Study of trauma patients evacuated from frontlines provides insight into en route care

A groundbreaking study of nearly 4,000 trauma patients evacuated from the frontlines in Afghanistan over a six-year period offers insight that can inform decisions on team composition, staff training and skill mix on the battlefield and beyond.

Published in the April 2018 issue of Critical Care Nurse (CCN), the study provides the first detailed description of combat casualty care provided to trauma patients evacuated from a forward surgical facility to a combat support hospital for comprehensive care in a combat setting.

"En Route Critical Care Transfer From a Role 2 to a Role 3 Medical Treatment Facility in Afghanistan" marks one of the first studies using patient data from the Joint Trauma System Role 2 Registry.

The interprofessional research team included representatives from the U.S. Army Institute of Surgical Research, the Joint Trauma System, the U.S. Air Force En Route Care Research Center and the En Route Critical Care Nursing Consultant to The Army Surgeon General.

The researchers conducted a retrospective review of more than 4,500 patient records from the Joint Trauma System Role 2 Registry. The database includes prehospital data, arrival and discharge status, diagnosis, interventions, blood administration and complications data.

To be included in the study, patients had to meet specific criteria, including sustaining a traumatic injury in Afghanistan between February 2008 and September 2014. They also had to have received treatment at a role 2 military medical treatment facility (MTF) and been transferred to a U.S. role 3 MTF. Based on these criteria, 3,927 patients were included in the study.

Among study patients, fractures, amputations and other types of orthopedic injury were the most common diagnosis. Other diagnoses included soft tissue trauma, brain injury and penetrating injury.

"Our study revealed that more than 25 percent of patients transferred from a role 2 MTF were intubated, and nearly 40 percent were postoperative patients," said retired Army Col. Elizabeth Mann-Salinas, PhD, RN, one of the study's co-authors. "A postoperative patient tends to require specialized care that may be outside the scope of a combat-trained medic or EMT and require a higher and specialized provider skill level."

In a combat setting, the continuum of care begins with role 1 on-scene care that may include basic and advanced first aid and non-surgical lifesaving interventions before transfer. Role 2 MTFs may be fixed or mobile facilities used for immediate resuscitation and surgical stabilization, while role 3 combat support hospitals have multiple surgical specialties and intensive care. Role 4 MTFs provide the full spectrum of trauma care at fixed facilities.

Multiple studies have evaluated the en route care of patients during transport from point of injury to first MTF, as well as out of the combat zone to the nearest role 4 medical center in Landstuhl, Germany. This study is the first comprehensive review of patients transported from a role 2 forward surgical facility to a more robust role 3 combat support hospital in Afghanistan.

"Understanding the characteristics and needs of these patients will inform provider training and appropriate skill mix for the transfer of postsurgical patients within a combat setting," Mann-Salinas said. "Given our study results, we must specifically train medical attendants to care for postoperative patients, train flight paramedics in critical care and individually assign critical care nurses to transport patients."

The study is one of several articles in the April issue of CCN that focus on en route care for combat casualty patients.

As the American Association of Critical-Care Nurses bimonthly clinical practice journal for high-acuity, progressive and critical care nurses, CCN is a trusted source of information related to the bedside care of critically and acutely ill patients.​

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