Quantifying Clinical Opportunities at the Navy Trauma Training Center

ABSTRACT

Introduction

Military-Civilian partnerships (MCPs), such as the Navy Trauma Training Center, are an essential tool for training military trauma care providers. Despite Congressional and military leadership support, sparse data exist to quantify participants’ clinical opportunities in MCPs. These preliminary data from an ongoing Navy Trauma Training Center outcomes study quantify clinical experiences and compare skill observation to skill performance.

Materials and Methods

Participants completed clinical logs after each patient encounter to quantify both patients and procedures they were involved with during clinical rotations; they self-reported demographic data. Data analyses included descriptive statistics and chi-square statistics to compare skills observed to skills performed between the first and second half of the 21-day course.

Results

A sample of 47 Navy personnel (30 corpsmen, 10 nurses, 3 physician assistants, 4 physicians) completed 551 clinical logs. Most logs (453/551) reflected experiences in the emergency department, where corpsmen and nurses each spent 102.0 hours, and physician assistants and physicians each spent 105.4 hours. Logs completed per participant ranged from 1 to 31, (mean = 8). No professional group was more likely than others to complete the clinical logs. Completion rates varied by cohort, both overall and by clinical role. Of emergency department logs, 39% reflected highest acuity patients, compared with 21% of intensive care unit logs, and 61% of operating room logs. Penetrating trauma was reported on 16.5% of logs. Primary and secondary trauma assessments were the most commonly reported clinical opportunities, followed by obtaining intravenous access and administration of analgesic medications. With few exceptions, logs reflected skill observation versus skill performance, a ratio that did not change over time.

Conclusion

Prospective real-time data of actual clinical activity is a crucial measure of the success of MCPs. These preliminary data provide a beginning perspective on how these experiences contribute to maintaining a skilled military medical force.

INTRODUCTION

Military-civilian partnerships (MCPs) such as trauma training centers provide military medical personnel with exposure to high volume, high acuity trauma cases not seen in military treatment facilities.¹ Level I Trauma centers are specifically used for these partnerships because they most closely mirror clinical experience with the trauma patients military personnel may encounter when deployed. However, neither the types of trauma (such as blast injuries) nor experience of caring for personnel in a combat zone is fully replicated. Few data are available to evaluate the trauma-specific clinical opportunities of participants during the program, although MCPs were established across the services (Army, Navy, and Air Force) nearly 20 years ago.² Most reports focus on confidence/self-efficacy.^3–5

The Navy Trauma Training Center (NTTC) at Los Angeles County + University of Southern California Medical Center was established in 2002 to provide trauma training for Navy personnel. The course, which currently offers both a 21-day and 10-day course format, includes didactic presentations, clinical simulations, small group simulation events, and clinical rotations through the emergency department (ED), operating room (OR), and intensive care unit (ICU). Clinical rotations occur with small teams, proctored by an NTTC training cadre member, in each location simultaneously. Opportunities during rotations may involve both observation and direct care provision. The opportunities vary depending on the type and number of persons who present to the ED, require surgery, and are hospitalized in the ICU. Most participants in the 21-day course have 3- to 5-hour and 8- to 10-hour clinical shifts before course mid-point and 7- to 9-hour and 8- to 10-hour clinical shifts after course mid-point. Although permanent NTTC staff and rotating participants discuss experiences, no published data to date quantitatively report the rotators’ clinical opportunities, skills observed, or skills performed. Thus, no quantitative evaluation of the trauma-related clinical opportunities is possible. Without data on the volume of clinical experiences over time, it is difficult to determine the optimal course duration and clinical time needed to meet training objectives. Finally, because rotating personnel cannot enter data into the electronic medical record, it is impossible to extract information about rotators’ clinical learning opportunities from patient records. Therefore, we prospectively collected data on NTTC participants and their clinical learning opportunities at NTTC to fill this important knowledge gap.

This is the first known systematic, quantitative evaluation of clinical opportunities for military personnel on a short-term clinical rotation in a Level 1 Trauma Center MCP. Clinical opportunities by location (ED, OR, and ICU) and by clinical role (physician [MD], physician assistant [PA], nurse [RN], corpsman [HM]) are reported. Additionally, skill observation is compared with skill performance over the course of training to determine if more performance is observed later in training.

METHODS

These data are part of a larger, ongoing observational descriptive study of outcomes at NTTC approved by the responsible Institutional Review Board, Naval Medical Center Portsmouth, VA. There are no interventions.

Sample, Measures, and Materials

The sample for this report was composed of NTTC participants who completed the program between March and May 2018. A demographic data form and clinical log were used to assess clinical experiences consistent with Tactical Combat Casualty Care (TCCC) and trauma care overall. Demographic data included the NTTC rotators’ clinical and military experience, education, and trauma training. The clinical log was developed by the lead investigators (T. Torres and J. Stakley) based on TCCC guidelines, the NTTC trauma course curriculum, and recognition of the types of patients seen at Los Angeles County + University of Southern California Medical Center. A panel of military trauma experts confirmed appropriateness of the content. It was then pilot tested and refined by the investigators over several iterations of NTTC participants before study initiation.

Data recorded on the log include clinical rotation (ED, OR, or ICU); clinical role (MD, PA, RN, or HM); patient acuity; mechanism of injury; injury location; assessments (primary, secondary), Focused Assessment with Sonography in Trauma (FAST); Extended-FAST; hemorrhage, airway, and breathing interventions; surgical procedures; TCCC medications; and miscellaneous activities. The clinical log is formatted to record all procedures observed or performed by an NTTC participant on one individual patient. Participant time for log completion was estimated at 2 minutes per log. Total clinical hours per participant (based on clinical role and course type) range from 16 to 95 (2-12 shifts). Therefore, the number of records anticipated was 6 to 72 per participant. The log contains no personally identifiable information for patients or NTTC rotators. The log is currently available in paper form, with 2 logs per 8.5 × 11 inch page (Fig. 1). Data on course structure and time spent in each clinical rotation were obtained from course faculty.

FIGURE 1.

The clinical log with examples of instructions to users.

Procedures

The clinical log is part of the routine data collected during the NTTC course. All rotators complete logs. Data from only those participants who have provided written, informed consent are included in the study.

Rotators were oriented to the clinical log in the classroom before their first clinical shift and repeatedly reminded of the instructions throughout their rotations. The rotators were instructed to complete a log for each trauma patient in whose care they participated, estimating 3 to 6 logs per person per shift. Rotators were instructed to complete their clinical logs after each patient encountered, to optimize recall. The logs were collected at the end of each shift and stored securely, either by an NTTC training cadre member or rotating personnel team leader. Data were then entered into a spreadsheet by research personnel to facilitate analysis.

Analysis

The demographic characteristics, prior trauma training and experience of the participants, and patient types encountered were summarized with descriptive statistics. Both frequencies and mean number of logs completed by each participant were calculated. Sub-groups of NTTC participants were in more than one clinical area simultaneously, thus summing all of the clinical hours led to hours being double-counted. Therefore, it is not possible to sum all clinical hours and calculate the mean hours per area per person. Mean hours per clinical role per class are therefore presented. Not all clinical roles participated in all clinical settings; the training cadre tailored clinical opportunities to the learning needs of participants. As shown in Fig. 1, each log may reflect multiple skills observed and performed. To identify if NTTC participants grew from observing clinical procedures to performing them, the chi-square statistic was used to compare the total skills observed across all logs to skills performed between the first and second half of participants’ time in the clinical environment. For those analyses, HMs and RNs were combined as “nonproviders,” whereas MDs and PAs were combined as “providers” because of small sample sizes.

RESULTS

Sample Demographics

Data from 47 Navy medical personnel enrolled in an ongoing study with a projected final enrollment of approximately 650 personnel were available for this report. Of eligible personnel, 78% enrolled in the study, and there were no drop-outs during the clinical log data collection period. The personnel providing data for this preliminary analysis of clinical logs were predominantly male HMs, with a military rank between E4-E6, and mean age of 29 years (Table I). Half of HMs and RNs and all of the PAs and MDs reported 5 or fewer years in their current health care role. Approximately half of the participants across all clinical roles reported no prior experience with trauma patients, and most had never participated in a combat-support deployment in their current clinical role. (Note that Navy personnel deploy to combat support roles to support the Marine Corps as well as to shipboard and humanitarian settings, where combat trauma patients are rare.) In contrast to their lack of clinical experience, over 90% of Corpsmen, and more than half of nurses and physicians reported training in TCCC within the previous five years. All of the nurses reported completion of the Trauma Nursing Core Course, and 4 of the 10 had completed the Joint En Route Care Course. All of the MDs and one PA reported prior completion of Advanced Trauma Life Support.

TABLE I.

Sample Demographic, Trauma Education, and Trauma Experience Characteristics

Criteria	All participants (n = 47)	(HM (n = 30)	RN (n = 10)	PA (n = 3)	Physician (n = 4)
Age =  Mean (SD)	30.7 (5.9)	29.10 (4.5)	35.70 (8.1)	32.33 (5.13)	29 (1.41)
Male = n (%)	37 (78.7)	26 (86.7)	5 (50)	2 (66.7)	4 (100)
Completed TCCC Course in past 5 years	34 (72.3)	23 (76.7)	6 (60)	1 (33.3)	4 (100)
Completed TCCC Course—never = n(%)	12 (25.5)	6 (20)	4 (40)	2(66.7)	0
Prior trauma experience: Civilian Level 1 ED	4 (8.5)	3 (10)	1 (10)	0	0
Prior trauma experience: Civilian trauma ICU	3 (6.4)	2 (6.7)	1 (10)	0	0
Scheduled to deploy in < 6 months	27 (57.4)	20 (66.7)	4 (40)	2 (66.7)	1 (25)
Not currently scheduled to deploy	10 (21.3)	4 (13.3)	5 (50)	0	1 (25)
Number of combat support deployments in current health care role:* None 1 >1	35 (74.4) 7 (14.9) 5 (10.6)	20 (66.7) 6 (20) 4 (13.3)	9 (90) 0 1 (10)	3 (100) 0 0	3 (75) 1 (25) 0
Years in current health care role: 2 or fewer 3-4 5 or more	8 (17.0) 12 (25.5) 27 (57.4)	2 (6.7) 8 (26.7) 20 (66.7)	0 3 (30) 7 (70)	2 (66.7) 1 (33.3) 0	4 (100) 0 0
Personnel with < 5 years of active duty **	19 (40.4)	12 (40)	3 (30)	2 (66.7)	2 (50)
Dominant specialty =  N (%)	N/A	Fleet Marine Force = 30 (66.7%)	Emergency = 5 (50%)	N/A	General Medical Officer = 3 (75%)

ED, emergency department; HM, corpsman; ICU, intensive care unit; PA, physician assistant; RN, registered nurse; SD, standard deviation; TCCC, tactical combat casualty care.

*

The Navy offers many opportunities for health professions education. It is not uncommon for RNs, Physicians, and PAs to have previously served in another enlisted or officer military role.

**

The Physicians and PAs had the least amount of time on active duty, and therefore the least socialization to Navy culture. A need exists for clarity between clinical and organizational expertise, and need for development of both knowledge domains for all members of the trauma care team.

Quantification of Clinical Opportunities

Nonproviders (a total of 40 HMs and RNs) spent a mean of 102.0 hours in the ED, with 56.3 hours before the mid-point of the course. During the same period, providers (a total of 7 MDs and PAs) spent a mean of 105.4 hours in the ED, with 59.7 hours before the mid-point of the course. Nonprovider mean hours in the ICU and OR were 49.3 and 91.0, respectively, with 23.7 and 49.0 before course midpoint. Provider mean hours in the ICU and OR were 170.2 and 7.7, respectively, with 93.5 and 0 before course midpoint. Overall, the majority of clinical logs (453/551) reflect experiences in the ED, followed by the ICU and OR. The number of logs completed per participant ranged from 1-31; the mean was 8. No single professional group was consistently more likely than others to complete the clinical logs. Completion rates varied by cohort, both overall and by clinical role. Of ED logs, 39% reflected highest acuity patients, compared with 21% of ICU logs and 61% of OR logs.

Clinical Logs

A total of 551 logs were collected; 470 had dates enabling comparison between first and second half of training. Of those, 464 logs recorded mechanism of injury. The mechanisms of injury reported were motor vehicle/motorcycle crash (n = 79); motor vehicle versus pedestrian, bicycle, or wheelchair (n = 81); inter-personal violence (stabbing, assault, and gunshot wounds) (n = 127); falls (n = 84); substance abuse/drug overdose (n = 51); burns (n = 16); and “other” (n = 26). Participants averaged 2 to 3 minutes of data entry time per log.

TABLE II.

Clinical Activities Reported by Navy Trauma Training Center Participants

Clinical action			Participant type (clinical role)
	All participants Obs Perf		Corpsman (HM) (n = 30) Obs Perf		Nurse (RN) (n = 10) Obs Perf		Physician assistant (PA) (n = 3) Obs Perf		Physician (MD) (n = 4) Obs Perf
Primary assessment	328	71	191	26	75	11	29	19	33	15
IV access	222	164	123	102	39	49	41	3	19	10
Tourniquet	13	6	9	4	3	0	0	1	1	1
Life-Saving Interventions
Pelvic binder OR Damage control Surgery OR REBOA	6	3
Massive transfusion protocol	12	2
PRBC*	63	13
ETT	117	4
CRIC	5	0
BVM	54	9
Chest tube	44	1
Finger thoracostomy	5	0
Needle thoracostomy	0	0
Additional Assessments
Secondary assessment	242	67
ABG	25	12
EtCO2	34	6
FAST	192	47
E-FAST	76	36
Selected Additional Interventions
Hypertonic saline	9	2
Tranexamic acid (TXA)	0	8
Analgesic meds (fentanyl, morphine, ketamine)	141	24
Fentanyl	85	14
Morphine	29	7
Ketamine	27	3
IO access	31	5
FFP	23	3
Platelets	22	7

ABG, arterial blood gas sampling; BVM, bag-valve mask; CRIC, cricothyroidotomy; E-FAST, extended focused assessment with sonography in trauma; EtCO₂, end tidal carbon dioxide; ETT, endotracheal tube placement; FAST, focused assessment with sonography in trauma; FFP, fresh frozen plasma; IO, intraosseous; IV, intravenous; Obs, observed; Perf, performed; PRBC, packed red blood cells; REBOA, resuscitative endovascular balloon occlusion of the aorta; TXA, Tranexamic acid.

*

Whole blood is recommended resuscitation fluid for trauma patients, but is seldom available in Level I trauma centers. In deployed settings, the current Joint Trauma System Clinical Practice Guidelines recommend low titer “O” whole blood as the first line intervention, followed by fresh warm whole blood from a walking blood bank.

TABLE III.

Clinical Skills Observed and Performed by Setting, Provider Type, and Phase of NTTC Timing

				Nonprovider (n = 40)		Provider (n = 7)
Total logs with complete data for this analysis = 470				Before mid-point	After mid-point	Before mid-point	After mid-point
ED (n = 385 logs)
	Skills performed
			ESI 1	39	17	24	6
			ESI 2	26	21	25	10
			ESI 3	13	9	12	14
			ESI 4	15	0	9	8
			ESI 5	0	0	3	0
	Total skills			93	47	74	38
	Skills observed
			ESI 1	206	78	55	18
			ESI 2	95	65	55	36
			ESI 3	49	32	30	37
			ESI 4	29	11	11	6
			ESI 5	6	0	9	0
	Total skills			329	385	186	160
ICU (n = 42 logs)
	Skills performed
			Critical unstable	8	9	0	1
			Critical stable	4	0	0	0
	Total skills			12	9	0	1
	Skills observed
			Critical unstable	44	30	0	3
			Critical stable	14	6	0	0
	Total skills			58	36	0	3
OR (n = 43 logs)
	Skills performed
			Emergent	7	0	0	0
			Urgent	1	0	0	0
			Nonurgent	1	0	0	0
	Total skills			9	0	0	0
	Skills observed
			Emergent	87	15	24	0
			Urgent	38	6	0	0
			Nonurgent	18	15	0	0
	Total skills			143	36	24	0

ESI, Emergency Severity Index.

Clinical skills include all assessment and intervention activities recorded on the clinical log;

nonproviders include hospital corpsmen and registered nurses; providers include physician assistants and physicians;

ESI 1 is most urgent, and ESI 5 is least urgent.

Clinical logs reflected care of patients with penetrating trauma in 78/470 (16.6%) of logs. Nonproviders (RNs and HMs) completed the majority (n = 64, 82%) of those 78 logs. Primary and secondary trauma assessments, followed by obtaining intravenous (IV) access and administration of analgesic medications were the most frequently documented clinical opportunities (Table II). Participants observed over 100 endotracheal intubations, yet performed only four. Tourniquet placement, a key TCCC skill, was observed only 13 times and performed by Navy personnel only six times. Other TCCC skills taught to improve airway or breathing including cricothyroidotomy, bag-valve-mask ventilation, finger or needle thoracostomy, and chest tube placement were observed and performed rarely or never.

Clinical skills observed and skills performed by NTTC participants in the first and second half of the course were evaluated according to patient acuity in each setting (Table III). When clinical skills observed were compared with skills performed, more logs reflected skill observation than skill performance. Among RNs and HMs, skill observation exceeded skill performance by a ratio of at least 3:1, with the notable exception of obtaining IV access, arterial blood gas sampling, and administration of hypertonic saline. A total of 248 primary trauma assessments were observed and the rotating personnel performed only 41.

Owing to the preliminary nature of the data and to avoid over-interpretation of a small sample, the sample was aggregated into nonproviders (HM and RN) and providers (PA and MD) across settings. Both nonproviders and providers recorded interactions with more critical, unstable (Emergency Severity Index [ESI] 1 and 2) patients than with stable or nonurgent (for example, ESI 5) patients in all clinical settings. Findings in each clinical area were examined by clinical role, based on the variability of clinical assignments; for example, MDs and PAs spent no time in the ICU or OR in the first half of the training. More skills, both observed and performed, were logged in the first half than in the second half of the NTTC clinical rotations. Specifically, HMs and RNs logged 700 skills in the first half and 314 in the second half; PAs and MDs logged 258 skills in the first half and 139 in the second half. Chi-square, used to compare skills observed versus skills performed between the first and second half of training, showed statistically nonsignificant differences for both nonproviders (χ2 [1, N = 1014] = 0.2699, p = 0.60; confidence interval − 0.112, 0.003) and providers (χ2 [1, N = 397] = 0.0002, p = 0.98; confidence interval − 0.075, 0.154).

DISCUSSION

The preliminary data presented in this paper identify the varied practice opportunities available to military personnel participating in a MCP in a busy Level 1 trauma center.⁶ The clinical logs reflected approximately 80 total hours spent in clinical settings, with the most hours spent and clinical experiences reported in the ED, followed by the ICU and OR. This distribution may reflect the emphasis on TCCC as few Navy medical centers provide emergency trauma care. However, it is also possible that the distribution of logs by setting is explained by faster patient turnover in the ED.

Typically MDs and PAs are the roles expected to lead trauma assessments and perform the most invasive procedures (thoracostomy, endotracheal intubation). Given the small number of these participants in the sample, it is not surprising that the number of these procedures performed by NTTC participants reported was very small. However, both HMs and RNs in this sample reported completing primary trauma assessment. Given the typical workflow in the trauma bay, in which the trauma surgeon, emergency medicine physician or PA conducts the primary trauma assessment, it is unclear how to interpret these self-reported data. Because it was not possible to obtain permission to record clinical volume at the medical center for this study, it is not known if the variation in clinical logs reflects a stable or changing patient population. However, given the hospital’s historic, steady high volume of high acuity patients, such an explanation seems unlikely.

The primary limitation of this study is the preliminary nature of these data. The data presented in this paper reflect only a three month sample of a much larger study. Findings identified in this small sample may not be present in the entire data set. The education, training, experience, and deployment data were obtained by self-report and were not verified. Despite repeated refinements of the data collection tool before study initiation, after several months of data collection, the research team recognized a need to include a category for “assisted” in addition to “observed” or “performed” for each clinical skill. This additional category may more accurately reflect each scope of practice. Short-term clinical rotations in MCPs may also present opportunities for role cross-training or familiarization, e.g., ED nurses in the ICU and vice versa; both ED and ICU nurses observing in the OR. Complete data for this study will help to explore the utility of those cross-training and familiarization opportunities as they relate to the development of both knowledge and confidence in new clinical areas.

A second modification needed for the clinical log is the addition of a box “this was not a trauma patient.” Not only are many emergency/critical care procedures performed on nontrauma patients, but these patients represented one third to nearly half of the personnel medically evacuated from combat zones at the height of recent conflicts.^7,8 Patients with diagnoses other than trauma also need procedures such as placement of cardiac monitors, emergency ultrasound, intubation, IV access, and arterial blood gas sampling. It is vital for military medical personnel to be adept in these skills, regardless of the patient’s presenting problem.

These changes to the clinical log hold promise for more robust full-study data. While seeking to interpret the data conservatively, several explanations may be at play to explain these preliminary findings. For all clinical roles, the logs reflect more skill observation than skill performance and the nonsignificant chi-square statistic indicated that this did not vary when the first and second half of the course was compared. The expectation was that after additional classroom and simulation lab training, rotators would be more clinically engaged in patient care. However, the data analysis did not control for either the individual patient or date of patient encounter, therefore it is impossible to determine the overlap of skill observation and skill performance amongst trainees. Multiple trainees may have been involved in the care of a single patient. A single procedure may have been a skill performed by one rotator, and assisted or observed by two others. Those who assisted most likely recorded it as “observed.”

Given that these are preliminary data from a much larger study, it is important not to over-interpret the finding that participants continued to observe more than perform clinical skills throughout their MCP clinical rotations. If these trends remain in the full data set, three possibilities that might explain this phenomenon include: competition for clinical engagement; little incentive for documentation among rotating personnel; or need for more assertive clinical leadership by the permanently assigned NTTC training cadre. Competition, such as multiple trainees trying to participate in the care of few patients is a concern for MCPs at academic training centers with multiple training programs. Incentive for NTTC rotators to complete clinical logs is currently missing; a graduation requirement that specifies a minimum number of clinical procedures performed might be useful. Clinical leadership by the NTTC cadre and rotating group leaders shapes the rotators’ experiences, and differing emphasis on clinical logs may influence variation in clinical log completion rates.

NTTC participants were informed that clinical log completion was an NTTC course requirement regardless of study participation status. However, there were no consequences for noncompliance. Therefore, it may be that individual initiative was the primary driver for log completion. This theory may explain why reporting of all clinical skills (both skill observed and skills performed) was disproportionately lower in all settings in the second half of the course compared with the first, when accounting for hours in the clinical setting. Although it is tempting to believe that “everyone will want to do this!” or “all of the personnel will appreciate the importance of having these data recorded!” it is worth noting the ongoing challenges faced by health systems everywhere to achieve 100% compliance with documentation requirements.^9–11

When complete data are available, it will be important to identify if trends in skill observation versus skill performance are consistent with these preliminary data. Changes at NTTC that occurred after study initiation affected the population of rotating personnel and to some extent the curriculum. Previous rotators were more likely to be more junior, novice personnel deploying to larger medical facilities. Current rotators consist of austere surgical teams, who are more senior, more expert, and more experienced on arrival. How these differences affect engagement in clinical opportunities at NTTC is unknown.

An additional limitation is the inability to verify the data entered in the clinical logs against actual patient care records. Owing to the short-term rotations of NTTC rotators, participants do not record data in the electronic medical record, and therefore it is impossible to cross-check the self-reported clinical activities with those documented in the medical record. Further, inconsistent clinical rotation patterns complicated our ability to evaluate if rotating personnel grew from skill observation to skill performance during their time at NTTC. For example, some participants spent the first half of the course in the ED, and in the ICU during the second half of the course. Given the nature of the skills (e.g., primary and secondary trauma assessment), these individuals had many fewer opportunities to complete those skills in the second half of their clinical rotations.

The strengths of this study are real-time, systematic data collection across all clinical roles and multiple clinical environments. Complete data will enable more complex evaluation of skills observed versus skills performed within clinical roles, such as surgical technologist HM versus Fleet Marine Force HM. These additional analyses may help to create more targeted clinical opportunities. For personnel who have never seen trauma, observation is an essential first step. The MCP provides an important opportunity for novice health care personnel to be mentored through their first exposure to trauma patients. Without MCPs, junior military medical personnel may well meet their first trauma patient while deployed. Surgical team personnel may not require the same emphasis on individual skill development. However, ad hoc teams of experts without prior experience working together may benefit from observation and deliberate debriefing of high acuity trauma resuscitations.

This study adds to the limited literature on trauma training MCPs by quantifying the clinical opportunities for military personnel in temporary training situations at a single, well-established MCP. Broader use of the clinical log will enable systematic evaluation across all services’ MCP platforms to identify the optimal sites for sending personnel in need of specific clinical opportunities. It is imperative to have objective data to optimize training opportunities within funding constraints to enable data-driven policy decisions about where to send military personnel and for how long. Given the Navy’s focus on ready, relevant learning,¹² robust, quantitative data will provide needed information on return on investment. Evaluating the actual clinical activities performed by military trauma personnel in civilian partner settings may also help to clarify how knowledge and technical skill development in the classroom leads to skilled, competent, and confident performance in the clinical setting.¹ Optimized medical capability adds to the medical force projection required by the military services.¹³

CONCLUSIONS

Prospective, real-time data collection of actual clinical activity is a critical process measure of the success of MCPs. Different military trauma mission sets and team types likely require different clinical activities for military medical personnel. Therefore, it is imperative that all relevant partners (host institution, training cadre, and rotating military personnel) understand the targets for clinical participation in trauma MCPs. When data collection for this study is complete, data volume and quality may be high enough to begin to inform such analyses. These preliminary data demonstrate that the ED provides many opportunities for hands-on clinical care of seriously ill and injured patients. It is unclear if the smaller number of logs from the ICU and OR settings indicates a need for a different mechanism to capture the clinical opportunities encountered by military personnel in these settings.

Future research is needed to determine how many clinical experiences in short-term, high-intensity training evolutions are needed to translate to clinical proficiency for all clinical roles. Such knowledge is critical to developing an evidence-based standard for training and may help to inform a more flexible training plan. That is, HMs, RNs, and PAs who have less prior trauma experience may require a longer training time at NTTC or other MCPs compared with MDs who often have a more robust foundation in trauma. Alternatively, some basic skills might be honed before MCP training, e.g., IV catheter insertion, so time spent at the MCP can be dedicated to trauma-specific skills.

ACKNOWLEDGMENTS

We thank the study participants and the training cadre staff at the Navy Trauma Training Center for their dedication to improving military trauma care and enabling the execution of this study.

FUNDING

This study was supported by a grant from the Tri-Service Nursing Research Program #HU0001-17-2-TS06; Project #N17-B03

Author notes

Presented as a poster at the 2019 Military Health System Research Symposium, Kissimmee, FL; MHSRS-19-02614.

The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University, Navy Trauma Training Center, University of California-San Francisco, Department of the Navy, or the Department of Defense.