The National Academy of Science released the seminal report, Accidental Death and Disability: The Neglected Disease of Modern Society, 50 years ago.1 Three Fellows of the American College of Surgeons (ACS)—Sam Seeley, MD, FACS; Alan Thal, MD, FACS; and John Howard, MD, FACS—played a critical role in the development of this document.2 The report was, in large measure, stimulated by and based on the experiences of these surgeons during their military deployment in the Korean War. The authors took what they learned in the military and translated those lessons into a list of recommendations to improve trauma care for injured U.S. civilians. The findings and recommendations described in Accidental Death and Disability were pivotal in the early development of emergency medical services (EMS), emergency medicine, trauma centers, and trauma care systems across the nation.
Today, however, the U.S. trauma system remains an incomplete patchwork. Many of the gaps identified in Accidental Death and Disability remain, and summary paragraphs describing areas in need of improvement in the report are as applicable today as they were when the report was written.
In an effort to develop strategies for improving the U.S. trauma system, the National Academies of Sciences, Engineering, and Medicine (NASEM) Committee on Military Trauma Care’s Learning Health System and Its Translation to the Civilian Sector released a report this spring, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury.3 The report was sponsored by the ACS, the U.S. Department of Defense, and other leading health care organizations dedicated to improving outcomes after injury. This new report calls for eliminating all preventable trauma-related deaths in both military and civilian trauma patients.
The leadership of the ACS Committee on Trauma (COT) is grateful for the contributions of the National Academies and our dedicated Fellows of the College, specifically those who produced both the original white paper and this latest comprehensive report. In the tradition of the original contributors from 50 years ago, six Fellows of the College served on the most recent committee (all MD, FACS): Adil Haider; John B. Holcomb; Cato T. Laurencin; the late Norman E. McSwain, Jr.; Thomas M. Scalea; and C. William Schwab. The Academies dedicated the report to Dr. McSwain, who died during production of the current report.
This latest document outlines important opportunities for strengthening the relationship between the ACS and the U.S. military. Moreover, the efforts of the Academies committee provide a roadmap for improving the trauma care of U.S. citizens and of our troops in times of war.
This article outlines the events leading up to the release of the report, summarizes its 11 recommendations, and describes how the ACS and other trauma leaders have collaborated to promote optimal care of the injured patient and to advance the agenda established by the NASEM.
Events leading up to the report
Dr. Schwab set the stage for developing A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury in the Scudder Oration, which he delivered at the ACS Clinical Congress 2014. In his presentation, Dr. Schwab called for the establishment of “…a think tank of senior civilian consultants to take on the larger and more difficult issues for the readiness and surgical mission of the Defense Health Authority and the Department of Defense.” He went on to state that “these subject content experts should be structured to assure relevance, impact, and value. This think tank should be composed of the best thinkers in academic surgery and medicine, health administration, finance, and economics.”4
In line with this vision, other key sponsors of the NASEM report included the American College of Emergency Physicians, the National Association of EMS Physicians, the National Association of Emergency Medical Technicians, the Trauma Center Association of America, the U.S. Department of Defense, the U.S. Department of Homeland Security, and the U.S. Department of Transportation. Although sponsored by the ACS and these other leading organizations, one of the strengths of the Academies’ report is that the recommendations were derived independently from a group of experts convened by NASEM.
Donald Berwick, MD, chair of the NASEM Committee on Military Trauma Care’s Learning Health System and Its Translation to the Civilian Sector, noted, “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…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.”5
The report is comprehensive and broad in scope, calling for the development of a national trauma care system and highlighting 11 specific recommendations. These recommendations can be summarized as follows:
- The White House should set a national aim of achieving zero preventable deaths after injury and minimizing trauma-related disability.
- The White House should lead the integration of military and civilian trauma care to establish a national trauma care system. This initiative would include assigning a locus of accountability and responsibility that would ensure the development of common best practices, data standards, research, and workflow across the continuum of trauma care.
- The Secretary of Defense should ensure combatant commanders and the Defense Health Agency (DHA) Director are responsible and held accountable for the integrity and quality of the execution of the trauma care system in support of the aim of zero preventable deaths after injury and minimizing disability. To this end:
- The Secretary of Defense also should ensure the DHA Director has the responsibility and authority and is held accountable for defining the capabilities necessary to meet the requirements specified by the combatant commanders with regard to expert combat casualty care personnel and system support infrastructure.
- The Secretary of Defense should hold the Secretaries of the military departments accountable for fully supporting the DHA in that mission.
- The Secretary of Defense should direct the DHA Director to expand and stabilize long-term support for the Joint Trauma System so its functionality can be improved and used across all combatant commands, giving players in the system access to timely evidence, data, educational opportunities, research, and performance improvement activities.
- The Secretary of the U.S. Department of Health and Human Services (HHS) should designate and fully support a locus of responsibility and authority within the department for leading a sustained effort to achieve the national aim of zero preventable deaths after injury and minimizing disability. This leadership role should include coordination with governmental (federal, state, and local), academic, and private-sector partners and should address care from the point of injury to rehabilitation and post-acute care.
- The Secretary of HHS and the Secretary of Defense, together with their governmental, private, and academic partners, should work jointly to ensure that military and civilian trauma systems collect and share common data spanning the continuum of care. Within that integrated data network, measures related to prevention, mortality, disability, mental health, patient experience, and other intermediate and final clinical and cost outcomes should be made readily accessible and useful to all relevant providers and agencies.
- To support the development, continuous refinement, and dissemination of best practices, the designated leaders of the recommended national trauma care system should establish processes for real-time access to patient-level data from across the continuum of care and just-in-time access to high-quality knowledge for trauma care teams and those who support them.
- To strengthen trauma research and ensure that the resources available for this research are commensurate with the importance of injury and the potential for improvement in patient outcomes, the White House should issue an Executive Order mandating the establishment of a National Trauma Research Action Plan requiring a resourced, coordinated, joint approach to trauma care research across the Department of Defense (DoD), HHS (including the National Institutes of Health, Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Food and Drug Administration, and Patient-Centered Outcomes Research Institute), the Department of Transportation, the Department of Veterans Affairs, and others (academic institutions, professional societies, and foundations).
- To accelerate progress toward the aim of zero preventable deaths after injury and minimizing disability, regulatory agencies should revise research regulations and reduce misinterpretation of the regulations through policy statements—that is, guidance documents.
- All military and civilian trauma systems should participate in a structured trauma quality improvement process.
- Congress, in consultation with HHS, should identify, evaluate, and implement mechanisms that ensure the inclusion of prehospital care (for example, emergency medical services) as a seamless component of health care delivery, rather than merely a transport mechanism.
- To ensure readiness and to save lives through the delivery of optimal combat casualty care, the Secretary of Defense should direct the development of career paths for trauma care—for example, foster leadership development, create joint clinical and senior leadership positions, remove any relevant career barriers, and attract and retain a cadre of military trauma experts with financial incentives for trauma-relevant specialties. Furthermore, the Secretary of Defense should direct the Military Health System to pursue the development of integrated, permanent joint civilian and military trauma system training platforms to create and sustain an expert trauma workforce.
Commitment to better trauma care
The ACS COT and the Military Health System Strategic Partnership ACS (MHSSPACS) strongly support and endorse the findings and recommendations in the report. In an invited commentary published in 2015 in the Journal of the American College of Surgeons, Margaret “Peggy” Knudson, MD, FACS, Director of MHSSPACS, noted, “Dr. (Col.) Edward D. Churchill is quoted as saying, ‘Surgeons in a current war never begin where the surgeons in the previous war left off; they always go through another long learning period.’ Dr. Churchill, we will do our best to not let that be the case going forward.”6 The ACS—through the COT, the MHSSPACS, the ACS Division of Advocacy and Health Policy, and the Coalition for National Trauma Research (CNTR)—is committed to effective implementation of the NASEM recommendations as a means of responding to Dr. Churchill’s concerns.
The ACS COT’s activities are administered through an 85-member national committee that oversees a field force of more than 3,500 trauma care professionals nationwide. These individuals work together to develop and implement meaningful trauma care programs in local, regional, national, and international arenas. The COT was established in 1922 and has worked to continuously improve the care of injured patients. The COT is dedicated to preventing injuries, improving all phases and systems of care that are important to the injured patient, and to actively cooperating with other national organizations that have similar strategic goals.7
Since its founding, the ACS has been dedicated to promoting the highest standards of surgical care through the pillars of education, quality, and advocacy.7 The ACS COT has formally adopted this pillar approach to national leadership in trauma and has championed trauma systems strength, as depicted in Table 1.
Table 1. National trauma leadership pillars
|Advance Trauma Education||Ensure Quality
|Champion Trauma Systems Strength||Drive Advocacy|
|Accredited continuing education programs that support medical professionals across the continuum of trauma care:
||A verification program helps trauma centers confirm that they have adequate resources, ensures readiness, and improves trauma care. The quality cycle continues with TQIP, a risk-adjusted local and national benchmarking program to measure and inform the improvement of outcomes, and a PIPS program that continuously measures and evaluates in order to improve care.
Resources for Optimal Care of the Injured Patient
|Comprehensive expert assessment and consultative guidance for the improvement or development of state and regional trauma systems
Integrates and partners with multidisciplinary teams in each locality or region
Trauma Systems Consultation for counties, regions, states, or systems
Benchmarks, indicators, and scoring facilitations
|Advocacy activities at the federal and state level focused on prevention as well as socioeconomic, legislative, and regulatory issues that affect trauma care
Develop and advocate health care policies that are in the best interests of trauma patients, such as the Stop the Bleed campaign (bleeding control or BCon)
Promote injury prevention and control programs aimed at reducing needless injury, death, and suffering
To advance trauma education with respect to A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury, the ACS COT’s Trauma Systems Committee has partnered with NHTSA to convene the Innovations in Trauma Care Conference, which is scheduled to take place in spring 2017. The conference will highlight the findings of the NASEM report, generate information and knowledge aimed at implementation of the report’s recommendations, and stimulate further innovation in trauma systems.
Working with the American Association for the Surgery of Trauma (AAST), the National Trauma Institute (NTI), the Eastern Association for the Surgery of Trauma (EAST), the Western Trauma Association (WTA), and their respective memberships, the ACS COT helped establish the CNTR. Bill Cioffi, Jerry Jurkovich, Tim Fabian, Thomas Scalea, Don Jenkins, Chris Cocanour, and Kim Davis (all MD, FACS) played crucial early roles in the establishment of the coalition. As a result of the joint advocacy efforts of CNTR members, Congress appropriated $10 million in 2016 for the development of a national trauma clinical trials network and has authorized an additional $10 million for the 2017 budget to further support that initiative.8
Three key programs form the foundation of the COT’s Quality Pillar, which is poised to help make the NASEM quality goals a reality. The Trauma Quality Improvement Program (TQIP®), the Verification, Review, and Consultation Program (VRC), and the Performance Improvement and Patient Safety (PIPS) programs provide an integrated comprehensive approach to quality improvement, as called for in the report. The COT’s Trauma System Committee is currently partnering with the Department of Defense and the MHSSPACS to comprehensively address the goals outlined in the latest Academies’ report.
Moving forward together with key partners
Along these lines of partnership and to advance the goals of a national trauma system described in the report, the ACS COT, MHSSPACS, and CNTR are moving forward together to further coordinate and integrate civilian and military trauma systems and to improve the quality and impact of trauma-related research.
The CNTR is developing the National Trauma Research Repository and recently received its first major project aimed directly at reducing prehospital deaths in a manner recommended in the NASEM report. The ACS COT has committed to assist CNTR by using the National Trauma Data Bank® and the TQIP® systems to enhance the efficacy of clinical trials in these networks. Making the report’s research agenda a reality remains the top goal of the CNTR. The AAST, NTI, EAST, and WTA have been great partners to the ACS COT in advancing our combined efforts to improve the care of the injured patient.
The ACS COT and CNTR have both created position statements outlining support for specific implementation strategies aligned with the NASEM guidelines. These statements are scheduled to be published in the October issue of the Journal of Trauma and Acute Care Surgery.9-10 Creating this implementation strategy is vital, as the charge of the Academies’ committee is essentially complete once the report is fully released in November. This is a critical project for the ACS, CNTR, and other partner organizations. This past August, the American College of Emergency Physicians and the COT collaborated on the development of a national database that would enable an immediate preventable death analysis following active mass casualty incidents. A commitment to working together is at the heart of the COT’s approach to making zero preventable deaths a reality.
We believe the NASEM report will have a tremendous impact on the care of the injured patient, and the ACS COT is committed to making this belief a reality.
Grace Rozycki, MD, FACS, AAST President, commented: “The AAST has a long history of promoting, evaluating, and leading innovation in trauma systems. We are committed to dissemination, implementation, and working with our CNTR partners to create the research agenda called for in this latest report.” And, as Dr. Scalea, a founding member of CNTR and a contributor to the current recommendations, added, “It was a pleasure and an honor to serve on the Military Trauma Care’s Learning Health System and its Translation to the Civilian Sector Committee. I am confident that, working together, we can meet the goal of zero preventable deaths called for in our report.”
- National Research Council. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: The National Academies Press; 1966.
- Howard JM. Historical background to Accidental Death and Disability: The Neglected Disease Of Modern Society. Prehosp Emerg Care. 2000;4(4):285-289.
- National Academies of Sciences, Engineering, and Medicine. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury. Washington, DC: The National Academies Press; 2016.
- Schwab CW. Scudder Oration on Trauma. Winds of war: Enhancing civilian and military partnerships to assure readiness. White paper. J Am Coll Surg. 2015;221(2):254-255.
- National Academies of Sciences, Engineering, and Medicine. Up to 20 percent of U.S. trauma deaths could be prevented with better care. June 17, 2016. Press release. Available at: www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=23511. Accessed August 18, 2016.
- Knudson MM. Scudder Oration on Trauma. Invited Commentary. J Am Coll Surg. 2015;221(2):254-255.
- American College of Surgeons. About ACS. Committee on Trauma. Available at: facs.org/about-acs/governance/acs-committees/committee-on-trauma. Accessed August 18, 2016.
- Stewart RM. $10 million closer to meeting the trauma challenge. ACS Surgery News. February 17, 2016. Available at: www.acssurgerynews.com/?id=14883&tx_ttnews[tt_news]=482625&cHash=641c0f8bc7ab81c94b2eb3584c771f9d. Accessed August 18, 2016.
- Jenkins DH, Winchell R, Rotondo MF, et al. Position statement of the American College of Surgeons Committee on Trauma on the National Academies of Sciences, Engineering and Medicine report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury. J Trauma Acute Care Surg. August 16, 2016. [Epub ahead of print].
- Jenkins DH, Cioffi WG, Cocanour CS. Position Statement of the Coalition for National Trauma Research (CNTR) on the National Academies of Sciences, Engineering and Medicine (NASEM) Report: A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury. J Trauma Acute Care Surg. August 16, 2016. [Epub ahead of print].