Use of Combat Casualty Care Data to Assess the US Military Trauma System During the Afghanistan and Iraq Conflicts, 2001-2017.

Importance: Although the Afghanistan and Iraq conflicts have the lowest US case-fatality rates in history, no comprehensive assessment of combat casualty care statistics, major interventions, or risk factors has been reported to date after 16 years of conflict. Objectives: To analyze trends in overall combat casualty statistics, to assess aggregate measures of injury and interventions, and to simulate how mortality rates would have changed had the interventions not occurred. Design, Setting, and Participants: Retrospective analysis of all available aggregate and weighted individual administrative data compiled from Department of Defense databases on all 56 763 US military casualties injured in battle in Afghanistan and Iraq from October 1, 2001, through December 31, 2017. Casualty outcomes were compared with period-specific ratios of the use of tourniquets, blood transfusions, and transport to a surgical facility within 60 minutes. Main Outcomes and Measures: Main outcomes were casualty status (alive, killed in action [KIA], or died of wounds [DOW]) and the case-fatality rate (CFR). Regression, simulation, and decomposition analyses were used to assess associations between covariates, interventions, and individual casualty status; estimate casualty transitions (KIA to DOW, KIA to alive, and DOW to alive); and estimate the contribution of interventions to changes in CFR. Results: In aggregate data for 56 763 casualties, CFR decreased in Afghanistan (20.0% to 8.6%) and Iraq (20.4% to 10.1%) from early stages to later stages of the conflicts. Survival for critically injured casualties (Injury Severity Score, 25-75 [critical]) increased from 2.2% to 39.9% in Afghanistan and from 8.9% to 32.9% in Iraq. Simulations using data from 23 699 individual casualties showed that without interventions assessed, CFR would likely have been higher in Afghanistan (15.6% estimated vs 8.6% observed) and Iraq (16.3% estimated vs 10.1% observed), equating to 3672 additional deaths (95% CI, 3209-4244 deaths), of which 1623 (44.2%) were associated with the interventions studied: 474 deaths (12.9%) (95% CI, 439-510) associated with the use of tourniquets, 873 (23.8%) (95% CI, 840-910) with blood transfusion, and 275 (7.5%) (95% CI, 259-292) with prehospital transport times. Conclusions and Relevance: Our analysis suggests that increased use of tourniquets, blood transfusions, and more rapid prehospital transport were associated with 44.2% of total mortality reduction. More critically injured casualties reached surgical care, with increased survival, implying improvements in prehospital and hospital care.

The new reckoning: The Combat Casualty Care Research Program responds to real and present challenges in military operational projections.

This issue of the Journal of Trauma and Acute Care Surgery features topics from the 2017 Military Health System Research Symposium and starts a second decade of partnership between the Combat Casualty Care Research Program (CCCRP) and the journal. This publication comes at a time of significant change for the CCCRP, as it responds to military planning for the future multidomain battlefield (MDB). The projected MDB portends markedly different operational scenarios than those conducted over the past 17 years. Emerging threats around the globe have the Department of Defense preparing for more complex battlefields that are larger in size and scope and which pit the United States against better equipped and more sophisticated adversaries. As the CCCRP navigates this new reckoning associated with trauma care on the MDB, its research investments will need to be robust and enabled to plan, program, and budget for agile and closer-term solutions. To accomplish this, the program will need to expand on its strong foundation of lessons learned and assets developed over the past 20 years.

Defining and measuring nursing productivity: a concept analysis and pilot study.

AIMS: The purpose of this article is fourfold. First we report a concept analysis of nursing productivity to show the complexity of the concept and its measurement. We then show how the concept analysis was used to design a method for measuring nursing productivity. Third, we describe how we used this measure in a pilot study of the impact of a differentiated Registered Nurse (RN) practice model on productivity. Finally, we identify the challenges encountered and present recommendations for nurse executives and researchers based on our findings. RATIONALE: We believe our experience can be useful to nurse executives and researchers who are interested in studying the impact of care delivery models on nursing productivity. DESIGN: We defined productivity as the ratio of output (patient care hours per patient day) to input (paid salary and benefit dollars). We conducted a pilot test using the productivity measure developed from the concept analysis to determine the effects of a differentiated RN practice model on patient, staff, and organizational outcomes. The purpose of the pilot study was to determine whether the data needed to measure productivity could be obtained from administrative databases and to develop the steps and process for the analysis. We analysed data by 2-week pay periods for two quarters prior to implementation of the differentiated nursing practice model and for two quarters after implementation to assess for changes in nursing productivity. RESULTS: Pilot testing showed that we could detect changes in productivity using this measurement approach. It also revealed several challenges in using administrative databases to measure productivity. CONCLUSIONS: We discuss these challenges with recommendations for both nurse executives and researchers. The most reasonable approach for operational decision-making is longitudinal monitoring of productivity by organizational units combined with indicators of quality of patient care.