National Academies of Sciences, Engineering and Medicine Release Report on Trauma Integration
Friday, June 17, 2016
Across the current military and civilian trauma care systems, the quality of trauma care varies greatly depending on when and where an individual is injured, placing lives unnecessarily at risk, says a new report from the National Academies of Sciences, Engineering, and Medicine. Mass casualty incidents and increasing foreign and domestic threats to homeland security lend urgency to the translation of wartime lessons to civilian trauma systems, said the committee that carried out the study and wrote the report. The White House should lead the integration of military and civilian trauma care to establish a national trauma care system and set an aim to achieve zero preventable deaths after injury. In addition, Congress, in consultation with the U.S. Department of Health and Human Services, should help ensure that prehospital care, such as emergency medical services, are included as a seamless component of health care delivery, rather than being viewed and paid as merely transportation providers.
The leading cause of death for Americans under the age of 46 is trauma — a disabling or life-threatening physical injury that results from an event such as a motor vehicle crash, gun violence, or fall. In 2013, trauma cost approximately $670 billion in medical care expenses and lost productivity. Recognizing that the best strategy to reduce the considerable burden associated with trauma is to prevent injuries from occurring in the first place, the delivery of optimal trauma care when injuries do occur is a critical means of preventing unnecessary death and disability. Of the 147,790 U.S. trauma deaths in 2014, as many as 20 percent — or about 30,000 — may have been preventable after injury with optimal trauma care, the committee said.
Significant advances in trauma care have developed over the last decade in response to the large number of U.S. casualties during the wars in Iraq and Afghanistan. The percentage of wounded service members who died of their injuries in Afghanistan decreased by nearly 50 percent between 2005 and 2013. Those successes are to be heralded but need to be improved upon and sustained, the committee said. Nearly 1,000 service members who lost their lives on the battlefield between 2001 and 2011 died of potentially survivable injuries.
“Both the military and civilian sectors have made impressive progress and important innovations in trauma care, but there are serious limitations in the diffusion of those gains from location to location,” said committee chair Donald Berwick, president emeritus and senior fellow, Institute for Healthcare Improvement, Cambridge, Mass. “Even as the successes have saved many lives, the disparities have cost many lives. With the decrease in combat and the need to maintain readiness for trauma care between wars, a window of opportunity now exists to integrate military and civilian trauma systems and view them not separately, but as one.”
Given the military’s success in reducing trauma deaths after injury, the civilian sector stands to reap tremendous benefits if best practices can be reliably adapted from the military, the committee said. A joint effort is needed to ensure the delivery of optimal trauma care to save the lives of Americans injured within the U.S. and on the battlefield. The committee envisioned a national trauma care system grounded in sound learning health system principles applied across all phases of trauma care delivery — from prehospital care at the point of injury to hospitalization, rehabilitation, and beyond. This will require synergized military and civilian efforts, committed leadership from both sectors, and a strategy that aims to reduce variations in care and outcomes while supporting continuous learning and innovation.
The committee found that the current absence of any higher authority to encourage coordination, collaboration, standardization, and alignment in trauma care across and within the military and civilian sectors has resulted in variations in practice, suboptimal outcomes for injured patients, and a lack of national attention and funding directed at trauma care at a level commensurate with the importance of injury. For example, current trauma research funding falls below funding levels for other leading causes of death, such as cancer and heart disease. In addition, no single federal entity is accountable for trauma care capabilities in the U.S. The result is a patchwork of systems for trauma care and mortality rates that vary twofold between the best and worst trauma centers in the nation. No level of government below the White House has the leverage to achieve the necessary collaboration within and across military and civilian sectors, catalyze partnerships between governmental and nongovernmental leaders, and ensure accountability across many federal agencies, the committee said. Therefore, leadership from the White House will be required to optimize trauma care. The committee also recommended that the secretaries of the U.S. Department of Health and Human Services and the U.S. Department of Defense designate and fully support a locus of responsibility and authority within their respective agencies for leading a sustained effort to achieve the national aim of zero preventable deaths after injury and minimize disability.
The low volume of military trauma cases when combat decreases, especially between wars, makes it impossible for trauma teams to acquire and maintain the expertise necessary to deliver casualty care at the level of excellence that is both deserved and needed, the committee said. Military and civilian trauma centers should be integrated to help maintain military trauma training and transfer wartime lessons learned and best practices to the civilian sector. This should include embedding military trauma teams in the busiest and best civilian trauma centers across the nation. In addition, only three military hospitals are verified as trauma centers. More military hospitals should become trauma centers and participate fully in the existing civilian trauma system, caring for both military and civilian patients.
The collection and use of data is critical to generate new knowledge on best practices in trauma care, drive continuous improvement, and compare the performance of similar organizations. Leaders of the recommended national trauma care system should establish processes for real-time access to patient-level data across all phases of care and just-in-time access to high-quality knowledge for trauma care teams and those who support them. To facilitate use of those data, the secretary of HHS, secretary of defense, secretary of veterans affairs, and private-sector and professional society partners should apply appropriate incentives to ensure that all military and civilian trauma centers and VA hospitals participate in a risk-adjusted, evidence-based trauma quality improvement program.
The greatest opportunity to save lives after injury is in the prehospital setting, the committee said, and the integration of prehospital care, such as emergency medical services (EMS), into the broader trauma care system is needed to ensure the delivery of optimal trauma care. EMS is a disjointed set of systems across the nation with differing standards of care and few universal protocols. Additionally, the Centers for Medicare & Medicaid Services (CMS) reimburses EMS as a supplier of transportation to a medical facility, based on factors such as the miles traveled to an emergency department and the level of care provided while en route, rather than as a health care provider. Essentially, EMS agencies are discouraged from determining the need for transport to a hospital given that payers will deny reimbursement if such transport does not occur. Also, some EMS transports to emergency departments are medically unnecessary, adding costs to the health care system, burdening hospital-based providers, and limiting the ability to respond to disasters and other mass casualty incidents. This fee-for-transport model ignores the increasingly complex care and life-saving interventions performed by EMS providers at the point of injury and while en route and hinders the implementation of processes that would allow EMS providers to transport patients to a more appropriate setting or to treat and release them. The committee recommended that Congress, in consultation with HHS, ensure the integration of prehospital care as a seamless component of health care delivery, rather than being viewed and reimbursed as merely a patient transport mechanism. Possible ways to achieve this include amending the Social Security Act so EMS is designated as a provider type and modifying CMS’s ambulance fee schedule to better link the quality of prehospital care to reimbursement and health care delivery reform efforts.
The study was sponsored by the American College of Emergency Physicians, American College of Surgeons, National Association of EMS Physicians, National Association of Emergency Medical Technicians, Trauma Center Association of America, U.S. Department of Defense, U.S. Department of Homeland Security, and U.S. Department of Transportation. The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine. The Academies operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln. For more information, visit http://national-academies.org.