Injury Severity Score, the probabilities of survival were calculated for each separate operation. The body regions injured were identified for both fatalities and survivors. Using this information, comparisons of injury severities sustained at an Abbreviated Injury Scale of 3 and above (identified as a threshold for fatal injury) were conducted between the different operations.

Conclusions

The data showed that as operations changed over time, survivability improved and the proportions of body regions injured also changed; however, this study also highlights how studying casualty data from different conflicts without taking account for the contextual differences may lead to misleading conclusions.

Outcome of open abdominal management following military trauma

Background

Temporary abdominal closure (TAC) is increasingly common after military and civilian major trauma. Primary fascial closure cannot be achieved after TAC in 30 per cent of civilian patients; subsequent abdominal wall reconstruction carries significant morbidity. This retrospective review aimed to determine this morbidity in a UK military cohort.

Methods

A prospectively maintained database of all injured personnel from the Iraq and Afghanistan conflicts was searched from 1 January 2003 to 31 December 2014 for all patients who had undergone laparotomy in a deployed military medical treatment facility. This database, the patients' hospital notes and their primary care records were searched.

Results

Laparotomy was performed in a total of 155 patients who survived to be repatriated to the UK; records were available for 150 of these patients. Seventy-seven patients (51·3 per cent) had fascial closure at first laparotomy, and 73 (48·7 per cent) had a period of TAC. Of the 73 who had TAC, two died before closure and two had significant abdominal wall loss from blast injury and were excluded from analysis. Of the 69 remaining patients, 65 (94 per cent) were able to undergo delayed primary fascial closure. The median duration of follow-up from injury was 1257 (range 1–4677) days for the whole cohort. Nine (12 per cent) of the 73 patients who underwent TAC subsequently developed an incisional hernia, compared with ten (13 per cent) of the 77 patients whose abdomen was closed at the primary laparotomy (P = 1·000).

Conclusion

Rates of delayed primary closure of abdominal fascia after temporary abdominal closure appear high. Subsequent rates of incisional hernia formation were similar in patients undergoing delayed primary closure and those who had closure at the primary laparotomy.

Extremity injuries sustained by the UK military in the Iraq and Afghanistan conflicts: 2003-2014

INTRODUCTION

Extremity injuries predominate in warfare, however their nature, and overall burden to the individual and the health service is yet to be characterised for the UK military in the recent conflicts of Iraq and Afghanistan.

METHODS

We reviewed the all extremity injuries in survivors from the Joint Theatre Trauma Registry (JTTR) between 2003 and 2014. All cases recorded in the JTTR between the invasion of Iraq on the 19th March 2003 and cessation of combat operations in Afghanistan on the 27th October 2014, were examined. Casualties who were killed in action or died from their wounds were excluded. All extremity injury codes were included, capturing patients with soft tissue injuries but no fracture or amputation.

RESULTS

Of 2348 UK combatants surviving injury in Iraq and Afghanistan, 1813 (77%) had extremity injuries; of these 205 (11%) had at least one amputation at the wrist/ankle or more proximal. Trans-tibial was the most common level of limb loss. Eighty five casualties lost 2 limbs, 83 of these (98%) lost both lower limbs and 17 lost 3 limbs. Aside from amputations, there were 1530 fractures, 501 (33%) involving the upper limb and 1029 (67%) in the lower limb and pelvis. The tibia was the most frequently fractured bone. Of the lower limb fractures, 597 (58%) were open compared with 344 (69%) in the upper limb. Total Length of Stay (LOS) following extremity injury was 24,486days or 69 years and 1 month; there were a total 2817 surgical episodes performed on extremities. Median length of stay Length of Stay (LOS) for major amputations (i.e. those at the wrist/ankle or more proximal) was 51days (IQR 30-65) with a median of 7 surgical procedures on their limbs (IQR 5-9). In casualties with fractures but no amputation, median LOS was 13days (IQR 6-25) with a median of 2 surgical procedures (IQR 1-4).

CONCLUSION

Utilising a dedicated injury database, this study illustrates for the first time in the United Kingdom military population, that the extremities are involved in the vast majority of combat injuries and the large surgical workload required for their treatment.

Salvage of Combat Hindfoot Fractures in 2003-2014 UK Military

BACKGROUND

Hindfoot fractures pose a considerable challenge to military orthopaedic surgeons, as combat injuries are typically the result of energy transfers not seen in civilian practice. This study aimed to characterize the pattern of hindfoot injuries sustained by UK military casualties in recent conflicts, define the early amputation and infection rate, and identify factors associated with poor early outcomes.

METHODS

The UK Joint Theatre Trauma Registry was searched for British military casualties sustaining a hindfoot fracture from Iraq and Afghanistan between 2003 and 2014. Data on the injury pattern and management were obtained along with 18-month follow-up data. Statistical analysis was performed with the chi-square test and binomial logistic regression analysis. The threshold for significance was set at P < .05. One hundred fourteen patients sustained 134 hindfoot injuries. Eighteen-month follow-up was available for 92 patients (81%) and 114 hindfeet (85%).

RESULTS

The calcaneus was fractured in 116 cases (87%): 54 (47%) were managed conservatively, 32 (28%) underwent K-wire fixation, and 30 (26%) underwent internal fixation. Nineteen patients (17%) required transtibial amputation during this time. A deep infection requiring operative treatment occurred in 13 cases (11%) with Staphylococcus aureus, the most common infectious organism (46%). A deep infection was strongly associated with operative fracture management ( P = .0016). When controlling for multiple variables, the presence of a deep infection was significantly associated with a requirement for amputation at 18 months ( P = .023). There was no association between open fractures and a requirement for amputation at 18 months ( P = .640), nor was conservative management associated with a requirement for amputation ( P = .999). Thirty-six fractures (32%) required unplanned revision surgery within the first 18 months following salvage, of which 19 (53%) involved amputation.

CONCLUSION

A deep infection was the sole variable significantly associated with a requirement for amputation by 18 months. These results suggest that attempts at salvaging these injuries are at the limits of orthopaedic technical feasibility.

LEVEL OF EVIDENCE

Level III, comparative series.

Implementation of a clinical governance framework to 17 Combat Service Support Brigade, Australian Army

Purpose

In 2012, Headquarters 17 Combat Service Support Brigade (HQ 17 CSS Bde) implemented a clinical governance framework. The framework is intended as a quality improvement tool through which excellence in deployed healthcare is achieved. The purpose of this paper is to describe the implementation of this clinical governance framework to 17 CSS Bde and present feedback provided by users on their application of the clinical governance framework.

Design/methodology/approach

An electronic survey was disseminated to the four 17 CSS Bde deployable health battalions (n=1,061). Qualitative data were analysed using descriptive statistics and qualitative data using thematic analysis.

Findings

In total, there were 105 responses providing valid data for analysis. The data identified mixed understanding and awareness of clinical governance amongst participants, and pinpointed aspects of the framework that needed refinement.

Practical implications

The results highlight important challenges implementing a clinical governance framework for deployable health units. The authors propose embedding clinical governance education in all army soldier and officer health courses to remedy deficits in knowledge and understanding. Recommendations for further development of the clinical governance framework are also made with particular emphasis on education, clinical risk and clinical evaluation.

Originality/value

This paper offers unique insight into the implementation of a clinical governance framework to the 17 CSS Bde, Australian Army. The results suggest that levels of understanding and awareness of clinical governance are stalling its translation through the military hierarchy. The data identify that implementation of a clinical governance framework is not easy, even within a military environment where the culture is to follow orders and obey the chain of command.

Lessons from the organisation of the UK medical services deployed in support of Operation TELIC (Iraq) and Operation HERRICK (Afghanistan)

This paper provides the definitive record of the UK Defence Medical Services (DMS) lessons from the organisation of medical services in support of Operation (Op) TELIC (Iraq) and Op HERRICK (Afghanistan). The analysis involved a detailed review of the published academic literature, internal post-operational tour reports and post-tour interviews. The list of lessons was reviewed through three Military Judgement Panel cycles producing the single synthesis 'the golden thread' and eight 'silver bullets' as themes to institutionalise the learning to deliver the golden thread. One additional theme, mentoring indigenous healthcare systems and providers, emerged as a completely new capability requirement. The DMS has established a programme of work to implement these lessons.

The surgical management of facial trauma in British soldiers during combat operations in Afghanistan

INTRODUCTION

The recent Afghanistan conflict caused a higher proportion of casualties with facial injuries due to both the increasing effectiveness of combat body armour and the insurgent use of the improvised explosive device (IED). The aim of this study was to describe all injuries to the face sustained by UK service personnel from blast or gunshot wounds during the highest intensity period of combat operations in Afghanistan.

METHODS

Hospital records and Joint Theatre Trauma Registry data were collected for all UK service personnel killed or wounded by blast and gunshot wounds in Afghanistan between 01 April 2006 and 01 March 2013.

RESULTS

566 casualties were identified, 504 from blast and 52 from gunshot injuries. 75% of blast injury casualties survived and the IED was the most common mechanism of injury with the mid-face the most commonly affected facial region. In blast injuries a facial fracture was a significant marker for increased total injury severity score. A facial gunshot wound was fatal in 53% of cases. The majority of survivors required a single surgical procedure for the facial injury but further reconstruction was required in 156 of the 375 of survivors aero medically evacuated to the UK.

CONCLUSIONS

The presence and pattern of facial fractures was significantly different in survivors and fatalities, which may reflect the power of the blast that these cohorts were exposed to. The Anatomical Injury Scoring of the Injury Severity Scale was inadequate for determining the extent of soft tissue facial injuries and did not predict morbidity of the injury.

Gun-shot injuries in UK military casualties - Features associated with wound severity

INTRODUCTION

Surgical treatment of high-energy gun-shot wounds (GSWs) to the extremities is challenging. Recent surgical doctrine states that wound tracts from high-energy GSWs should be laid open, however the experience from previous conflicts suggests that some of these injuries can be managed more conservatively. The aim of this study is to firstly characterise the GSW injuries sustained by UK forces, and secondly test the hypothesis that the likely severity of GSWs can be predicted by features of the wound.

METHODS

The UK Military trauma registry was searched for cases injured by GSW in the five years between 01 January 2009 and 31 December 2013: only UK personnel were included. Clinical notes and radiographs were then reviewed. Features associated with energy transfer in extremity wounds in survivors were further examined with number of wound debridements used as a surrogate marker of wound severity.

RESULTS

There were 450 cases who met the inclusion criteria. 96 (21%) were fatally injured, with 354 (79%) surviving their injuries. Casualties in the fatality group had a median New Injury Severity Score (NISS) of 75 (IQR 75-75), while the median NISS of the survivors was 12 (IQR 4-48) with 10 survivors having a NISS of 75. In survivors the limbs were most commonly injured (56%). 'Through and through' wounds, where the bullet passes intact through the body, were strongly associated with less requirement for debridement (p<0.0001). When a bullet fragmented there was a significant association with a requirement for a greater number of wound debridements (p=0.0002), as there was if a bullet fractured a bone (p=0.0006).

CONCLUSIONS

More complex wounds, as indicated by the requirement for repeated debridements, are associated with injuries where the bullet does not pass straight through the body, or where a bone is fractured. Gunshot wounds should be assessed according to the likely energy transferred, extremity wounds without features of high energy transfer do not require extensive exploration.

Factors influencing infection in 10 years of battlefield open tibia fractures

The aim of this study was to characterise severe open tibial shaft fractures sustained by the UK military personnel over 10 years of combat in Iraq and Afghanistan. The UK military Joint Theatre Trauma Registry was searched for all such injuries, and clinical records were reviewed for all patients. One hundred Gustilo-Anderson III tibia fractures in 89 patients were identified in the 10 year study period; the majority sustained injuries through explosive weapons (63, 68 %) with the remainder being injured from gunshot wounds. Three fractures were not followed up for 12 months and were therefore excluded. Twenty-two (23 %) of the remaining 97 tibial fractures were complicated by infection, with S. aureus being the causative agent in 13/22 infected fractures (59 %). Neither injury severity, mechanism, the use of an external fixator, the need for vascularised tissue transfer nor smoking status was associated with subsequent infection. Bone loss was significantly associated with subsequent infection (p < 0.0001, Fisher's exact test). This study presents 10 years of open tibial fractures sustained in Iraq and Afghanistan. Most infection in combat open tibia fractures is caused by familiar organisms, i.e. S. aureus. While the overall severity of a casualty's injuries was not associated with infection, the degree of bone loss from the fracture was.

Health protection during the Ebola crisis: the Defence Medical Services approach

This paper is a narrative of the policies, procedures, mitigations and observations of the application of Force Health Protection measures applied by the Ministry of Defence (MOD) for the deployment of military personnel to West Africa as part of the UK contribution to the international response to the Ebola crisis from July 2014 to July 2015. The MOD divided the threat into three risk categories: risk from disease and non-battle injury, Ebola risk for non-clinical duties and Ebola risk for healthcare workers. Overall risk management was directed and monitored by the OP GRITROCK Force Health Protection Board. There were six cases of malaria, four outbreaks of gastrointestinal disease, two needlestick injuries in Ebola-facing healthcare workers, one MOD Ebola case and five non-needlestick, high-risk exposures. This experience reinforces the requirement for the Defence Medical Services to have a high level of organisational competence to advise on Force Health Protection for the MOD.

Human factors in decision making in major trauma in Camp Bastion, Afghanistan

INTRODUCTION

The concentration of major trauma experience at Camp Bastion has allowed continuous improvements to occur in the patient pathway from the point of wounding to surgical treatment. These changes have involved clinical management as well as alterations to the physical layout of the hospital, training and decision making. Consideration of the human factors has been a major part of these improvements.

METHODS

We describe the Camp Bastion patient pathway with the communication template that focused decision making at various key moments during damage control resuscitation and damage control surgery (DCR-DCS). This system identifies four key stages: 'command huddle', 'snap brief', 'sit-reps' (situation reports) and 'sign-out/debrief'. The attitude of staff to communication and decision making is also evaluated.

RESULTS

Twenty cases admitted to Camp Bastion with battlefield injuries were studied from 6 September to 6 October 2012. Qualitative responses from 115 members of staff were collected. All patients were haemodynamically shocked with a median pH of 7.25 (range: 6.83-7.40) and a median of 18 units of mixed red cells and plasma were transfused. In 89% of instances, theatre staff were aware of what was required of them at the beginning of the case, 86% felt there were regular updates and 93% understood what was required of them as the case progressed.

CONCLUSIONS

The evolution of the hospital at Camp Bastion has been a unique learning experience in the field of major trauma. The Defence Medical Services have responded with continuous innovation to optimise DCR-DCS for seriously injured patients. Together with the improvements in clinical care, a communication and decision making matrix was developed. Staff evaluation showed a high degree of satisfaction with the quality of communication.

Died of wounds: a mortality review

OBJECTIVES

Combat casualty care is a complex system involving multiple clinicians, medical interventions and casualty transfers. Improving the performance of this system requires examination of potential weaknesses. This study reviewed the cause and timing of death of casualties deemed to have died from their injuries after arriving at a medical treatment facility during the recent conflicts in Iraq and Afghanistan, in order to identify potential areas for improving outcomes.

METHODS

This was a retrospective review of all casualties who reached medical treatment facilities alive, but subsequently died from injuries sustained during combat operations in Afghanistan and Iraq. It included all deaths from start to completion of combat operations. The UK military joint theatre trauma registry was used to identify cases, and further data were collected from clinical notes, postmortem records and coroner's reports.

RESULTS

There were 71 combat-related fatalities who survived to a medical treatment facility; 17 (24%) in Iraq and 54 (76%) in Afghanistan. Thirty eight (54%) died within the first 24 h. Thirty-three (47%) casualties died from isolated head injuries, a further 13 (18%) had unsurvivable head injuries but not in isolation. Haemorrhage following severe lower limb trauma, often in conjunction with abdominal and pelvic injuries, was the cause of a further 15 (21%) deaths.

CONCLUSIONS

Severe head injury was the most common cause of death. Irrespective of available medical treatment, none of this group had salvageable injuries. Future emphasis should be placed in preventative strategies to protect the head against battlefield trauma.

Blast Injury in the Spine: Dynamic Response Index Is Not an Appropriate Model for Predicting Injury

BACKGROUND

Improvised explosive devices are a common feature of recent asymmetric conflicts and there is a persistent landmine threat to military and humanitarian personnel. Assessment of injury risk to the spine in vehicles subjected to explosions was conducted using a standardized model, the Dynamic Response Index (DRI). However, the DRI was intended for evaluating aircraft ejection seats and has not been validated in blast conditions.

QUESTIONS/PURPOSES

We asked whether the injury patterns seen in blast are similar to those in aircraft ejection and therefore whether a single injury prediction model can be used for both situations.

METHODS

UK military victims of mounted blast (seated in a vehicle) were identified from the Joint Theatre Trauma Registry. Each had their initial CT scans reviewed to identify spinal fractures. A literature search identified a comparison population of ejected aircrew with spinal fractures. Seventy-eight blast victims were identified with 294 fractures. One hundred eighty-nine patients who had sustained aircraft ejection were identified with 258 fractures. The Kruskal-Wallis test was used to compare the population injury distributions and Fisher's exact test was used to assess differences at each spinal level.

RESULTS

The distribution of injuries between blast and ejection was not similar. In the cervical spine, the relative risk of injury was 11.5 times higher in blast; in the lumbar spine the relative risk was 2.9 times higher in blast. In the thoracic spine, the relative risk was identical in blast and ejection. At most individual vertebral levels including the upper thoracic spine, there was a higher risk of injury in the blast population, but the opposite was true between T7 and T12, where the risk was higher in aircraft ejection.

CONCLUSIONS

The patterns of injury in blast and aircraft are different, suggesting that the two are mechanistically dissimilar. At most vertebral levels there is a higher relative risk of fracture in the blast population, but at the apex of the thoracic spine and in the lower thoracic spine, there is a higher risk in ejection victims. The differences in relative risk at different levels, and the resulting overall different injury patterns, suggest that a single model cannot be used to predict the risk of injury in ejection and blast.

CLINICAL RELEVANCE

A new model needs to be developed to aid in the design of mine-protected vehicles for future conflicts.

Improved survival in UK combat casualties from Iraq and Afghanistan: 2003-2012

BACKGROUND

The United Kingdom was at war in Iraq and Afghanistan for more than a decade. Despite assertions regarding advances in military trauma care during these wars, thus far, no studies have examined survival in UK troops during this sustained period of combat. The aims of this study were to examine temporal changes of injury patterns defined by body region and survival in a population of UK Military casualties between 2003 and 2012 in Iraq and Afghanistan.

METHODS

The UK Military Joint Theatre Trauma Registry was searched for all UK Military casualties (survivors and fatalities) sustained on operations between January 1, 2003, and December 31, 2012. The New Injury Severity Score (NISS) was used to stratify injury severity.

RESULTS

There were 2,792 UK Military casualties sustaining 14,252 separate injuries during the study period. There were 608 fatalities (22% of all casualties). Approximately 70% of casualties injured in hostile action resulted from explosive munitions. The extremities were the most commonly injured body region, involved in 43% of all injuries. The NISS associated with a 50% chance of survival rose each year from 32 in 2003 to 60 in 2012.

CONCLUSION

An improvement in survival during the 10-year period is demonstrated. A majority of wounds are a result of explosive munitions, and the extremities are the most commonly affected body region. The authors recommend the development of more sophisticated techniques for the measuring of the performance of combat casualty care systems to include measures of morbidity and functional recovery as well as survival.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

The management and outcome of open fractures of the femur sustained on the battlefield over a ten-year period

This is a retrospective study of survivors of recent conflicts with an open fracture of the femur. We analysed the records of 48 patients (48 fractures) and assessed the outcome. The median follow up for 47 patients (98%) was 37 months (interquartile range 19 to 53); 31 (66%) achieved union; 16 (34%) had a revision procedure, two of which were transfemoral amputation (4%).

The New Injury Severity Score, the method of fixation, infection and the requirement for soft-tissue cover were not associated with a poor outcome. The degree of bone loss was strongly associated with a poor outcome (p = 0.00204). A total of four patients developed an infection; two with S. aureus, one with E. coli and one with A. baumannii.

This study shows that, compared with historical experience, outcomes after open fractures of the femur sustained on the battlefield are good, with no mortality and low rates of infection and late amputation. The degree of bone loss is closely associated with a poor outcome.

Cite this article: Bone Joint J 2015;97-B:842–6.

Medium-term outcomes following limb salvage for severe open tibia fracture are similar to trans-tibial amputation

Extremity injuries define the surgical burden of recent conflicts. Current literature is inconclusive when assessing the merits of limb salvage over amputation. The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to equivalent outcomes for unilateral trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 and 2010, as described in a previously published series, were contacted. Consenting individuals conducted a brief telephone interview and were asked to complete a SF-36 questionnaire. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation between 2004 and 2010. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria. Telephone follow-up and SF-36 questionnaire data was available for 30 patients (61%). The median follow-up was 4 years (49 months, IQR 39-63). Ten of the 30 patients required revision surgery, three of which involved conversion from initial fixation to a circular frame for non- or mal-union. Twenty-two of the 30 patients (73%) recovered sufficiently to complete an age-standardised basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35-54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). Similarly there was no difference in mental component scores between the limb salvage and amputation groups (p=0.1595, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma.

UK combat-related pelvic junctional vascular injuries 2008-2011: implications for future intervention

In a recent publication, 297 of 6450 (4.6%) military coalition deaths over ten years were reported to be due to junctional bleeding. The authors suggested that some of these deaths could have been avoided with a junctional haemorrhage control device. Prospectively collected data on all injuries sustained in Afghanistan by UK military personnel from 1 August 2008 to 31 July 2011 period were reviewed, using the UK Joint Theatre Trauma Registry. All fatalities with significant pelvic injuries were identified and analysed, and the cause of death established to assess the potential role for a junctional haemorrhage control device. Significant upper thigh, groin or pelvic injuries were recorded in 124 casualties, of which 93 died. Of these the pelvic injury was the cause of death in 37, but only 1 casualty with potentially survivable injuries was identified where death was due to a vascular injury below the inguinal ligament, not controlled by a CAT. This represents <1% of all deaths in this period, a lower figure than previously published. We further identified 32 casualties where the cause of death was due to a vascular injury between the aortic bifurcation and the inguinal ligament. Eight of these survived to a medical facility but subsequently died of their wounds. These represent a subset in which vascular control proximal to the inguinal ligament could have altered the outcome. Some potentially survivable deaths due to exsanguination may be amenable to proximal vascular control. Our study does not substantiate previous conclusions that this can be achieved through use of a groin junctional tourniquet. We believe there may be a role for more proximal vascular control of pelvic bleeding, and this merits further research.

The patient experience: measuring the quality of care in the Defence Medical Services

Healthcare provided by the Defence Medical Services (DMS) is acknowledged to be of a high standard but patients' experiences of it has not been measured and collated in a consistent and meaningful way, which has limited strategic quality improvement initiatives. Responsibility for implementing and delivering a programme of healthcare governance and assurance for the DMS rests with the Inspector General (IG). An important aspect of this role is to nurture a culture of continuous improvement in the DMS and under this leadership the IG team has prioritised a number of projects to address this. The project to improve patient experience data capture was prioritised in the work schedule as it incorporated initiatives that would lead to improved quality in DMS healthcare, information exploitation and ultimately patient safety. This is the first in a series of articles that will document this important work and describe the methodological considerations associated with the initial questionnaire design, collaboration with NHS partners, the pilot study and progress towards the introduction of the definitive DMS tool later this year.