The future of trauma care on Capitol Hill: Implementing military-civilian trauma care and establishing a national trauma system

The American College of Surgeons (ACS) Division of Advocacy and Health Policy (DAHP) and the Committee on Trauma (COT) continue to work closely to craft and implement a trauma-focused agenda to take to Capitol Hill. While federal government budget debates and partisan politics have been an impediment to passing trauma-related legislation, within the last several months the momentum has shifted. This change is perhaps attributable to the publication of the National Academy 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. The report, released in June 2016, outlines 11 recommendations that would help achieve the goal of zero preventable deaths after injury through the establishment of a nationwide trauma system that incorporates elements of trauma care in both the military and civilian sectors. Since the release of the NASEM report, several pieces of trauma-focused legislation have been introduced in Congress, and the House Energy and Commerce Committee held a hearing on the establishment of a national trauma system. The ACS COT issued a statement in support of the NASEM report in October 2016.*

Previous barriers

Until this year, Congress’ focus was on two pieces of trauma legislation that would have funded trauma systems and centers. However, these bills faced multiple obstacles, including congressional leaders who were hesitant to appropriate funding to implement the legislation without finding a revenue stream to pay for these bills, or an equal number of budget cuts that would cover the cost. Congressional inaction has stalled the bills, but some progress has occurred with the emergence of trauma champions, including Reps. Michael Burgess, MD (R-TX), Gene Green (D-TX), and Larry Bucshon, MD, FACS (R-IN), and Sens. Patty Murray (D-WA), Jack Reed (D-RI), and Mark Kirk (R-IL), who retired in January 2017. With their support, trauma legislation remains on the congressional radar, and the ACS will work with these legislators and their colleagues to identify alternate funding mechanisms.

The NASEM report helped bring new policy ideas to the forefront and elevate trauma as an issue on Capitol Hill. As a result, several legislators have redoubled their efforts to pass legislation that addresses the concerns outlined in the NASEM report. Some recommendations highlight the need for greater cooperation between military and civilian trauma care, increased research for trauma care, expanded participation in trauma quality improvement programs, and inclusion of prehospital care as a seamless component of the health care delivery system. Building on this momentum, the ACS is revamping its trauma priorities and advocacy strategies for today and beyond. In February 2017, the ACS and the COT hosted a congressional briefing on Capitol Hill to highlight the Stop the Bleed® program, which trains civilian bystanders in the basics of hemorrhage control. The briefing featured an overview of Stop the Bleed and the Hartford Consensus—the mass casualty and active shooter response committee led by  ACS Regent Lenworth M. Jacobs, Jr., MD, MPH, FACS—and provided an opportunity for congressional legislators and staff to engage in a hands-on bleeding control simulation (BCon) led by COT leaders (see related article).

Legislative first steps: National Defense Authorization Act

As trauma care leaders were developing the NASEM report, congressional leaders working with DAHP staff were focused on addressing improvements to the military health system. In the 114th Congress (2015–2016), the ACS worked with Rep. Joe Heck, DO (R-NV), then-Chair of the House Armed Services Subcommittee on Military Personnel, to include a provision in the National Defense Authorization Act (NDAA), which calls for the establishment of a Joint Trauma System (JTS) within the U.S. Department of Defense (DoD). Under the NDAA, enacted in December 2016, the JTS will add uniformity to trauma care for the U.S. Armed Forces by aligning all military medical treatment facilities under the same set of trauma standards. In the past, each medical corps (Army, Navy, and Air Force) had its own protocols, including requirements for pre-deployment training. The JTS also will be responsible for coordinating the translation of research from DoD centers of excellence into standards of clinical trauma care, as well as incorporating lessons learned from trauma education and training partnerships into clinical practice.

Rep. Brad Wenstrup, DPM (R-OH), helped to secure language in the NDAA that calls for a review of the military trauma system by a nongovernment entity with subject matter experts. The ACS COT Trauma Systems Consultation Program regularly conducts such reviews. The comprehensive review will look at combat casualty care and wartime trauma systems from January 1, 2001, through the date of the review. It will include an assessment of lessons learned to improve combat casualty care in future conflicts. The reviewer will be required to make this report publicly available. The report will contain findings from the review and recommendations to establish a comprehensive trauma system for the U.S. Armed Forces.

The NDAA also contains a provision that establishes a Joint Trauma Education and Training Directorate, which is charged with ensuring that trauma providers in the Armed Forces maintain a state of readiness. Maintaining this capability will be accomplished, in part, by entering into partnerships with civilian academic medical centers and large metropolitan teaching hospitals that have Level I civilian trauma centers, providing trauma teams—including military surgeons—with continuous exposure to critically injured patients. Facilities eligible for these partnerships will be selected by the U.S. Secretary of Defense based on patient volume, acuity, and other factors deemed necessary to support the goal of readiness. Additionally, major military treatment facilities will be required to participate as trauma centers in their region in areas of need.

The directorate’s role is to improve military trauma care and increase readiness for the rapid deployment of integrated military trauma teams, including forward surgical teams (mobile surgical units in the field). For example, the directorate will establish goals and metrics for the partnerships to ensure that providers maintain professional competency in trauma care. The directorate also will be responsible for the communication and coordination of lessons learned from such partnerships to the JTS. Additionally, chief among the directorate’s duties is the development of standardized combat casualty care instruction for all members of the U.S. Armed Forces, including the use of standardized trauma training platforms. The Military Health System Strategic Partnership American College of Surgeons (MHSSPACS) is developing a blueprint for testing and maintaining currency and competency in combat casualty care.

Central to the mission of improving military trauma care, the directorate will be responsible for the creation of a comprehensive trauma care registry to compile relevant data from point of injury through rehabilitation of military service members. The directorate also will be charged with the development of quality of care outcome measures for combat casualty care. Aligning military trauma care and creating military-civilian trauma partnerships is expected to have a profound impact on the U.S. military and civilian trauma systems. These initiatives provide the opportunity not only to save lives and prevent disabilities domestically, but also globally for those serving in the U.S. Armed Forces.

Congressional action: Zero preventable deaths

On July 12, 2016, the U.S. House of Representatives Committee on Energy and Commerce Subcommittee on Health held a hearing on Strengthening Our National Trauma System. This hearing focused on implementing the parameters of the NASEM report to establish a nationwide trauma system that would achieve zero preventable deaths after injury. The ACS provided testimony for this hearing and echoed the view of the NASEM report, which noted that accomplishing this goal will depend on supporting civilian and military trauma center partnerships, ensuring that lessons learned from combat are implemented in civilian trauma care. C. William Schwab, MD, FACS, testified about his contribution to the NASEM report and his experiences in a military-civilian partnership project during the Vietnam War. Dr. Schwab highlighted the limited opportunities for military trauma training and how these partnerships will increase military readiness, skills, and competency.

As a result of the hearing, the Mission Zero Act (S. 3407 and H.R. 6229) was introduced in the Senate by Sens. Mark Kirk, Johnny Isakson (R-GA), and John Cornyn (R-TX), and in the House by Reps. Michael Burgess, Kathy Castor (D-FL), Gene Green, and Richard Hudson (R-NC). The Mission Zero Act, which did not pass, would have assisted military health care providers in maintaining a state of readiness by providing grants for military trauma teams and providers to embed in civilian trauma centers.

The Mission Zero Act would have specifically provided $40 million in grant funding from the Department of Health and Human Services to facilitate partnerships between military trauma care teams/providers and high-volume civilian Level I trauma centers. These partnerships would allow military trauma care teams/providers to gain exposure by treating critically injured patients and increase readiness for when these units are deployed.

Not only would these efforts improve sustained readiness among military providers, but they would allow for a smooth transition of trauma lessons learned from the military to the civilian setting, and may assist in alleviating staffing demands at civilian centers. In February 2017, the Mission Zero Act was reintroduced in the House of Representatives (H.R. 880) by the same sponsors from the 114th version. At press time, Senate reintroduction is forthcoming.

In addition to the Mission Zero Act, the ACS is inclined to support legislation that improves the U.S. trauma system and supports a sufficient number of trauma centers and trauma personnel to meet both civilian and military needs. The message of several NASEM recommendations clearly indicates that without a nationwide system, the goal of zero preventable trauma deaths is not obtainable. The COT, the MHSSPACS, and the DAHP will continue to advocate for a trauma system that will cover injured patients, regardless of their location.

BCon

In 2016, the American Medical Association House of Delegates (AMA-HOD) endorsed the ACS-led resolution to support the Stop the Bleed program, which encourages educating first responders and immediate first responders (bystanders) in bleeding control techniques, including the use of holding pressure, tourniquets and gauze dressings, and creative use of nontraditional materials such as clothing or belts. This initiative represents a revolutionary step in saving lives and turning bystanders of traumatic events into lifesaving heroes.

Building on this momentum, the ACS is working with congressional trauma champions to introduce legislation that would assist in bringing BCon training to the general public. The overarching goal is to ensure that the ability to control bleeding is as commonplace as the ability to perform the Heimlich maneuver or administer cardiopulmonary resuscitation.

As a leader in BCon training and trauma care, the College will have unique opportunities to advocate for the advancement of BCon and trauma priorities during the ACS Leadership & Advocacy Summit in Washington, DC, May 6–9.

Congressional Pediatric Trauma Caucus

The ACS is supportive of the congressional Pediatric Trauma Caucus, created in 2016 by Reps. Richard Hudson (R-NC) and G.K. Butterfield (D-NC), to ensure that all children have access to a properly resourced trauma facility within the golden hour. The goal of the caucus is to reduce the number of pediatric trauma fatalities in the U.S. Both Representatives Hudson and Butterfield serve on the House Committee on Energy and Commerce, one of the main committees with jurisdiction over health care legislation.

The caucus has hosted two congressional briefings—one on overall pediatric trauma, and the other on youth sports injuries in May and September of 2016, respectively. The ACS played an active role in both briefings.

The pediatric trauma briefing focused on pediatric trauma as the number one cause of death among children in the U.S., and on what can be done to prevent injuries and improve access to appropriate pediatric trauma care. David Adelson, MD, FACS; Barbara Gaines, MD, FACS; and John Petty, MD, FACS, served on the panel and offered their expert input.

The youth sports injury briefing focused on the importance of concussion diagnosis, treatment, and access to follow-up care post injury. Shelly Timmons, MD, FACS, and Brendan Campbell, MD, FACS, served on this panel and offered their perspectives on youth injury diagnosis and treatment. Drs. Timmons and Campbell emphasized the importance of funding for concussion research to further identify prognostic tools, diagnostic testing modalities, and the efficacy of treatment modalities for post-concussion symptoms.

Looking ahead

The College will continue to make strengthening the nation’s trauma system a high priority in the 115th Congress, while elevating the goal of zero preventable deaths and ensuring all trauma patients receive appropriate care within the golden hour.

On a daily basis, Congress, government regulators, and state legislatures are making decisions that could have drastic effects on the health care profession. As trauma research struggles to receive adequate federal funding relative to the number of injuries per year, the ACS and COT, along with trauma partners who represent the full spectrum of trauma care, will continue to join together to engage congressional leaders and public officials with a unified voice.

How to help

The involvement of surgeon-advocates is paramount to establishing an active relationship with federal and state legislators. The key to successful advocacy is an engaged membership, and the ACS suggests the following activities to support this work:

  • Attend the Leadership & Advocacy Summit, May 6–9 in Washington, DC
  • Host your federal/state legislators for a trauma center or facility tour
  • Meet with your member of Congress in your home district or in Washington, DC

The DAHP is available to help with these efforts, and can assist with preparations for a congressional meeting or facility tour.

For questions about military-civilian trauma policy, e-mail czlatos@facs.org. For questions about trauma policy, e-mail jrosen@facs.org.


*Stewart R, Jenkins D, Winchell R, Rotondo M. ACS Committee on Trauma pledges to make zero preventable deaths a reality. Bull Am Coll Surg. 2016;101(10):23-28. Available at: bulletin.facs.org/2016/10/acs-committee-on-trauma-pledges-to-make-zero-preventable-deaths-a-reality/. Accessed January 31, 2017.

Gillum LA, Gouveia C, Dorsey ER, et al. NIH disease funding levels and burden of disease. PLoS ONE. 2011;6(2):e16837. Available at: journals.plos.org/plosone/article?id=10.1371/journal.pone.0016837/. Accessed February 16, 2017.

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