The thin red line: Blood planning factors and the enduring need for a robust military blood system to support combat operations.

Battlefield lessons learned are forgotten; the current name for this is the Walker Dip. Blood transfusion and the need for a Department of Defense Blood Program are lessons that have cycled through being learned during wartime, forgotten, and then relearned during the next war. The military will always need a blood program to support combat and contingency operations.

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.

The DoD Trauma Registry Versus the Electronic Health Record.

There is a widely prevailing belief that electronic health records and data registries are the same, or that registries can be replaced by electronic health records given the advances in technology. While information systems have revolutionized documentation of medical care, distinctions continue to exist. This article will clear the confusion between the two systems, using the Joint Trauma System's (JTS) Department of Defense (DoD) Trauma Registry (DoDTR), the approved enterprise wide trauma registry for the military, as an example.

Comparison of Military and Civilian Methods for Determining Potentially Preventable Deaths: A Systematic Review.

Importance: Military and civilian trauma experts initiated a collaborative effort to develop an integrated learning trauma system to reduce preventable morbidity and mortality. Because the Department of Defense does not currently have recommended guidelines and standard operating procedures to perform military preventable death reviews in a consistent manner, these performance improvement processes must be developed.

Objectives: To compare military and civilian preventable death determination methods to understand the existing best practices for evaluating preventable death.

The Military Orthopedic Trauma Registry: The potential of a specialty specific process improvement tool.

Background: The Military Orthopaedic Trauma Registry (MOTR) was designed to replicate the Department of Defense Trauma Registry's (DoDTR's) role as pillar for data-driven management of extremity war wounds. The MOTR continuously undergoes quality assurance checks to optimize the registry data for future quality improvement efforts. We conducted a quality assurance survey of MOTR entrants to determine if a simple MOTR data pull could provide robust orthopedic-specific information toward the question of causes for late amputation.

Evaluation of role 2 (R2) medical resources in the Afghanistan combat theater: Initial review of the joint trauma system R2 registry.

Background: A Role 2 registry (R2R) was developed in 2008 by the US Joint Trauma System (JTS). The purpose of this project was to undertake a preliminary review of the R2R to understand combat trauma epidemiology and related interventions at these facilities to guide training and optimal use of forward surgical capability in the future.

Methods: A retrospective review of available JTS R2R records; the registry is a convenience sample entered voluntarily by members of the R2 units.

The Military Injury Severity Score (mISS): A better predictor of combat mortality than Injury Severity Score (ISS).

Background: The Military Injury Severity Score (mISS) was developed to better predict mortality in complex combat injuries but has yet to be validated.

Methods: US combat trauma data from Afghanistan and Iraq from January 1, 2003, to December 31, 2014, from the US Department of Defense Trauma Registry (DoDTR) were analyzed. Military ISS, a variation of the ISS, was calculated and compared with standard ISS scores.

Combat injury coding: a review and reconfiguration.

Background: The current civilian Abbreviated Injury Scale (AIS), designed for automobile crash injuries, yields important information about civilian injuries. It has been recognized for some time, however, that both the AIS and AIS-based scores such as the Injury Severity Score (ISS) are inadequate for describing penetrating injuries, especially those sustained in combat. Existing injury coding systems do not adequately describe (they actually exclude) combat injuries such as the devastating multi-mechanistic injuries resulting from attacks with improvised explosive devices (IEDs).

Improvements in the hemodynamic stability of combat casualties during en route care.

Three Forward Aeromedical Evacuation platforms operate in Southern Afghanistan: UK Medical Emergency Response Team (MERT), US Air Force Expeditionary Rescue Squadron (PEDRO), and US Army Medical Evacuation Squadrons (DUSTOFF), each with a different clinical capability. Recent evidence suggests that retrieval by a platform with a greater clinical capability (MERT) is associated with improved mortality in critical patients when compared with platforms with less clinical capability (PEDRO and DUSTOFF). It is unclear whether this is due to en route resuscitation or the dispatch procedure.

Evaluation of military trauma system practices related to complications after injury.

Background: The Joint Theater Trauma System (JTTS) was developed with the vision that every soldier, marine, sailor, and airman injured on the battlefield would have the optimal chance for survival and maximum potential for functional recovery. In this analysis, we hypothesized that injury and complication after injury surveillance information diffusion through the JTTS, via the dissemination of clinical practice guidelines and process improvements, would be associated with improved combat casualty clinical outcomes.

Methods: The current analysis was designed to profile different aspects of trauma system performance improvement, including monitoring of frequent posttraumatic complications, the assessment of an emerging complication trend, and measurement of the impact of the system interventions to identify potential practices for future performance improvement.

Evaluation of military trauma system practices related to damage-control resuscitation.

Background: The Joint Theater Trauma System (JTTS) was developed with the vision that every soldier, marine, sailor, and airman injured on the battlefield would have the optimal chance for survival and maximum potential for functional recovery. In this analysis, we hypothesized that information diffusion through the JTTS, via the dissemination of clinical practice guidelines and process improvements, would be associated with the acceptance of evidence-based practices and decreases in trauma practice variability.

Methods: The current evaluation was designed as a single time-series quasi-experimental study as a preanalysis and postanalysis relative to the implementation of clinical practice guidelines and process improvement interventions.

Infections complicating the care of combat casualties during operations Iraqi Freedom and Enduring Freedom.

Background: Continued assessment of casualty complications, such as infections, enables the development of evidence-based guidelines to mitigate excess morbidity and mortality. We examine the Joint Theater Trauma Registry (JTTR) for infections and potential risk factors, such as transfusions, among Iraq and Afghanistan trauma patients.

Methods: JTTR entries from deployment-related injuries with completed records between March 19, 2003, and April 13, 2009, were evaluated using International Classification of Diseases-9 codes for infections defined by anatomic/clinical syndromes and/or type of infecting organisms.

Improved characterization of combat injury.

Background: Combat injury patterns differ from civilian trauma in that the former are largely explosion-related, comprising multiple mechanistic and fragment injuries and high-kinetic-energy bullets. Further, unlike civilians, U.S.

Impact of joint theater trauma system initiatives on battlefield injury outcomes.

Introduction: The US military forces developed and implemented the Joint Theater Trauma System (JTTS) and Joint Theater Trauma Registry (JTTR) using US civilian trauma system models with the intent of improving outcomes after battlefield injury.

Methods: The purpose of this analysis was to elaborate the impact of the JTTS. To quantify these achievements, the JTTR captured mechanism, acute physiology, diagnostic, therapeutic, and outcome data on 23,250 injured patients admitted to deployed US military treatment facilities from July 2003 through July 2008 for analysis.

Infections in combat casualties during Operations Iraqi and Enduring Freedom.

Background: Infections are a common acute and chronic complication of combat-related injuries; however, no systematic attempt to assess infections associated with US combat-related injuries occurring in Iraq and Afghanistan has been conducted. The Joint Theater Trauma Registry (JTTR) has been established to collect injury specific medical data from casualties in Iraq and Afghanistan.

Methods: We reviewed the JTTR for the identification of infectious complications (IC) using International Classification of Diseases, 9th Revision (ICD-9) coding during two phases of the wars, before and after the end of the major ground operations in Iraq (19 March-May 31, 2003 and June 1, 2003-December 31, 2006).

Performance improvement on the battlefield.

The Joint Theater Trauma System (JTTS) is a formal system of trauma care designed to improve the medical care and outcomes for combat casualties of Operation Iraqi Freedom and Operation Enduring Freedom. This article describes the JTTS Trauma Performance Improvement Plan and how JTTS personnel use it to facilitate performance improvement across the entire continuum of combat casualty care.

Head injury and pulmonary embolism: a retrospective report based on the Pennsylvania Trauma Outcomes study.

Objective: We retrospectively examined the database of the Pennsylvania Trauma Systems Foundation to determine the risk of pulmonary embolism in adult patients sustaining isolated head trauma or multiple injuries, including head trauma, to answer two questions: What is the incidence of symptomatic pulmonary embolism during hospitalization in a trauma center in patients who have sustained a head injury? Are patients with head injuries more at risk for pulmonary embolism than trauma patients without head injuries?

Methods: We determined the total number of adult submissions per year to the Pennsylvania Trauma Outcomes Study from 1992 to 1996. Age, sex, Glasgow Coma Scale score, Abbreviated Injury Score for head injury, Injury Severity Score, intensive care unit days, hospital days, and the presence or absence of head injury, spinal injury, pelvic fractures, and/or femur fractures were recorded. Statistical techniques to evaluate their correlation with the incidence of pulmonary embolism included chi(2) testing, linear regression analysis, Kendall analysis, and logistic regression analysis.