A Collaborative To Evaluate And Improve The Quality Of Surgical Care Delivered By The Military Health System.

In an effort to improve surgical quality and reduce clinical variability, the Military Health System (MHS) expanded its participation in the National Surgical Quality Improvement Program to all military hospitals beginning in 2015. This expansion and a partnership with the American College of Surgeons laid the foundation for a surgical quality collaborative in the MHS. We review the history of the program in the MHS and the activities that have contributed to developing the collaborative. We also report promising trends in surgical outcomes at hospitals that were already participating in the program in 2014, when a critical MHS review identified areas for improvement in surgical care. We conclude with a discussion of possible lessons for other health systems and challenges ahead for the MHS, now that full enrollment in the program has been completed.

Response to infection control challenges in the deployed setting: Operations Iraqi and Enduring Freedom.

BACKGROUND: Infections caused by multidrug-resistant organisms (MDROs), including Acinetobacter, have complicated the care of military personnel injured in Operations Iraqi and Enduring Freedom. Cumulative data suggest that nosocomial transmission of MDROs in deployed medical treatment facilities (MTFs) has contributed to these infections. A 2008 review of deployed MTFs identified multiple factors impeding the performance of infection prevention and control (IC) practices. In response, efforts to emphasize IC basics, improve expertise, and better track MDRO colonization were pursued. METHODS: Efforts to increase awareness and enhance IC in deployed MTFs were focused on educating leaders and deploying personnel, producing deployed IC resources, and standardizing level IV and V admission screening for MDRO colonization. A repeat mission in 2009 reviewed interval progress. RESULTS: Increased awareness and the need for emphasis on basic IC practice, including hand hygiene, use of transmission-based (isolation) precautions, and cohorting of patients, were imparted to leaders and deploying personnel through briefings, presentations, and an All Army Activities message. Enhancement of IC expertise was implemented through increased standardization of IC practice, establishment of a predeployment IC short course, an IC teleconsultation service, and dedicated Internet resources. Standardization of admission colonization screening of personnel evacuated from the combat theater was established to better define and respond to the MDRO problem. A repeat review of the deployed MTFs found overall improvement in IC practice, including clear command emphasis in the Iraqi theater of operations. CONCLUSIONS: Maintaining a strong IC effort in the deployed setting, even in a stabilized operational environment, is difficult. Use of innovative strategies to enhance expertise and practice were implemented to reduce MDRO infections.

Now and then: combat casualty care policies for Operation Iraqi Freedom and Operation Enduring Freedom compared with those of Vietnam.

Between December 2004 and June 2007, 13 key Operation Iraqi Freedom/Operation Enduring Freedom combat casualty care policies were published to inform medical practice in the combat theater of operations. Published policies were authored by the 44th Medical Command (1), the Office of The Army Surgeon General (11), and the Office of the Assistant Secretary of Defense (Health Affairs) (1). These policies, published as an All Army Action message (and/or in memorandum format signed by The Army Surgeon General), were compared with published medical newsletters and medical bulletins issued during the Vietnam War era, beginning in 1966. Common to both wartime eras was the recognition that the presence of a medical research team in theater was a critical element to ensure accurate data capture for subsequent analysis, to document lessons learned, and to study the impact of new wounding mechanisms, whether it be the Pungi sticks and mines of Vietnam or the types of explosions specific to Operation Iraqi Freedom/Operation Enduring Freedom. It is important to recognize that both then and now, medical practice has been a reflection of the current state of medical practice, and that in both conflicts military medical personnel have been equally devoted to saving lives of combat casualties.

Establishing a human research protection program in a combatant command.

Extensive United States combat operations commenced for the first time in over decade in 2003. Early in 2004 there was no human research protection regulatory review and approval mechanism based in a deployed military combatant command. The absence of such a system presented a critical impediment to implementation of the time-honored tradition of a robust combat casualty care research effort. A coalition of concerned military medical personnel from the US Army proposed a novel mechanism to meet Department of Defense (DOD) requirements for the human research protection oversight of studies conducted in the combat theater of operations. In 2005, the Commander of Task Force 44 Medical Command (44th MEDCOM), who was serving as the Multi-National Corps Iraq (MNC-I) Surgeon, was charged with negotiating a DOD Assurance and implementing a new system of research review and protections. He deployed an Army Medical Department Medical Corps officer to assist in this endeavor and operationalize the plan. On March 19, 2005, the Multi-National Corps Iraq Commander signed a historic agreement with the US Army Surgeon General who developed a regulatory support and oversight mechanism to conduct research in theater. This innovative system not only honored the Army's commitment to human research protections, but also provided much needed support in the form of scientific and ethical review and compliance oversight to those deployed medical personnel with the vision to conduct healthcare studies in the combat environment. On July 20, 2005, the first DOD Assurance of Compliance for the Protection of Human Research Subjects was approved for MNC-I. This assurance allows the conduct of human subjects research in full compliance with all Federal, DOD, and Army regulatory requirements. This article describes that unique process.

Physiological changes in venous hemodynamics associated with elective fasciotomy.

It has been postulated that lower extremity fasciotomy may disrupt the calf musculovenous pump and predisposes to development of chronic venous insufficiency (CVI). However, studies based on trauma patients who undergo emergent fasciotomy are confounded by the possibility of concomitant vascular and soft tissue injury and use historical controls. This is a prospective study that evaluates venous hemodynamics in young patients undergoing elective fasciotomy for chronic exertional compartment syndrome (CECS), eliminating the problems associated with retrospective study of trauma patients. CECS was diagnosed by history and, when indicated, measurement of compartment pressures. Prior to elective two- or four-compartment fasciotomy, each patient underwent lower extremity air plethysmography (APG) and colorflow duplex ultrasonography. These studies were repeated a minimum of 6 weeks postoperatively. Fifteen patients who had fasciotomies for CECS were studied; two of these patients had bilateral fasciotomies for a total of 17 limbs. There were 13 male and two female patients (average age 31.2 years). APG and colorflow duplex were performed an average of 12 weeks after fasciotomy. Outflow fraction, venous volume, and ejection volume showed no significant changes postoperatively. However, the venous filling index (VFI) increased (0.9 +/- 0.1 vs. 1.1 +/- 0.1 mL/sec; p < 0.05, paired t-test), the ejection fraction tended to decrease (59 +/- 4% vs. 52 +/- 2%; p < 0.08, paired t-test), and the residual volume fraction (RVF) increased (26 +/- 3% vs. 36 +/- 5%; p < 0.05, paired t-test). There were no patients with evidence of deep venous reflux. Two extremities with preoperative greater saphenous vein (GSV) reflux did not worsen, and three extremities developed new GSV reflux following fasciotomy, although VFI remained normal in each extremity. Elective fasciotomy for CECS does not lead to significant venous reflux but likely does diminish calf muscle pump function and increases RVF moderately in young adult patients. With longer follow-up this diminished calf muscle pump function may increase the risk of CVI.