Clinical Guidelines in Theater
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A SYSTEMATIC APPROACH TO THE CARE OF TRAUMA PATIENTS ACROSS A CONTINUUM—INJURY IN THE FIELD TO DISCHARGE FROM A HOSPITAL—HAS BECOME THE STANDARD OF CARE WITHIN THE CIVILIAN COMMUNITY. A MILITARY VERSION OF THIS ORGANIZED APPROACH HAS BEEN CREATED IN THE JOINT THEATER TRAUMA SYSTEM.
The Joint Theater Trauma System (JTTS) is integral to not only the delivery of modern trauma services within the theater of combat operations but is evolving as a pivotal military doctrine. Such a combat trauma system would improve coordination of care and provide data to address and answer operational questions, predict manpower needs and provide medical situational awareness (i.e. injury patterns, and evaluate protection/prevention maneuvers). Furthermore, such information could be used to evaluate outcomes, training needs, improving continuity of care and facilitate system-wide decision, real-time changes and mid-course corrections based upon data.
A trauma system director and team of trauma nurse coordinators (TNCs) have been deployed in support of operations Iraqi Freedom and Enduring Freedom. One goal for the JTTS is to develop and implement clinical practice guidelines (CPGs) to improve care and survival of war casualties. Additionally these CPGs need to address the challenges of delivering trauma care in austere environments without the predictability afforded in a non-war setting.
Clinical practice guidelines are defined as systematically developed statements to assist practitioner decisions about appropriate health care for specific clinical circumstances and represent an attempt to distill a large body of medical knowledge into a convenient readily usable format. CPG developers gather, appraise and combine evidence in an attempt to address all the issues relevant to a clinical decision and all the values that might sway a clinical recommendation. Such guidelines refine clinical questions and balance trade-offs, relying on a quantitative reasoning emphasizing an individual context.
Furthermore, CPGs make explicit recommendations, often on behalf of health organizations with a definite intent to influence what clinicians do. These suggestions about what should be done go beyond a simple presentation of evidence, cost or decision models. They reflect value judgments about the relative importance of various health and economic outcomes in specific clinical situations. Guideline developers in combat scenarios must consider not only the best management options with eyes towards most important factors of morbidity, mortality and quality of life but with realistic constraints of the austere field environment.
Two of the leading potentially preventable complications identified by the JTTS in combat casualties were hypothermia (low body temperature) and deep venous thrombosis (DVT). Clinical evidence had been gathered by clinicians in the area of responsibility and U.S. military medical treatment facilities (CONUS) as to the deadly nature of these complications on injured casualties. A quality of evidence hierarchical scale can be used to rate different categories of evidence (expert opinion, clinical investigation, etc). Most evidence used was II-2, based on Canadian task force levels, corresponding to evidence obtained from well-designed cohort or case control analytic studies, preferably from more than one center or research group.
Hypothermia is a key component of the lethal triad in trauma patients. Over 80 percent of non-surviving patients have had a body temperature of less than 34 degrees Centigrade. Hypothermia occurs irrespective of the ambient temperature, in both hot and cold climates. Prevention decreases the negative effects of heat loss and decreases death from uncontrolled hemorrhage. It is much easier to prevent than treat, and therefore prevention should start as soon as possible after wounding. Thus the prevention of hypothermia needed to be emphasized in casualty care in military and combat operations.
In December 2004, the original CPG on the prevention, monitoring and treatment of hypothermia was published. It included guidance that hypothermia was increasingly prevalent in severe trauma casualties irrespective of the climate. Emphasis was placed on capturing patient temperatures using a temperature strip on all casualties (forehead) at Level I (battalion aid station) and Level II facilities (forward surgical teams) and during casualty evacuation (CASEVAC) to Level III (combat surgical hospital or emergency medical group). Also, facilities were advised to keep emergency medical treatment (EMT) units temperature at least 78 degrees Fahrenheit, use warmed IV fluids and, where available, forced air warming devices, like Bair Huggar systems, as well as implementing mandatory documentation of patient temperature on arrival to and discharge from all Level II and III facilities. Lastly, mandatory use of a heat conservation bag (i.e., body bag) for all rotary wing evac/ground evac or immediate triage category casualties was implemented as a field expedient method to prevent heat loss in March 2005.
JTTS TNCs monitored compliance with the CPG and the incidence of hypothermia. Previous to the implementation of the CPG, 7 percent of patients arriving at Level III facilities were hypothermic. Since implementation, that number has trended down to 2.5 percent. In the fall of 2005 a spike to 3.5 percent of patients arriving hypothermic was noted. This occurred with the changing of hospital units and was corrected with education and emphasis of the CPG by on-site JTTS staff.
DVT and pulmonary embolus (PE) can easily be prevented in surgical and trauma patients by use of a systematic preventive strategy. Trauma-specific DVT risk factors include: spinal cord paralysis injury, multiple limb fractures, pelvis/hip socket (acetabulum) injury, and use of clotting medications (rVIIa) or transfusions (platelets).
Prevention consists of mechanical (sequential compression devices—SCD), chemical (i.e. heparin or Lovenox) or combined prophylaxis strategies. These strategies should be individualized based on patient risk factors found in existing guidelines but must be employed.
With a 5 percent PE rate reported from a busy CONUS Level V (medical center) facility, this was the second CPG written and implemented. The quick tempo of injury, surgical intervention and evacuation out of theater often does not allow DVT/PE preventive strategy to “kick in” prior to evacuation. Initial resistance stemmed from the notion that DVT/PE prophylaxis was not relevant in a population whose traumatic injuries were prone to hemorrhage. Attention to the continuum of care from theater to stateside needed to be emphasized so that DVT/PE prophylaxis was considered as part of the long term outcome and not viewed in the isolation of the care provided in theater.
A theater-wide policy was put in place that included drug/dose and mechanical intervention choices. The next challenge was accessing mechanical devices and necessary supplies in theater. The use of SCD has historically not been part of the inventory of Level II and III facilities. Standardized order forms were implemented as prompts to staff.
This CPG was implemented in early 2005; initially noting that only 35 percent of eligible patients received anticoagulation treatments. By April of 2006, this number had increased to 61 percent of patients meeting these criteria to receive either mechanical or chemical anticoagulation therapy. It was our observation that clinical teams need reminding about the importance of DVT/PE prevention. Discussion remains vigorous among clinicians as to the exact criteria that should be followed in a population of predominately healthy younger men with regard to preventive anticoagulation post massive transfusion. This demonstrates the need to continually review and update CPGs to ensure that the best evidence is applied to the process.
The aggressive use of CPGs is proving to be of great benefit in the provision of care to trauma victims of war. The two CPGs developed by the JTTS and deployed in support of OEF/OIF demonstrate the positive effect that CPGs can play in the provision of trauma care in austere, unpredictable environments that experience frequent transitions in personnel and leadership. ♦