Looking forward – March 2020

David B. Hoyt, MD, FACS

In October 2014, the American College of Surgeons (ACS) and the U.S. Department of Defense (DOD) formed the Military Health System Strategic Partnership American College of Surgeons (MHSSPACS) in order to share information in the areas of surgical education, trauma and combat casualty care, systems-based practice, and research capabilities. In just five years, the MHSSPACS has evolved rapidly under the leadership of my co-authors this month, Drs. Knudson, Elster, and Rich.

Quality

An initial goal of the MHSSPACS was to address the perception that the quality of surgical care provided at Military Treatment Facilities (MTFs) was inferior to that of other public and private hospitals in the U.S. With the assistance of the ACS Division of Research and Optimal Patient Care, a military quality consortium was formed to include all of the major MTFs in the U.S., as well as a few abroad. This consortium, including both the Surgeon Champions and their surgical clinical case reviewers, meets twice a year to discuss issues that relate to the challenges unique to MTFs.

The recent cumulative data across the entire military medical enterprise demonstrate measurable improvement in surgical quality care indices, with several MTFs now among the top performing hospitals in the nation. In addition, Walter Reed National Military Medical Center, Bethesda, MD, was among the first to be formally reviewed by the ACS using the ACS Red Book, Optimal Resources for Surgical Quality and Safety. These military quality initiatives have recently been highlighted in a paper published in Health Affairs.*

Trauma centers and trauma systems

In 2016, the National Academies of Sciences, Engineering, and Medicine released the report A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury. Members of the MHSSPACS and the ACS Committee on Trauma (COT) were actively involved in its rollout. In addition, the College advocated for the passage of the National Defense Authorization Act for fiscal year 2017, which requires all major MTFs to either participate in their regional civilian trauma system or to form partnerships with civilian trauma centers to ensure that military trauma teams always are prepared for deployment.

The legislation that would provide grant funding for the development and sustainment of these partnerships (the Mission Zero Act) was passed in June 2019, but the funding has yet to be allocated. In preparation for these grants, the MHSSPACS has developed the “Blue Book,” which outlines the criteria for selecting and evaluating institutions that are interested in participating in this program. The Blue Book has been endorsed by both the Defense Health Board and the Defense Health Agency. Members of the COT and the MHSSPACS are providing both consultation and verification trauma site visits for MTFs seeking to participate in their local trauma systems.

Education

The military has done a spectacular job of developing a trauma system to provide care to wounded warriors in Iraq and Afghanistan. However, preparation for deployment varied from service to service, and without sustainment, many of the lessons learned soon will be forgotten. To meet the challenge of keeping a ready military force, the MHSSPACS has developed a method for assessing knowledge points and skills for deploying general surgeons (the Knowledge, Skills and Abilities [KSA] Project). The knowledge exam is administered electronically and has been demonstrated to be capable of distinguishing an experienced surgeon from one with no deployment history. The skills testing is based on the ACS COT Advanced Surgical Skills for Exposure in Trauma (ASSET) course with some additional surgical specialty stations added (ASSET+). This course has been delivered four times to date and is popular with both the students and the faculty. In areas where knowledge gaps are identified, a multimedia curriculum is being developed and housed on the ACS network for easy access.

The ASSET+ expeditionary course developed by Colonel (ret) Mark W. Bowyer, MD, FACS, was piloted in Baltimore at the University of Maryland R Adams Cowley Shock Trauma Center in April 2019

The ASSET+ expeditionary course developed by Colonel (ret) Mark W. Bowyer, MD, FACS, was piloted in Baltimore at the University of Maryland R Adams Cowley Shock Trauma Center in April 2019

 

The Excelsior Surgical Society

After World War II, a group of surgeons met in Rome, Italy, at the Excelsior Hotel to discuss their surgical experiences during the war. This society then met annually until the last members died in the 1980s. In 2015, the Excelsior Surgical Society was reorganized and is now a formal society within the ACS with elected officers, bylaws, and committees. The Society meets by teleconference monthly and formally for an entire day in conjunction with the Clinical Congress for scientific exchange and named lectureships. Membership is open to all surgeons who have served in the U.S. military (active or retired). Excelsior surgeons also participate in the Military Section of the Surgical Forum.

Excelsior Surgical Society Scientific Session, Clinical Congress, Chicago, IL, from left: Colonel Jeffrey Bailey, MD, FACS, USAF; Dr. Knudson; Colonel Robert Lim, MD, FACS, USA; Captain Gordon Wisbach, MD, FACS, USN; Colonel Jeffrey McNeil, MD, FACS; Colonel Matthew Martin, MD, FACS, USA; Lieutenant Colonel Steve Satterly, MD, FACS, USA; Dr. Hoyt; Dr. Elster; and Garrett Kirk, MPH, Program Adminstrator, MHSSPACS

Excelsior Surgical Society Scientific Session, Clinical Congress, Chicago, IL, from left: Colonel Jeffrey Bailey, MD, FACS, USAF; Dr. Knudson; Colonel Robert Lim, MD, FACS, USA; Captain Gordon Wisbach, MD, FACS, USN; Colonel Jeffrey McNeil, MD, FACS; Colonel Matthew Martin, MD, FACS, USA; Lieutenant Colonel Steve Satterly, MD, FACS, USA; Dr. Hoyt; Dr. Elster; and Garrett Kirk, MPH, Program Adminstrator, MHSSPACS

 

Research

The MHSSPACS works with both the DOD and the newly reorganized Coalition for National Trauma Research to identify and support areas of research relevant to combat casualty care, recognizing that research is an essential component of the readiness mission and for a continuous learning national trauma system.

Appropriate recognition

Three military surgeons were instrumental in forming the MHSSPACS. First is retired U.S. Army Colonel Dr. Rich, who was awarded the inaugural Distinguished Lifetime Military Contribution Award at Clinical Congress 2019 in recognition of his outstanding contributions to military surgery and as a pioneer of modern vascular surgery. Dr. Rich, Dr. Elster, and I worked directly with Jonathan Woodson, MD, MSS, FACS, then Assistant Secretary of Defense for Health Affairs, to create the foundation of this program in 2014.

In addition, Vice Admiral Raquel C. Bono, MD, FACS, former Director of the Defense Health Agency, received the Mary Edwards Walker Inspiring Women in Surgery Award. Vice Admiral Bono has served on the ACS Board of Governors (2014–2016) and has been honored with three Defense Superior Service Medals, four Legion of Merit Medals, two Meritorious Service Medals, and two Navy and Marine Corps Commendation medals for her military service and extensive commitment to the care of injured service members.

Looking forward

The year 2020 is already proving to be a significant year for the MHSSPACS. Multiple military quality site visits are in the planning stages. The KSA Project for military trauma surgeons and the first version of the multimedia curriculum both will be completed this year. A mapping project will highlight MTFs that can serve as trauma centers in areas of the nation that lack access to trauma care, thus expanding the U.S. trauma system to all injured patients. Dr. Knudson and other members of the MHSSPACS will be briefing Congress about the importance of military-civilian partnerships for the readiness mission and the need to fund the Mission Zero Act, and the Blue Book will be published with a formal rollout.

In these unsettled times, the need to continue our partnership with the U.S. military based on the legacy established by my contributors could not be more important.

Dave

If you have comments or suggestions about this or other issues, please send them to Dr. Hoyt at lookingforward@facs.org.


*Tanielian T, Farmer C. The US Military Health System: Promoting readiness and providing health care. Health Aff. Published online August 5, 2019. Available at: www.healthaffairs.org/doi/10.1377/hlthaff.2019.00239. Accessed January 24, 2020.

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. Berwich D, Downey A, Cornett E (eds). Available at: https://nam.edu/a-national-trauma-care-system/. Accessed January 27, 2020.

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