Focus On the Warfighter Patient
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INNOVATIONS AT LANDSTUHL REGIONAL MEDICAL CENTER BOLSTER CARE FOR ITS OEF AND OIF PATIENTS.
Landstuhl Regional Medical Center (LRMC) provides primary and tertiary care, hospitalization and treatment for active and reserve component members, their dependents and Department of Defense retirees from throughout Europe. The facility is also the evacuation center for U.S. forces requiring hospitalization from units in Iraq, Afghanistan, Kuwait, the Horn of Africa, Bosnia, Kosovo, the Republic of Georgia, and other nearby nations and regions.
Since the opening salvos of operations Enduring and Iraqi Freedom (OEF and OIF), LRMC has lvaunched several innovations to enhance Level IV health care and enable it to serve as the link between medical treatment programs in Iraq and Afghanistan, and continental U.S. facilities for its OEF and OIF patients. The center’s capstone effort is the Deployed Warrior Medical Management Center (DWMMC).
POST-9/11 PROGRAM
The DWMMC was established in October 2001 in response to the global war on terror to meet the envisioned surge in patient volume and the accompanying increases in accountability, support and administrative workloads.
Seven DWMMC sections were established to allow LRMC meet its new combat-driven requirements: a mission team, case management, movement and orders, medical clinic, administrative support, logistics and air evacuation.
While the traditional medical holding company was used as the center’s model, enhanced information systems, manning augmentation and other programs have allowed the DWMMC to become a model for patient-tracking and accountability during major contingency operations.
GAINING EFFICIENCIES
One DWMMC section, the Medical Clinic, provides services for 20-to-30 OEF and OIF patients who daily report for treatment. Some representative clinic responsibilities include conducting outpatient sick call, troubleshooting patient-related issues, ordering medication refills for return to duty patients and supporting the patients’ Transferred for Continued Care (TCC) program. It is the TCC, in particular, which has allowed LRMC to be at the forefront of a DoD medical effort to maximize the speed and efficiency for returning an injured warfighter either to the U.S. for additional recovery or therapy, or back to the in-theater, parent unit if he or she is stabilized.
Since the start of OIF, LRMC has had a twoweek return-to-duty policy for its newly reported patients. Under the guidelines, if the medical care can be provided at LRMC and the servicemember can be returned to duty in this time, the individual will stay at the center. If a level of medical care cannot be provided at LRMC, the individual is returned to the U.S.
“The thought is that TCC will occur at the stateside post where the family is,” said Colonel Ronald Place, deputy commander LRMC. Place continued, “If the service man or woman is single and has no family at home post or base, we can transfer the individual to the base or station that is close to the family so that he or she can have the recovery and recuperation near the family. Part of the healing process is getting the family involved in the recovery and therapy—which is helpful both from the medical aspect and a psychological aspect.”
One of the observations of the TCC system which emerged during the first several months of OIF was that the average length of stay at LRMC for servicemembers being returned to the U.S. for care was 10 days. Using the Joint Patient Tracking Application (JPTA), described later in this article, and other enabling programs, protocols were put in place to allow TCC patients to be transferred in three or four days. And for critically injured servicemembers who are stabilized to fly, the process has been reduced further to one to two days.
Efficiencies that allowed these reductions were gained in issuing lost identification cards, generating orders, replacing lost uniforms and civilian clothes, and other administrative and quality-oflife functions. One procedure provides all patients with $250 AAFES vouchers upon arrival at LRMC to purchase civilian clothing.
Technology has allowed the center to make other improvements.
INFORMATION SYSTEMS
The TRANSCOM (U.S. Transportation Command) Regulating and Command and Control Evacuation System (TRAC2ES) is one technology foundation on which DWMMC is built.
TRAC2ES is a Web-based initiative that tracks and coordinates movement of sick or injured servicemembers within the U.S. military’s global health care facility network.
“The advantage of that particular system is that clinical information [about a disease, injury, or wound or other diagnosis] that is important to a flight surgeon, and that the physician would like to have before the patient is taken onto an aircraft and taken to some sort of elevation, is put into this computerized system,” observed Place.
The network provides health care providers at destination facilities, including LRMC, with the ability to routinely monitor the system and prepare to receive its patients during flights from the theater. Flight times for medical evacuation missions arriving at LRMC are about six hours from Iraq and approximately eight hours from Afghanistan.
“When we see the aircraft coming our way, we can access that particular flight [in the system] and can get all the clinical information that we want about that group of patients,” explained Place. “This allows us to make the appropriate planning for inpatients, whether it is making bed assignments or staffing plans for nursing. For outpatients, this allows us to know how many outpatient rooms to have available, whether to have box dinners for them because they are coming in later, and other administrative support requirements,” he added.
The LRMC-developed JPTA, mentioned earlier, is another Web-based system that supplies a health care provider in Iraq, at LRMC or any other venue with the ability to search for patients by name or social security number, and enter continuous medical information.
Place cited the advantages of using this application. “Because it is Web-based it doesn’t matter where you are—you have access to it if you have the correct password. And if you are the physician or physician’s assistant who initially treated the servicemember on the battlefield, you can track what happened to that individual after he or she was evacuated.”
JPTA also provides the current health care provider with a comprehensive history of the patient. “Once we know the patient is on a particular flight and is inbound to LRMC we can search for him or her through JPTA and read dozens of clinical notes written by physicians, nurses or other providers, to get a more complete picture of what has happened,” he pointed out.
The application also allows the warfighter’s commanding officer with readonly, real-time access to the status of the service man or woman who has been evacuated.
TRAUMA VTC
The services’ medical community regularly collaborates to discuss the latest trends and health care issues affecting the warfighter. LRMC participates in a weekly, clinical video teleconference (VTC) that was initiated to allow physicians from in-theater medical units, and medical community members at the center and U.S.-based facilities the opportunity to discuss medical policies and procedures, and clinical outcomes for select patients.
Successes from the VTC initiative have included the implementation and standardization of policy for standards of care.
Many VTC agenda items are ironically generated as a result of the challenges of a more efficient evacuation process, which transfers servicemembers with significant injuries from Iraq and Afghanistan often in less than one day. Previous health care and treatment policies for evacuated soldiers, airmen, marines and sailors, were tied to the standards of Operation Desert Storm— when injured warfighters were often evacuated several weeks from the time of their significant medical event.
One specific success that is attributed to the VTC initiative involves the establishment of policy on deep-vein thrombosis prophylaxis.
“There was no policy in place when OIF started about whether patients should have anti-coagulation, or should they not, when being evacuated,” recalled Place. Indeed, health care providers in the evacuation process had different opinions on deep-vein thrombosis prevention. A concerted effort was made among all the services and among all the commands in the evacuation chain to establish policy to treat that condition.
“So now we have a policy in place that is a theater [U.S. Central Command] policy and an LRMC policy on what should be happening to patients—on who should take anti-coagulation and who shouldn’t— which describes the risk factors, and discusses why we are doing it that way. This has been patient-centric and service member-centric with respect to quality of life,” observed Place.
THE OIF/OEF PATIENT LOAD
LRMC’s monthly OIF and OEF patient totals reached their highest level during the combat phase in Iraq (July-August 2003). Since that high-water mark, there has been a gradual decrease in outpatients. “The outpatient care load has decreased through augmentation of different critical care packages in and around the theater which are able to deal with many of the outpatient disease or injury problems,” pointed out Place.
Inpatient totals have remained constant since the summer of 2003, with monthly averages hovering between 237 to 253 servicemembers.
At the end of the day, it is military, contracted and civilian health care providers who enable the inpatient or outpatient servicemember to complete the healing process.
ARMY FACILITY—JOINT MANNING
Personnel augmentation was provided to accommodate the increase in LRMC patient workload.
In April 2007, Navy Reserve medical personnel were the majority of augmentees at the center. Members from this reserve component replaced preceding rotations of Army Reserve health care providers.
The cadre of LRMC permanent staff continues to primarily consist of Army military personnel, who are supplemented by officers and enlisted members from other services, and U.S. and German national civilians.
As required, LRMC personnel are assigned to cells to provide pastoral care, financial services, uniforms and other administrative and quality-of-life support for OIF and OEF patients. ♦