Transcript view slides - AMSUS | Meetings

Eating Soup with a Knife - Evolving En
Route Care Clinical Practice
Tamara Averett-Brauer, MN, RN, DR-III, Civ, USAF
Colonel (Ret), USAF, NC, CFN
Core Research Competency Lead -- En Route Care/Expeditionary Medicine USAFSAM
Deborah L. Willis, MS, RN, Major, USAF, NC, FN
FN/AET Instructor, USAFSAM
HQ AMC/SGK:
Colonel Andrea K. Gooden
Lieutenant Colonel James S. Speight, III
Ms Lisa D. DeDecker
Disclosures
• The presenter has no financial relationships to disclose.
• This continuing education activity is managed and accredited by Professional
Education Services Group in cooperation with AMSUS.
• Neither PESG, AMSUS, nor any accrediting organization support or endorse
any product or service mentioned in this activity.
• PESG and AMSUS staff has no financial interest to disclose.
• Commercial support was not received for this activity.
Learning Objectives:
At the conclusion of this activity,
the participant will be able to:
a. Recognize the research continuum and how it
contributes to the clinical policy.
b.Identify specific translational research put into practice
today.
c. Discuss future research projects targeting clinical gaps.
How do we know what needs research?
• Strategic Guidance
• Requirements
• AFMS Research Thrust Areas
• Clinical Inquiry Process
• AF Research Execution Wings
• Doing the hard work
Strategic Guidance
U.S. Defense 3rd Offset Strategy
Line
• DoD
• AF Service Core Functions
Medical
AF Future Operating
Concepts
• MHS / Joint
Joint Concept for
Health Services
• DHA, Joint Staff Surgeon
• AF: SG; SG5
• MEFPAKs/MAJCOMs
• Rapid Global Mobility
• Command and Control
• Agile Combat Support
• ACC, AMC, AFSOC
• AETC, PACAF, USAFE
• MAJCOMs
• AMC, ACC, AFSOC, AETC
• AFRL
AF Service Core
Functions
AFMS Trusted Care
CONOPS
Requirements
• Gaps (Integrated Capabilities List)
• 2015 Air Force Medical Service (AFMS) Capabilities Based Assessment (CBA)
• MAJCOMS, MEFPAKS
• Portfolio Managers / Research Area Managers
• Time Sensitive Operational Needs
Optimal Time to Transport / Effects of Flight
Research Capabilities Assessment (RCA)
En Route Care Research
Research Development Document (RDD)
Patient Safety Research
Research Development Document (RDD)
AF SG Modernization/Research Thrust Areas
1. Force Health Protection (FHP)
• Prevention of injury/illness and the early detection of emerging threats.
2. En Route Care (ERC/EC)
• Continuum of care during transport of patients from point of injury to point of definitive care.
3. Operational Medicine (OM) /In-Garrison Care
• Providing definitive patient care/treatment in-garrison.
4. Human Performance (HP)
• Enhancing performance of Airmen in challenging environments.
5. Innovations (rolled into Operational Medicine)
• Identify, evaluate, and develop novel concepts, new processes, or disruptive technologies.
6. Expeditionary Medicine (EM)
• Improving care during contingency operations; and medical countermeasures against
combat/operational stressors.
Clinical Inquiry Process
YES
Apply
Evidence
EBP
Project
Evidence
in
Literature
Clinical
Question
(Gap)
Evaluate
Quality of
Practice
Change
NO
Create
Evidence
Research
Project
Translate
Evidence to
Practice
AFMS Research Execution
• Validated Need (Gap)
• Proposed Solutions
• Impact, Cost, Priority/Relevance, Transition/Translation Plan
• Implementation – Research Programs/Projects
• Proposal, Scientific/Technical Methods, Data Collection, Analysis
• Deliver Results – Capability, Device, Practice Guidelines, Evidence
• Research Execution Wings
• 59 MDW
• 711 HPW
• Corporate Oversight –
• HQ AF/SG5, MRAWG, RTAB, Portfolio Managers
59th Medical Wing, Texas
• Office of the Chief Scientist / Science & Technology
•
•
•
•
•
•
•
Vision: Grow Medical Leaders, Drive Innovations in Patient Care and Readiness
Clinical Investigations & Research Support
Diagnostics & Therapeutics Program
Center for Advanced Molecular Detection
Nursing Research
Dental Research
Trauma & Clinical Care Research Program
•
•
•
•
•
•
En Route Care Research Center
Extracorporeal Life Support
Vascular Injury and Forward Damage Control Surgery
Restorative and Reconstruction Research
Trauma, Hemostasis & Resuscitation Research
Immune Modulation Research
711th Human Performance Wing, Ohio
Part of the Air Force Research Laboratory (AFRL)
• Airman Systems Directorate (RH)
• Human Systems Integration Directorate (HP)
• USAF School of Aerospace Medicine (USAFSAM)
•
•
•
•
•
•
Office of the Dean (ED)
International & Expeditionary Education & Training (ET)
Aerospace Medicine (FE)
Occupational & Environmental Health (OE)
Preventive Medicine & Public Health (PH)
Aeromedical Research Department (FH)
• En Route Care Research Division (FHE)
• Operational Medicine Research Division (FHO)
• Human Performance (HP) and Force Health Protection (FHP) Research
• Applied Technology and Genetics Center (FHT)
• Research Support Division (FHS)
Doing the Hard Work
• Work with Stakeholders / Champions
• JPC, SG Portfolio Managers, MEFPAKS (AMC)
• Proposal Writing
• Abstract; Background; Military Relevance; Technical Program Summary/Methods;
References; Milestones/Deliverables; Facilities/Equipment/Experience; Subcontracts;
Cost Proposal; Biosketches of Investigators; Letters of Support; Quad Chart
• Scientific/Technical Reviews
• Methods, Sample Sizes, Statistics, Data Analysis
• Resource Requirements
• Funding, Personnel, Equipment, Aircraft/Chamber Test Plans
• Research Protection Program
• Institutional Review Board (IRB) / Institutional Animal Care & Use Committee (IACUC)
• Get Funded
• Do the work!
• Tell the story -- Disseminate findings
Finding Funding – DHP Sources
• Joint RDT&E
• Defense Medical Research and
Development Program (DMRDP)
• Joint Program Committees (JPC)
1 – Medical Simulation Training &
Informatics
2 – Military Infectious Disease
5 – Military Operational Medicine
6 – Combat Casualty Care
7– Medical Radiological Defense
8– Clinical & Rehabilitative Medicine
9 – Advanced Development
• Joint DHP Small Business Innovation
Research (6.1-6.3a)
• Air Force
• RDT&E (Research, Development,
Test & Evaluation)
• O&M (Operations & Maintenance)
• 59 MDW Clinical Investigations
• 711 HPW Studies & Analysis
• Other
• Congressionally Directed Medical
Research Program (CDMRP)
• Joint Warfighter Medical Research
Program (JWMRP)
Types of DHP RDT&E Funding
1.
Basic Research
• Attaining greater knowledge and understanding of fundamental principles of science and medicine.
2.
3.
Applied Biomedical Research Technology
• Refinement of concepts and ideas into potential solutions with a view toward evaluating technical
feasibility.
Medical Technology Development
• Development of candidate solutions and components of early prototype systems for test and evaluation,
including support of early stage clinical trials.
• 6.3a Advanced Technology Development / 6.3b Demonstration & Validation
4.
Advanced Component Development
• Clinical trials for FDA licensed products and accelerated transition of FDA regulated and non-regulated
products and medical practice guidelines to operational users through clinical and field validation studies.
5.
6.
Medical Systems Development
• Development of demonstration of medical commodities prior to initial full-rate production and fielding,
including initial operational test and evaluation and clinical trials.
Management Support
• Infrastructure and civilian salary support.
7.
Medical Systems Sustainment Activities
• Pre-planned product improvement of fielded medical products and evaluation of
the effectiveness of fielded products, therapies, treatments, or medical guidelines.
So….What does this mean for En Route Care?
Where have we been? Where are we going?
• History – Advances in En Route Clinical Care
• Here we are … 2016
• What has changed?
• What’s the next step?
Advances in En Route Clinical Care
• Where it all began??
• The 1st part of the 20th Century, as the concept of fixed wing
aircraft flight became a reality, so did moving wounded by air.
• Prior to WWI – little to no advancements
• WWI – began to see the need for moving patients by air and
realized the need for specially designed aircraft
• By the end of WWI (1918), the Curtis JN-4 “Jenny” was modified for
air transport of wounded
• In 1922, the US converted a Fokker F-IV into an “Air
Ambulance”
• In 1928, the USMC in Nicaragua developed what we now call
“retrograde AE”
• But…..the leading nurses in the Red Cross and the Army NC
were not interested!!
Advances in En Route Clinical Care
• At the beginning of WWII, AE was considered dangerous,
medically unsound and militarily impossible.
• The Army SG did not feel it was a substitute for field ambulances
• The 3rd AF (Lt Col Malcolm Grow) was willing but until the Army agreed
there would be no progress
• War has a way about changing minds…..by 1942 10,000 casualties had
been moved on the C-47 from the Pacific Theater to CONUS
• In 1942, Lt Col David Grant, advocated for AE and for specially trained
personnel
• In Feb, 1943, the first class of flight nurses graduated from Bowman
Field, KY after a 4 week course in flight physiology, survival and loading
procedures
• At its peak, the US evacuated almost 100,000 casualties per month; in
1945, the 1-day AE record was set at 4704 patients
Advances
in
En
Route
Clinical
Care
• Korea and Vietnam saw increasing dependence on AE as
C-54
both field medicine and AE evolved in planning and
complexity
• The C-54, C-46 and C-47 were used as retrograde AE
aircraft in Korea
• In the first 6 months of the war over 30,000 were evacuated
• AE contributed to a decreased death rate of the wounded
which was 50% less than seen in WWII
C-54
• Vietnam initially used the C-118 and C-130 Cargo aircraft
until the C-141 came on the scene in 1965
• By 1969, MAC evacuated an average of 11,000 casualties per
month
• The C-9A was brought on board in 1968 and the USAF AE
system remained relatively stable until our recent
operations
Here we are…2016
• Just short of 100 years of AE under our
belts
• Conflict in CENTCOM began in 2003
• Since 2003 we have had an explosion
of changes to the AE system
• Operational changes which we will not
discuss in this briefing
• Clinical changes - both lessons learned
and evidence based practice
• More evidence is needed in many
areas
• Let’s look at a few of our clinical
changes……….
How the World has Changed
• From stable to stabilized to stabilizing with the advent of critical care
transport teams
• For AE, a new way to look at old practices, a better way to care for our
patients and an improved way to train for the next war
En Route Critical
Care
TCCET
BAS
Wounde
d Self
Aid &
Buddy
Care
First
Responder
Continuous
TCCET
Forward
Surgical
teams
Forward
Resuscitati
ve
IncCraepaabsielityin Level
Time
CSH, EMEDS,
Fleet
Definitive
Care
Theater
Hospitals
of Care Provided
What has changed?
• Heimlich Valves
• Used for 50 yrs. on all chest tubes preventing
backflow of drainage into the chest
• As we moved from stable to stabilized, what
drains from the chest also changed
• No longer serous, it became primarily blood
products
• Blood clots – serous does not
• Several patients with tension pneumothorax
due to clotted Heimlich valves
What we did
Selected a chest drainage system with an integral
valve, preventing backflow, eliminating the Heimlich
Valve
What has changed?
• Enteral feedings
• Continuous enteral feedings not allowed due to the risk
of aspiration
• All tube feedings were stopped for AE
• New research on burn patients showed the earlier you
started tube feedings and re-started the GI system, the
better the recovery of the patient
• What we did
• Talked with GI, CC, Burn consultants for the Army and AF
• Identified critical steps to allow for safe feedings to the
patient
• Published a policy letter allowing feedings if criteria were
met
What has changed?
• Pain Control
• Prior to this conflict oral and IM used almost exclusively
• Poor pain control for our wounded
• Standard of care on the ground used IV/PNB/Epidural
• What we did
• Started a massive training program to train all AECMs on pain control
•
•
•
•
•
•
•
Use of pain scales and how to apply them
IV instead of IM pain medication
Peripheral Nerve Blocks and how to care for the patient
Epidural catheters for pain control and how to care for the patient
Use of pulse oximetry
Other adjuncts for pain control
High-risk medication requires 2-person validation
What has changed?
• Position of the head of the litter aft
• Configuration guidelines stated the head of the
patient is always to the aft of the aircraft
• What we did
• Limited scope research project showed the g-forces
of take-off increases intracranial pressure
• Identified this can be mitigated by loading the
patient with the head of the patient towards the
front of the aircraft
• The critical care physician decides how the critical
care patient should be loaded
What has changed?
• Balloons of ET tubes and urinary
catheters were filled with saline to
mitigate the affects of altitude on air
• What we did
• Research showed that filling ET tubes with
fluid did more damage to the trachea than
those filled with air.
• It is impossible to remove all air bubbles of the
fluid and those will expand
• By using a cuff pressure monitor, ET
balloons are filled with air and the minimal
leak technique is used to avoid tissue
trauma
• Urinary catheters can be filled with saline as
they are not associated with tissue damage
in the bladder
What has changed?
• Hemoglobin - Below 8 could
not be moved
• What we did
• Evaluate underlying cause, is
it chronic and acute
• Blood products for acute plus
continuous oxygen ordered
• Chronic has likely
compensated – PRN oxygen
order
What has changed?
• Myocardial Infarction must wait 10
days before movement
• What we did
• No research to support this, infuse
thrombolytics if indicated
• TVFS will decide when it is appropriate
to move the patient
What has changed?
• No standardized call criteria to
alert the trauma team at the
destination MTF
• What we did
• Reviewed current civilian call
criteria for EMS
• Developed a standardized Rapid
Response Criteria checklist for
AE
What has changed?
• No standardized hand-off
format
• What we did
• Researched current hand
off tools and how they
could or could not fit the AE
mission
• Modified a current hand off
tool for AE
• Fielded the ISBAR format for
use in AE
What has changed?
• Paper documentation. DoD was
directed to go paperless to
create a longitudinal medical
record
• What we did
• Launched the AE EHR
• The AE EHR is operational at key
operational hubs
• Yes, it still has a long way to go!
What has changed?
• No standardized prophylaxis for
DVT
• Several pulmonary embolisms
manifested during AE
• Unprecedented in the age group we
were moving
• What we did
• Developed and fielded a CPG for
prevention of thromboembolism
What has changed?
• No contagious patient movement capability
• The USAMRIID Airborne Isolation Team was
disbanded
• USAF CCATTs picked up the mission
• What we did
• PIU developed and fielded
• TIS developed and fielded
What has changed?
• No standardized guidelines for SAM patients
• Difficult to identify who should or should not self administer
• No documentation of patient education
• No standardized amounts of medication
• What we did
• Developed and coordinated a policy to allow for self medicating patients
• Included patient education
• Physician approval required
• Re-evaluated at each stop
What’s the next step?
En Route Care Research at 711HPW
En Route Car e Resear ch
Division
Aeromedical Research Depar tment
Cleared, 88PA, Case # 2016-3951, 9 Aug
2016.
• Impact of Transport
• Patient Safety
• En Route Clinical Care
• Medical Technologies / Clinical
Validation
• Training & Simulation
Continuum of Care
En Route Care (EC)
Expeditionary Medicine (EM)
Point of
Injury
(Role I)
Far Forward
Care
(Role II)
Theater
Level Care
(Role III)
Definitive
Care
(Role IV)
http://www.defense.gov/DODCMSShare/NewsStoryPhoto/201105/hrs_110506-D-6666M-444.JPG
Impact of Transport
• Provider Impacts
• Moral Distress in CCAT Nurses: Phenomenological Exa mination
• Fatigue
• Patient Impacts
• Assessment of Aeromedical Evacuation Transport Pati ent Outcomes with and
without Cabin Altitude Restriction (CAR)
• Quantifying C-130 Patient Vibration Patterns
• Hypobaric Exposure Timing after TBI: Targeted Modulation to Improve Outcomes
• Aeromedical Evacuation (AE) of Military Working Dogs (MWD)
• Hypobaria
• Effect of Hypobaria during Sepsis on Survival, Encephalopathy, and Energy
Metabolism
• Hypoxia
• Hypoxemia during Aeromedical Transport of the Walking Wounded: Determining the
Etiology and Incidence of Hypoxemia
Patient Safety
• Regulated Aeromedical Evacuation – A
Retrospective Database
• e.g. Aeromedical Evacuation Registry
(AER)
• En Route Patient Staging System
(ERPSS): Translating Competencies
• Evaluation of Handoff Outcomes in a
Multi-site Continuum of Care Exercise
(I-SBAR)
• Risk Factors for Pressure Ulcer
Development in CCATT Patients
• Assessment of Pain in AE
http://www.defense.gov/news/newsarticle.aspx?id=63808
Biomarkers and Decision Support
Validation of Prototype Continuous
Real Time Vital Signs Video
Analytics Monitoring System
“CCATT Viewer”
Viewer 2.0 (Updated Viewer)
En Route Clinical Care
• CPGS
• Based on Solid Evidence
• Pain Management in the AE Environment
• ERPSS
• Intercostal Liposomal Bupivacaine for the Management of Blunt Chest Trauma
http://www.defense.gov/DODCMSShare/NewsStoryPhoto/201105/hrs_110506-D-6666M-444.JPG
• Effect of Fluid Resuscitation Strategy during En Route Care on Acute
Lung Injury after Hemorrhage and Burn Injury
• Development and Usability of a Mobile Pain Assessment Application
(App) for En Route Care
Medical Technologies / Clinical Validation
of Equipment
• Closed Loop Control
• Oxygen / Ventilation / Fluid Management
• Evaluation of Mechanical Ventilator Use
w/ Liquid Oxygen Systems
• Device Testing -- In hypobaric environment
• Evaluating the Usefulness of Noise Immune Stethoscope (NIS) Technology in
the Aeromedical Evacuation (AE) and Critical Care Air Transport (CCAT)
Simulated High Ambient Noise (C-130) Environment
NoiseImmune
Stethoscope
Photo from Thinklabs website
with permission from manufacturer
Training & Simulation
• How to best train to achieve objectives
• Training Gap Analysis of Active Duty AE Techs/Nurses
Using Simulation
• Features of Simulation
• Simulation Practices Assessment for Active Duty AE Sustainment Training
• Standardized Debriefing Process for Cadre and Impact on CCAT Advanced Course Student
Performance
• Learning Styles, Teaching Methods
• CCATT Nurse Performance Prediction: Application of a Cognitive Model to Mitigate Skill
Decay Using Simulation
• Types of simulation
• Synthetic/Immersive Environments, Augmented Reality, Serious Medical Games
• Aircraft Simulators – Cargo Compartment Trainers, Fuselage Trainers
• Building a Program of Research for Simulation in AE/CCAT System
There’s so much more…..
• Working with others
• Army, Navy, Coast Guard
• International Partners
• University and Industry Partners
• What we don’t know…..
• Future requirements, operating environments
• Distances, platforms, mechanisms of injury/illness
• Cellular/molecular impacts of hypobaria, hypoxia
• Technologies
•
•
•
•
•
Telemedicine/ Tele-mentoring, Remote Monitoring, Human-Machine Teaming
EHR -- Voice to Text, Continuous Monitoring w/Decision Support, Wearable Sensors
Nanotechnology, Semi/Autonomous Transport
Robotics, Machine Learning Techniques
Tricorder….? Suspended Animation….?
Clinical Inquiry Process
YES
Apply
Evidence
EBP
Project
Evidence
in
Literature
Clinical
Question
(Gap)
Evaluate
Quality of
Practice
Change
NO
Create
Evidence
Research
Project
Translate
Evidence to
Practice
Learning Objectives:
a.Recognize the research continuum and how it
contributes to the clinical policy.
b.Identify specific translational research put into
practice today.
c.Discuss future research projects targeting clinical
gaps.
Obtaining CME/CE Credit
If you would like to receive continuing education credit for this activity,
please visit:
http://amsus.cds.pesgce.com
Additional info if time permits
• Pressure Ulcers
• Our litter patients are at risk for pressure ulcers
• The original orange AE mattress did little to mitigate pressure ulcer concerns
• What we did
• Researched and developed new litter mattress using technology designed for operating room
tables
• Procured new black mattresses and disposed of old orange mattresses
• New medications
• Phenergan changed out for Zofran – faster effect with less sedation
• Dramamine changed out for Meclizine –
• No communication tools to facilitate crew to crew or crew to patient communication
• Researched, developed and fielded the AWIS for AECMs
• ASF, MASF, CASF – legacy planning factors
• ERPSS building block approach to patient staging much like EMEDS