Leveraging Mil-Civ Collaborations to Achieve Zero ...€¦ · • Winds of War: Enhancing Civilian and Military Partnerships to Assure Readiness • 2014-Military Health System Strategic

ARMY MEDICINEOne Team…One PurposeConserving the Fighting Strength Since 1775

Leveraging Mil-Civ Collaborations to Achieve Zero Preventable Deaths from Injury

US Army Opportunities

2019 AMSUS-Annual Meeting“Transforming Healthcare through Partnership and Innovation”

COL Jason Seery, MD, FACS

Army Medical Skills Sustainment Program-Clinical Advisor

UNCLASSIFIED

UNCLASSIFIED 07 June 2019

1. The opinions in this presentation are those of the presenter and do not necessarily represent the official opinion of the Department of the Army or the Department of Defense.

2. The presenter, Department of the Army, and the Department of Defense have no official preference toward specific products, manufactures, or facilities found in images or bullets within this presentation.

3. The presenter has no financial ties to the products, manufactures or facilities discussed in this lecture.

Disclaimer

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Disclaimer Objectives Army

Historical Info Current Info Concept Processes Challenges Future

Defense Health Agency/Joint Trauma Education and Training Discussion

Outline

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Identify the various Mil-Civ clinical partnership program opportunities across the services, and the objectives of each

Discuss the criteria necessary to initiate a Mil-Civ partnership

Recognize and prepare for future initiatives

Objectives

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1991 - 1993 AARs / GAO Reports / Articles

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1993 IG Report

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Mil Med. 1996 Mar;161(3):137-42.The peacetime trauma experience of U.S. Army surgeons: another call for collaborative training in civilian trauma centers.Knuth TE1.

Mil Med. 1997 Aug;162(8):iv, xiii.Training for operational readiness.Knuth TE.

Mil Med. 1998 Sep;163(9):608-14.Military training at civilian trauma centers: the first year's experience with the Regional Trauma Network.Knuth TE1, Wilson A, Oswald SG.

Mil-Civ Literature

https://www.ncbi.nlm.nih.gov/pubmed/8637640

https://www.ncbi.nlm.nih.gov/pubmed/?term=Knuth%20TE%5BAuthor%5D&cauthor=true&cauthor_uid=8637640





https://www.ncbi.nlm.nih.gov/pubmed/?term=Wilson%20A%5BAuthor%5D&cauthor=true&cauthor_uid=9753986

https://www.ncbi.nlm.nih.gov/pubmed/?term=Oswald%20SG%5BAuthor%5D&cauthor=true&cauthor_uid=9753986

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1995 & 1996 GAO Reports / 1996 NDAA

•Demonstration Training Program NLT April 1996

•Termination NLT March 1998

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1997 Combat Trauma Surgery Committee

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1998 GAO Report

• CTSC Recommendations / 1996 NDAA Section 744– Demo Program

• Naval Medical Center Portsmouth, VA and Eastern Virginia Medical School (Surgeons Only)

• Wanted more specialties, not just surgeons• Other organizations / locations did their own similar pilot

programs

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Joint Trauma Training Center

• Sustainment training within the DoD wouldn’t work– 1996

• BAMC-Level I, but only 600-800 trauma admissions per year

• Ben Taub in Houston, TX – 1996

• 2800 admissions per year– Became the Level I Trauma Center that would execute

the next phase of implementation

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Joint Trauma Training Center

• 30-Day rotation– Didactics and Clinical time– All health care specialties within the team attended

• One Army and one Air Force team rotated in 1998• Other teams rotated through in following years• Issues:

– 30 day TDY deemed too long for some rotators– Competition with in house students/residents/fellows– State not fully reciprocating license– Hospital provided minimal privileges/limited scope of practice– Not allowed to fully care for the patient– DoJ and DoD had concerns with malpractice coverage– Did not included Compo 2 or 3 healthcare providers– One location couldn't meet tri-service needs– Other facility staff and military cadre challenges

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JTTC - Articles

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Service Specific Training Centers

• ATTC (Army Trauma Training Center) – Miami, FL-2001 (>5000 TA; 30% P; >20% ISS

over 15)• ATTD (Department and then Detachment)

– 4, then 3 and now 2 week rotation– 32-84 patients over 5 days ~ 54 (27/team)

• C-STARS (Centers for the Sustainment of Trauma and Readiness Skills)

– Baltimore, MD-2001– Cincinnati, OH-2001– St Louis, MO-2002

• NTTC (Navy Trauma Training Center)Los Angeles, CA-2002

-- 3 week rotation

3 week rotation

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Key Events:• GWOT

• CTSC• JTS / JTTS

• DoDTR• PI• CPGs• DCoTs (CoTCCC / CoSCCC / CoERCCC)

• PDTT requirements• Other Mil-Civ Partnerships• Numerous AMEDDC&S, BUMED, AFMS, DMRTI, etc courses• New technologies and TTPs• RAND, Booz-Allen-Hamilton, and other reports• Published articles/editorials

Additional Factors

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Current:• 2003-Senior Visiting Surgeons program

• Support of the AAST, EAST, WTA, ACS-COT, AAOS, OTA and others• LRMC• Various OCO locations in Iraq and then Afghanistan

• 2014-ACS Scudder Oration• Winds of War: Enhancing Civilian and Military Partnerships to Assure Readiness

• 2014-Military Health System Strategic Partnership with the American College of Surgeons

• 2015-Booz-Allen-Hamilton Report

• 2016-National Academies of Sciences, Engineering and Medicine• A National Trauma Care System-Integrating Military and Civilian Trauma

Care Systems to Achieve “Zero Preventable Deaths After Injury”

Recent Factors

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2017 NDAA

17

“Public Law”

• 2017-NDAA, Section 708• “Joint Trauma Education and

Training Directorate”• Paragraph C

• Establish and embed combat trauma teams, like forward surgical teams, into ”Mil-Civ Partnerships”

UNCLASSIFIED


Nested Authorities

NDAA 2017, 708C

AMCT3 Task Force CharterMEDCOM OPORD #18-78

*AW NDAA 17 Section MEDCOMauthorized the execution of Medical Training Agreements (MTA) with civilian Level 1 trauma Centers

Commissioned 27 October 2017

Published 07 August 2018

UNCLASSIFIED


2019 NDAA, Section 719

Removed verbiage for partnerships to be at only at:

“large metropolitan teaching hospitals and academic center's”

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Training the way we fight: supporting and sustaining our armed forces with a ready medical force able to fight and win today and prepared for the battlefields of the future!

S.M.A.R. T

Expeditionary Combat Medic Course

Aeromedical Evacuation Training

Military-Civilian Combat Trauma Team Partnerships

Simulation & TrainingMSTC, MTFs &

Civilian Facilities

Global Medic / JRTC / NTC / VR

Emergency War Surgery Course

Surgical Team TrainingER Physician/Nurses, CRNA, OR Techs, Paramedics, PAs

Joint Forces Combat Trauma Management

Course

Brigade Combat Team Trauma Training Course

& Tactical Combat Medical Care Course

Army Trauma Training Course -

Ryder Trauma Center

Combat Casualty Care CourseJoint Enroute Critical

Care Course

OCONUS Training

Bridge to Readiness

UNCLASSIFIED


Expert / Mastery?

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1. Total number…hundreds2. Focus varies from

1. Initial Training, Refresher, Skills Sustainment, Just-In-Time, vs other 2. Individual vs Team3. Enlisted vs Officer4. Conventional vs Special Operations5. Patient care only, Didactic Only, Mixed6. Simulation vs No Simulation7. Clinical vs non-clinical vs research8. GME/SoN vs Military Units

3. Modern “708” Mil-Civ Partnerships1. Army Medical Skills Sustainment Program (AMSSP)

1. AMEDD Military-Civilian Trauma Team Training (AMCT3) Program (Team)2. Strategic Medical Asset Readiness Training (SMART) Program (Individual)3. *Local MTF Agreements (various medical staff, SOCOM, etc)

Current Army MCPs

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SMART Program Concept(Strategic Medical Asset Readiness Training)

• The program was piloted at Hackensack University Medical Center, (HUMC), Hackensack NJ.

• Expansion into several hospitals in Cincinnati Aug 18• 68K, 68P, 68V, 68W; adding 68X and others• Collaboration with Civilian Universities/ VA Hospital Systems

– Soldiers work with their civilian counterpart for 15 day rotations.– Interactive observation and hands-on training documented

through an Army provided checklist.• Incorporate program across all Components, Services,

Branches• Possible expansion across CONUS• * one weekend EOM vs 15 days annually

Total Force Concept: All Compos/ All Services

• Hackensack, NJ• Cincinnati, OH (x4)• Laredo, TX (x2)• San Jaun, P.R. • Camden, NJ*

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ARMY MEDICINEUNCLASSIFIED//FOUO

Operation SMART Training Frequency

Time

Skill

Sust

ainm

ent

Time

Skill

Sust

ainm

ent

Annual Training (AT)

One Team…One PurposeConserving the Fighting Strength Since 1775

Current Guard/Reserve Training Model

SMART Guard/Reserve Training Model AT

04 January2019UNCLASSIFIED//FOUO Slide 24 of 11

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SMART Program Questionnaire


The questionnaire offers a better understanding of the Soldier as in individual and as a medical professional.

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Scope of Practice Information


Individual scopes of practice for each MOS is provided to better understand daily duties, roles, and responsibilities respective to each job.

Process Items for SterilizationOperate a Steam Sterilizer

Put on Sterile GlovesAssess a Patient's Pulse Rate

Measure a Patient's Blood PressureMeasure a Patient's Temperature

Perform Cardiopulmonary Resuscitation (CPR)Perform Rescue Breathing

Operate an Automated External Defibrillator (AED)Ventilate a Patient with a Bag-Valve-Mask System

Establish a Sterile FieldPerform a Surgical Scrub

Put on Sterile Gown and GlovesPlace Gown and Gloves on Surgical Team Members

Assist Surgical Team Member in Donning/Doffing Sterile GarmentsReplace A Glove Using Open Gloving Technique

Select Equipment, Sterile and Unsterile Supplies for a Surgical ProcedureOrganize Prep Set Items

Position Draped Equipment Prepare the Electrosurgical Unit for a Surgical ProcedureRemove Contaminated Items from the Operating Room

Clean the Operating RoomPrepare a Patient for Movement to the Operating Room

Place a Patient in the Lithotomy PositionPlace a Patient in the Kraske (Jackknife) Position

Prepare Specimens for ProcessingPass Medical Items During Surgical Procedure

Prepare Field Suction MachinePrepare Field Scrub Sink

Prepare Field Operating Room Light for UsePrepare Field Operating Room Table

Prepare Field Steam Sterilizer for UsePlace a Patient in the Lateral PositionPlace a Patient in the Prone Position

Perform Sponge, Instruments, Sharps, Needle CountsDrape the Patient for an Upper Extremity Procedure

Discard Disposable Sharps/Soiled SpongesInspect Surgical Instruments Prior to Use

Assist in Draping the Patient for a Lower Extremity Procedure Assist in Draping the Patient for a Laparotomy

Assemble Sterile Drills and SawsPrepare Sterile Dressings

Pour Solutions in the Appropriate Receptacle on a Sterile Field.Perform Comfort and Safety Measures for the Patient in the Operating Room

Hold Retractors or Instruments as Directed by the SurgeonAssemble Surgical Stapling Devices

Provide Surgical Sharps Using Hands Free TechniquePlace a Patient in the Supine PositionAssemble Fiberoptic Surgical Scopes

Transfer Specimens from Surgical Technologist to Circulator

Operating Room Specialist (68D) Job Functions

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Critical Task List


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SMART Program

SMART-Way Ahead

Current Sites

Future Sites

Representation of potential spread

Puerto Rico

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AMCT3 Concept Plan

• 1-3 months• Pre deployment training• Simulation and training

programs• Complement ATTC

**FRST

Just in Time• 2-3 years • Embedded as staff

members• Simulation and training

programs• Leverage fellowship

program• Manage/supervise rotating

teams

**Forward Resuscitative Surgical Team (FRST)

Sustainment• 3-6 months • Rotate

individuals/teams • Simulation and training

programs• May support pre/post

deployment trauma/non-trauma skills training

**FRST

Refresher

*Primary Team: Surgeon (GS/TS/OS), ER Physician, Anesthetist, ER Nurses, ICU Nurse

Benefits:• Increase surgical team’s deployment readiness and skillset • Enhance surgical team’s operability and capability • Gain necessary case volume, mix, complexity, and acuity

Secondary Team: PAs, NPs, Medics, Paramedics, various Techs, other physician and nurse specialties ** Owned by FORSCOM

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Compo 1 Role 2* / Role 3 Locations

Fort with FST only

Fort with CSH only

CONUS FST/CSH Units

Fort with FST(s) & CSH745th FST31st CSH

127th FST555th FST21st CSH 115th CSH

14th CSH

240th FST274th FST (A)541st FST (A)759th FST (A)28th CSH

SORT-1SORT-2SORT-3

JMAU-*

8th FST

102nd FST250th FST758th FST47th CSH

772nd FST86th CSH

2nd FST10th CSH135th FST

121st CSH

Korea67th FST160th FST212st CSH

Germany

OCONUS FST/CSH Units

Future additional FRST Units

CONUS SOF Units

42nd FRST10th FRST

*Some FSTs are now FRST**Some CSH are now HC/FH

UNCLASSIFIED


Legacy Emanuel

University of Chicago

Grady

Vanderbilt

Oregon Health & Science Univ.

Harborview

University of Colorado

**Columbus Regional

***Cape Fear Regional

Mass General

INNOVA-Fairfax

Capital Regional

Cooper Health

John Strogger-Cook County

UPenn

PennState

Temple

Milwaukee Regional

Carolinas

Johns Hopkins

Kansas University

AMCT3: The Partnerships Landscape

Fort with FST only

University Health

Fort with CSH only

Primary embed site-FY18

MTA signed-possible embed site-FY20

Visited-Possible site for SOF

Visited-Possible local rotation site

Fort with FST(s) & CSH

Visited-Possible embed site-FY 21

Future site visit-Embed

Future site visit-Rotation

Regional One

University Medical

Queens Medical Center

Rutgers

Unknown x 2

WakeMed

Hartford

Denver Health

** Level II Trauma Center*** Level III Trauma Center

San Juan SMART

University Medical

Ryder Trauma Center***Laredo

***McAllen

Cincinnati SMART x4

Hackensack SMART

SMART site-Rotation

Pre-existing Army Role 2 MCP site Cox Medical

Wake Forest

UNC

Del Sol Medical Center

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• 2 initial team programs • Cooper University Hospital, Camden NJ• Oregon Health & Science University Hospital, Portland OR

• 5 specialties from MTFs• General or Trauma Surgeon; Emergency Medicine• CRNA; Critical Care; Emergency • No Orthopedic Surgeons• Assigned for ~3 years• No enlisted tech specialties at this time• Perioperative Nurse x2 (FY19)• Neurosurgeon x1 (FY19)• CT Surgeons x 2 or more (FY20)

• 3* initial individual programs• Vanderbilt University Medical Center, Nashville, TN; with Blanchfield Army

Community Hospital, Fort Campbell, KY• Del Sol Medical Center, El Paso, TX; with William Belmont Army Medical

Center, Fort Bliss, TX• Cape Fear Regional Medical Center, Fayetteville, NC; with Womack Army

Medical Center, Fort Bragg, NC

Initial Roll Out

UNCLASSIFIED

UNCLASSIFIED 07 June 2019Name/Office Symbol/(703) XXX-XXX (DSN XXX) / email address [email protected]/[email protected]

AMCT3 Team Overall Battle Rhythm

PCS*

PCS*

*PCS• MEDCOM / AMEDDC&S• FORSCOM / SOCOM• PME / DARPA / KD / SB /

Other• ETS / Retire

Deploy as

“PROFIS”

FRST

Role 2

Function as “Cadre”(Phase II)

Deploy as

“PROFIS”

FRST

Role 2

Refresher Rotations

T/NT)

FTX/STX FTX/STX

PHASE I• Orientation• Onboarding• ICTLs

Initial 90-120 days

PHASE II• ICTLs / KSAs• MUC

-CPG/TCCC-Literature

• Interprofessional Team Development

• Trauma Simulation

• FTX/STX• PDTT• Military Duties

Next 180-270 daysPHASE III

Next 2 years

PCS• GME• MEDCOM /

AMEDDC&S• FORSCOM /

SOCOM• PME• Deployment /

Mission

AMCT3 Staff

Refresher Rotations

(T/NT)

Function as “Cadre”(Phase II)

Just-in-Time

Training

UNCLASSIFIED


Full FRST

AMCT3 Staff

FORSCOMFST

MEDCOMMTF

5-6 vs 10 vs 20 (2x10)

• Two 10 Person elements (Entire 20 person Team)1. Can Alternate Deployment and Cadre phases2. 75% at Host Partner Facility : 25% at Base* (return

to their home base every 2-4 months for a one-two week TDY)

1. FTX/STX2. Inventories/inspections3. Mandatory training4. Face to Face meetings/training5. Range6. Jumps7. Etc.

*TBD

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• GME collaboration• Trauma/Critical Care Fellowships• Emergency Medical System Fellowships• Orthopedic Trauma Fellowships• Advanced Nursing Training Opportunities

• Supporting Compo 2 and Compo 3 rotations

• Integration of other specialties:

• Integration of MBA/MHA interns

• Supporting DoD related Research and Process Improvement

Other Considerations

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Future program• RHC-A OPORD 18-78

• 5 additional programs in FY 20 (Goal of 15 total)• Goal of 1:1 ratio for each CONUS Role 2

• Currently have 16, but will grow to 18 over next three years• FORSCOM

• FRST• Field Hospitals• Head and Neck Detachments• Lab Detachments

Future Concept of AMCT3 Partnerships

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Future considerations/impacts to the program• Mission Zero Act H.R 880/ Pandemic All-Hazards Preparedness

Act H.R. 6378 (Passed, but unfunded)• Teams• Individuals

• DHA Joint Trauma Education and Training Directorate

Future Policy Impacts

UNCLASSIFIED


[email protected] Director

[email protected] Clinical Advisor

POCs

mailto:[email protected]

mailto:[email protected]

UNCLASSIFIED


Discussion

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Latest Borden Institute Text

CHAPTERS1 - Casualty Care From the Revolutionary War to the War of 1812

2 - Surgery and Medicine in the War of 1812: A New Nation Challenged

3 - The Civil War: Military Medical Care in the War Between the States

4 - Transitions: Army Medicine in the Post-Civil War Period to the Start of World War I

5 - Forward Surgery in the Great War: A War of New Technologies

6 - World War II: Army Forward Surgery on a Worldwide Scale

7 - Forward Surgery in the Korean War: The Mobile Army Surgical Hospitals

8 - Vietnam: The Rise of Helicopter Medical Evacuation in a War Against a New Kind of Enemy

9 - From the Falklands to the Balkans: Toward Formal Designation of the Forward Surgical Team

10 - Put to the Test: Forward Surgical Teams Challenged During the Global War on Terrorism

11 - Homeland Defense, Contingency Operations, and Future Directions

Documents

Leveraging Mil-Civ Collaborations to Achieve Zero ...€¦ · • Winds of War: Enhancing Civilian and Military Partnerships to Assure Readiness • 2014-Military Health System Strategic