U.S. Army Medical Department journal

Material Information

U.S. Army Medical Department journal
Alternate title:
United States Army Medical Department journal
Alternate Title:
AMEDD journal
Running title:
Army Medical Department journal
Abbreviated Title:
U.S. Army Med. Dep. j.
United States -- Army Medical Department (1968- )
Place of Publication:
Fort Sam Houston, TX
U.S. Army Medical Department
Publication Date:
Quarterly[<Oct.-Dec. 2001->]
Bimonthly[ FORMER Sept.-Oct. 1994-]
Physical Description:
volumes : illustrations ; 28 cm


Subjects / Keywords:
Medicine, Military -- Periodicals -- United States ( lcsh )
Military Medicine ( mesh )
Medicine ( mesh )
Medicine, Military ( fast )
United States ( mesh )
United States ( fast )
United States
Electronic journals.
Periodicals. ( fast )
Government Publications, Federal.
Internet Resources.
serial ( sobekcm )
federal government publication ( marcgt )
periodical ( marcgt )
Electronic journals ( lcsh )
Periodicals ( mesh )
Periodicals ( fast )
Government Publications, Federal
Internet Resources


Dates or Sequential Designation:
Sept.-Oct. 1994-
General Note:
Title from cover.

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Source Institution:
University of Florida
Holding Location:
University of Florida
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This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Resource Identifier:
32785416 ( OCLC )
98642403 ( LCCN )
1524-0436 ( ISSN )
RC970 .U53 ( lcc )
616.9/8023/05 ( ddc )
W1 JO96 ( nlm )

Related Items

Preceded by:
Journal of the US Army Medical Department.

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Digital Military Collection


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OctoberDecember 2015 Functional Restoration for Chronic Pain Patients in the Military: 1en Early Results of the San Antonio Military Medical Center Functional Restoration ProgramLynette A. Pujol, PhD; Lewis Sussman, PsyD; Jamie Clapp, DPT; et al Posttraumatic Stress Disorder: Five Vicious Cycles that Inhibit Effective Treatment 8Navid Ghaffarzadegan, PhD; Richard C. Larson, PhD Reliability of a Novel Return to Duty Screening Tool for Military Clinicians 14LTC Mark D. Thelen; LTC Shane L. Koppenhaver; MAJ Carrie W. Hoppes; et al Incremental Effects of Telephone Call Center and Healthcare Utilization Database 24en Use to Improve Follow-up Rate in the Prevention of Low Back Pain in the Military TrialJohn D. Childs, PhD; Samuel S. Wu, PhD; CPT Robert L. Andrade; et al Using Evidence to Increase Compliance with Therapeutic Stretching 31en for Chronic Low Back Pain1LT David E. Gisla; 1LT Mauricio J. Izaguirre; LTC Susan G. Hopkinson US Military Drawdowns 1970-1999: Army Medical Department 38en and Military Health System ResponsesSanders Marble, PhD Paralysis as a Presenting Symptom of Hyperthyroidism in an Active Duty Soldier 48CPT John Jennette; Dustin Tauferner, DO A Field-Expedient Method for Direct Detection of Enterotoxigenic 51en E Coli and Shigella from StoolSasikorn Silapong, BS; Pimmnapar Neesanant, PhD; Orntipa Sethabutr, MS; et al Data Analytics Under Deployed Conditions: A Case Study 59LTC Mark D. Mellott; Mark J. Bonica, PhD; LTC Matthew J. Mapes Leveraging Health Information Technology to Improve Quality in Federal Healthcare 68MAJ Fred K. Weigel; LTC Timothy L. Switaj; LT Jessica Hamilton, USCGImplementation of TeamSTEPPS at a Level-1 Military Trauma Center: 75en The San Antonio Military Medical Center ExperienceMichelle M. Fischer; LTC(P) Creighton C. Tubb; Col Joseph A. Brennan, USAF; et al Integration and Coordination of Governmental, Nongovernmental, and Host Nation 80en Preventive Medicine Assets During Medical Stability OperationsCDR Jeff Stancil, USN A Review Of Supplementary Medical Aspects of Post-Cold War UN Peacekeeping 83en Operations: Trends, Lessons Learned, Courses of Action, and RecommendationsLTC Ralph J Johnson III Nursing in the 8th Evacuation Hospital, 1942-1945 92LTC William J. Brown A New Monograph From the Borden Institute 99 Airborne Hazards Related to Deployment Reviewed by LTC Daniel E. Banks J OURNAL THE UNITED STATES ARMY MEDICAL DEPARTMENT


J J O U R N A L OURNAL A Professional Publication of the AMEDD Community THE UNITED STATES ARMY MEDICAL DEPARTMENTOnline issues of the AMEDD Journal are available at October–December 2015 US Army Medical Department Center & School PB 8-15-10/11/12 The Army Medical Department Journal [ISSN 1524-0436] is published quarterly for The Surgeon General by the AMEDD Journal Of ce, USAMEDDC&S, AHS CDD3630 Stanley RD STE B0204, JBSA Fort Sam Houston, TX 78234-6100. Articles published in The Army Medical Department Journal are listed and indexed in MEDLINE, the National Library of Medicine’s premier bibliographic database of life sciences and biomedical information. As such, the Journal’ s articles are readily accessible to researchers and scholars throughout the global scienti c and academic communities.CORRESPONDENCE: Manuscripts, photographs, of cial unit requests to receive copies, and unit address changes or deletions should be sent via email to, or by regular mail to the above address. Telephone: (210) 221-6301, DSN 471-6301DISCLAIMER: The AMEDD Journal presents clinical and nonclinical professional information to expand knowledge of domestic & international military medical issues and technological advances; promote collaborative partnerships among Services, components, Corps, and specialties; convey clinical and health service support information; and provide a peer-reviewed, high quality, print medium to encourage dialogue concerning healthcare initiatives. Appearance or use of a commercial product name in an article published in the AMEDD Journal does not imply endorsement by the US Government. Views expressed are those of the author(s) and do not necessarily re ect of cial policies or positions of the Department of the Army, Department of the Navy, Department of the Air Force, Department of Defense, nor any other agency of the US Government. The content does not change or supersede information in other US Army Publications. The AMEDD Journal reserves the right to edit all material submitted for publication (see inside back cover).CONTENT: Content of this publication is not copyright protected. Reprinted ma-terial must contain acknowledgement to the original author(s) and the AMEDD Journal .OFFICIAL DISTRIBUTION: This publication is targeted to US Army Medical Department units and organizations, other US military medical organizations, and members of the worldwide professional medical community. By Order of the Secretary of the Army: Of cial:GERALD B. O’KEEFE Administrative Assistant to the Secretary of the Army Mark A. Milley General, United States Army Chief of Staff DISTRIBUTION: Special 1522602LTG Patricia D HorohoThe Surgeon General Commander, US Army Medical CommandMG Steve JonesCommander US Army Medical Department Center and School


October December 2015 1 Musculoskeletal disorders are the leading cause of dis ability in the Army, accounting for 73% of the total dis ability cases between the years 1997 to 2002. Costs of disability are staggering, totaling $21 billion over all military services in 2001. 1 The rate of disability dis charge for musculoskeletal disorders has increased dra matically over the last 2 decades and exceeds the rate for all other conditions combined. 1 Further, women in the Army are 67% more likely to receive a disability discharge for a chronic musculoskeletal disorder, 1 and this rate has increased as new, physically demanding military jobs have opened to women. 2 As the armed forces transition to a smaller force, retention of the most highly trained service members becomes increasingly important to overall force readiness. Preventing muscu loskeletal injury, predicting risk factors for injury and disability, managing injuries when they occur, and reha bilitating individuals with musculoskeletal disorders are part of a systemic approach to reducing lost work days and disability, while optimizing a healthy force. 1,2 Appropriate pain management is a critical component of decreasing disability and increasing return to duty for service members with chronic musculoskeletal disor ders. In fact, Interdisciplinary Pain Management Cen ters were recently created in order to relieve acute pain, minimize progression to chronic pain, maximize func tion, decrease disability, and optimize treatment of Soldiers and their families. 3 Functional restoration, an intensive interdisciplinary approach to pain manage ment which involves physical strengthening and psy chological conditioning, was envisioned to address one key task of the campaign plan, which is to improve rehabilitation, reintegration, and recovery through im proved pain management. The Functional Restoration Program (FRP) at San Antonio Military Medical Center (SAMMC) is described in this article and early results of the program are reported. BACKGROUND Research shows that pain is a complex phenomenon that is best treated by the biopsychosocial model, 4 which con siders physiological, psychological, and social aspects of the patient. Over the past 2 decades, it has become clear that biomedical approaches, such as opioid medications, injections, and surgery alone have not been effective in reducing chronic musculoskeletal pain for the long term. Mayer and Gatchel 5 tion as an evidence-based pain management interven tion lead by a physician and nurse that used psychologi cal, physical, and occupational therapies in a biopsycho social model. Treatment is delivered in an intensive for mat, generally consisting of 6 to 8 hours per day for 3 to 6 weeks in nationally-recognized programs such as the Mayo Clinic Rehabilitation Center (Rochester, MN), the Brooks Pain Rehabilitation Program, (Jacksonville, FL), the Rehabilitation Institute of Chicago Center for Pain Management (Chicago, IL), and the Cleveland Clinic Foundation. 4 tional restoration for a variety of outcomes. A review of 12 randomized comparisons (1,964 patients) found strong evidence for increased function for individuals with low back pain for more than 3 months following participation in the intensive multidisciplinary function al restoration programs when compared with inpatient or nonmultidisciplinary outpatient treatments. 6 Overall, strong evidence was found for improvement in function, moderate evidence for pain reduction, and mixed results reporting work-readiness. Less intensive programs did not report improvements in pain, function, or vocational Functional Restoration for Chronic Pain Patients in the Military: Early Results of the San Antonio Military Medical Center Functional Restoration Program Lynette A. Pujol, PhD Justin Boge, DO Lewis Sussman, PsyD Benjamin Keizer, PhD Jamie Clapp, DPT, PT Margaux M. Salas, PhD Rebekah Nilson, MSPT, PT LTC Brandon Goff, MC, USA LtCol Howard Gill, MC, USAF


2 outcomes, 6 and cost-effectiveness of interdisciplinary pain manage ment programs. 7,8 Functional restoration was applied to a military popula tion in a study at Wilford Hall Medical Center (Lack land Air Force Base, Texas). 9 Outcomes measured were return to full duty; retention of at least 6 months; health care utilization for pain treatment; patient reported separated from active duty. A total of 66 participants, matched for age, gender, race, and time since the onset of pain, were randomly assigned to a treatment compari son group (ie, participation in an anesthesia-based pain clinic) or functional restoration. Results over the 3-week program showed physical measures (including lifting metabolic equivalents, oxygen consumption, and lumbar the functional restoration group compared to the treat ment comparison group. No subject in either treatment arm was separated from the military secondary to pain at 6-month follow-up. However, service members in the comparison group had over 4 times as many medical ap pointments at the end of the one-year follow-up period than those in the functional restoration program. DESCRIPTION OF THE SA MM C FUNCTIONAL RESTORATION PROGRA M In March 2014, the Interdisciplinary Pain Management Center at SAMMC opened its Intensive Outpatient Functional Restoration Program. The program is located on the Brooke Army Medical Center campus, and has a dedicated gym space of approximately 2,500 sq ft. The program runs for 3 weeks, 5 days a week. The duty day starts at 7:45 AM and ends at 4 PM Approximately 4 hours each day are spent participating in physical activity in conditioning, cardiovascular exercise, aquatic exercise, All exercise activities are geared to improve strength, promote and support lifestyle changes to be continued postprogram. Currently the exercise programs are pre scribed and instructed by physical therapists. Programs are designed for group participation but individualized to meet each participants overall physical needs. The program day typically ends at the pool where program participants perform aquatic exercise and participate in cludes a group session led by a pain psychologist; the programming also includes a lecture series on self-man agement topics such as goal setting, pain neuroscience, pain education, body mechanics, anatomy, nutrition, pain medications, and vocational resources. The program emphasizes a self-care model that teaches participants how to manage their own pain instead of relying on primary care, emergency rooms, and special ists. Much time is spent explaining the nature of chronic pain, which does not represent new tissue damage, as distinct from acute pain, which appropriately warns of new injury. Participants are taught how to distinguish between the usual waxing and waning of their persistent pain, which should be self-managed, from new or differ ent symptoms that should be evaluated by a medical pro fessional. A key element in the success of this approach is it challenges the patients fear of increased pain from physical activity by providing them with a direct experi ence of pushing their perceived physical limits in a safe setting. Patients typically experience initial increases in pain with increased activity levels, but begin to see functional abilities increase concurrently. At completion of the program most patients report at least a modest reduction in pain, with notable improvements in their physical function. The program tracks changes in physical function and ad ditional outcome measures which have been standard ized for Interdisciplinary Pain Management Centers by Work Group. Moreover, participants are evaluated on physical and psychosocial measures preand postpro gram at 4-week, 4-month, and 12-month follow-ups. PARTICIPANT EXA M PLES ful statistical analysis, the early anecdotal results have been positive, with most participants experiencing great improvements in function. A senior noncommissioned over approximately 10 years, progressively worsening to limit activity, tolerance, and ability to perform duty requirements. He desired to continue his military career and entered the FRP. By the end of the 3-week program, he was pain free and able to mow his lawn, lift and carry his young children, tolerate standing to coach tee-ball, and perform his job requirements, all activities that had previously been limited or relinquished. At one-month follow up, he had maintained the gains and had addition vascular and strength measures. He was able to control duced during the program. He offered this statement: Going through the Functional Restoration Program has been life changing for me. I cannot imagine there is FUNCTIONAL RESTORATION FOR CHRONIC PAIN PATIENTS IN THE MILITARY: EARLY RESULTS OF THE SAN ANTONIO MILITARY MEDICAL CENTER FUNCTIONAL RESTORATION PROGRAM


October December 2015 3 anything that I want to do that I now cannot do. I am very thankful for the opportunity to participate in the program and will recommend anyone with chronic pain to take advantage of the program if possible. who had submitted retirement paperwork prior to the FRP due to limitations following lumbar spine fusion. He demonstrated remarkable improvements participat ing in the FRP. His preprogram 10-minute walking tol erance improved so much that after the program he was able to complete the 7th annual Center for the Intrepid Minitriathlon in San Antonio, TX. After completing the FRP, he reported he felt he could have continued per forming his duties had he not already completed retire ment processing. RESULTS sults are presented as anecdotal and no claims are made at this time as to the effectiveness of the program. At the time this article was written, 14 service members had completed the program. An additional 2 individuals dropped out of the program due to emergent personal/ family situations. Individuals who completed the pro gram comprised 6 males (43%) and 8 females (57%) with an average age of 37 (SD=4.9). Fifty-seven percent were white, 36% Hispanic/Latino, and 7% AfricanAmerican. Ranks of participants ranged from specialist to lieutenant colonel. Back pain, including lower back and thoracic back pain, was the most common primary location of pain (71%), with another 21% endorsing back pain as a secondary concern. Other primary locations of pain were lower extremity (14%), upper extremity (7%), and cervical pain (7%). The average length of duration of pain was 8 years (SD=5). Fifty-seven percent of par ticipants indicated that pain began secondary to workrelated factors, primarily training accidents, work-relat ed activities, or deployment. Other precipitating events included motor vehicle accidents (n=2), surgery (n=1), participation in sports (n=1), or unknown (n=2). Pain Rating and Pain Interference The goal of the FRP is to increase functioning at work and in daily life in spite of painful sensations. The nature of chronic pain is long-lasting, most often with intermit tent exacerbations. Since most participants had reduced regular exercise, sometimes for years, prior to the pro gram, engagement in the physical conditioning aspects of the FRP was expected to increase painful sensations initially. Participants in the program reported reduced pain on a numerical rating scale (0=no pain, 10=pain as bad as it can be) at the end of the program. A reduction of 2 points on this scale is considered to be moderately clinically meaningful. 10 Ratings of current pain intensity changed from 5/10 to 4/10, pain at its worst in the past 7 days from changed from 7/10 to 6/10, and average pain in the past 7 days changed from 5/10 to 4/10 from the beginning to the end of the program. Although these ratings represent a change in pain intensity, the magni tude was likely not clinically meaningful. However, any reduction of pain at the end of the program was surpris ing given the intense physical conditioning nature of the program. Interference of pain in life activities was measured by the Brief Pain Inventory. 11 Figure 1 shows decreases in pain interference, including stress, mood, sleep, and activity over a 24-hour period. Small differences were found from the beginning to the end of the program that ference found in the area of reduced interference with usual activity. Functional Outcome Measures Functional outcome measures examine patients subjec tive reports of their ability to perform activities or their avoidance of certain activities secondary to pain such as bending, kneeling, or walking. In a systematic review of studies looking at factors associated with workers with musculoskeletal pain who stayed at work, deVries found a consistent association with low perceived physi cal disability. 12 Chapman et al 13 reviewed 10 years of literature concerning treatment of CLBP. They found that perception of physical disability due to back pain was most often measured by the Oswestry Disability In dex and the Roland Morris Disability Scale, indicating broad acceptance of those instruments as reliable, valid measures of functional outcomes for patients with back pain. Participants in the FRP showed improvements in functioning on both measures, as shown in Figures 2 Figure 1 pain intensity and the effect of pain on functioning (interfer ence), was assessed by the Brief Pain Inventory questionnaire before and after the Functional Restoration Program (N= 14 ). Range: 0 =no interference; 10 =interferes completely. No Interference Complete Interference Average Score per Life Activity Stress Mood Sleep Activity 0 2 4 6 8 10 End of Program Before Program 6 5 5 5 4 4 5 3


4 and 3. Scores on the Oswestry Dis ability Index indicated a change in scores from an average perception of severe disability to moder ate disability over the course of 3 weeks. Scores on the Roland Mor ris Disability Scale indicated an av erage of 42% decrease in disability perception from baseline to end of the program. CATASTROPHIZING exaggerated negative mental set brought to bear during actual, or anticipated painful experience that and helplessness. 14,15 Catastrophiz ing is associated with a variety of negative outcomes for individuals with chronic pain, to include great er levels of physical and occupa tional dysfunction, greater percep tions of disability, increased anal gesic use, and increased depression and anxiety. 16 It is the most consis tent psychosocial factor associated with pain and dysfunction in sam ples of persons with chronic pain. Catastrophizing has been observed in military personnel with poly trauma following injury in Iraq and Afghanistan and is especially com mon in young Wounded Warriors ical disabilities. 17 Participants were asked to think about past painful experiences and complete the Pain the degree which they experienced certain thoughts and feelings on a 0-5 scale (eg, I feel I cant stand it anymore). This mea sure is widely used in the pain management literature and has adequate internal consistency. A clinically rel evant cut-off score was set at 30 (75th percentile) of the normative sample. Scores on the Pain Catastrophizing Scale decreased from an average of 25 to 14 following treatment in the FRP (Figure 4). Altogether, catastroph izing behavior in FRP patients reduced catastrophizing by half of the original measurement. Fear Avoidance Beliefs Chronic pain patients are also prone to fear avoidance. Fear avoidance beliefs are perceptions that certain physical activities will worsen pain and should be avoided. In order to assess fear avoidance in our FRP population, we used the Fear Avoid ance Beliefs Questionnaire (FABQ) which has 2 subscales to identify fearful beliefs that patients hold re lated to how physical activity and work affect low back pain. 18 The fear avoidance criterion is greater than 15 for the physical activity subscale and greater than 34 for the work subscale. Participants in the FRP scored lower on both subscales of the FABQ at the end of the pro gram compared to starting scores (Figure 4). However, the majority of the participants (57% for the physi cal activity subscale and 71% for the work subscale) did not meet the scoring criteria for clinically mean at the beginning of the program. Depression and Anxiety Depression and anxiety are mood states that are commonly associ ated with chronic pain. In fact, research has shown many neural networks within the brain which are associated with pain processing also play roles in mood. Patients in the FRP reported decreases in de pression and anxiety measured by the Patient Health Questionnaire-9 (PHQ-9) assessment. In fact, aver age scores on the PHQ-9 fell from 11 (SD=6.7; moderate depression range) to 8 (SD=5.5; mild depres sion range) from start to completion of the program, as shown in Figure 5. Three of 4 participants who scored in the moderately program had scores that dropped to the mild range by the end of the program. Additionally, administration of the General Anxiety Disorder-7 19 questionnaire, which is used to measure anxiety, showed average scores de creased from 8 to 5 over the course of the program, in dicating a decrease in depression and anxiety, possibly attributable to FRP (Figure 5). Physical Therapy/Functional Measures The intensely physical nature of the FRP is essential for the restoration of function to chronic pain participants. FUNCTIONAL RESTORATION FOR CHRONIC PAIN PATIENTS IN THE MILITARY: EARLY RESULTS OF THE SAN ANTONIO MILITARY MEDICAL CENTER FUNCTIONAL RESTORATION PROGRAM Figure 3 The average total score of disabil ity assessed by the Roland Morris Disability Questionnaire before and after the Function al Restoration Program (N= 14 ) Range: 0 =no disability; 24 =maximum disability. Average Total Score 0 2 4 6 8 10 12 14 16 15 8 Before Program End of Program Figure 2 The average score of disability upon administration of the Oswestry Disabil ity Index, a common outcome measure for lower back pain, before and after the Func tional Restoration Program (N= 14 ). Range: 0-20% =minimal disability; 21-40% =mod erate disability; 41-60% =severe disability. 20% 30% 0% 50% 40% 10% End of Program Before Program 44% 33%


October December 2015 5 Physical measures were used to establish a functional baseline on day one of the program. Progress was tracked throughout the FRP (days 1, 8, and 15), and served as a data points to compare physically functional measures. Additionally, physical measures provided indirect insight into the degree to which kinesiophobia was a limiting factor in a participants functional level. It should be noted that several of the tests used have a subjective component, ie, the participant determines when he or she has performed maximal effort or when a comprehensive neuromusculoskeletal physical therapy evaluation, including a thorough evaluation and assess ment of reported pain or other physical symptoms in order to rule out any previously missed diagnoses or im properly rehabilitated conditions. The evaluation includ ed a postural assessment, gait analysis, range of motion measurements of the affected area, gross strength test chronic pain. When available, labs and diagnostic imag ing were reviewed as well. 20 is a test waist level, and then from waist level to shoulder level in sets of 4 repetitions at a 12 lifts per minute pace. It yields a variety of qualitative and quantitative data, in cluding strength, muscular endurance, range of motion, work tolerance, as well as the functional ability to lift. Weights are incrementally increased by 10 pounds af ter each set for men, and by 5 pounds for women. The test is terminated when the participant can either no lon ger safely perform the maneuver (judged by the physi cal therapist administering the test), or the participant subjectively reports that he or she cannot continue due to increased pain or fatigue. This procedure is then re peated in the same fashion raising the box from waist to shoulder level. Maximum weight attempted, maximum weight with 4 lifts completed, heart rate before and after, and reason for testing stop are all recorded. Both cervi cal and lumbar lift was improved in participants of FRP as shown in Figure 6. Figure 4 The average score of catastrophizing assessed by the Pain Catastrophizing Scale (score of 30 is clinically relevant) and average scores of fear avoidance behaviors assessed by the Fear Avoidance Beliefs Questionnaire (FAB-Q; max score= 42 ) to both physical activity (FAB-Q PA) and work related activity (FAB-Q W; max score= 24 ) before and after the Functional Restoration Program (N= 14 ) Average Score 15 20 0 30 25 5 10 FAB-Q Physical Activity FAB-Q Work Catastrophizing 8 25 25 15 17 14 After Program Before Program Figure 5 The average score of anxiety was assessed by the Generalized Anxiety Disorder 7 Scale (GAD7 ), and the average score of depression was assessed by Pain Health Questionnaire (PHQ9 ) before and after the Functional Restoration Program (N= 14 ). GAD7 score: 0 7 =none and > 8 =probable anxiety disorder. PHQ9 score: 0 4 =mini mal depression, 5 9 =mild depression, 10 14 =moder ate depression, 15 19 =moderately severe depression, 20 27 =severe depression. 0 2 4 6 8 10 12 11 8 8 5 GAD7 Anxiety PHQ9 Depression After Program Before Program Average Score Figure 6 The ability to perform repetitive lifting as quickly as possible was assessed using the Progressive Isoiner tial Lifting Evaluation. The average weight in pounds was recorded before and after the Functional Restoration Pro gram (N= 14 ). Average of Maximum Lifts Pounds 20 30 0 50 40 10 60 70 Cervical Lumbar 43 29 63 47 After Program Before Program


6 ample of a physical measurement assessed and tracked throughout the program in order to observe changes in strength. Participants were asked to stand in the cen ter of a standard Total Gym mat (Total Gym Fitness, distances reached. Measurements were taken using a standard retractable tape measure and recorded in cen timeters. The test was performed in the anterior, poste rior lateral, and posteromedial directions. Three efforts were recorded and averaged for each of the 3 directions strated that dynamic strength on both right and left sides of the body improved from the start to the completion of FRP as shown in Figure 7. Although chronic pain pa tients may limit themselves physically due to psycholog ical factors (catastrophizing and fear avoidance), consis tent physical activity along with psychological support and education on chronic pain management was shown to increase physical strength measure in our cohort of FRP participants. CO MM ENT Management Center Functional Restoration Program are promising. Improvements were seen in perception of disability, pain interference, catastrophizing, fear/ avoidance beliefs, depression and anxiety, as well as in physical function such as lifting, balance, and range of motion. Due to the small number of subjects, these data potential as an alternative management technique for ings are consistent with outcomes from other, established programs in the wider civilian medical community. The Functional Restoration model has been shown to be ef fective in a civilian population, and these results suggest that it can be used effectively in a military population as well. We will continue statistical analysis as we cycle through larger numbers of patient cohorts. REFERENCES 1. Technical Bulletin Medical 592: Prevention and Control of Musculoskeletal Injuries Associated with Physical Training Washington, DC: US De partment of the Army; May 2011. Available at: tbmed592.pdf. Accessed August 6, 2015. 2. Musculoskeletal Injuries in Military Women. Fort Sam Houston, TX: The Bor den Institute; 2011. 3. moderate and severe pain in mountain rescue. High Alt Med Biol 2013;15(1):8-14. 4. Stanos S. Focused review of interdisciplinary pain rehabilitation programs for chronic pain manage ment. Curr Pain Headache Rep 2012;16(2):147-152. 5. Mayer TG, Gatchel RJ. Functional Restoration for Spinal Disorders: The Sports Medicine Approach Philadelphia, PA: Lea & Febiger; 1988. 6. bilitation for chronic low back pain: systematic re view. BMJ 2001;322(7301):1511-1516. 7. data documenting the treatment and cost-effective ness of comprehensive pain programs for chronic nonmalignant pain. J Pain 2006;7(11):779-793. 8. cost-effectiveness treatment of chronic pain: An analysis and evidence-based eds. Chronic Pain Management: Guide lines for Multidisciplinary Program Development New York, NY: Informa Heathcare; 2007:15-38. 9. Gatchel RJ, McGeary DD, Peterson domized controlled trial of an interdisci plinary military pain program. Mil Med 2009;174(3):270-277. 10. Dworkin RH, Turk DC, Wyrwich KW, et al. Interpreting the clinical im portance of treatment outcomes in chron ic pain clinical trials: IMMPACT recom mendations. J Pain 2008;9:105-121. FUNCTIONAL RESTORATION FOR CHRONIC PAIN PATIENTS IN THE MILITARY: EARLY RESULTS OF THE SAN ANTONIO MILITARY MEDICAL CENTER FUNCTIONAL RESTORATION PROGRAM Figure 7 ity, and proprioception was assessed on both left and right sides of the body using the Star Excursion Balance Test. The average mobility was assessed in centimeters before and after the Functional Restoration Program (N= 14 ). Centimeters End of Program Before Program Positions Left Right Crossed Extension Lateral Extension Forward Forward Lateral Extension Crossed Extension 20 0 40 60 80 100 120


October December 2015 7 11. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Sin gapore 1994;23(2):129-138. 12. De Vries HJ, Reneman MF, Groothoff JW, Geert zen JH, Brouwer S. Factors promoting staying at skeletal pain: a systematic review. Disabil Rehabil 2013;34(6):443-458. 13. Chapman JR, Norvell DC, Hermsmeyer BS, Brans common outcomes for measuring treatment suc cess for chronic low back pain. Spine 2011;36(sup pl 21):S54-S68. 14. Sullivan MJL, Thorn B, Keefe FJ, Martin M, Brad ley LA, Lefebvre JC. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain 2001;17:52-64. 15. Sullivan MJL, Bishop SR, Pivik J. The pain cata strophizing scale: development and validation. Psy chol Assess 1995;7(4):524-532. Available at: http:// Accessed February 5, 2015. 16. to chronic pain in persons with physical disabili ties: a systemic review. Arch Phys Med Rehabil 2011;92:146-160. 17. Spevak C, Buckenmaier C. Catastrophizing and pain in military personnel, Anesth Analg 2011;15(2):124-128. 18. Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs Question naire (FABQ) and the role of fear avoidance be liefs in chronic low back pain and disability. Pain 1993;52(2):157-168. 19. liams MJ, Hartzell MM, Gatchel RJ. The poten tial utility of the patient health questionnaire as a screener for psychiatric comorbidity in a chronic disabling occupational musculoskeletal disorder population. Pain Pract of print. 20. Smeets R, Koke A, Lin CW, Ferreira M, Demoulin C. Measures of function in low back pain/disor ders: Low Back Pain Rating Scale (LBPRS), Os westry Disability Index (ODI), Progressive Isoiner Disability Scale (QBPDS), and Roland Morris Dis ability Questionnaire (RDQ). Arthritis Care Res 2011;63(suppl 11):S158-S173. AUTHORS Dr Pujol is a Psychologist, Department of Pain Manage ment, and member of the faculty, San Antonio Uniformed Fellowship, San Antonio Military Medical Center, Joint Base San Antonio Fort Sam Houston, Texas. Dr Sussman is a Psychologist, Department of Pain Man agement, and member of the faculty, San Antonio Uni Medicine Fellowship, San Antonio Military Medical Center, Joint Base San Antonio Fort Sam Houston, Texas. Dr Clapp is a Physical Therapist, Department of Pain Management, and member of the faculty, San Antonio Medicine Fellowship, San Antonio Military Medical Center, Joint Base San Antonio Fort Sam Houston, Texas. Ms Nilson is a Physical Therapist, Department of Pain Management, and member of the faculty, San Antonio Medicine Fellowship, San Antonio Military Medical Center, Joint Base San Antonio Fort Sam Houston, Texas. LtCol Gill is an Assistant Professor, Department of Physi cal Medicine & Rehabilitation, Uniformed Services Uni versity of the Health Sciences. He is also a Pain Medi cine Physician, Department of Pain Management, and member of the faculty, San Antonio Uniformed Services San Antonio Military Medical Center, Joint Base San An tonio Fort Sam Houston, Texas. Dr Boge is an Assistant Professor, Department of Physi cal Medicine & Rehabilitation, Uniformed Services Uni versity of the Health Sciences. He is also a Pain Medi cine Physician, Department of Pain Management, and member of the faculty, San Antonio Uniformed Services San Antonio Military Medical Center, Joint Base San An tonio Fort Sam Houston, Texas. Dr Keizer is a Psychologist, Department of Pain Manage ment, and member of the faculty, San Antonio Uniformed Fellowship, San Antonio Military Medical Center, Joint Base San Antonio Fort Sam Houston, Texas. Dr Salas is a Staff Scientist appointed to the Postgraduate Research Participation Program at the US Army Institute of Surgical Research administered by the Oak Ridge In Army Medical Research and Materiel Command. Dr Sa las serves as the Clinical Science Coordinator in the Pain Clinic, San Antonio Military Medical Center, Joint Base San Antonio Fort Sam Houston, Texas. LTC Goff is an Assistant Professor, Department of Phys ical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences. He is also a Physician and Fellowship Program Director, Department of Pain Management, San Antonio Uniformed Services Health Antonio Military Medical Center, Joint Base San Anto nio Fort Sam Houston, Texas.


8 Posttraumatic stress disorder (PTSD) is one of our ma jor public health challenges. More than 2% of the US population (about 7.7 million people) are known to suf fer from PTSD, and 7% to 8% report experiencing it at some point during their lifetime. Approximately 11% to 20% of veterans of the Iraq and Afghanistan wars have been coping with PTSD. These veterans are 4 times more likely to abuse alcohol and 6 times more likely to develop a marijuana dependence. 1-3 In addition to the pa tients, many others are indirectly affected by PTSD, in cluding family members, friends and community mem bers, colleagues, and employers. Their reactions toward care-seeking behavior and treatment progress. Despite a wide range of studies and medical progress, it seems Major social and behavioral issues are involved with PTSD. Data show that about 50% to 75% of people with psychiatric disorders do not receive mental health ser vices and, of those who do, 50% to 60% drop out from treatments. 3-5 The authors believe that developing inno vative policies to address PTSD requires a broad scope of analysis and consideration of the highly interconnected social, behavioral, and medical variables. This process requires a systems approach. Drawing upon the system dynamics methodology, we offer an illustrative causal loop diagram that demonstrates 5 major barriers for ef knowledge of an interdisciplinary research team and is a step forward for using a systems approach to study PTSD. SYSTE M S SCIENCE System dynamics is a common method among systems scientists primarily used to analyze behavior of complex social systems. 6,7 Feedback loops are at the heart of the method to help demonstrate circular causality in a sys tem (eg, X causes Y and Y causes X ). Feedback loops are considered reinforcing when an increase in a variable reinforces its future increase, and balancing when an increase in a variable results in a future decline in the same variable. Feedback loops can be major sources of continuous growth and improvement (virtuous cycles) or exponential collapses (vicious cycles). A few recent applications of system dynamics in public health are in the studies of dental health, 8 obesity, 9,10 cardiovascular diseases, 11 and obstetrics. 12 System dynamics provides a platform to develop causal maps and help productive discussion across different stakeholders. 13,14 These maps are effective tools for prob lem conceptualization. 15 Here we follow a similar goal by developing a simple but hopefully useful model of PTSD for making sense of complexities of the problem. major challenges for PTSD treatment. CAUSAL DYNA M ICS Our focus, PTSD treatment, is a complex process and depends on a wide range of factors. We categorize the factors as medical, social, and personal, as shown in Fig ure 1. Medical factors represent the quality of services provided by the healthcare system. Performance of the healthcare system, medical advancements, and timely response to needs can help patients treatment. Social factors include how families, relatives, friends, and so of a social nature are central in accelerating treatment. Personal factors include patients willingness to receive care and their compliance with treatments. Patients ment; otherwise medical expertise and social supports Posttraumatic Stress Disorder: Five Vicious Cycles That Inhibit Effective Treatment Navid Ghaffarzadegan, PhD Richard C. Larson, PhD AB STRACT problem of posttraumatic stress disorder (PTSD). The problem has major social and behavioral components. Developing innovative and effective policies requires a broad scope of analysis and consideration of the highly interconnected social, behavioral, and medical variables. In this article, we take a systems approach and offer an illustrative causal loop diagram which includes individual and social dynamics. Based on the map, we discuss 5 major barriers for effective interventions in PTSD. These barriers work as vicious cycles in the system, reduce effectiveness and therefore value of PTSD treatment. We also discuss policy implications of this perspective.


October December 2015 9 are less likely to help. In order to increase the treatment rate, we should take actions that improve all three, a complex task. We take a further step in Figure 2, depicting how the 3 (individual, family/friend, and societal layers). The blue boxes present different layers of the model. At the Indi vidual layer, the smallest box in Figure 2, patients are medical factors and ones willingness to seek care. The Family/friend layer includes dynamics that are imposed by how ones close circle of people behave regarding the illness. At the Societal layer, the behavior of the society at large regarding PTSD patients is depicted, which, in turn, eventually has an effect on the Individual layer. As shown in the form of balanc ing loops B1, B2, and B3, there are potentially self-correcting mecha nisms that can help PTSD treat ment. In the absence of social and psychological barriers, a patient is expected to seek care once he or she knows about the illness (loop B1), which reduces the PTSD extent, and reduces PTSD symptoms. Further more, people in close proximity to patients with whom they have regular contact, such as family members and friends (hereafter, close circle), can play an important role in patients treatment. They can directly help PTSD treatment (loop B2) and encourage PTSD patients to seek care (loop B3), thus increasing the chances of early diagnosis and treatment. 16 barriers that work against these self-correcting mecha nisms. We review 5 major ones. FIVE MAJOR VICIOUS CYCLES R 1 : Cascading Illness and Medical Complexity A number of effective treatment procedures have been developed and successfully tested. 17 The problem is that if patients avoid actively seeking care, the illness pro gresses (PTSD extent goes up), and their medical con dition worsens. As the disease progresses, and as other mental and physical illnesses co-occur, complications increase nonlinearly and make medical interventions complex and progressively less effective. Data indicate that about 8% of patients with PTSD develop co-occur ring psychiatric disorders. 18 The link between cardiovas cular diseases (including heart failure) and PTSD has been consistently found in different studies. 19,20 Patients self-treatment in the form of alcohol or drug abuse contributes to complications. Other evidence suggests high likelihood of developing other mental disorders for PTSD patients. 21 These patterns result in a reinforc ing loop (R1), which pushes mild medical illnesses to chronic and chronic to life-threatening conditions. Such a comorbidity is so regularly observed that it is referred to as a rule. 22 R 2 : Cascading Illness and Exclusion from Family and Friends Supportive behavior is not always guaranteed. While close circles can support and help treatment, their tol erance is limited. As illness progresses with more and more PTSD-related symptoms and incidents, family and friends are increasingly likely to drop out from support ing the patient (loop R2a) and to start keeping their dis tance from the patient, further exac erbating the situation (loop R2b). 21 Lack of social support contributes to PTSD extent, 16 where one prob lem leads to another, resulting in bigger social and medical problems, cascading illness, and related com problems and breakups, unemploy ment, homelessness, and suicidal ideation. 21 This potential cascade stresses the importance of early treatment before it be comes too late and before family members and friends coping capacities have deteriorated. R 3 : Stigma and Social Exclusion Stigma has been cited as the main social barrier to receiv ing care. 3,17,23,24 Patients revealing their mental illnesses publicly may suffer a wide range of consequences such as a higher likelihood of losing jobs or discrimination in ing, and exclusions from social communities. 25 Social psychological mechanisms (such as fear) that contribute to worsening PTSD. 26 Consequently, a reinforcing loop emerges where PTSD treatment affected by stigma and society at large is incapable of supporting the patients. In Figure 2, Loop R3 depicts how stigma and social number of PTSD-related incidents increases, affecting public perception of patient risk, people increasingly keep their distance from PTSD patients or even discrim inate against them in workplaces. Such social exclusion affects the PTSD treatment rate and contributes to an accumulation of untreated PTSD patients. R 4 : Stigma, Fear of Exclusion, and Self-fulfilling Prophecy One important causal mechanism depicted in Figure 2 as loop R4 is the relation between fear of social exclusion Figure 1 A simple representation of factors (positive) signs indicate that the variables move in the same direction. PTSD Treatment Effect of Social Factors Effect of Personal Factors Effect of Medical Factors + + +


10 Figure 2 Multilayer dynamics affecting PTSD treatment. The multilayer dynamics are represented as individual, family/friend, and societal layers. At the individual haviors are observed and create public perceptions and the associated labels, which ultimately affect individual layer dynamics. Note: Plus (positive) signs indicate the variables move in the same direction. Minus (negative) signs mean variables move in the opposite direction. POSTTRAUMATIC STRESS DISORDER: FIVE VICIOUS CYCLES THAT INHIBIT EFFECTIVE TREATMENT


October December 2015 11 and social exclusion. As new patients see that people with PTSD are labeled, excluded from various oppor tunities in the society, and lose their family members support, they become unwilling to accept and announce their illness and seek treatment. Fear of social exclusion decreases individuals willingness to seek care, which results in progression of illness and symptoms. 17 If the majority of patients think being labeled with PTSD has considerable negative consequences, they will hide their illness, which will exacerbate it and will actually result in considerable negative consequences once symptoms inforcing mechanism that is likely to work as a vicious The psychology literature refers to this type of mecha exclusion and discrimination results in exclusion and discrimination. This pattern is not limited to patients, but a similar selfpectation of risks of PTSD contributes to risks of PTSD. If, assuming that there are high risks associated with social engagement with PTSD patients, the majority of people limit their contacts with PTSD patients, those patients well-being can suffer, illness progress can ac celerate, and PTSD related incidents can increase. Thus, perception of risks of engagement with PTSD patients contributes to an increase in risks of engagement with PTSD patients. R 5 : Incentives, Backlash, and the Malingerer Stigma A seemingly smart policy is to increase early diagnosis and care of PTSD patients. But we do not know exactly how to do this. In the military, policymakers have of encourage patients to seek early care (loop B4). However, a considerable number of false reports have emerged. 29 known as malingerers. 27,28 cial supports for PTSD patients have grown by about 400%. 30 Anecdotal evidence suggests that exaggeration or fabrication of symptoms might be as high as half of the population of patients. 30 Whether those anecdotes are right or wrong, they depict an emerging perception of some PTSD patients being malingerers. In military culture, malingering is an unacceptable behavior. Since nancial incentives lose their legitimacy (B5). In addition, false positives have resulted in a major neg ative effect on willingness to seek care by those actu ally needing care. This is due to the emerging label of malingerers and its associated stigma. In the military context, many people might initially join the military with a high level of pride. They might prefer to tough it out with problems rather than being labeled as weak or lazy or manipulative. Society, friends, and family mem bers have high expectations. However, as people notice that some are using PTSD as an excuse to take advan tage of the system, fear of being labeled as a malingerer discourages real patients from seeking care (loop R5). Thus, providing incentives not only falls short in resolv ing the high risk label and associated stigma, but also creates the malingerer label and its associated stigma. TOWARD INNOVATION While the map illustrates several challenges for PTSD of the problem. The goal was to offer an example of a systems approach to the problem of PTSD and discuss 5 major barriers for PTSD treatment that work as vicious cycles at individual, family/friends, and societal layers. What can be done? There are a few examples of structur al changes that have been offered to overcome the prob lem of PTSD, such as addressing public stigma through providing better knowledge of PTSD, educating families, and addressing cultural barriers. 17 Several other studies of PTSD offer incremental steps for improvement. As we discussed, various sources of resistance to PTSD treatment exist which create numerous vicious cycles, making seemingly smart policies, such as providing Overcoming the vicious cycles of public perception and fear of social exclusion requires positive and constructive approaches to the problems of PTSD. Public perceptions of PTSD patients are formed by seeing or hearing news about these patients. Rarely does the public hear news about riskless patients. Rather, media news focuses on individual extreme cases. As a result, low risk patients are equated with high risk patients through the PTSD label. To remove the label from patients, one solution is to offer a continuous measure of PTSDness. The idea is that everyone in the target population (such as all mili tary personnel) would receive a number in a continuous rangenot a binary label. Such a number could, for in stance, be on the scale of 1 to 99, the assigned number dependent on level of symptoms. In this approach, every one has a positive PTSD score, rather than a binary yes or no PTSD label. Also, nobody is 100% free of PTSD (there are no zeros) and nobody is 100% PSTD (there are no 100s). The number represents the level of care that a our intuition that people cognitively like simple catego can help overcome the labeling issues. Once people see


12 that the population of patients is dominated by low risk individuals, their judgment can more easily change and the label can lose its association with high risk patients. The proposed model considers PTSD treatment at the center of attention with feedback loops that are beyond any single organizations boundary. This is another in dicator that PTSD is a multiorganizational challenge. In simple words, no single organization is responsible for the described feedback loops. The loops are due to ac tions and reactions of multiple entities such as patients, patients family members, employers, colleagues, com munity, neighborhood, and larger entities such as media, the military, veterans affairs, and elected government and sets of interests: the military focuses on effects of PTSD on servicepersons military readiness, the health care system focuses on healthcare coverage, Congress is concerned with costs, and the VA focuses on health out comes. While all these variables are interconnected, at any given time a service member or veteran may be un der the jurisdiction of a single-organization whose sys tems view is a narrow subset of the larger system we have discussed. Placing internal boundaries within the larger system and optimizing for the subsystem may in fact lead to negative consequences that few would support. There is no easy way to overcome the problem of stakeholder misalignments. However, systems mod els have been successfully used in other contexts to help different stakeholders communicate and understand the whole system. 13 Systems maps, such as the one repre sented by Figure 2 in this article, are used as boundary objects for effective communications across organiza tions with differing goals and world views. 13,14 We think an effective systems approach should consider a large boundary for the problem of PTSD, one that includes multilayer dynamics, connects all relevant variables, and elaborates on the links to the most important vari able of interest: public health. ACKNOWLEDGE M ENTS This article is based upon MIT work supported, in part, Health Affairs, under Award No. W81XWH-12-0016. The US Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick MD 21702-5014, is the interpretations, conclusions and recommendations are those of the authors and are not necessarily endorsed by the Department of Defense, MIT, or Virginia Tech. The agencies. Publication of this article is not contingent on the sponsors approval of the manuscript. We thank research team members of the MIT Post-Traumatic Stress Innovations project for useful comments on ear lier drafts. REFERENCES 1. National Center for PTSD. How common is PTSD [internet]. Washington, DC: US Department of Vet eran Affairs; 2015. Available at: http://www.ptsd. mon-is-ptsd.asp. Accessed August 1, 2014. 2. Telehealth & Technology. Post-Traumatic Stress. Afterdeployment website. 2013. Available at http:// Accessed August 1, 2014. 3. Lee DJ, Warner CH, Hoge CW. Advances and con troversies in military posttraumatic stress disorder screening. Curr Psychiatry Rep 2014;16(9):1-6. 4. croft, G. Mental illness stigma, help seeking, and public health programs. Am J Public Health 2013;103(5):777-780. 5. Corrigan PW, Shapiro JR. Measuring the impact of programs that challenge the public stigma of men tal illness. Clin Psychol Rev 2010;30(8):907-922. 6. Forrester JW. Industrial Dynamics Cambridge, MA: Productivity Press; 1961. 7. Sterman JD. Business Dynamics: Systems Think ing and Modeling for a Complex World Boston, MA: Irwin/McGraw-Hill; 2000. 8. tems perspective for dental health in older adults. Am J Public Health 2011;101(10):1820-1823. 9. Fallah-Fini S, Rahmandad H, Huang TTK, Bures RM, Glass TA. Modeling US adult obe sity trends: a system dynamics model for estimat ing energy imbalance gap. Am J Public Health 2014;104(7):1230-1239. 10. Sabounchi NS, Hovmand PS, Osgood ND, Dyck of female obesity and fertility. Am J Public Health 2014;104(7):1240-1246. 11. Homer J, Milstein B, Wile K, Trogdon J, Huang P, ing Local Interventions to Improve Cardiovascular Health. Prev Chronic Dis 2010;7(1):A18. 12. tice variation, bias, and experiential learning in cesarean delivery: a data-based system dynamics approach. Health Serv Res 2013;48:713-734. 13. Black LJ, Andersen DF. Using visual representa collaborative model building approaches. Syst Res Behav Sci 2012;29(2),194-208. POSTTRAUMATIC STRESS DISORDER: FIVE VICIOUS CYCLES THAT INHIBIT EFFECTIVE TREATMENT


October December 2015 13 14. Black LJ. When visuals are boundary objects in sys tem dynamics work. Syst Dyn Rev 2013;29(2):70-86. 15. Martinez Moyano IJ, Richardson GP. Best prac tices in system dynamics modeling. Syst Dyn Rev 2013;29(2):102-123. 16. Boscarino JA. Post traumatic stress and associ ated disorders among Vietnam veterans: the sig J Trauma Stress 1995;8(2):317-336. 17. Corrigan PW, Druss BG, Perlick DA. The impact of mental illness stigma on seeking and participat ing in mental health care. Psychol Sci Public Inter est 2014;15(2):37-70 18. ser KT, Brady KT. Treatment of PTSD and comor MJ, Cohen JA, eds. Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies 2nd ed. New York, NY: The Guilford Press; 2009:508-535. 19. Boscarino JA. Posttraumatic stress disorder and physical illness: results from clinical and epidemio logic studies. Ann N Y Acad Sci 2004;1032:141-153. 20. Spitzer C, Barnow S, Vlzke H, John U, Freyberger HJ, Grabe HJ. Trauma, posttraumatic stress disor population. Psychosom Med 2009;71(9):1012-1017. 21. The Nebraska Department of Veterans Affairs. What is PTSD? [internet]. 2007. Available at: http:// Accessed Au gust 4, 2015. 22. Brady KT, Killeen TK, Brewerton T, Luceri ni S. Comorbidity of psychiatric disorders and posttraumatic stress disorder. J Clin Psychiatry 2000;61(suppl 7):22-32. 23. Hoge CW, Grossman SH, Auchterlonie JL, Riviere diers after combat deployment: low utilization of mental health care and reasons for dropout. Psychi atr Serv 2014;65(8):997-1004. 24. Hoge CW, Castro CA, Messer SC, McGurk D, Cot ting DI, Koffman RL. Combat duty in Iraq and Af ghanistan, mental health problems, and barriers to care. New Engl J Med 2004;351(1):13-22. 25. Hatzenbuehler ML, Phelan JC, Link BG. Stigma as a fundamental cause of population health inequali ties. Am J Public Health 2013;103(5):813-821. 26. Mooren N, van Minnen A. Feeling psychologi cally restrained: the effect of social exclusion on tonic immobility. Euro J Psychotraumatol 2014;13(5):eCollection 2014. 27. Hall RCW, Hall RCW. Detection of malingered PTSD: an overview of clinical, psychometric, and physiological assessment: where do we stand?. J Forensic Sci 2007;52(3):717-725. 28. Ahmadi K, Lashani Z, Afzali MH, Tavalaie SA, Mirzaee J. Malingering and PTSD: detecting ma lingering and war related PTSD by Miller Forensic Assessment of Symptoms Test (M-FAST). BMC Psychiatry 2013;29(13):154. 29. Taylor S, Frueh BC, Asmundson GJ. Detection and management of malingering in people present ing for treatment of posttraumatic stress disorder: methods, obstacles, and recommendations. J Anxi ety Disord 2007;21(1):22-41. 30. Zarembo A. As disability awards grow, so do con cerns with veracity of PTSD claims. Los Ange les Times August 3, 2014 [internet]. Available at: ty-20140804-story.html#page=1. Accessed August 4, 2015. AUTHORS Dr Ghaffarzadegan is Assistant Professor, Industrial and Tech University, Blacksburg, Virginia. Fundamentals, and Mitsui Professor, Institute for Data, Systems, and Society, Massachusetts Institute of Tech nology, Cambridge, Massachusetts.


14 Military personnel often carry more than 100 pounds of gear and equipment during training exercises and deployment. 1 This, in conjunction with rapid and pro longed movement over rough terrain and other physi forces through the joints of the lower extremity and lumbar spine. 2 These factors contribute to a high rate of injury, often in the lower extremity and low back, healthcare system. In 2010, approximately 2.5 million musculoskeletal injury-related ambulatory visits were reported. 3 In the same period, musculoskeletal injuries proximately 1 million medical encounters were docu mented for back injuries, representing almost 20,000 lost manpower days. 4 In addition to the high cost of initial injury, subsequent injuries often occur during the recuperation period or immediately afterwards when the patient returns to full duty. This recuperation period can vary in length from a few days to several weeks depending upon the severity Reliability of a Novel Return to Duty Screening Tool for Military Clinicians LTC Mark D. Thelen, SP, USA 1LT Jaimie-Lee Musen, SP, USA LTC Shane L. Koppenhaver, SP, USA 1LT Ryan Davidson, SP, USA MAJ Carrie W. Hoppes, SP, USA Capt Matthew K. Williams, BSC, USAF 1LT Casey Shutt, SP, USA AB STRACT Purpose/Hypothesis: military healthcare system. Subsequent injuries often occur during the recuperation period or in the period directly after physical therapy ends when the patient returns to full duty. Medical providers have relatively few objective tools with which to determine if someone is ready for return to duty (RTD). The purpose of this study is to assess interrater and test-retest reliability of a novel gender-neutral RTD screening tool that requires minimal training, equipment, and time. Subjects: This study included 34 active duty military participants (male=22, female=12, age=28.55.9). 23 subjects (male=14, female=9, age=28.76.3) returned for follow-up testing within one week. Materials/Methods: After answering a medical questionnaire, all participants completed the RTD screening tool composite score ranged from 0 to 16 with higher scores indicating better performance. Results: 12.611.73 during the second session. There was good interrater reliability for the composite score (intraclass Conclusions: This novel RTD screening tool showed good overall interrater reliability, suggesting that entrylevel clinicians trained on the grading requirements are able to reliably administer the tool. In addition, the screening tool had only moderate test-retest reliability, suggesting the possible presence of a learning effect. The including a longer practice session to ameliorate any possible learning effect and to modify the hip abduction test to improve reliability. Clinical Relevance: This study has demonstrated that a novel RTD screening tool can reliably be administered to an active duty population to assist clinicians in making RTD decisions. However, at this time, it cannot be determined if a certain composite or individual event score will indicate increased risk for injury.


October December 2015 15 of the initial injury, and reinjury during this period may depend upon both intrinsic and extrinsic factors affect ing the patient. 5 Intrinsic factors include incomplete tis sue healing combined with subjective symptom resolu turely, perceived or actual pressure from supervisors to return to prior levels of activity right away, and returning injured personnel may have decreased pain and increas ingly functional motion and strength. As such, patients may feel ready to participate in military activities even though the healing tissues are not at full strength. Addi tionally, injured personnel may develop musculoskeletal compensations throughout the body during the healing period, which could contribute to injuries in other re gions of the body. Medical providers have relatively few objective tools for determining if someone is ready for return to duty (RTD). Several screening tools have been developed for this purpose, but to date, they are fairly complex, re Functional Movement Screen (FMS) (Functional Move ment Systems, Chatham, VA) has been shown to be predictive of injury risks in both athletic and military populations, but requires specialized training and spe transport in a deployed environment. 6,7 The Y-Balance Test has also been shown to be predictive of injury risks, 8,9 but has similar equipment requirements as the perform correctly. Military clinicians who diagnose and treat musculoskeletal injuries lack a screening tool that is simple yet thorough, inexpensive, and readily per formed with minimal training. The purpose of this study was to present and assess the RTD screening tool that requires minimal training, equipment, and time. The tool was developed to be used by any military clinician, in any environment, to help determine whether military personnel are at risk for subsequent injury with resumption of normal training activities. METHODS Participants Active duty service members from Joint Base San An tonio between the ages of 18 and 50 who had a history of low back or lower extremity injury in the previous 6 months were included. Lower extremity and low back in to modify their daily activities for at least one day in the past 6 months. Participants were excluded if they had any pain in their low back or lower extremities for 2 weeks prior to participating, if they were currently preg nant, or if they had low back or lower extremity surgery within the past year. Screening Examiners Personnel administering and grading the RTD screen the US Army-Baylor University Doctoral Program in approximately 12 years of relevant military clinical ex perience. However, none of the screening examiners had any clinical experience using RTD screening tools. Testing Procedures The protocol was approved by the Brooke Army Medical vided informed consent and completed a medical screen ing questionnaire prior to performing the RTD screening tool. The screening questionnaire included demographic data and medical history questions such as date of injury, duration of symptoms, and prior treatment received. For each event, the instructions were read from a stan dard script (Figure 1) by the same examiner. Two exam iners simultaneously graded each event while blinded of 1 to 2 or 3 points for level of performance when pain was not experienced. Graders could ask the participant to perform the task up to 3 times in order to determine an accurate score. The last attempt performed for each event was recorded as the score of record. If a partici pant experienced any degree of pain during the task, they received zero points for that task. The possible scoring ranged from 0 to 16, with higher scores indica tive of better performance. The grading criteria for each event are outlined in Figure 2. EQUIP M ENT The equipment used for this study was kept simple with used for the tasks included a 2 by 6 by 24 inch wooden board, a 3 foot length of PVC pipe, an 8 inch step, a penlight, 2 rectangular hardcover textbooks weighing a total of 12 pounds, a tape measure, and a plinth. RTD SCREENING TOOL DESCRIPTION The 7 events used in this study were chosen based on varying levels of evidence and the senior authors


16 experience in predicting injury in subjects without a recent history of injury. A majority of the events have in either the scoring rubric or the event execution. The military population used in this study. The events, any described below. Grading criteria for each event are de tailed in Figure 2. Question Regarding Perceived Risk of Injury Psychological factors including increased levels of ing skills are linked to increased injury rates and slower healing rates. 12-15 A study of Air Force Academy cadets found that higher levels of fear and anxiety correlated with lower scores on outcome measures. 16 The participant was asked the following question to would you describe your personal concern for sustain ing a musculoskeletal injury within the next 6 months? The participant could choose from 3 possible answers: No concern for injury Mild to moderate concern for injury Modified Deep Squat dictor of injury rates, particularly in physically demand ing occupations. 17,18 Low scores in the deep squat may also predict how well athletes progress through a cor rective exercise program. 19 formed using a PVC pipe and a wooden board. The ing the subjects place their feet on a wooden board. 6 A study that used the FMS deep squat in a healthy popula Event Instructions Given for Each Event Question regarding perceived risk of injury How would you describe your personal concern for sustaining a musculoskeletal injury within the next six months? No concern for injury. Mild to moderate concern for injury. Significant concern for injury. Modified Deep Squat Place your heels on the board and place your feet in a comfortable position, approximately shoulder width or slightly greater than shoulder width apart. Point your toes forward and keep them pointing forward. Hold the PVC pipe with both hands over your head in order for both your shoulders and elbows to maintain a 90-degree angle. Now, press the PVC pipe over your head and hold it there. While maintaining an upright posture, the PVC pipe over your head, and your heels on the board, descend into a deep squat in order for your thighs to break paral lel with the floor. Hold this down position for a count of one and then return to the starting position. 10(p18) Forward Step Down in Low Lighting While looking straight ahead, step down as you would if you were getting out of the rear of a military vehicle, using one leg at a time. Do not step or jump down with both legs simultaneously. Modified Feagin Hop Test From the starting position, hop directly up and down 2 times. The height of your hops should be whatever is comfortable for you; ensure that both feet clear the ground but this is not in tended to be a maximum effort hop. Begin. Modified Trunk Stability Push-up Lay on your stomach with your hands positioned shoulder width apart with the thumbs in line knees and elbows off of the ground. Maintain a rigid torso; raise yourself as one unit, with no lag in the low back, into a push-up position. 10(p38) Modified Anterior Reach Reach as far as possible with the reaching limb along the reaching line; lightly touch the line with the toes only of the reaching foot without shifting weight to or coming to rest on this foot of the reaching limb; and then return the reaching limb to the beginning position in the center reassuming a bilateral stance. 8(p340) Modified Hip Abduction Please keep your knee straight and raise your top thigh and leg towards the ceiling, keeping them in line with your body, and try not to let your pelvis tip forwards or backwards. 11(p650) Figure 1 The standard script of instructions read by the same examiner for each event in the RTD evaluation. RELIABILITY OF A NOVEL RETURN TO DUTY SCREENING TOOL FOR MILITARY CLINICIANS


October December 2015 17 Task Grading Criteria Maximum Score Question Regarding Perceived Risk of Injury 2 =No concern for injury 1 =Mild to moderate concern for injury 0 2 Deep Squat Test 3 =All of the following checkpoints are met: upper torso is parallel with tibia or toward vertical, femur is below horizontal, knees are aligned over feet, and the PVC pipe is aligned over feet 10(p18) 2 =Limitation in the upper torso OR lower extremity only 1 =Limitation in the upper torso AND lower extremity 0 =Any pain associated with the movement 3 Forward Step Down in Low Lighting 2 =No deviation of either lower extremity into the frontal plane during movement 1 =Any deviation of either lower extremity into the frontal plane during movement 0 =Any pain associated with the movement 2 Feagin Hop Test 2 =All of the following checkpoints are met: no deviation of either lower extremity into the frontal plane during take-off or landing, no obvious lateral pelvic rotation or compensatory spine motion noted, symmetrical and quiet landing sound heard, makes initial landing contact using the balls of the feet, and no pain noted in the lower back or either lower extremity during testing 1 =No pain noted in the lower back or either lower extremity during testing and at least one additional checkpoint above is not met 0 =Any pain noted in the lower back or either lower extremity 2 Trunk Stability Push-Up Test 2 =Performs 1 repetition to standard 1 =Unable to perform 1 repetition to standard 0 =Any pain associated with the movement 2 Anterior Reach Test 3 =Less than 4 cm difference side-to-side 2 = 4 cm to less than 6 cm difference side-to-side 1 = 6 cm or greater difference side-to-side 0 =Any pain associated with the movement 3 Hip Abduction Test 2 =No deviation from the frontal plane during active hip abduction bilaterally 1 =Any deviation from the frontal plane during active hip abduction on either side 0 =Any pain associated with the movement 2 Total Score (Range: 0-16) 16 Figure 2. Grading criteria for the return to duty screening tool.


18 scored 2 points much more frequently than they scored 3 points. 7 By using a board under the heels for the en likely that participants with a lower risk of injury will be able to score 3 points. It decreases the amount of ankle bility requirements in the upper and lower body. 20 The participant was instructed to place his/her heels on the board, place feet shoulder-width apart with toes pointed forward, and hold the PVC pipe with both hands overhead with their elbows at a 90 degree angle. After pushing the PVC pipe directly overhead, they descended into a squat deep enough for their thighs to break paral lel, and held it for a count of one before returning to the starting position. 10(p18) The graders scored the participant by viewing them once in the frontal plane and once in the sagittal plane. Forward Step Down in Low Lighting The forward step down was designed with the intention of predicting participants risk of injury when perform ing tasks in low lighting. The rationale behind the exer cise is that military service members are often required to perform occupational activities in environments with low lighting and uneven terrain. Research that examined parachute and air assault jumps in a military environ ment concluded that jumping in low light or jumping with blindfolds increased factors associated with injury. 21,22 The forward step down in low lighting simulates hold ing a weapon while stepping down from an obstacle. This was performed using an 8-inch step, two 12-pound hardcover books, and a penlight as the only illumina tion source in the room. The participant was told to step then with the left side, while an investigator directed a penlight at the back of their legs for grading purposes. asked to remove it before starting the task to limit inten Modified Feagin Hop Test Single limb tests such as the triple hop, single leg hop, and reliably measure function following anterior cruci ate ligament reconstruction. 23-25 The Feagin hop test is an assessment of low impact ballistic movement capabil ity that was introduced to clinicians by COL (Ret) John Feagin, a noted orthopedist, as a simple clinical assess ment. Although the test has not yet been reported or vali dated in the literature, variations of the Feagin hop test and other hopping tests have been shown to be reliable methods for identifying functional ankle instability. 26,27 Before performing the test, the participant was instruct ed to hop up and down 2 times on both feet at a com fortable height. Next, the participant hopped twice on the previously uninjured lower extremity (if applicable). Finally, the participant hopped twice on the previously injured lower extremity (if applicable). If the participant did not have any previous lower extremity injury or his tory of bilateral lower extremity injury, the right side Modified Trunk Stability Push-Up The trunk stability push-up is used as part of the FMS. Lower muscular endurance as indicated by poor form and few repetitions of pushups is linked to higher injury rates. 28 In the current study, we altered the hand position to chin-level for both genders. It is assumed that most female military members can perform a regular push-up, so adjusting hand position due to gender was not neces sary for our participants. 6 The participant was instructed to lay on his/her stomach with hands positioned shoulder width apart, and thumbs neutral position with toes on the ground. The participant was told to extend knees and elbows off the ground and maintain a rigid torso as it was raised into a push-up position. 10(p38) The graders viewed the participants trunk stability push-up from the side. Modified Anterior Reach The anterior reach task is used as part of the lower quar ter Y-balance test. Side-to-side differences in the ante rior direction during the Y-balance test have been shown to be predictive of lower extremity injury. 29 Participants were required to remove shoes and socks for the event. A standard clinical measuring tape was of their toes at the zero mark of the measuring tape, and reached forward along the length of the tape with their opposite foot. The participant was required to maintain their balance throughout the task in order for the trial to count. 8 He/she performed three practice trials on each leg, and then performed 3 graded trials on each leg, Modified Hip Abduction Hip abductor weakness has been linked to ankle inju ries, iliotibial band syndrome, and low back pain. 11,30,31 The hip abduction test described by Nelson-Wong et al 11 ranged from 0 to 3 points and was determined by de grees of frontal plane motion, with zero being no loss of frontal plane motion and 3 points being severe loss of frontal plane motion. The grading criterion for this task RELIABILITY OF A NOVEL RETURN TO DUTY SCREENING TOOL FOR MILITARY CLINICIANS


October December 2015 19 Partici pants were given one point if they had any frontal plane deviations, and no points if they had any pain. Participants were in a side-lying position on the plinth instructed to put their bottom arm under their head, and top arm across their stomach or chest without using ei ther arm to brace themselves against the plinth. The par ticipant raised their top thigh and leg toward the ceiling, attempting to keep it in line with the body and keep the pelvis stable. The participant performed the test on the right side followed by the left. FOLLOWUP SCREENING Following completion of the RTD screening tool, partic ipants were asked to schedule a follow-up appointment within 3-7 (mean=6.17) days to repeat the test protocol. Graders did not give participants feedback regarding movement patterns until after the second testing session. STATISTICAL ANALYSIS Both test-retest and interrater reliability were estimated retest reliability of the overall screening tool between initial evaluation and follow-up evaluation was calcu lated using ICC (2,1) and 95% CIs. Interrater reliabil ity of 2 different raters simultaneously evaluating the performance of each individual at baseline was calcu lated using ICC (2,1). Test-retest and interrater reliabil ity of each individual task was calculated using kappa assess the internal consistency of the screening tool. RESULTS Composite Scores For the primary rater, the mean score was 11.262.35 second trial session. For the secondary rater, the mean 12.611.73 on the second session. Paired t tests revealed secondary rater only, with P values of .058 and .041 re spectively. The interrater reliability (ICC 2,1 (95% CI)) for 0.88 (0.78, 0.94). The test-retest reliability (ICC 3,1 (95% (0.21, 0.79). The standard error of the measurement for the composite score was 0.84 and 1.25 for interrater and test-retest reliability respectively. The minimum detect level was 3.46. As shown in Table 1, there were no sig scores ( P <.05). Individual Events Reliability estimates of individual events are listed in Table 2. Interrater reliability was highest for the anterior reach and the perceived risk events. The next highest values of interrater reliability were for the deep squat, sta bility push-up, and hop test. Systematic bias of the raters across each event was not statistically analyzed, but a graphi cal depiction of the average score given by each rater per event, shown in Figure 3, showed no consistent pattern. The test-retest reliability was highest for the perceived risk question and the stabil analysis was done to look at the internal Table 1 Composite Score for Each Rater by Trial and Gender of Subjects. Primary Rater (Trial 1 ) Primary Rater (Trial 2 ) Secondary Rater (Trial 1 ) Secondary Rater (Trial 2 ) Male mean (SD) Female mean (SD) Male mean (SD) Female mean (SD) Male mean (SD) Female mean (SD) Male mean (SD) Female mean (SD) Composite Score 11 27 ( 2 27 ) 11 58 ( 3 00 ) 12 93 ( 1 38 ) 12 11 ( 2 15 ) 11 45 ( 2 22 ) 10 91 ( 2 64 ) 12 57 ( 1 55 ) 12 22 ( 1 39 ) Note: The t -test revealed no significant differences ( P <. 05 ) between male and female subjects. Trial 1 Event Score Means Anterior Reach Hop Test Perceived Risk Deep Squat Step Down Stability Push-up Hip 2.0 2.5 0 1.5 1 0.5 Secondary Rater Primary Rater


20 consistency of all 7 items, detailed in Table 3. Inter-item correlations revealed the highest correlations between the deep squat and the hop test, as well as the hip abduc tion and the hop test. There were little to no correlations between the deep squat and anterior reach, hip-abduc tion and the step-down test, or the stability push-up with the step-down/hop test. Furthermore, the perceived risk question had no correlation with any event except ante rior reach. CO MM ENT The purpose of the current study was to present and assess the reliability of a novel, gender-neutral, mili training, equipment, and time. Results indicate that the composite RTD screening tool is fairly reliable when used by novice examiners, both across different raters and across different occasions. Reliability of individual events varied widely and ranged from excellent to no better than chance. Reliability of Composite Scores Interrater reliability, assessed between the 2 raters on entry-level clinicians can be trained on this tool and consistently grade individuals. Furthermore, there was posite scores for this screening tool, indicating that it is gender-neutral. Graders are only required to learn one set of grading criteria that can be applied to male and female participants. The test-retest reliability was substantially lower than in terrater reliability, indicating only fair reliability. Closer inspection of composite score means revealed higher composite scores for both grader 1 and 2 on trial session two, which the authors at least partially attribute to a learning or training effect. This tool demonstrated low er test-retest reliability than the Functional Movement Screen which ranged from ICC=0.81 to 0.91. 32 While the reason for this in unknown, it could be that many of the events of the RTD screening tool are easier to perform than those of the FMS, which may allow for a small degree of improved performance during a second testing session. Test-retest reliability of the composite scores also could have been adversely affected by poor reliability of some of the individual events. Reliability of Individual Events The hip abduction test showed the lowest interrater re liability and also had poor test-retest reliability. This supports previous research that this task is not reliable from future screening tools. 33 All other individual items showed moderate to good interrater reliability, again sup porting the conclusion that the items included can be ac curately assessed between 2 entry-level clinicians. This also adds support to previous studies, which have shown good interrater reliability among novice clinicians for the deep squat and the trunk stability push-up. 34-36 Hip abduction, the anterior reach, the step down, and the hop test all showed poor test-retest reliability. This may Table 2 Mean Score by Gender of Subjects with Interrater and Test-retest Reliability for Individual Events. Male mean (SD) Female mean (SD) Interrater (CI) % Agreement Test-retest (CI) % Agreement Anterior Reach 2.50 (1.06) 2.25 (1.22) 0.93 (0.76,1.00) 97.1 -0.03 (-0.19, 0.17) 56.5 Deep Squat 2.00 (0.98) 2.33 (0.79) 0.57 (0.32,0.78) 70.6 0.51 (0.16,0.79) 69.6 Stability Push-up 1.68 (0.57) 1.25 (0.62) 0.67 (0.39, 0.89) 82.4 0.61 (0.24,0.90) 82.6 Hip Abduction 1.09 (0.53) 1.42 (0.51) 0.26 (-0.11,0.59) 70.6 -0.03 (-0.37,0.40) 56.5 Step Down 1.82 (0.39) 2.00 (0.00) 0.52 (-0.05,1.00) 91.2 0.45 (-0.07,1.0) 91.3 Hop Test 1.09 (0.61) 1.33 (0.65) 0.65 (0.37,0.85) 79.4 0.40 (0.03,0.74) 69.6 Perceived Risk 1.23 (0.53) 1.08 (0.51) 1.00 (1.00,1.00) 100.0 0.91 (0.70,1.00) 95.7 Note: The maximum score for the anterior reach and deep squat is 3 ; for all other events the maximum score is 2 Table 3 Inter-item Correlation Matrix with Cronbachs Anterior Reach Deep Squat Stability Push-up Hip Abduction Step Down Hop Test Perceived Risk Cronbachs (if item deleted) Anterior Reach 1.00 0.43 Deep Squat 0.04 1.00 0.47 Stability Push-up 0.12 0.16 1.00 0.52 Hip Abduction 0.16 0.20 -0.16 1.00 0.47 Step Down 0.31 -0.16 0.02 -0.03 1.00 0.50 Hop Test 0.33 0.44 0.07 0.43 0.25 1.00 0.33 Perceived Risk 0.24 0.08 -0.02 0.08 -0.05 0.09 1.00 0.49 RELIABILITY OF A NOVEL RETURN TO DUTY SCREENING TOOL FOR MILITARY CLINICIANS


October December 2015 21 have been due to a learning effect. In the future, more practice trials should be allowed in order to establish a more accurate baseline. However, a restricted score range and prevalence bias may have also affected some of the items. For example, the step down test was scored on a scale from 0-2, but all participants scored either a 1 or a 2. Therefore, despite 91.3% agreement between trial 1 and trial 2, the reliability was still poor. It is in teresting to note that hip abduction, step down, and hop tests (all of which had poor test-retest reliability) were also all scored on a 0-2 point scale. These tests may not differentiate between participants very well, making the information they provide less meaningful. In the future, including more items that have a wider range of vari ability may help to better screen participants. It also may the items to have such a large effect on the test-retest reliability. Internal Consistency internal consistency of the screening tool. Unlike a ques tionnaire that aims to measure one construct, the RTD of tasks, each of which measures different aspects of are desired as this indicates that 2 tests are measuring different aspects of the same construct. The items with the highest inter-item correlation were the hop test and the deep squat, and the hop test and the hip abduction. This may suggest that these items were essentially look should be excluded from a future screening tool. Based a minimum, the hip abduction test be excluded from fu ture tools due to low test-retest reliability and high cor relation with items that were more reliable. The other items had lower correlations, indicating that most of the items were indeed assessing different components of functional movement. LI M ITATIONS AND FUTURE RESEARCH Perhaps the largest limitation of the current study was tween testing sessions. This might have been minimized session. Additionally the grading scale used for this tool was purposefully inconsistent across events so that tests with stronger evidence were weighted more heavily than those with less evidence to support their use. A couple of events exhibited very poor reliability, which likely adversely affected the reliability of the composite tool. Lastly, having a restricted range for some items (scores 0-2) could be perceived as a limitation of the study. ments in the RTD screening tool. Future research should seek to analyze the predictive validity of an appropri and potentially its convergent validity with the relative industry standard such as the FMS. This study serves as a starting point for developing a return to duty screening tool that can be reliably performed by any military clini CONCLUSION This novel RTD screening tool showed good overall in terrater reliability, suggesting that entry level clinicians trained on the grading requirements are able to reliably administer the tool. In addition, the screen showed gen males and females. In the future, the tool should be adapted to improve test-retest reliability. REFERENCES 1. Bernton H. Weight of war: gear that protects troops also injures them. Seattle Times February 12, 2011. Available at: world/2014209155_weightofwar06.html. Accessed January 5, 2015. 2. Sell TC, Pederson JJ, Abt JP, et al. The addition of body armor diminishes dynamic postural stability in military soldiers. Mil Med 2013;178(1):76-81. 3. Armed Forces Health Surveillance Center. Ambula tory visits among members of the active component, U.S. Armed Forces, 2011. MSMR 2012;19(4):17-22; discussion 22. 4. Armed Forces Health Surveillance Center. Ambula tory visits among members of the active component, U.S. Armed Forces, 2013. MSMR 2014;21(4):15-20; discussion 20. 5. tional training program bridges rehabilitation and return to duty. J Spec Oper Med 2009;9(2):29-48. 6. Kiesel K, Plisky PJ, Voight ML. Can serious injury in professional football be predicted by a preseason functional movement screen? N Am J of Sports Phys Ther 2007;2(3):147-158. 7. OConnor FG, Deuster PA, Davis J, Pappas CG, Knapik JJ. Functional movement screening: pre Med Sci Sports Exerc 2011;43(12):2224-2230. 8. cursion Balance Test to assess dynamic posturalinjury: a literature and systematic review. J Athl Train 2012;47(3):339-357.


22 9. KB, Underwood FB. Field-expedient screening and injury risk algorithm categories as predictors predict lower extremity injury. Scand J Med Sci Sports 2013;23(4):e225-e232. Available at: http:// Accessed Janu ary 3, 2015. 10. Cook G, Burton L, Fields K. The Functional Move ment Screen and Exercise Progressions Manual 2nd ed. Chatham, VA: Functional Movement Sys tems; 2009. 11. ment of active hip abduction as a screening test for identifying occupational low back pain. J Or thop Sports Phys Ther 2009;39(9):649-657. Avail able at: jospt.2009.3093. Accessed January 3, 2015. 12. Wiese-Bjornstal DM. Psychology and socioculture affect injury risk, response, and recovery in highintensity athletes: a consensus statement. Scand J Med Sci Sports 2010;20(suppl 2):103-111. 13. Taylor J. Predicting athletic performance with selffunction of motor and physiological requirements in six sports. J Pers 1987;55(1):139-153. 14. nation of hardiness throughout the sport-injury process: a qualitative follow-up study. Br J Health Psychol 2012;17(4):872-893. 15. Bauman J. Returning to play: the mind does matter. Clin J Sport Med 2005;15(6):432-435. 16. Ross MD. The relationship between functional lev els and fear-avoidance beliefs following anterior cruciate ligament reconstruction. J Orthop Trau matol 2010;11(4):237-243. 17. Butler RJ, Contreras M, Burton LC, Plisky PJ, Work 2013;46(1):11-17. 18. Peate WF, Bates G, Lunda K, Francis S, Bel lamy K. Core strength: a new model for injury prediction and prevention. J Occup Med Toxicol 2007;2(1):3-12. 19. Kiesel K, Plisky P, Butler R. Functional move ment test scores improve following a standard ized off-season intervention program in profes sional football players. Scand J Med Sci Sports 2011;21(2):287-292. 20. Butler RJ, Plisky PJ, Southers C, Scoma C, Kiesel KB. Biomechanical analysis of the different classi squat test. Sports Biomech 2010;9(4):270-279. 21. Chu Y, Sell TC, Abt JP, et al. Air assault soldiers demonstrate more dangerous landing biome chanics when visual input is removed. Mil Med 2012;177(1):41-47. 22. Aviat Space Environ Med 1985;56(6):564-567. 23. legged hop tests as predictors of self-reported knee function in nonoperatively treated individuals with anterior cruciate ligament injury. Am J Sports Med 2011;39(11):2347-2354. 24. Myer GD, Schmitt LC, Brent JL, et al. Utilization tion. J Orthop Sports Phys Ther 2011;41(6):377-387. Available at: jospt.2011.3547. Accessed January 3, 2015. 25. Reid A, Birmingham TB, Stratford PW, Alcock valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Phys Ther 2007;87(3):337-349. Available at: http://pt Ac cessed January 3, 2015. 26. The ability of 4 single-limb hopping tests to detect functional ankle instability. J Orthop Sports Phys Ther 2009;39(11):799-806. 27. Sharma N, Sharma A, Singh Sandhu J. Func tional performance testing in athletes with func tional ankle instability. Asian J Sports Med 2011;2(4):249-258. 28. Knapik JJ, Sharp MA, Canham-Chervak M, Hauret K, Patton JF, Jones BH. Risk factors for training-related injuries among men and women in basic combat training. Med Sci Sports Exerc 2001;33(6):946-954. 29. Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. extremity injury in high school basketball players. J Orthop Sports Phys Ther 2006;36(12):911-919. 30. Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med 2000;10(3):169-175. 31. Friel K, McLean N, Myers C, Caceres M. Ipsilat eral hip abductor weakness after inversion ankle sprain. J Athl Train 2006;41(1):74-78. 32. Smith CA, Chimera NJ, Wright NJ, Warren M. Interrater and intrarater reliability of the func tional movement screen. J Strength Cond Res 2013;27(4):982-987. RELIABILITY OF A NOVEL RETURN TO DUTY SCREENING TOOL FOR MILITARY CLINICIANS


October December 2015 23 33. Rabin A, Shashua A, Pizem K, Dar G. The inter rater reliability of physical examination tests that may predict the outcome or suggest the need for lumbar stabilization exercises. J Orthop Sports Phys Ther 2013;43(2):83-90. 34. Frohm A, Heijne A, Kowalski J, Svensson P, Myklebust G. A nine-test screening battery for athletes: a reliability study. Scand J Med Sci Sports 2012;22(3):306-315. 35. Minick KI, Kiesel KB, Burton L, Taylor A, Plisky P, Butler RJ. Interrater reliability of the func tional movement screen. J Strength Cond Res 2010;24(2):479-486. 36. Teyhen DS, Shaffer SW, Lorenson CL, et al. The Functional Movement Screen: a reliability study. J Orthop Sports Phys er 2012;42(6):530-540. AUTHORS LTC Thelen is an Assistant Professor, US Army-Baylor University Doctoral Program in Physical Therapy, US Army Medical Department Center and School, Joint Base Fort Sam Houston, Texas. LTC Koppenhaver is an Associate Professor, US ArmyBaylor University Doctoral Program in Physical Therapy, US Army Medical Department Center and School, Joint Base Fort Sam Houston, Texas. MAJ Hoppes is an Assistant Professor, US Army-Baylor University Doctoral Program in Physical Therapy, US Army Medical Department Center and School, Joint Base Fort Sam Houston, Texas. 1LT Shutt, 1LT Musen, 1LT Davidson, and Capt Wil liams are Physical Therapy Interns, US Army-Baylor University Doctoral Program in Physical Therapy, US Army Medical Department Center and School, Joint Base Fort Sam Houston, Texas.


24 Achieving adequate follow-up in clinical trials is essen ized to the population of interest and more accurately inform decision-making. Studies with low follow-up rates potentially confound interpretation by increasing the chance of attrition bias. 1 Low follow-up rates can further threaten external validity by impairing the abil based on their data, 1 and follow-up rates that exceed 95% minimize the potential for attrition bias to exist, whereas follow-up rates lower than 80% pose a threat to external validity. 2,3 can bias a studys results if few individuals have the outcome of interest. Collectively, these issues make it imperative for researchers to conduct clinical trials that maximize retention. Postal surveys and face-to-face interviews have long been used as a means to secure follow-up, and while more expensive than web-based surveys, they tend to yield higher response rates. 4 Due to the increasing ap plication of technology in clinical research, web-based follow-up has become more popular in recent years, and Incremental Effects of Telephone Call Center and Healthcare Utilization Database Use to Improve Follow-up Rate in the Prevention of Low Back Pain in the Military Trial John D. Childs, PhD, MBA, PT CPT Julie A. Bowman, SP, USA Samuel S. Wu, PhD Capt Aaron M. Butler, BSC, USAF CPT Robert L. Andrade, SP, USA COL Deydre S. Teyhen, SP, USA AB STRACT Background: Studies that have relied exclusively on web-based surveys to secure follow-up have yielded in adequate follow-up rates, resulting in the need to explore whether supplementing with other methods results in incremental improvements. The primary purpose of this study was to determine the effectiveness of each follow up strategy that was used to collect the follow up data in our ongoing Prevention of Low Back Pain in the Military (POLM) trial. Methods: This study represents a secondary analysis of the POLM trial. Twenty companies of Soldiers (N=4,325) were cluster randomized to complete one of four exercise programs. Since web-based response rates were lower than anticipated, a telephone call center was established to contact Soldiers who had not responded to the web-based survey. A military healthcare utilization database (M2) was also used to capture additional followsupplementing the primary web-based follow-up strategy in our ongoing POLM trial and determine whether differences existed in demographic characteristics, pain intensity, and low back pain incidence based on followup strategy. Results: Of the 4,325 Soldiers who were enrolled, 632 (14.6%) subjects completed the monthly web-based survey only; 571 (13.2%) responded only to the telephone call; and 233 (5.4%) responded to both the webbased and telephone survey. Adding the telephone call center contributed 804 unique contributions to follow-up, increasing the overall follow-up to 33.2% (n=1,436) and resulting in a net 18.6% increase in follow-up rate. Querying the M2 database yielded follow-up data for an additional 2,788 Soldiers, increasing the follow-up rate by 64.5%. This rate, combined with the web-based and telephone strategies, resulted in an overall follow-up rate of 97.7%. Compared to the web-based survey, those who responded to the telephone call center tended to be younger, white, have a lower income, more likely to smoke, more likely to exercise regularly, and less likely to have low back pain (all with P <.05). Conclusions: supplementing a web-based survey with a telephone call center to secure additional follow-up.


October December 2015 25 although potentially effective and less expensive than more traditional follow-up strategies, it is not without disadvantages. 4,5 For example, its effectiveness depends on having accurate email addresses to reach study par ticipants and insuring emails are not delivered to spam folders. Web-based surveys also require that subjects have access to computers and be comfortable with tech nology, without which response rates are likely to be suboptimal. 4 Finally, the accuracy of subjects responses has been shown to be lower with web-based follow-up methods compared to that received when subjects com municate directly with study staff. Any single method to secure follow-up is likely to be in ferior to follow-up approaches that use multiple followup methods. 6 Therefore, it seems logical to supplement follow-up in clinical trials with other available methods. For example, it is possible that supplementing follow-up further with a telephone call center could be a useful adjunct to further enhance follow-up. However, scant evidence is available to inform the extent to which each method contributes to overall follow-up rates in clini cal trials. We recently completed the Prevention of Low Back Pain in the Military (POLM) trial, in which we used a novel web-based surveillance system to track subject response rate and record incidence and sever ity of low back pain (LBP) episodes among a group of geographically dispersed Soldiers in the US Army over a 2-year period. 7,8 Due to lower than expected followup rates, 9 we incorporated a telephone call center and healthcare utilization database to enhance follow-up among Soldiers who did not respond to the original web-based survey, providing a unique opportunity to our initially proposed web-based follow-up. Therefore, the primary purpose of this study was to determine if adding a telephone call center and healthcare utilization database to a web-based response strategy in our ongo ing POLM trial increased overall follow-up. Secondly, we wanted to determine if differences in follow-up strat egy existed based on demographic characteristics, pain intensity, and the incidence of LBP. METHODS This study represents a secondary analysis of the Prevention of Lower Back Pain in the Military trial (NCT00373009) that has been registered at http://clini 7 Soldiers (N=4,325) with no previous his tory of LBP were recruited from a military training set ting from 2007 to 2008 and randomly assigned to receive traditional lumbar exercise, traditional lumbar exercise with psychosocial education, core stabilization exercise, or core stabilization with psychosocial education over a 12-week training period. The primary outcome for the trial was incidence of LBP resulting in the seeking of healthcare. At baseline, Soldiers completed standard de mographic information (ie, age, sex, past medical his tory, etc) and factors related to military status (ie, current duty status [active duty, reservist, etc] and current lo cation [within the United States or overseas]). Detailed methods and previous results from the POLM trial have been thoroughly described in previous reports. 8,10 The institutional review boards at the Brooke Army Medi cal Center (#C.2006.066) and the University of Florida (#130-2006) granted approval for this project. All sub jects provided written, informed consent prior to their participation. At the end of the initial 12 weeks of physical training, Soldiers were trained in a computer lab on the use of the web-based surveillance system to complete the monthly follow-up surveys. The purpose of these surveys was to record the incidence and severity of subsequent LBP episodes in the previous calendar month. Access to the web-based surveillance system was prompted by an dress on the 1st of each month. The web-based survey was initiated with an email prompting the Soldier to visit website was accessed, Soldiers were asked, Have you had any back pain in the past 30 days? A no answer ended the survey and Soldiers were thanked for their participation. A yes answer prompted the Soldiers to complete an additional set of 46 items about the back pain episode including duration, impact on work ac tivities, whether healthcare was sought, and response to standard LBP-related questionnaires. 8,10 Soldiers were provided their login credentials during the initial train ing session, at the end of the 12-week trial, and in the monthly email reminders. If a Soldier did not respond to of the month, and again on the 7th of the month if the Soldier still had not responded. Subjects were encour aged to complete monthly web-based surveys sent via email for 2 years following completion of the assigned intervention. A telephone call center was established to contact Sol diers who had not responded to 3 monthly web-based were comprised of graduate student personnel who at tended a 45-minute training session and were provided a call center instructional pamphlet. Soldiers were que ried as to whether they had current LBP or had experi enced LBP since having completed the physical train ing component of the study. A no answer ended the survey and Soldiers were thanked for their participa tion. A yes answer prompted the Soldiers to answer


26 an additional 12 questions about the back pain episode, including duration, impact on work activities, whether healthcare was sought, and response to standard LBPrelated questionnaires. 8,10 Call center personnel used a personal computer, headset, and commercial internet telephone (Skype) to make follow-up calls. Soldiers who had not responded to 3 monthly web-based surveys were called up to 3 times over a 2-week period to elicit follow-up, after which the subject was no longer con tacted and considered lost to follow-up. During the course of the trial, we found that response rates to the web-based and telephone call center surveys were suboptimal, thus it became incumbent to identify alternative strategies to procure additional follow-up. Therefore, in addition to the web-based and telephone call center surveys, the Military Health System (MHS) Management Analysis and Reporting Tool (M2 data base) was used to determine LBP incidence because of its comprehensive nature in capturing healthcare utilization from the direct care system (care provided in military treatment facilities), network care (care pro vided at civilian facilities), and deployed regions such as Iraq or Afghanistan. The M2 database was searched Diseases (ICD) codes for Soldiers enrolled in the POLM 11-15 The primary dependent variable was whether a Soldier responded to a follow-up strategy. Independent vari ables were the 4 levels of follow-up strategy: web-based only (sent monthly to Soldiers email addresses), tele phone only (contacted by call center personnel after no response from 3 monthly emails), health utilization database only (used for those not contacted by email or phone), or both web-based and telephone strategies (Soldiers who initially answered web-based surveys, but eventually stopped responding to web based and were contacted by the call center). Descriptive statistics were used to determine the number (percentage of total co hort) of Soldiers and their different respective follow-up strategies (Figure 1). Descriptive statistics were com pared between the responders and nonresponders using two sample t tests or 2 tests, as appropriate. Pairwise comparisons were performed to determine differences in baseline demographic characteristics, pain intensity, at .05 a priori, and all statistical analyses were performed using SAS version 9 (SAS Institute, Inc, Cary, NC). RESULTS AND CO MM ENT Of the 4,325 enrolled Soldiers, 608 (14.1%) subjects completed the monthly web-based survey only; 571 (13.2%) responded only to the telephone call; and 257 (5.9%) responded to both the web-based and telephone survey (Figures 1 and 2). The web-based response rate prior to implementation of the telephone call center was 20.0% (n=865). Adding the telephone call center con tributed 828 unique contributions to follow-up, increas ing the overall follow-up to 33.2% (n=1,436) and result ing in a net 13.2% increase in follow-up rate. Querying the M2 database yielded follow-up data for an additional 2,788 Soldiers, increasing the follow-up rate by 64.5%. This rate, combined with the web-based and telephone strategies, resulted in an overall follow-up rate of 97.7%. Follow-up data from 101 subjects were not available for any method of follow-up (Figures 1 and 2). Table 1 shows the comparison between Soldiers who re sponded to the monthly web-based survey only (n=608), those who responded only to the telephone call center survey (n=571), and those who responded to both sur veys (n=257). Table 2 shows the comparison between Soldiers who responded to the monthly web-based sur vey (n=865, including those responded to both surveys) and those who responded only to the telephone call center survey (n=571). Among the 571 Soldiers who re sponded only to the telephone call survey, 203 (35.6%) reported having had LBP. Compared to the web-based survey, those who responded to the telephone call center tended to be younger, white, have a lower income, more likely to smoke, more likely to exercise regularly, and Figure 1 Venn diagram illustrating the intersection of total POLM subjects (n = 4,325 ) based on follow-up strategy. Note that the total count for each circle (N) equals the sum of the 4 distinct components (n). n=101 n=583 n=25 n=28 n=2,788 n=248 n=543 Web-based Survey (N=865) M2 Database (N=4,162) Phone Survey (N=828) n=9 INCREMENTAL EFFECTS OF TELEPHONE CALL CENTER AND HEALTHCARE UTILIZATION DATABASE USE TO IMPROVE FOLLOW-UP RATE IN THE PREVENTION OF LOW BACK PAIN IN THE MILITARY TRIAL


October December 2015 27 less likely to have LBP (all with P <.05, Table 2). Among the 257 Soldiers who responded to both surveys (Table 1), 156 (60.7%) reported having LBP. Of those 156 Sol diers, 70 reported having LBP in both surveys; 30 re sponded as having LBP in the telephone call sweep but not the web-based survey; and 56 subjects responded as having LBP in the web-based survey but not the tele phone call sweep. When designing clinical trials, researchers must make important decisions about which follow-up methodolo gies to use, each of which has its own inherent strengths and weaknesses with respect to cost, ease of use, and success rate. It is also important to consider the known bias that exists in the characteristics of individuals like ly to respond to web-based surveys. For example, in a previous secondary analysis from the POLM trial, 7 re sponders to the web-based survey were more likely to be older, white, have higher levels of education and income, are less likely to smoke, and have lower body mass in dex compared to nonresponders. Subjects who received individualized attention in the POLM trial based on having received detailed physical and ultrasound imag ing examinations were also more likely to respond to the web-based survey. We found similar results when com paring differences in the characteristics of Soldiers who responded to the web-based survey versus the telephone call center. In particular, Soldiers who were stationed overseas were more likely to respond to the web-based survey compared to the telephone call center, presum phone given time zone differences and lack of telephone accessibility. The lessons learned in conducting the POLM trial gave medical care, etc). For example, both the web-based sur vey and telephone call center queried Soldiers about their history of LBP via self-report. Although the identical question was presented, Soldiers might report LBP inci dence and severity differently depending on whether the question was presented via the web-based survey versus orally via the telephone call center. Respondents to the web-based survey were in fact more likely to report LBP and higher levels of pain compared to respondents to the telephone call center. It may be that web-based surveys offer more perceived anonymity and respondents may have more time to contemplate their health history in a more relaxed setting in front of a computer, compared to answering the same questions asked by telephone call center personnel. In contrast, the data available within the M2 healthcare on Soldiers having sought healthcare for LBP, which is meaningful since the validity of self-report measures for determining LBP has been questioned for military populations. 16 Health policy experts also contend that indicating increasing rates of healthcare utilization for LBP 14,17 with trends of greatly increasing cost, but of no 15,18 One advantage of healthcare utilization databases is that follow-up rates are not dependent on voluntary participant response, Figure 2 Flow diagram for total subjects and responders in POLM trial based on follow-up strategy.


28 since their data is de facto included based on their having accessed the healthcare system as part of rou tine clinical care for reasons not associated directly with their par ticipation in research. However, a comprehensive healthcare claims database will not always be read ily accessible and may not contain of interest to researchers, such as to the condition of interest. CONCLUSION The results of this study can in form the design of future clinical supplementing a web-based survey with a telephone call center and emphasizing the value of compre hensive healthcare utilization da tabases. This study also highlights the importance of understanding that response rates may vary based of incidences of LBP. A few limi tations from these data should be noted. For example, all Soldiers were either active duty or reserve not be generalizable to a civilian population. The results are also only applicable to outcomes that can be captured via self-report, as opposed to outcomes that require face-to-face contact (ie, physical examination, performance-based tests, etc). ACKNOWLEDG M ENTS This study was funded by the Con gressionally Directed Peer Re viewed Medical Research Program (#W81XWH-06-1-0564). The authors thank Christopher Barnes, ation and management of the website and database; and Donna Cunning ham, Jessica Dugan, and Alison Lin berg for their administrative support and assistance conducting the day-today operations of the clinical trial. Table 1 Comparison of baseline characteristics and pain intensity information among 3 groups based on 2 surveys (those who followed-up). Variable Overall [ N=1,436 ] Monthly Web-based Survey Only [ n=608 ] Phone Sweep Only [ n=571 ] Web-based Survey and Phone Sweep [ n=257 ] P value Average Age mean (yrs)SD 22.24.4 23.04.8 21.53.8 22.24.3) <.0001 Gender Female 416 182 (30.1%) 148 (26.0%) 86 (33.5%) .071 Male 1,015 423 (69.9%) 421 (74.0%) 171 (66.5%) Race Black 120 54 (8.9%) 44 (7.7%) 22 (8.6%) .042 Hispanic 118 58 (9.6%) 42 (7.4%) 18 (7.0%) White 1,094 438 (72.3%) 456 (80.0%) 200 (77.8%) Other 101 56 (9.2%) 28 (4.9%) 17 (6.6%) Education High school or less 529 216 (35.5%) 226 (39.6%) 87 (33.9%) .098 Some college 723 307 (50.5%) 287 (50.3%) 129 (50.2%) College graduate or beyond 184 85 (14.0%) 58 (10.2%) 41 (16.0%) Annual Income < $20,000 708 271 (44.6%) 309 (54.4%) 128 (49.8%) .004 $20,000 or more 724 336 (55.4%) 259 (45.6%) 129 (50.2%) Military Status Active duty 683 318 (52.3%) 267 (46.8%) 98 (38.1%) .001 Reserve 751 290 (47.7%) 302 (52.9%) 159 (61.9%) Other 2 0 2 (0.4%) 0 Length of Service < 5 months 818 352 (57.9%) 338 (59.2%) 128 (49.8%) .046 5 months to 1 year 355 145 (23.8%) 128 (22.4%) 82 (31.9%) > 1 year 263 111 (18.3%) 105 (18.4%) 47 (18.3%) Depression (BDI) 5.96.0 6.16.6 5.65.7 5.85.2 .378 Fear of Pain (FPQ) 18.15.6 18.3.8 17.95.6 18.15.4 .521 Back Beliefs (BBQ) 43.97.1 44.17.5 43.76.6 43.87.5 .679 Anxiety (STAI) 35.28.9 35.49.4 35.18.4 35.08.8 .738 Physical Health Status (PCS Total) 53.65.0 53.55.2 53.74.9 53.65.1 .693 Mental Health Status (MCS Total) 49.87.9 49.48.2 50.17.6 49.97.9 .273 Smoked prior to joining Army Yes 394 (27.4%) 163 (26.8%) 174 (30.5%) 57 (22.2%) .042 No 1,042 (72.6%) 445 (73.2%) 397 (69.5%) 200 (77.8%) Exercise Routinely Yes 798 312 (51.3%) 341 (59.7%) 145 (56.4%) .014 No 638 296 (48.7%) 230 (40.3%) 112 (43.6%) Low Back Pain (LBP) Yes 653 294 (48.4%) 203 (35.6%) 156 (60.7%) <.0001 No 783 314 (51.6%) 368 (64.4%) 101 (39.3%) LBP Incidence Rate 234 100 (16.4%) 94 (16.5%) 40 (15.6%) .941 Body Mass Index 24.73.1 24.73.1 24.73.0 24.63.4 .819 Physical Examination Yes 141 (9.8%) 73 (12.0%) 48 (8.4%) 20 (7.8%) .056 No 1,295 (90.2%) 535 (88.0%) 523 (91.6%) 237 (92.2%) Values in parentheses indicate %n. BDI indicates Beck Depression Inventory; FPQ, Fear of Pain Questionnaire; BBQ, Back Beliefs Question naire; STAI, State-Trait Anxiety Index; PCS, Physical Component Summary of the SF12 Health Survey; and MCS, Mental Component Summary of the SF12 Health Survey. INCREMENTAL EFFECTS OF TELEPHONE CALL CENTER AND HEALTHCARE UTILIZATION DATABASE USE TO IMPROVE FOLLOW-UP RATE IN THE PREVENTION OF LOW BACK PAIN IN THE MILITARY TRIAL


October December 2015 29 We also acknowledge the support and assistance of vari ous students within the physical therapy programs at the University of Florida, US Army-Baylor University Doc toral Program in Physical Therapy, the University of Tex State University, the University of Colorado at Denver and Health Sciences Center, Texas State University, and the University of Puget Sound. REFERENCES 1. search. Contemp Clin Trials 2005;26(1):59-77. 2. Evidence Based Medicine: How to Practice and Teach EBM 3rd ed. London, UK: Churchill Livingstone; 2005. Table 2 Comparison of baseline characteristics and pain intensity information between Soldiers who responded to the monthly web-based survey and those who only responded in the phone sweep survey. Variable Monthly Web-based Survey Only [ n=865 ] Phone Sweep Only [n=571] P value Variable Monthly Web-based Survey Only [ n=865 ] Phone Sweep Only [n=571] P value Average Age mean (yrs)SD 22.84.7 21.33.8 <.0001 Exercise Routinely Yes 457 (52.8%) 341 (59.7%) .010 Gender No 408 (47.2%) 230 (40.3%) Male 594 (68.9%) 421 (74.0%) .038 Last APFT Score Female 268 (31.1%) 148 (26.0%) Below 150 2 (0.2%) 4 (0.7%) .016 Race 150-200 192 (22.2%) 96 (16.8%) Black 76 (8.8%) 44 (7.7%) .028 200-250 404 (46.8%) 260 (45.6%) Hispanic 76 (8.8%) 42 (7.4%) 250-300 243 (28.1%) 198 (34.7%) White 638 (73.9%) 456 (80.0%) Above 300 23 (2.7%) 12 (2.1%) Other 73 (8.5%) 28 (4.9%) Army Medical Profile Education Yes 169 (19.5%) 96 (16.8%) .193 High school or less 303 (35.0%) 226 (39.6%) .028 No 696 (80.5%) 475 (83.2%) Some college 436 (50.4%) 287 (50.3%) Physical/USI Examination College graduate or beyond 126 (14.6%) 58 (10.2%) Yes 93 (10.8%) 48 (8.4%) .056 No 772 (89.2%) 523 (91.6%) Annual Income Low Back Pain <$20,000 399 (46.2%) 309 (54.4%) .002 Yes 450 (52.0%) 203 (35.6%) <.0001 $20,000 or more 465 (53.8%) 259 (45.6%) No 415 (48.0%) 368 (64.4%) Military Status Pain Rating 2.92.3 2.12.0 <.0001 Active duty 416 (48.1%) 267 (46.8%) .200 Reserve 449 (51.9%) 302 (52.9%) Other 0 2 (0.4%) Length of Service < 5 months 480 (55.5%) 338 (59.2%) .238 5 months to 1 year 227 (26.2%) 128 (22.4%) > 1 year 158 (18.3%) 105 (18.4%) Depression (BDI) 5.96.0 6.16.6 .378 Fear of Pain (FPQ) 18.15.6 18.35.8 .521 Back Beliefs (BBQ) 43.97.1 44.17.5 .679 Anxiety (STAI) 35.28.9 35.49.4 .738 Physical Health Status (PCS Total) 53.65.0 53.55.2 .693 Mental Health Status (MCS Total) 49.87.9 49.48.2 .273 SF12 Total 103.1.7 103.98.1 .079 Smoked prior to joining Army Yes 220 (25.4%) 174 (30.5%) .036 No 645 (74.6%) 397 (69.5%) Values in parentheses indicate %n. BDI indicates Beck Depression Inventory; FPQ, Fear of Pain Questionnaire; BBQ, Back Beliefs Questionnaire; STAI, State-Trait Anxiety In dex; PCS, Physical Component Summary of the SF12 Health Survey; MCS, Mental Component Summary of the SF12 Health Survey; APFT, Army Physical Fitness Test; and USI, ultrasound imaging. The response number totals in the following sections of the table do not match the sample sizes (n) in the category col umns due to incomplete data provided by respondents. Duty Status Active Duty 30 (39.0%) 195 (35.1%) .602 Active National Guard and Re serve (AGR) 7 (9.1%) 43 (7.7%) Reservist/National Guard not cur rently activated 22 (28.6%) 178 (32%) Reservist/National Guard currently on active duty orders (not AGR) 9 (11.7%) 46 (8.3%) No longer in mili tary service 9 (11.7%) 94 (16.9%) Location United States 70 (90.9%) 544 (98.7%) <.0001 Overseas, not in combat pay area 2 (2.6%) 2 (0.4%) Overseas in com bat pay area 5 (6.5%) 5 (0.9%)


30 3. Fergusson D, Aaron SD, Guyatt G, Hebert P. Postrandomisation exclusions: the intention to treat principle and excluding patients from analysis. BMJ 2002;325(7365):652-654. 4. Shih T-H, Fan X. Comparing response rates in email and paper surveys: a meta-analysis. Educ Res Rev 2009;4(1):26-40. 5. Heerwegh D, Loosveldt G. Face-to-face versus web surveying in a high-internet-coverage popula tion differences in response quality. Public Opin Q 2008;72(5):836-846. 6. Cook C, Heath F, Thompson RL. A meta-analysis of response rates in webor internet-based surveys. Educ Psychol Meas 2000;60(6):821-836. 7. Childs JD, Teyhen DS, Van Wyngaarden JJ, et al. Predictors of web-based follow-up response in the prevention of low back pain in the military trial (POLM). BMC Musculoskelet Disord 2011;12:132. 8. George SZ, Childs JD, Teyhen DS, et al. Rationale, design, and protocol for the prevention of low back pain in the military (POLM) trial (NCT00373009). BMC Musculoskelet Disord 2007;8:92. 9. George SZ, Childs JD, Teyhen DS, et al. Brief psy chosocial education, not core stabilization, reduced incidence of low back pain: results from the pre vention of low back pain in the military (POLM) cluster randomized trial. BMC Med 2011;9:128. 10. George SZ. Prevention of low back pain in the mili tary cluster randomized trial: effects of brief psy chosocial education on total and low back pain-re lated health care costs. Spine J 2014;14(4):571-583. 11. Gellhorn AC, Chan L, Martin B, Friedly J. Man agement patterns in acute low back pain: the role of physical therapy. Spine 2012;37(9):775-782. 12. Fritz JM, Cleland JA, Brennan GP. Does adherence to the guideline recommendation for active treat ments improve the quality of care for patients with acute low back pain delivered by physical thera pists?. Med Care 2007;45(10):973-980. 13. Fritz JM, Childs JD, Wainner RS, Flynn TW. Pri mary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine 2012;37(25):2114-2121. 14. Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med 2009;169(3):251-258. 15. Deyo RA, Mirza SK, Turner JA, Martin BI. Over treating chronic back pain: time to back off?. J Am Board Fam Med 2009;22(1):62-68. 16. back pain. Spine 2009;34(9):978-983. 17. Deyo RA, Mirza SK, Martin BI. Back pain preva lence and visit rates. Spine 2006;31(23):2724-2727. 18. tures and health status among adults with back and neck problems. JAMA 2008;299(6):656-664. AUTHORS Dr Childs is Associate Professor, US Army-Baylor Uni versity Doctoral Program in Physical Therapy, Army Medical Department Center and School, Joint Base San Antonio-Fort Sam Houston, Texas. Dr Wu is Professor and Associate Chair, Department of Biostatistics, University of Florida, Gainesville, Florida. CPT Andrade is the Brigade Physical Therapist, 3rd Bri gade Combat Team, 82nd Airborne Division, Fort Bragg, North Carolina. MAJ Bonner is the Regimental Physical Therapist, 3rd Infantry Regiment (The Old Guard), Joint Base MeyerHenderson Hall, Arlington, Virginia. CPT Bowman is Chief, Physical Therapy, Irwin Army Community Hospital, Fort Riley, Kansas. cal Therapy Clinic, Wilford Hall Ambulatory Surgical Center, Joint Base San Antonio-Lackland, Texas. COL Teyhen is with the System for Health and Perfor the Army Surgeon General, Falls Church, Virginia. Dr George is Associate Professor and Assistant Depart ment Chair, Department of Physical Therapy, University of Florida, Gainesville, Florida. INCREMENTAL EFFECTS OF TELEPHONE CALL CENTER AND HEALTHCARE UTILIZATION DATABASE USE TO IMPROVE FOLLOW-UP RATE IN THE PREVENTION OF LOW BACK PAIN IN THE MILITARY TRIAL


October December 2015 31 TOPIC SELECTION AND FOR M ING A TEA M A work group was formed in June 2012 to establish a project, as part of the requirement for completion of the Clinical Nurse Transition Program (CNTP) at the Landstuhl Regional Medical Center in Germany. The director of nursing encouraged selection of a topic from an outpatient setting since there was a relatively large mented. The nurse manager at the Physical Medicine and Rehabilitation Center (PM&R) requested assistance in improving patient compliance with a stretching pro gram designed to control pain for patients suffering team consisted of the 2 CNTP nurses, a mentor nurse scientist, the nurse manager of the PM&R, and 3 pro viders as stakeholders. The providers, as part of a non pharmacological approach to treating lower back pain, prescribed the stretching program. The team followed Quality Care 1 to guide the project. PRO B LE MFOCUSED AND KNOWLEDGEFOCUSED TRIGGERS The PM&R was a relatively new program established under the Department of Orthopedics. The mission of the clinic is to care for patients with a variety of muscle, tendon, joint, and nerve disorders using a patient-cen tered focus on improving the quality of life. Including the specialties of pain management, orthopedics, neurol ogy, rheumatology, physical therapy, and occupational therapy, the clinic focuses on providing diagnostic and treatment methods to reduce pain and increase function. The mission and goal of PM&R were dictated by the Force. 2 The nurse manager acted as the primary point of contact and clinical expert of the PM&R. Her desire to improve ed her outreach to the CNTP nurses. A meeting was set to discuss her concerns about the existing program and her suggestions for improvement. The PM&R staff had During the initial meetings with PM&R staff, it was dis covered that there had been little compliance tracking peutic stretching. Further, due to the lack of standard ization of practice among clinicians and the relative lack Using Evidence to Increase Compliance With Therapeutic Stretching for Chronic Low Back Pain 1LT Mauricio J. Izaguirre, AN, USA LTC Susan G. Hopkinson, AN, USA AB STRACT Purpose: In June 2012, a team of nurses at the Armys Landstuhl Regional Medical Center was tasked to gener ate an evidence-based practice recommendation for patients experiencing chronic low back pain (CLBP). Methodology: Based on 14 articles, the evidence ( a ) validated the use of therapeutic stretching for control of CLBP, ( b c ) supported military relevance. The team developed a questionnaire to assess previous experience with stretching exercises and preferred learning methods. Based on the responses from 32 patients, the initial goals included an increase in patient reported compliance within 3 months and a decrease in reported pain within 6 months. Long-terms goals targeted a 90% patient compliance in daily stretching regimen and a continued decrease in pain within 1 year. Results: At 3 months, a 96% compliance rate was reported for patients returning for follow-up appointments; however, the average reported pain level did not decrease. Implications: compliance becomes a deterrent to quality of care.


32 exactly each patient was taught and by whom. These PICO DEVELOP M ENT Asking the right question is fundamental to an evi dence-based practice project. The key components of the statement are captured in the pneumonic of PICO (population, interventions, comparison, and outcome). The development of the PICO statement was discussed seen at the PM&R suffering from CLBP. Adapted from a clinical standard, 3 cle tension, or stiffness lasting longer than 12 weeks. The intervention initially selected was the provision of nursing modalities to increase compliance with thera peutic stretching exercises. As a beginning evidencebased practice project led by novice nurses, the guid ance focused on keeping the interventions within the scope of nursing practice. Nursing modalities were de nursing staff to bring about a desired result. A baseline measure of the current practice, including compliance and pain level, was selected as the comparison. The out come measures included compliance rate and pain level at selected time points after the intervention. SYNTHESIS OF EVIDENCE An exhaustive literature review and article appraisal was conducted using the Army Nurse Corps Rating 5 The team critiqued a total of 14 articles. As shown in Table 1, the quality of the articles ranged from A (high) thors (D.R.G. and M.J.I.), both primary members of the dividually graded and then opinions of all 3 raters were compared for accuracy. Disagreements were discussed article. There were 3 primary foci of the literature review. The control of CLBP. The use of therapeutic stretching in the control of CLBP was not consistent among the cli nicians. It was decided that to properly create clinical practice recommendations for increasing compliance, therapeutic stretching must be validated as an effective means of controlling CLBP. Five articles exemplifying the positive effects of therapeutic stretching were found (Table 2). The articles supported 3 basic conclusions: Use of therapeutic stretching in conjunction with prescribed pharmacological interventions de creased patient reported pain. A well-designed and regularly implemented stretch ing program decreased patient reported CLBP. gram remained unknown. The studies were inconclusive as to which exact exer cises and what length of time was optimal to have the greatest effect on CLBP; rather, it was concluded that as long as some muscular skeletal exercise was completed regularly, then favorable results could be achieved. The second focus of the literature review discovered mo dalities to increase patient adherence to medically pre scribed interventions for back pain. Originally, the team focused primarily on searching literature regarding in creasing compliance to stretching exercises designed low number of articles found, the team expanded the search to discover a principle behind increasing compli ance for any medical interventions. Review of a total of 7 articles (Table 3) generated the following conclusions: Physician involvement in the instruction of the pre scribed exercise regiments aided in establishing pa important. Patients are more likely to comply when the disease process and therapeutic effects of therapeutic inter ventions are explicitly explained. dence in the therapeutic prescribed interventions. USING EVIDENCE TO INCREASE COMPLIANCE WITH THERAPEUTIC STRETCHING FOR CHRONIC LOW BACK PAIN Internal use document, not readily accessible by the general pub lic. It is based on the Melnyk & Fineout-Overholt rating scale. 4 Table 1 Synthesis of Evidence Critique of All Articles. Level of Evidential Strength Number of Studies Overall Quality Level I: Systematic reviews, meta-analysis of RCTs, EBP clinical practice based on system atic reviews of randomized controlled trials 4 4A Level II: Well-designed randomized controlled trials 5 3A/2B Level III: Well-designed controlled trials with out randomization 0 N/A Level IV: Well-designed case-control and cohort studies 0 N/A Level V: Systematic reviews of descriptive and qualitative studies 0 N/A Level VI: Single descriptive or qualitative study 5 5A Level VII: The opinion of authorities and/or reports of expert committees 0 N/A


October December 2015 33 Some form of reminders, whether personal or elec tronic, encouraged the consistent use of the pre scribed interventions. The third focus of the literature review involved estab ration at a military treatment facility. Two articles de scribed the effects of chronic lower back pain on mili tary personnel (Table 4). Three conclusions were drawn from these articles: The more combat oriented the branch, the higher the prevalence of CLBP. Combat effectiveness and mission readiness de creased when Soldiers suffered from CLBP. Healthcare costs increased sharply when Soldiers struggled with CLBP. COLLECTION OF BASELINE DATA Based on the conclusions from the literature review, the team created a needs assessment questionnaire, present ed as Figure 1, to gather data on 3 major areas: patient demographics, patient perception of therapeutic stretch ing, and preferred methods of communication. For con venience, the questionnaire was given to all patients seen at the PM&R. Baseline questionnaires were dis tributed and collected for one month. A total of 32 ques tionnaires were returned from patients seen for CLBP at a rated pain of 5 or less on a scale of 1 to 10. The Table 2 Evidence Supporting Use of Therapeutic Stretching for CLBP. Source (article title) Relevance Level Back Schools for Non-Specific Low-Back Pain [review] 6 Therapeutic stretching and regular medical interventions reduced CLBP. I/A Exercise Therapy for Treatment of Nonspecific Lower Back Pain 3 Supports use of therapeutic stretching for control of CLBP. I/A Systematic Review: Strategies for Using Exercise Therapy to Im prove Outcomes in Chronic Low Back Pain 7 Supports use of individually designed therapeutic stretching for control of CLBP. I/A Effects of Motor Control Exercises Versus Graded Activity in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial 8 Supports need for a well-designed therapeutic stretching program for control of CLBP. II/A A Randomized, Controlled Trial of Manual Therapy and Specific Adjuvant Exercise for Chronic Low Back Pain 9 Supports use of therapeutic stretching for control of CLBP. II/B Table 3 Evidence Supporting Adherence to Interventions. Source (article title) Relevance Level Interventions to Improve Adherence to Exercise for Chronic Mus culoskeletal Pain in Adults 10 Adherence not affected by type of exercise prescribed. I/A Self-management of Chronic Neck and Low Back Pain and Rel evance of Information Provided During Clinical Encounters: An Observational Study 11 Supports education on disease process and benefits of therapeutic exercise for increasing patient compliance. II/A A Randomized Study of Serial Telephone Call Support to Increase Adherence and Thereby Improve Virologic Outcome in Persons Initiating Antiretroviral Therapy 12 Telephone reminders increase patient compliance. II/B A Cognitive Behavioral Intervention to Increase Adherence of Adult Women Exercises 11 Provides modalities to increase patient adherence. II/A How Do Care-Providers and Home Exercise Program Characteris tics Affect Patient Adherence in Chronic Neck and Back Pain: A Qualitative Study 14 Importance for professional presentation of instructional content. VI/A Managing Time: An Interpretative Phenomenological Analysis of Patients' and Physiotherapists' Perception of Adherence to Therapeutic Exercises for LBP 15 Supports provider designed daily stretching programs for aid in time management. VI/A Mechanical Diagnosis and Therapy in Back Pain: Compliance and Social Cognitive Theory 16 Supports the need for supervised instruction of therapeutic stretching. VI/A Table 4 Evidence Supporting Military Relevance Source (Article Title) Relevance Level Diagnosis and Mechanism of Musculoskeletal Injuries in an Infan try Brigade Combat Team Deployed to Afghanistan Evaluated by the Brigade Physical Therapist 17 Establishes relevance to patient population seen at PM&R. VI/A Back Pain During War 18 Establishes relevance to patient population seen at PM&R. VI/A




October December 2015 35 data from these 32 questionnaires were gathered into a dations. At baseline, 63% of the patients had received education on therapeutic stretching exercises. Of those who received the instructions, 85% completed the ex ercises 50% or more of the time. Furthermore, patients preferred one-on-one instruction (70%) with reminders sent weekly (65%) via email (65%). Two-thirds of the re spondents (66%) stated that they would have 20 minutes or less available for daily exercises. PILOT THE CHANGE IN PRACTICE Based on the literature review, the needs assessment, and the goals presented to the PM&R staff, the follow mendation for change in practice: Standard instructions among all healthcare pro viders, including written instruction for further reference. Physician provided explanation of the disease pro by nursing staff. Weekly compliance reminders via email. The 2 short-term goals established from the data were a 25% increase in patient reported compliance within 3 months of implementation and a decrease in patient reported pain within 6 months, by at least a factor of 1 (0 being no pain to 10 being the worst pain ever expe rienced). The 2 long term goals established were a 90% patient compliance to daily therapeutic stretching and a continued decrease in pain by a factor of one within one year of implementation. The goals were generated based on the data collected from the needs questionnaire, as well as the input of the staff and stakeholders. implementation to the patients seen by one physician. Based on the provider stakeholder preferences, 4 thera peutic stretches compiled from the US Army Medical Command pamphlet Managing Low Back Pain: VA/ DoD Clinical Practice Guidelines 19 were selected as part of the intervention. The team created a 2-sided in struction sheet (Figure 2) to aid patients in understand ing and completing the stretches. The front side of the instruction sheet detailed the 4 selected exercises and proper execution. The back side presents the rationale for the stretches and information about disease pro cess of CLBP, as well as a weekly log for patients to track their progress. Additionally, the nurse manager arranged for weekly reminder emails to be sent to all pilot patients. A complete protocol was created that in cluded the 4 stretching exercises, the patient education plementation. Prior to implementation, the protocol was reviewed and evaluated by the medical director of the a staff meeting to review the guidelines with the PM&R staff and answer all questions. IS CHANGE APPROPRIATE FOR ADOPTION INTO PRACTICE? A revised questionnaire was released to patients to track starting at one month and continuing to 3 months after the implementation. Of the 45 participants completing the questionnaire during a follow-up visit, 43 reported completing the exercises 50% or more of the time (96% compliance rate). However, reported pain was unaffect ed, with the average pain rating at 5. Based on the data worksheet to accurately measure the goals. The team at tempted to collect the data again at about the 12-month period, with only 5 questionnaires returned. All 5 par ticipants reported receiving instructions on the thera peutic stretching exercises, including explanation of the importance, demonstration, and the developed handout (Figure 2). Overall, the participants considered the in structions easy to read, easy to understand, and useful. Since the majority of these participants were on their not yet be applied as outcomes from the exercises. The clinic staff, however, remained 100% compliant with providing the exercises per the protocol. LI M ITATIONS was gathering the patient data for baseline and outcome measures. Although the needs questionnaire provided the easiest method for collecting the appropriate data, encouraging patient participation was challenging. Due to limited staff in the PM&R and current systems, track ing patients seen by only one of the providers for CLBP tionnaires were gathered from 61 patients seen in the sion criteria. A second limitation noted was tracking staff compli ance to the protocol. It was clear from the second needs questionnaire that patients were given instruction on the performance of stretches. During audits at the clinic, however, the CNTP nurses overheard variances in how the instructions were given. Corrections were made at


36 Although initially implemented as nursing modalities, the instruction was primarily reinforced by the medical technicians rather than nurses. This was due to the limit ed availability of the PM&Rs only registered nurse (RN). Admittedly, the RN oversaw the instruction on the ma jority of cases and ensured project parameters were met. nurses were only allocated one day per month to assist in the process at the PM&R clinic. In order to assist the PM&R clinic on the assigned day, each CNTPs ward census/patient acuity had to be taken into consideration. questionnaires, patient reported pain did not decrease. Although this was a goal of the project, the overall focus Many factors may have contributed to the lack of ef fect on pain, one of which is the consistency and use of pharmacological interventions. This was not tracked and should be taken into consideration in any focus on decreasing overall pain, as the data from the literature review suggests. Finally, funding constraints eliminated positions of two of the participating providers. Therefore, only one prac titioner who saw patients with CLBP continued partici pation, greatly reducing the number of patients being seen at the clinic. Due to the low volume of patients with CLBP, very few outcome questionnaires were collected ued and the protocol is still used by the clinic staff. IM PLICATIONS Patient compliance to medically prescribed interven tions is vital to ensuring the highest quality of care. and to discover ways of reducing the lack of compliance. Furthermore, the prevalence of CLBP among Soldiers USING EVIDENCE TO INCREASE COMPLIANCE WITH THERAPEUTIC STRETCHING FOR CHRONIC LOW BACK PAIN Figure 2. Front side of the instruction sheet created by the EBP team to assist patients in understanding and correctly performing and completing the daily therapeutic stretches.


October December 2015 37 improve the quality of care provided at the PM&R. The methods and tools used in the project may be used in similar clinics where low levels of compliance are a con tributing factor to decreased quality of care. ACKNOWLEDGE M ENTS The authors recognize LTC Betty Garner, Nurse Sci entist, for her guidance on evidence-based practice and Barbara Peterson, Nurse Manager of the clinic, for sub cantly in project development and implementation. REFERENCES 1. Titler MG, Kleiber C, Steelman VJ, et al. The Iowa model of evidence-based practice to pro mote quality care. Crit Care Nurs Clin North Am 2001;13(4):497-509. 2. Pain Management Task Force Final Report May 2010 geon General. 2010. 3. Hayden J, van Tulder M, Malmivaara A, Koes BW. back pain. Cochrane Database Syst Rev 2011;(2). 4. Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. Philadelphia: Lippincott Williams & Wilkin. 2011. 5. Newhouse RP, Dearholt SL, Poe SS, Pugh LC, White KM. Johns Hopkins Nursing EvidenceBased Practice Model and Guidelines Sigma The ta Tau International: Indianapolis, IN; 2007:207. 6. bardier C, Koes BW. Back schools for non-spe Cochrane Database Syst Rev 2004;18(4). 7. Hayden JA, van Tulder MW, Tomlinson G. System atic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Int Med 2005;142(9):776-786. 8. of motor control exercises versus graded activ pain: A randomized controlled trial. Phys Ther 2012;92(3):363-377. 9. A randomized, controlled trial of manual therapy pain. Clin J Pain 2005;21(6):463-470. 10. terventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev 2010(1):CD005956. 11. novas J, Montilla-Herrador J, Valera-Garrido J, Col lins SM. Self-management of chronic neck and low back pain and relevance of information provided during clinical encounters: an observational study. Arch Phys Med Rehabil 2009;90(10):1734-1739. 12. Collier AC, Ribaudo H, Mukherjee AL, Feinberg J, Fischl MA, Chesney M. A randomized study of serial telephone call support to increase adherence and thereby improve virologic outcome in per sons initiating antiretroviral therapy. J Infect Dis 2005;192(8):1398-1406. 13. tervention to increase adherence of adult women exercisers. Adv Physiother 2004;6(2):84-92. 14. novas J, et al. How do care-provider and home ex ercise program characteristics affect patient adher ence in chronic neck and back pain: A qualitative study. BMC Health Serv Res 2010;10:60-60. 15. Dean SG, Smith JA, Payne S, Weinman J. Manag ing time: An interpretative phenomenological anal ysis of patients and physiotherapists perceptions of adherence to therapeutic exercise for low back pain. Disabil Rehabil 2005;27(11):625-636. 16. cal diagnosis and therapy in back pain: Compli ance and social cognitive theory. Adv Physiother 2007;9(4):190-197. 17. Roy TC. Diagnoses and mechanisms of musculo skeletal injuries in an infantry brigade combat team deployed to Afghanistan evaluated by the brigade physical therapist. Mil Med 2011;176(8):903-908. 18. Cohen SP, Nguyen C, Kapoor SG, et al. Back pain during war: An analysis of factors affecting out come. Arch Intern Med 2009;169(20):1916-1923. 19. Managing Low Back Pain: VA/DoD Clinical Prac tice Guidelines JBSA-Ft Sam Houston, TX: US Army Medical Command; November 2009. Avail able at: nal_LBP_Booklet.pdf. Accessed July 29, 2015. AUTHORS 1LT Gisla is a Critical Care Nurse specializing in car diovascular intensive care, Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, Texas. When this article was written, he was assigned to the Landstuhl Regional Medical Center, Landstuhl, Germany. 1LT Izaguirre is a Registered Nurse with the 212th Com bat Support Hospital assigned to the Medical Surgical/ Pediatrics Unit, Landstuhl Regional Medical Center, Landstuhl, Germany. LTC Hopkinson is a Nurse Scientist, Landstuhl Regional Medical Center, Landstuhl, Germany.


38 As the US Army contends with manpower and budget cuts in the medium term, the Army Medical Depart effects on its budget, manning levels, and operational capabilities. From the 1970s through the 1990s, the operate and deliver increasingly sophisticated care with budget pressures and fewer personnel. While many of them may generate some ideas for the future while re minding us that painful cuts can be absorbed. BACKGROUND From the American Revolution through World War II, the United States military mobilized for war and demo bilized afterwards. Following the Revolution, the Army was reduced to 80 men; after the Civil War to around 25,000 men; and following World War II, from 8.3 mil lion in mid-1945 to 684,000 in mid-1947, and 591,000 in mid-1950. There was proportionally less drawdown after the Korean War because there was no longer mobi lization time in US doctrinethe US military switched from a defense philosophy of mobilization after a dec laration of war to maintaining a substantial force dur ing periods of relative peace. The Army was 1.5 million strong in 1953, but although it was reduced in following rose to over 1.5 million in 1968, but shortly thereafter downsizing began and continued into the 1970s. Army strength stabilized in the late 1970s, but was substan tially cut again in the early 1990s. Not surprisingly, the personnel to perform tasks; for example, physician assistants and nurse practitioners instead of physi cians. This worked, but only to the limit of adverse ly affecting the standard of care. When military manpower was reduced, the personnel. This was successful when civilian per sonnel budgets were not under the same pressure as military headcount. the Military Health System (MHS). This worked in places (such as the Delaware Valley Health Servic es System) and not in others (such as the 1987-1991 Joint Military Medical Command in San Antonio). sources with the Veterans Administration (VA) and other Federal healthcare systems. This has gener ally worked, but has avoided costs (for example, du plicate CT scanners) rather than reduce them. the 1970s, but became more troublesome when CHAMPUS budgets were centralized. Processing Stations, and US Department of Agri culture inspectors examine foods at plants. How ever, Army requests for the VA to perform some examinations were unsuccessful. Facilities were downsized or closed when the active duty population was reduced and/or moved. THE 1970S The 1970s drawdown had elements of both coping with declining forces and seeking ways to recruit more per sonnel. The former of these seems more relevant to the near future, and recruiting methods are not covered here. This study was also limited by availability of material. Background Factors of the 1970 s By 1970, American involvement in the Vietnam War was declining and the Department of Defense (DoD) was downsizing; there were fewer patients in Army hos pitals in 1971 because the Army was shrinking. Total military numbers (both active and reserve) fell and the All-Volunteer Force replaced the draft. However, the ly, through the 1970s. The armed forces had to simul taneously manage personnel reductions while enticing substantially more recruits. Some personnel who want ed to stay in the military were discharged and others were allowed to remain but accept a reduction in rank, US Military Drawdowns 1970-1999 : Army Medical Department and Military Health System Responses Sanders Marble, PhD


October December 2015 39 prices and wages substantially higher while the govern ment was trying to reduce military spending. American medical practice was changing to increased outpatient treatment, but inpatient hospitalization also decreased (both in numbers of hospitalizations and length of stay) due to a broadening pharmacopeia and increasing hospi talization costs. Medicine was more physician-centered, with few physician-extenders in the Army at the begin ning of the period. AMEDD Coping Strategies in the 1970 s sively that it needed to expand. The Chief of Staff of the Army proactively sought to address factors that would gued that long waiting periods and poor facilities would whole. In early 1971, the Vice Chief of Staff approved vacant authorizations were eventually lost, they presum ably cushioned somewhat against actual personnel cuts. 4,056 in 1977, many of whom were interns and residents with practice limitations. Alternatives had to be found, Some examples: Medical Service Corps (MSC) sanitarians were substituted for roughly 40% of preventive medicine physicians. 1 positions, albeit sparingly. 2,3 peacetime, as the Professional Filler System was time. 3,5 tions; since mid-rank physicians received fewer command/staff positions, few were ready for deployment as unit commanders during Desert Shield/Storm in 1990-1991. This in turn led to in the mid-1990s. signed to some medical research and development positions. 6 Psychologists and social workers were used where possible for psychiatrists. 7 Occupational therapists also became increasingly involved with behavioral healthcare patients. Physical therapists (PTs) were used to screen (and treat) some back pain and many orthopedic pa surgeons. 3,7 In FY1979, PTs saw 6.6% of all outpa tients, especially basic trainees with musculoskel etal injuries. Physician assistants were recognized beginning in 1970 as a viable alternative to a second physician in maneuver battalions, and the Army began training and using them. Numbers were relatively small, but increased from zero in the Health Services Com mand (HSC) in 1973 to 92 in 1979. 3,8 Nurse practitioners (including midwives) were gaining acceptance in American medicine and the Army began training and employing them. Num bers in HSC rose from 69 in 1973 to 203 in 1979. 8 Community health nurses replaced physicians as head of occupational health divisions in some hos pitals. 9 Some community health nurses working in the tuberculosis program were authorized to write 10 Civilian physicians were hired as government ser vice (GS) civilians or contracted. The HSC had 200 GS physicians and 10 contractors in 1973 and 453 GS and 55 contractor physicians in 1979. 8 ized, with both GS and contractors, from FY1965 to FY1967, and there were approximately 5,000 more by FY1975. By the beginning of FY1975, the ratio of en listed to civilians in HSC was 39:61. 11 There were lim its to this. Since many military personnel from military bilization, civilianizing positions jeopardized support of response to one Army study: The decision maker who decides to further reduce the combat Soldier that appropriate health care services in all probability will not be available to him on the next 8 However, one function was entirely civilianized. Medical examination of recruits of all services at Armed Forces 96-513 passed in 1980 sonnel management structure across DoD. The Professional Filler System, commonly known as PROFIS, pre tions in early deploying and forward deployed Army medical units execution of an operations plan or a contingency operation, or for the conduct of mission-essential training. 4


40 Those physician requirements were ci vilianized with no apparent problems. There were efforts to save money by cutting personnel grades. In FY1971, there was an effort to save money by downgrading civilian positions to 12 In 1976, recommended cutting the grades of of 13 A few military positions were downgrad 11 and some VC food inspection positions were 14 There were also efforts to reduce de mand for medical care. Substantial health promotion ef forts included antismoking cam paigns, antidrinking campaigns, advice on nutrition, advice on exercise, warnings about atherosclerosis, and advice on avoiding loud noises and hearing conservation. These could be blunt, as shown in the Figure, and include headlines common today, such as, Many US Children are Overweight. 15-21 Available data does not indicate re sults, but notwithstanding the effectiveness of these efforts, many patients still required care by the HSC. An entire category of civilian employees, Com munity Health Dental Hygienists, was approved to encourage dental hygiene and prevent clinic visits. However, the need for personnel in clinics was so pressing that these positions were gradually con verted into ordinary hygienists. 22 The Occupational Safety and Health Act (Pub L No. 91-596, 84 Stat 1590) was passed in 1970, imple but presumably reduced patient numbers over the long term. standards for recruits. The theory was that higher entry standards should reduce the amount of health care they would need early in their careers. 23 There is no indication if this was adopted, but the proposal seemed to run counter to helping the broader re cruiting problems of the 1970s. Some healthcare was administratively required, and could be reduced by changing the requirements. Instead for periodic examinations. 23 This pro posal was accepted, resulting in the requirement for an examination every 5 years. It also sought to reduce docu To Service separations. The effect of these initiatives is not clear. With a smaller Army, programs and fa cilities were closed or reduced in scale. Reduction in the number of available facilities resulted in reduced capabil ity for mobilization and casualty care for potential major wars. The DoD re sponded to this by working within the government, primarily the VA, and the civilian sector to establish what is now the National Disaster Medical System. Several recruiting programs that count ed against end strength were elimi nated. These included one that com missioned medical students while they were in school, and the Walter Reed Army Institute of Nursing. Replacement programs did not count against end strength. Research, dental, veterinary, and environmental health laboratories were cut. It is not clear how much of this was related to the smaller Army reducing workload; how much closed/downsized posts changed the distribu tion of work; and how much to accepting increased costs in temporary assignments of personnel and shipments of samples in order to reduce numbers of personnel and facilities. 8 Where posts closed, hospitals and clinics were closed, such as hospitals in the Panama Canal Zone and 30 clinics at Nike-Hercules air defense missile bases. The Base Closure and Realignment (BRAC) process did not yet exist, and Congressional attention could delay and/ members of the US House of Representatives where the er. However, political pressure countered a number of 1979 closure of Letterman Army Medical Center in San Francisco did not happen; it remained open until 1994. Some hospitals on surviving posts were converted to clinics, such as Dunham Army Hospital at Carlisle Barracks, PA. This was facilitated by the shift from in patient care to outpatient care. It appears this also was Fat+Smoking=Heart Attack Caricature used in antismoking and other harmful lifestyle aware ness campaigns in the HSC Mer cury newsletter, February 1977 US MILITARY DRAWDOWNS 1970-1999: ARMY MEDICAL DEPARTMENT AND MILITARY HEALTH SYSTEM RESPONSES


October December 2015 41 briefed to Congress, but may have met less resistance. One general hospital (the equivalent of a medical cen ter), the Valley Forge General Hospital, was closed, but Army Hospital at Fort Gordon, GA, to a medical center. Proposals to provide certain types of healthcare using contractors were considered. Occupational health clin ics were the easiest category to approve, and the concept of hiring civilians to run facilities including small hos pitals was studied as well. This was an open-ended idea, which considered civilian hospitals, medical schools, group practices, or individual providers to provide ser vices.8 The provision of all healthcare by contract was considered for 35 Army posts. The evaluation process was lengthy, but ultimately 2 posts (Dugway Proving Ground, UT, and White Sands Missile Range, NM) were selected. However, commercial offers substantial ly exceeded audited government costs and the proposal was rejected in January 1977. Another effort to contract healthcare at Army facilities was begun in 1979, when DoD and the House Appropriations Committee both di rected a test. The HSC looked at 5 facilities: Fox Army Hospital (Redstone Arsenal, AL), Munson Army Hos pital (Fort Leavenworth, KS), Patterson Army Hospital (Fort Monmouth, NJ), Keller Army Hospital (West Point, NY), and Bassett Army Hospital (Fort Wainwright, AK). Fox Army Hospital was ultimately chosen, but the program slipped into FY1982. Ultimately, healthcare at the facility was not contracted. Major efforts were made to facilitate sharing DoD medi cal facilities and personnel. Triservice regionalized health services were started in 4 areas in the continen cy, economy, and improved delivery of services. Three regions had one lead military service and subregions for each of the other services; the fourth had a rotating lead. on October 1, 1972, and to all of CONUS in FY1974. 9,24 Surgeons General and the Assistant Secretary of De changed to ASD (Health Affairs). The HSC Annual Historical Report 1 April 1973-30 June 1975 11 included an assessment of results of the regionalization approach: The system worked as a give-and-take low key consor tium of administrators interested in providing profes sional health care by the best use of their pooled assets. It helped formalize a process which had operated on an ad hoc basis for several decades. Working on a triservice basis led to greater standardiza tion of terms and policies. These had to be implement involved. In the mid-1970s, a government-wide study looked at Federal healthcare, including the Department This led to calls for DoD-wide standardization in man odology, and accounting. Creation of a Defense Health Agency was also recommended. In the 1970s, the GAO reported on wide variances in federal healthcare and that sharing had been: inhibited by cumbersome or inequitable reimburse ment mechanisms, the lack of economic incentives, or agencys and hospitals desires to maintain autonomy and ready access to a full range of health services. 3 A Federal Health Resources Sharing Committee was chartered in February 1978 from DoD, service Surgeons General, VA, and the Public Health Service. It largely avoided costs (for example, not establishing multiple cancer centers in Augusta, GA) and could only point to nisms. 3 There was rationalization of medical support in certain locations. For example, the Army hospital on Okinawa was transferred to the Navy. 3 There was a one-time savings when the Public Health Service stopped operating hospitals and clinics in the late 1970s. One hospital (San Francisco, CA) and one clinic (St Louis, MO) were transferred to the Army, avoiding projected facilities construction costs. 25 There were also occasional examples of allies funding facilities. In 19761977, the United States negotiated the return to Japan of the US Army Hospital Honshu and some other proper ties in exchange for Japan building a new Navy hospital at Yokosuka and an Army clinic at Camp Zama. 3 The DoD also centralized approval of procurement of items over $100,000, as well as approval to begin, end, or curtail medical services. 3 There was recognition of common items and training. For instance, spectacle fab rication was better shared, with a test program to sup port the VA as well. 3 Some training programs began accepting personnel from multiple services. 3,10 In 1979, planning to consolidate veterinary support began. This was planned to occur over FY80-85 (later accelerated to FY80-82), with the Army assuming responsibility cers and enlisted personnel. Some positions were civil corps, which generally avoided specialty pay. 3 This pre There were efforts to manage the healthcare system


42 management would control costs. As mentioned earlier, there were triservice management efforts which led to Reporting System. The DoD also recognized trends in civilian healthcare and sought to use health mainte nance organizations as an alternative to CHAMPUS. 9 Concurrently, CHAMPUS was centralized under DoD at the beginning of FY1975. This had limited effect in controlling, let alone reducing, costs. The DoD did ad ministratively reduce CHAMPUS reimbursement rates to physicians, but that discouraged physician participa automatically caused increased referrals to the CHAM CHAMPUS budget to more than double in 5 years (up 142% over FY1969-1974). While arguably a rational de ment overall, and Congress held hearings in 1974. Late in FY1974, Secretary of Defense Schlesinger restricted some practices that had become customary but were not authorized in law. The changes meant copayments from individuals and were a deterrent to care. personnel. While physicians were in notably short sup ply in the 1970s, dentists were also scarce. While the Army sought to recruit more dentists, it recognized the cially as this would help morale of dentists and enhance recruitment and retention. Dental assistants received extra training to handle certain procedures, and den tal clinics were upgraded to provide multiple treatment rooms per dentist who could then see more patients in the same amount of time. 9,22,24 This proved effective, with dental workload up 77% between 1975 and 1979 despite a 9.5% reduction in dental personnel; military personnel fell 13.3%, civilian personnel fell 0.1%. 8 Reservists were used in MTFs. From its earliest days, HSC tried to utilize reservists during their weekend and annual training, as well as inactive duty training. 9,26 This was said to improve training in the Reserve com ponent while providing staff for HSC. 27 reservists were used in 1975. 28 Members of the Individ ual Ready Reserve were also used, starting with 100 in 1975 and quadrupling through 1979. 8 services. Certain functions were transferred to other government agencies, or were examined for transfer. In the late 1970s, Congress directed the transfer of veteri nary inspection of meat and other food processing from the VC to the US Department of Agriculture. This saved 8 It should be noted that this was not undertaken as a manpower savings, but because a group of ineffective food inspectors caused a problem into which Congress intervened. The Army Staff (presumably with support from The Surgeon General) submitted several requests to DoD for legislation to shift both disability determinations and Temporary Disability Retirement List (TDRL) exami nations to the VA. Under these proposals, the military periodic examinations of 13,000 TDRL personnel. This proposal was studied by DoD without further action. 29 THE 1980S Background Factors of the 1980 s The 1980s are not generally considered a period of mili tary drawdown. However, military personnel authoriza tions dropped 13,000 between 1974 and 1989, roughly 1,000 personnel per year, as some positions were civil ianized. Civilian personnel numbers climbed roughly 128,000, or 13%, through the decade. Thus, military cert with increasing civilian manpower. The military budget rose through 1986 and then was cut slightly, with substantial cuts scheduled to start in FY1989. Despite the drop in military manpower, CHAMPUS costs rose rapidly, partly due to costs of medical care Cold War military was retiring and getting care through CHAMPUS rather than MTFs. Thus, total CHAMPUS costs tripled between 1984 and 1994. The Secretary of Defense wrote in 1988: Our greatest medical challenge today is to continue im proving our medical-readiness capability and to provide ciaries, while containing the cost of care provided. 30 By the 1980s, closing bases under the Federal Property and Administrative Services Act of 1949 (40 USC et al) had become highly sensitive to political pressure. In 1988, Public Law No. 100-526 authorized a special commission to recommend base realignments and clo sures to the Secretary of Defense. The Carlucci Com mission was chartered by the Secretary of Defense on May 3, 1988, and by December 1988 had recommended closure of 5 Air Force Bases. The Carlucci Commission the Base Closure and Realignment Act of 1990 (Pub L No. 101-501), which itself established a Commission, now commonly known simply as BRAC. US MILITARY DRAWDOWNS 1970-1999: ARMY MEDICAL DEPARTMENT AND MILITARY HEALTH SYSTEM RESPONSES


October December 2015 43 AMEDD Coping Strategies in the 1980 s active, shifting to prevention rather than cure. Health promotion and preventive medicine increasingly be came the emphasis across DoD. The Secretary of the Army and the Army Chief of Staff designated 1982 as eas of weight control, nutrition, stress management, and reductions in substance abuse (alcohol, tobacco, and drugs). 30,32 While some of the initiatives, particularly drunk-driving campaigns, were effective, healthcare costs still rose at alarming rates. Better management techniques to reduce costs were ex plored. Diagnosis related groups were adopted instead of allowing CHAMPUS physicians to set their own fees. Health maintenance organizations (HMOs) and preferred provider organizations were tried, including medical centers essentially running their own HMOs. Catchment area management was tested in the late 1980s, which put CHAMPUS budgets in the hands of MTF commanders and allowed them to negotiate rates with local providers. 33 (started in 1985) provided more administrative and sup There was another effort at contracting care. Since many CHAMPUS patients needed a nonavailablity statement, the MTF could control network utilization. Beginning April 1, 1987, Primary Medical Care For Uniformed Services (PRIMUS) clinics were tried, government out would be less expensive than care delivery by CHAM PUS. 34 Available data is inconclusive on whether PRI MUS clinics were less expensive per patient visit than CHAMPUS, but they were more expensive than MTF care, and increased overall visits. They thus increased access (a goal) but at greater cost. They were phased out Military Health System Coping Strategies in the 1980 s During the 1980s, outside experts were consulted through a Blue Ribbon Panel on the Sizing of Defense Medical Treatment Facilities. The panel not only recom mended that control of medical construction plans be placed under the Assistant Secretary of Defense (Health Affairs) (ASD(HA)), which was implemented, it also recommended coordination and even consolidation of There were further efforts towards the establishment of joint medical organizations. Creation of a Joint Military Medical Command for San Antonio was initiated in 1986 and completed in 1987. Two similar efforts covered the Delaware Valley (including Fort Dix, NJ) and the San Francisco area (including Letterman Army Medical Center). Facilities were sometimes transferred between services. For example, Walson Army Community Hospi tal at Fort Dix was transferred to the Air Force in 1992 as a result of the 1991 BRAC Report which recommended realignment of mission the Fort Dix and consolidation of medical support with adjoining McGuire Air Force Base. CHAMPUS reforms were investigated. The CHAMPUS Reform Initiative was the experiment that ultimately be California and Hawaii. More centralization initiatives during this period culmi nated in creation of the Defense Health Program. The healthcare delivery. The 1990 Defense Appropriations Act directed DoD to plan for more centralization of health 35 The Military Health System (MHS) considered im posing user fees in MTFs on dependents and retirees, roughly equal to copays under CHAMPUS. Due to soar ing costs, in 1989 the Bush Administration considered user fees in MTFs, a proposal that had proved highly unpopular in the past. 33 The proposal was not adopted. However, to access healthcare insurance coverage of private and employer insurance plans held by eligible 1980s to allow it to bill civilian insurance plans for care rendered by military medical facilities. Such legislation was enacted in the early 1990s. THE 1990S Background Factors of the 1990 s With the end of the Cold War, the late 1980s trend of reductions accelerated, both in manpower and money. From 1989 to 1999, Army active duty strength fell 38%, from 772,000 to 480,000. The Army base budget fell one-third between 1989 and 1994, and declined slightly every year thereafter. It was not possible to hire civilians to replace military personnel, and the centralized De rather than treat them in an MTF. There was strong inter est in using contractors rather than government civilians, and in reducing headquarters/management personnel. AMEDD Coping Strategies in the 1990 s The 1990s saw continued efforts to reduce the require ment for delivery of medical care to patients. The Army


44 Health Promotion Program sought to educate Soldiers about both risky and unhealthy behaviors. The 1994 Agency as the Center for Health Promotion and Preven health and reduce the need for healthcare. By the late sulting in healthier lifestyles and reduction in unneces sary trips to doctors. 36 War reductions. The Army was persuaded that the large until completion of the bulk of Army-wide cuts. Sur geon General Frank Ledford was particularly outspoken al to the overall force are not acceptable because the 37 He argued that MTF care was more cost-effective than CHAMPUS care, so cutting the MHS was no bargain. Although his arguments were well received by DoD, the Army was both losing personnel and changing its base eral hospitals became outpatient clinics, and both Let terman and Fitzsimons (Denver, CO) Army Medical Centers were closed through BRAC recommendations. Personnel were to be distributed to improve healthcare at other bases with large active-duty populations and to Smaller hospitals, many clinics, laboratories, and other facilities were also consolidated. Both military and civil ian personnel were reduced. Between 1992 and 1999, the sonnel, and 20.1% of civilian full-time equivalents. 38-44 Reorganizations have always been examined as a means to save substantial numbers of personnel. Army Sur geon General Lanoues 1993 reorganization of functions with the establishment of the US Army Medical Com in Washington, DC. LTG Blancks creation of the On eStaff in 1997 was not intended to reduce personnel, but did result in elimination of several positions. 45 In at least one location, Fort Monmouth, NJ, the der contract) and restructured from a small hospital to an outpatient clinic. 46 better established, inpatient services could be reduced 47 There was further civilianization of positions. LTG Lanoue argued that hiring civilian staff would be less work. While civilian employees were cut substantially approximately 2,000 more civilians than originally planned. 48-51 Civilianization included nondeploying spe cialties such as orthotic specialists and podiatrists. 52 The repeated arguments that MHS care was less expensive than CHAMPUS apparently prevented some cuts. Plans over the period 1987 to 1995, while combat arms as a whole would be cut 30%, combat support by 34%, and 53 The Professional Filler System was expanded from pre designating only physicians to include the bulk of medi General Blanck estimated each combat support hospi tal manned at caretaker levels meant $24 million in healthcare delivered. There were further initiatives to improve management. clinical pathways to reduce negative clinical variance. While doubtlessly effective, this action apparently did adopted prime vendor procurement, not just in support of TDA facilities but for deployments to Guantanamo and Haiti. 54 Some senior leaders promoted telemedicine as a tool to save some referrals. 55 There was another move to reduce the average enlisted grade. In 1998, the Army announced changes in the million per year, and helped promotion rates from grade 56 However, these changes were adjusted a year later because the Army realized it was rapidly losing too much lower-level NCO leadership. 57 MHS Coping Strategies in the 1990s The MHS explored additional initiatives involving joint medical organizations and sharing with the VA dur ing the 1990s. The Joint Military Medical Commands equipment for a military organization or unit. A Table of Distribution and Allowances prescribes the organiza tional structure, personnel, equipment authorizations, and re which there is no appropriate TO&E. US MILITARY DRAWDOWNS 1970-1999: ARMY MEDICAL DEPARTMENT AND MILITARY HEALTH SYSTEM RESPONSES


October December 2015 45 in San Francisco and in San Antonio were eliminated. Resource sharing continued, including purchasing and some graduate military education. 58 The Tidewater TriService Managed Care Project was started in southeast ern Virginia in 1992. 59 seeing family members as well as active duty personnel and veterans. 60 There were further efforts towards centralization. A triservice formulary was started in 1993. 61 by centralizing functions. In 1991, the ASD(HA) as sumed oversight of medical research and development programs, forming the Armed Forces Medical Research and Development Agency, which was later disestab lished. 62 Some clinical training programs were merged. The Army and Navy merged their tropical medicine courses in 1996. 63 The Army, Navy, and Air Force merged their dental assistant and dental laboratory tech termined that dental specialist training was inadequate Health Sciences. 22 Programs, including graduate medi cal education, were rationalized where possible. For instance, in the Washington, DC area, Malcolm Grow Medical Center (Andrews Air Force Base) and DeWitt Army Community Hospital (Fort Belvoir) were given primary care missions, while the National Naval Medi cal Center and the Walter Reed Army Medical Center retained a range of secondary and tertiary programs, but reduced overlap. 64 The DoD tried a coordinated care program. The to an MTF, then be referred onwards as necessary. This was something like a medical home, but it also allowed the MHS to decide which patients to send to CHAM PUS and which to treat in-house. This program was only sen instead. In the mid-1990s, DoD obtained approval for Medicare subvention. Somewhat like charging insur ance companies, DoD became able to bill Medicare for care of patients aged 65 years or more. In the 1990 Defense Appropriations Act, Congress di rected a study of doctors in administrative positions, with the intent of making more available to see patients. How There were also proposals to make a larger and pre were proposals to merge the military health services. subordinate commands (for example, preventive medi cine, doctrine/education/training, research and acqui sitions, healthcare delivery) rather than service com mands (Army, Navy, Air Force) was considered. 65 There was a larger proposal for a federal health agency which included merging the MHS with the VA. 65 CONCLUSION numerous challenges in delivering healthcare. Cost was a consistent pressure. Less expensive care provid ers (nonphysicians) were deployed in the 1970s, and tient population and thus avoid costs. However effective this was, the savings were overtaken by cost increases the other military medical departments) for more stan dardization, centralization, and joint operation; this is only continuing with the Defense Health Agency. Coop eration with other federal health agencies also increased, and may well continue to expand in the future. Congress and the DoD were willing to pay for new or clear requirements. When the doctor draft was coming to an end in the early 1970s, Congress approved both the Uniformed Services University of the Health Sciences and the Health Professions Scholarship Program. These were, and remain, costly programs, but were judged nec essary. Similarly, professional special pay, retention bo expenditures had to be made repeatedly, but because the requirement is genuine it was approved, even when bud gets were tight. Drug testing and treatment was a new requirement in the early 1970s, and HIV/AIDS testing was new in the mid-1980s. These were funded because the President and Congress judged them necessary. In 1973, the Secretary of Defense recognized the services were not investing enough in medical facilities and not asking for enough resources, and directed the Surgeons received $40 million more for FY1974 alone (a 23% increase, and equivalent to some $2 billion today) and even more money for a 5-year plan to replace 11 hospi tals and dozens of dental clinics. Both in the 1970s and 1990s, DoD recognized that mili tary healthcare was important for recruiting and reten tion, and either provided money for personnel and facili ties or at least reduced cuts. Careful stewardship of re sources has always been necessary, and there have been continuous reviews of how to contain or avoid costs. There is no straight line from the past, and change will


46 be painful and complex, but there are strong reasons for REFERENCES 1. Fact Sheet. Fort Sam Houston, TX: Historical Re search Collection, Army Medical Department Cen ter of History and Heritage; May 31, 1972. 2. and Command Positions. Fact Sheet. Fort Sam Houston, TX: Historical Research Collection, Army Medical Department Center of History and Heritage; May 31, 1972. 3. Oland DD, Greenhut J. Report of The Surgeon General United States Army Fiscal Years 1976-80 Washington, DC: US Dept of the Army; 1978. 4. Army Regulation 601-142: Army Medical Depart ment Professional Filler System Washington, DC: US Dept of the Army; April 2007. 5. Letter. Fact Sheet. Fort Sam Houston, TX: Histori cal Research Collection, Army Medical Depart ment Center of History and Heritage; May 31, 1972. 6. Development. Fact Sheet. Fort Sam Houston, TX: Historical Research Collection, Army Medical De partment Center of History and Heritage; May 31, 1972. 7. Taylor RT. Surgeon Generals Conference for Army Medical Department Surgeons and Commanders. November 14-16, 1973. Fort Sam Houston, TX: Historical Research Collection, Army Medical De partment Center of History and Heritage; 1974. 8. US Army Health Services Command. Draft Annu al Historical Report, 1 July 1977-30 June 1979. Fort Sam Houston, TX: Historical Research Collection, Army Medical Department Center of History and Heritage; 1980. 9. Taylor RT. Annual Report: The Surgeon General United States Army Fiscal Year 1974 Washington, DC: US Dept of the Army; 1974. 10. Taylor RT. Annual Report: The Surgeon General United States Army Fiscal Year 1975 Washington, DC: US Dept of the Army; 1975. 11. US Army Health Services Command. Annual His torical Report 1 April 1973 30 June 1975. Fort Sam Houston, TX: Historical Research Collection, Army Medical Department Center of History and Heritage; March 1, 1978. 12. Taylor RT. Annual Report: The Surgeon General United States Army Fiscal Year 1972 Washington, DC: US Dept of the Army; 1972. 13. Alternatives in Controlling Department of Defense Manpower Costs. GAO website. 1976. Available at Accessed July 24, 2014. 14. Fact Sheet. Fort Sam Houston, TX: Historical Re search Collection, Army Medical Department Cen ter of History and Heritage; May 31, 1972. 15. US Army Health Services Command. Smoking: look out for dangers. HSC Mercury November 1974;2(2):2. 16. US Army Health Services Command. Lieutenant drink. HSC Mercury May 1975;2(5):4. 17. Seiffert D, Thomas C. Physician links fat to early overfeeding. HSC Mercury January 1977;4(3):6-7. 18. Seiffert D. Doctors mend more hearts. HSC Mer cury February 1977;4(4):1. 19. Seiffert D. Many U.S. Children Overweight. HSC Mercury December 1977;5(3):1. 20. Armed Services Press Service. Loud noise: it can cause medical problems. HSC Mercury May 1979;6(8):4. 21. Cheatham JL. Preventive Care: Hygienists extend Army Dentistry. HSC Mercury May 1978;5(8):5. 22. the History of U.S. Army Dentistry. 2012. Avail able at DCHighlights2012.pdf. Accessed July 24, 2014. 23. duced Reliance on the Doctor Draft. Fact Sheet. Fort Sam Houston, TX: Historical Research Col lection, Army Medical Department Center of His tory and Heritage; May 31, 1972. 24. Taylor RT. Annual Report: The Surgeon General United States Army Fiscal Year 1973 Washington, DC: US Dept of the Army;1973. 25. Depart ment of the Army Historical Summary Fiscal Year 1981 Washington, DC: US Dept of the Army;1988. 26. US Army Health Services Command. HSC pro ceeds full steam on priorities. HSC Mercury Oc tober 1973;1(1):1. 27. US Army Health Services Command. HSC, re serves eye aid. HSC Mercury November 1973;1(2):1. 28. US Army Health Services Command. Medical re serve tries year-round annual training. HSC Mer cury August 1975;2(8):1. 29. Fact Sheet. Fort Sam Houston, TX: Historical Re search Collection, Army Medical Department Cen ter of History and Heritage; May 31, 1972. US MILITARY DRAWDOWNS 1970-1999: ARMY MEDICAL DEPARTMENT AND MILITARY HEALTH SYSTEM RESPONSES


October December 2015 47 30. Carlucci FC. year 1988 Washington, DC: US Dept of Defense, 1989. 31. Department of the Army Historical Summary Fiscal Year 1982 Washington, DC: US Dept of the Army;1988. 32. Asch C. Army targets lifestyles: lets stay healthy. HSC Mercury November 1988;16(2):6. 33. Demma VH, Department of the Army Historical Summary Fiscal Year 1989 Washington, DC: US Dept of the Army; 1988. 34. Kennell D, Savela T, Mitchell R, Roehrig C. Report on the PRIMUS/NAVCARE Programs Washing ton, DC: US Dept of Defense; 1991. Available at: Accessed July 2, 2015. 35. HSC Mercury January 1990;17(4):1. 36. Mercury May 1997;24(8):4. 37. Ledford FF Jr. Army medicine. U.S. Medicine Jan uary 1991:27-28. 38. Department of Defense. Health Manpower Statis tics. Washington, DC: US Dept of Defense; 1992. 39. Department of Defense. Health Manpower Statis tics. Washington, DC: US Dept of Defense; 1993. 40. Department of Defense. Health Manpower Statis tics. Washington, DC: US Dept of Defense; 1994. 41. Department of Defense. Health Manpower Statis tics. Washington, DC: US Dept of Defense; 1995. 42. Department of Defense. Health Manpower Statis tics. Washington, DC: US Dept of Defense; 1996. 43. Department of Defense. Health Manpower Statis tics. Washington, DC: US Dept of Defense; 1998. 44. Department of Defense. Health Manpower Statis tics. Washington, DC: US Dept of Defense; 1999. 45. structure. Mercury July 1997;24(10):3. 46. Burris C. Agreement provides for inpatient care at Monmouth. Mercury December 1995;23(3):5. 47. Harben J. Budget decision shrinks small hospitals. Mercury February 1997;24(5):4. 48. Harben J. Army will convert HSC military slots to civilians. HSC Mercury April 1990;17(7):7. 49. Army News Service. Army civilian reductions will be steep but wont mirror active-duty reductions. HSC Mercury September 1990;17(12):3. 50. Cohen WS. Report of the Secretary of Defense to the President and the Congress Washington, DC: US Dept of Defense; 2000. 51. DASG-HCM. Revised Army Five Year Medical TX: Historical Research Collection, Army Medical Department Center of History and Heritage; May 27, 1994. 52. readiness, promotions. Mercury April 1994;21(7):1. 53. US Army Health Services Command. The shrink ing Army. HSC Mercury September 1991;18(12):12. 54. Kaplan LM. Department of the Army Historical Summary Fiscal Year 1994 Washington, DC: US Dept of the Army; 2000. 55. Reeves CL. Department of the Army Historical Summary Fiscal Year 1996 Washington, DC: US Dept of the Army; 2002. 56. Mercury February 1998;25(5):1. 57. Gilmore GJ. NCO strength lost to CINCOS will be partially restored. Mercury June 1999;26(9):9. 58. Harben J. Proposed budget sees BAMC back in HSC. HSC Mercury May 1991;18(8):1. 59. Webb WJ, Anderson C, Andrade D, et al. Depart ment of the Army Historical Summary Fiscal Years 1990 and 1991 Washington, DC: Department of the Army, 1997. 60. US Army Health Services Command. Army, Air Force cooperate to save on magnetic resonance im agers. HSC Mercury May 1990;17(8):9. 61. Noyes H. Center seeks solutions for drug-cost di lemmas. HSC Mercury November 1993: 7. 62. Harben J. Defense ponders restructuring military health-services system. HSC Mercury August 1990;17(11):12. 63. Thombs C. Army, Navy merge courses to train doctors in tropical medicine. Mercury October 1996;24(1):2. 64. Council of Deputies. Developing an Integrated Na tional Capital Area Military Health Care System. Memorandum. Fort Sam Houston, TX: Historical Research Collection, Army Medical Department Center of History and Heritage; August 27, 1998. 65. organization. Mercury October 1996;24(1):1. AUTHOR JBSA Fort Sam Houston, Texas.


48 Thyrotoxic periodic paralysis is an endocrine disorder characterized by the presence of motor weakness or paralysis, hypokalemia, and clinical signs or labora 1 in many cases, the paralysis may be the only symptom of hyper thyroidism. Because it bears tremendous similarity with other causes of hypokalemic periodic paralysis but re quires different treatment, it should be strongly consid ered in any case of hypokalemic paralysis, particularly in patients of Asian descent. CASE REPORT The patient was a 30-year-old male Soldier who present ed to the emergency department in the morning after he was unable to get out of his bed secondary to pro found weakness, primarily in his lower extremities. He noted that this had happened on 2 occasions recently, al beit with much less severe symptoms, and had resolved spontaneously without evaluation or treatment in each pertension, and he had no family history of similar com plaints. He denied back pain, numbness anywhere, and bowel/bladder incontinence. He was initially slightly hypertensive and tachycardic, with a blood pressure of 154/63 and a heart rate of 113. His exam noted profound symmetric muscle weakness, greater in the lower ex diminished in the upper extremities. His laboratory and a serum thyrotropin (TSH) and free thyroxine of AV block, a prolonged T wave, and the presence of a U a diagnosis of thyrotoxic periodic paralysis. Additional the head was also normal. The patient was subsequent ly admitted to the medicine service for treatment and further evaluation. His symptoms resolved completely following repletion of potassium and treatment of his hyperthyroidism. CO MM ENT Thyrotoxic periodic paralysis (TPP) is an endocrine disorder characterized by paralysis, hypokalemia, and hyperthyroidism. 1 The condition is most common in Asian males, with greater than 90% of cases occurring in Japanese patients. 2 There have, however, also been case reports of TPP occurring in white, black, Hispanic, Polynesian, Greek, and Native American populations, 2-8 The male to female ratio has been reported to be between 20:1 and 70:1, in spite of the fact that hyperthyroidism is more common in women. 1,6 As in our patient, the pa ralysis is typically worse in the lower extremities and the proximal muscle groups. 9 In one review of cases in a Chinese population, the mean serum potassium was re ported to be 2.17, with the lowest reported value of 1.1. 9 Several reviews of this disorder have noted that 60% to 70% of patients have paralysis as their initial present ing symptom of hyperthyroidism. 9,10 This was true in our patient, and it underscores the importance of sus pecting this condition, as there may be no other signs of hyperthyroidism. More extreme presentations have Paralysis as a Presenting Symptom of Hyperthyroidism in an Active Duty Soldier CPT John Jennette MC, USA Dustin Tauferner, DO AB STRACT Thyrotoxic periodic paralysis (TPP) is an endocrine disorder presenting with proximal motor weakness, typi roidism. The incidence of TPP is highest in Asian males. This is a case report of a 30-year-old male active duty Soldier who presented to the emergency department complaining of several recent episodes of lower extremity found to be hypokalemic and hyperthyroid. Following consultation with neurology, the patient was admitted to the medicine service and treated for thyrotoxic periodic paralysis with potassium replacement and treatment of his hyperthyroidism. Since achieving a euthyroid state, he has had no recurrences of TPP. This disease should be considered in patients presenting with symmetric motor weakness and hypokalemia, whether or not symp toms of hyperthyroidism are elicited during the review of systems.


October December 2015 49 also been reported, with many associated complications myxedema, renal tubular acidosis, nystagmus, deafness, and deaths from cardiac and respiratory depression. 11-16 The pathophysiology of TPP is incompletely understood. All patients must have hyperthyroidism, usually caused by Graves disease, however there are also case reports of TPP occurring in patients with active thyroid nodules, TSH secreting pituitary tumors, and exogenous thyroid hormone. 5,17-19 tients with TPP were more likely than controls to have inherited gene may play a role. 20 There is also substantial evidence to suggest that increased activity of the Na/K ATPase in response to thyrotoxicosis plays a consider able role. 21,22 Additionally, recent studies have implicat ed a mutation in a cell wall potassium channel named Kir2.6, which is present in 33% of TPP patients studied, and is regulated by thyroid hormone. 23,24 Attacks of TPP in susceptible individuals can be precipitated by trauma, cold exposure, carbohydrate ingestion, administration of glucose and insulin, exogenous thyroid hormone, high-dose steroids, and a number of different medica tions, and in some circumstances can be aborted by ex ercise. 5,11,25,26 Treatment of TPP includes both repletion of potassium and elimination of the hyperthyroid state. 1 Reports have generally demonstrated that the typical precipitants of TPP are unable to cause paralysis once a patient has reached a euthyroid state. 17,18,25 REFERENCES 1. Vijayakumar A, Ashwath G, Thimmappa D. Thy rotoxic periodic paralysis: clinical challenges. J Thyroid Res 2. Michail S, Dagounaki P, Stamatiadis D, Vaiopou los G, Stathakis C, Vosnides Gr. A case of thyro toxic hypokalaemic periodic paralysis in a Greek man. Nephrol Dial Transplant 1996;11:1634-1636. 3. paralysis in a hyperthyroid black woman. JAMA 1988;80(12):1343-1344. 4. mic periodic paralysis in a Hispanic male. J Natl Med Assoc 1990;82(2):129,133-134. 5. Carroll DG. Hypokalaemic periodic paraly sis in a thyrotoxic Polynesian. Postgrad Med J 1994;70(819):39-40. 6. Ahlawat S, Sachdev A. Hypokalaemic paralysis. Postgrad Med J 1999;75(882):193-197. 7. Zumo LA, Terzian C, Brannan T. Thyrotoxic hy pokalemic periodic paralysis in a Hispanic male. J Natl Med Assoc 2002;94(5):383-386. 8. Ovadia S, Zubkov T, Kope I, Lysyy L. Thyrotoxic hypokalemic periodic paralysis in a Philippine man. Isr Med Assoc J 2006;8(8):579-580. 9. Ko GT, Chow CC, Yeung VT, Chan HH, Li JK, Cockram CS. Thyrotoxic periodic paralysis in a Chinese population. QJM 1996;89(6):463-468. 10. Trifanescu R, Danciulescu Miulescu R, Carsote M, sign of thyrotoxicosis. J Med Life 2013;6(1):72-75. 11. Feldman DL, Goldberg WM. Hyperthyroidism with periodic paralysis. CMAJ 1969;101(11):61-65. 12. Guan R, Cheah JS. Hyperthyroidism with periodic paralysis, acropachy, pre-tibial myxoedema, tran Postgrad Med J 1982;58(682):507-510. 13. T, Kouichi Y. Sudden deafness in a man with thy rotoxic hypokalemic periodic paralysis. Jpn J Med. 1988;27(3):329-332. 14. Szeto CC, Chow CC, Li KY, Ko TC, Yeung VT, Cockram CS. Thyrotoxicosis and renal tubular aci dosis presenting as hypokalaemic paralysis. Br J Rheumatol 1996;35(3):289-291. 15. Loh KC, Pinjeiro L, Ng KS. Thyrotoxic periodic paralysis complicated by near-fatal ventricular ar rhythmias. Singapore Med J 2005;46(2)88-89. 16. Goldberger ZD. Images in cardiovasculare medi cine. An electrocardiogram triad in thyrotoxic hypokalemic periodic paralysis. Circulation. 2007;115(6):e179-e180. 17. Kiso Y, Yoshida K, Kaise K, et al. A case of thyro tropin (TSH)-secreting tumor complicated by peri odic paralysis. Jpn J Med. 1990;29(4)399-404. 18. Crane MG. Periodic paralysis associated with hy perthyroidism. Calif Med 1960;92(4):285-288. 19. Lin YC, Wu CW, Chen HC, et al. Surgical treat ment for thyrotoxic hypokalemic periodic paraly sis: case report. World J Surg Oncol 2012;10:21. 20. Yeo PP, Chan SH, Lui KF, Wee GB, Lim P, Cheah JS. HLA and thyrotoxic periodic paralysis. Br Med J 1978;2(6142):930. 21. Chan A, Shinde R, Chow CC, Cockram CS, Swam inathan R. In vivo and in vitro sodium pump activ ity in subjects with thyrotoxic periodic paralysis. BMJ 1991;303(6810):1096-1099. 22. Murakami K. Studies on the intracellular water, sodium and potassium in thyrotoxic myopathy and in thyrotoxic periodic paralysis. Endocrinol Jpn 1964;11:291-307. 23. Ryan DP, da Silva MRD, Soong TW, et al. Muta tions in potassium channel Kir2.6 cause suscepti bility to thyrotoxic hypokalemic periodic paralysis. Cell 2010;140(1):88-98.


50 24. Lin SH, Huang CL. Mechanism of thyrotoxic period ic paralysis. J Am Soc Nephrol 2012;23(6):985-988. 25. Feely J. Potassium shift in thyrotoxic periodic pa ralysis. Postgrad Med J 1981;57(666):238-239. 26. Tigas S, Papachilleos P, Ligkros N, Andrikoula M, Tsatsoulis A. Hypokalemic paralysis following ad ministration of intravenous methylprednisolone in a patient with Graves thyrotoxicosis and ophthal mopathy. Hormones. 2011;10(4):313-316. AUTHORS R. Darnall Army Medical Center, Fort Hood, Texas. Dr Tauferner is a member of the Faculty of the Depart Medical Center, Fort Hood, Texas. PARALYSIS AS A PRESENTING SYMPTOM OF HYPERTHYROIDISM IN AN ACTIVE DUTY SOLDIER


October December 2015 51 Diarrhea is a leading cause of disease related morbidity and mortality worldwide, especially for children younger than 5 years. 1 Escherichia coli and Shigella are primary infectious agents of bacterial classes of heat-stable (STIa and STIb) and/or heat-labile (LT) plasmid-encoded toxins are produced and mani fested by acute diarrhea. 2 The shigellosis or bacillary dysentery form of diarrheal disease is caused by vari ous chromosomal and plasmid produced virulence fac tors including invasion plasmid antigen H (Shig-ipaH) encoded by a gene conserved across Shigella and en teroinvasive E coli 3 In the absence of prompt and appropriate treatment, these pathogens have the ability to cause fatal diarrhea. and public health practitioners worldwide. 4 Accurate and rapid diagnosis and epidemiological surveillance focused utilization of public health resources in areas and populations most at risk of developing diarrheal ity and mortality and economic cost. However, current limitations in diarrheal disease diagnostics drive the arrheagenic Escherichia coli disease, shigellosis, and Diagnosis, therefore, is often retrospective clinically as well as epidemiologically. Time critical treatment and public health response are unachievable. The time re quired for routine culture as well as relatively poor sen sitivity have driven the development of molecular-based becoming well established in diarrheal disease diagnos tics, surveillance, and food and water safety protocols. This includes restriction enzyme analyses, conventional and RT-PCR, multiplex PCR, loop-mediated isothermal Man Array Card. 5-18 Immunochromatographic dipstick technologies show promise in diarrheal disease agent detection. 19 However, traditional culture remains the reference methodology. Disproportionately high diarrheal disease morbidity and mortality occur in developing countries and can increase exponentially during times of natural disaster A Field-Expedient Method for Direct Detection of Enterotoxigenic E Coli and Shigella from Stool Sasikorn Silapong, BS Ladaporn Bodhidatta, MD Pimmnapar Neesanant, PhD James C. McAvin, MS Orntipa Sethabutr, MS Carl J. Mason, MD Paphavee Lertsethtakarn, PhD AB STRACT of causative agents of enterotoxigenic Escherichia coli were prepared in a thermal-stable, hydrolytic enzyme resistant format. The assays were packaged as a kit for use with a portable, ruggedized, qRT-PCR thermocycler. The analytical limit of detection of each qRT-PCR: Shigella /enteroinva sive E coli stool samples previously obtained from enterotoxigenic E coli disease (n=91) and shigellosis (n=47) patients. Sample processing and analyses were completed in 3 days. Test results of the qRT-PCR assays showed promise ( Shigella Shigella /enteroinvasive E coli (81.6%). Sequenc Shigella from stool and is applicable for use in clinical diagnostics and biosurveillance as an extension of temporary


52 4 The risk of diarrhea outbreak is of ten heightened in these situations due to lack of clean water, poor hygiene, malnutrition, inadequate medical intervention, and limited or absent prevention and con trol intervention. Medical care providers in regions with underdeveloped medical and public health resources or in situations with failing or totally absent infrastructure operating under austere conditions often have no access to laboratory facilities or fundamental public services such as electricity, water, or an intact transportation system. Under these conditions, culture and micros copy methodologies and molecular-based technologies designed for use within conventional laboratory infra structure are unsuitable. These obstacles drive the need for mobile, stand-alone analytic capability. 20,21 In this article we describe a unique analytic capability; Shigella / enteroinvasive E coli assays with portable, ruggedized, real-time qRT-PCR method for direct detection from stool. METHODS Study Site Shigella / was conducted at the Walter Reed Research Unit Nepal (WARUN) central laboratory in Kathmandu. Kathman du is located in south-central Nepal within the Hill Re gion (called Pahar in Nepali) where elevations are mostly between 1,000 m and 4,000 m. Pahar is the most heavily populated region of Nepal, however, development of in frastructure and social services have been hindered due to its geographical isolation, limited economic potential, and a history of political instability. Testing was con ducted during March 31 to 2 April, 2009. March through April is considered the spring season with daily temper atures ranging from 10C to 27C and 80% to 100% hu and Shig-ipaH qRT-PCR assays, thermocycler (Rug (R.A.P.I.D.), BioFire Diagnostics, Inc (BDI), Salt Lake City, UT), and equipment and supplies were packed in 2 hardened cases (Pelican Products, Inc, Torrance, CA). A single individual transported the system by com mercial aircraft as checked-baggage from Department of Medical Sciences (AFRIMS), Bangkok, Thailand, single room of a building without environmental con trol using 2 tabletops approximately 1 m 2 in area. The qRT-PCR assays, nucleic acid preparation reagents, and RAPID instrument were transported and stored and sample preparation and analyses conducted under am bient temperature and humidity conditions, vastly sim plifying reagent management. The RAPID is powered by 110-220 V source such as an electric generator or, if necessary, from the battery of a vehicle with the engine laboratory was equipped with main 220 V power. Samples and Microbiology For the purpose of this study, a test panel of 138 well characterized diarrheagenic E coli disease and shigel ic Escherichia coli and Shigella infecting agents were Shigella serotyping. The test panel consisted of STIa (n=21), STIb (n=30), LT (n=40), and Shig-ipaH (n=47) positive samples. Sampling protocol, stool process Shigella gies have been previously described. 22 Under a previ ous study, clearance for the collection and use of stool the Nepal Health Research Council (NHRC) and the In stitutional Review Board (IRB), Walter Reed Army In stitute of Research (WRAIR), Silver Spring, Maryland (WRAIR IRB #1276 and #1311). Clearance for the use from the NHRC and IRB, Privacy Board, Wilford Hall Medical Center, Lackland AFB, San Antonio, Texas. Stool samples were labeled by code and double-blinded testing was conducted. Routine culture, DIG-labeled Shigella ), were compared to qRT-PCR and sequences of amplicon products. Prior earity, limit of detection (LOD), and in vitro sensitivity ized reference strains from culture using the RAPID in strument. Type strains were subcultured on agar plates and several colonies were picked and suspended in nor mal saline. The measured absorbance at 625 nm was trophotometrically. Stocks of undiluted cell suspension (viable cell count 1.5 10 8 cells/mL) were established; extracted nucleic acid was prepared and serially diluted at 1.5 10 8 cells/mL to 1.5 10 0 cells/mL. Linearity and strain ATCC12022, respectively. A FIELD-EXPEDIENT METHOD FOR DIRECT DETECTION OF ENTEROTOXIGENIC E COLI AND SHIGELLA FROM STOOL


October December 2015 53 Nucleic Acid Preparation kit; a 10% (wt/vol) stool suspension was prepared with 2,600 g for 15 minutes. Nucleic acid was extracted Kit (bioMrieux, Inc., Durham, NC) according to the manufacturers in L of the stool suspension was treated with 1.4 mL lysis-buffer and mixed with para magnetic silica particles. The bound nucleic acid was washed twice with 400 L wash buffer I (5 M guanidine with 500 L wash buffer III (disodium tetraborate). Finally, the nucleic acid was eluted from the silica by incubation in 75 used in this study was equipped with a -70C freezer used for qRT-PCR testing. Polymerase Chain Reaction preparation of thermal-stabilized, hydrolytic enzyme resistant RAPID-based qRT-PCR freeze-dried assays. 5-7,23,24 Separate Shigella for infection by either of these agents. Moreover, Shigella Optimal wet reaction conditions for STIa, STIb, LT, and Shig-ipaH qRT-PCR assays were: 400 nM Forward Primer, 400 nM Reverse Primer, and 150 nM TaqMan Probe, 1:10 dilution of 10X qRT-PCR buffer with BSA and 30 mM MgCl 2 (BDI part number 1770), 1:10 dilution of 10X 2 mM dNTP mixture (BDI part number 1774), and 2 L of a mixture of 10X Taq polymerase (0.16 L), antibody (0.16 L), and enzyme diluent (1.68 L) (BDI). Reaction volume was 20 L consisting of 18 L of master mix and 2 L of template. A standardized qRT-PCR thermocy cling protocol consists of an initial DNA denaturation at 95C for 3 minutes, and qRT-PCR for 45 cycles at 95C for zero seconds (sinusoidal temperature curve) for template denaturation and 60C for 20 seconds of combined CATATAACATGATGCAA-3), Reverse Primer (5-CTAATGTAATTTTCTCTTTTGAAGAGTCA-3), and Probe (5-FAM-TTAGCTTTTTCATGTTACCTCCCGTCATGT-TAMRA-3) designed using BLAST database nucleic acid sequence of the E coli toxin I ( estA1 Primer (5 -TTCACCTTTC(G/C)CTCAGGATGC -3), Reverse Primer (5-ATAGCACCCGGTACAAGCAGG-3), and Probe (5-FAM-TCACAGCAGTAATTGCTACTATTCATGCTTTCAGGA-TAMRA-3) target sequence was E coli heat-stable toxin ( st TACGGCGTTACTATCCT-3), Reverse Primer (5-GGGACTTCGACCTGAAATGTT-3), and Probe (5-FAM -CTTTTGCCTGCCATCGATTCCGTATAT-TAMRA-3) target sequence was E coli heat-labile enterotoxin B subunit at accession number S60731; Shig-ipaH Forward Primer (5-CCTTTTCCGCGTTCCTTGA-3), Reverse Primer (5-CGGAATCCGGAGGTATTGC-3), and Probe (5-FAM-CGCCTTTCCGATACCGTCTCTGCA-TAM RA-3), target sequence was invasion plasmid antigen H ( ipaH ) gene at accession number M32063. 24,25 master mix reagents (BDI). 26,27 Thermal-stable qRT-PCR Assays and Validation Testing PCR assays were freeze-dried in a thermal-stable, hy drolytic enzyme resistant formulation by a proprietary process and packaged in a preformatted kit by BDI. The freeze-dried qRT-PCR master mix reagents only re quired hydration and addition of sample template prior to analysis. Assays were prepared according to manu facturer (BDI) instructions. A standardized qRT-PCR thermal cycling protocol was used (described above). Linear regression analysis was conducted using tripli cate dilution series samples spanning 6 orders of mag nitude (1.5 10 8 cells/mL to 1.5 10 3 cells/mL). Corre 2 ) values were established at unity provided in the RAPID analytical software (Roche Mo lecular Biochemicals, Indianapolis, IN). Based on linear regression analysis results, the LOD of each assay was estimated and subjected to replicate testing (n=60) by STIa, STIb, LT, and Shig-ipaH qRT-PCR assay in vitro consisting of well characterized nucleic acid extracts. Stringent cross-reactivity testing of each qRT-PCR as say was conducted using each genetic near neighbor as well as other common diarrheal pathogens. To deter mine the ability of the assay to detect multiple strains of the same organism (in vitro sensitivity), extract of


54 1-fold LOD and 10-fold LOD viable cell con centrations were prepared and testing was conducted in triplicate. To determine whether the assay cross-reacts with other closelyand tract of at least 1000-fold LOD viable cell concentrations were prepared and testing was conducted in triplicate. Data Acquisition and Analyses tered electronically in the RAPID operating sys tem run protocol. Analyses and results were au tomatically archived. The criterion for a positive over background levels, ie, critical threshold (Ct), analytical software (Roche Molecular Biochemicals, 26,27 The Ct cutoff value was 40 or less. Nucleic Acid Sequencing PCR and a combination of culture with DIG-labeled Shigella serotyping were compared to qRT-PCR amplicon product sequencing. The se quencing reaction was one direction. The acceptance mology using generated sequence of 150 or more base pairs of an acceptable quality. Several samples tested concentration of amplicon for use in sequencing. The associated qRT-PCR results were excluded from se Shigella ipaH sample (n=47-1 excluded=46). Additionally, Shi gella positive samples by culture were excluded from sequencing comparison with Shigella ipaH qRT-PCR (n=46-31 positive culture=15). RESULTS Linearity and Limit of Detection of qRT-PCR Assays says resulted in an estimated LOD at 30 CFU per 20 L of reaction volume and 3 CFU per 20 L reaction vol ume for Shig-ipaH qRT-PCR assay (Table 1). Replicate testing by 2 different operators, over 3 days, running 20 samples per day at the estimated LOD achieved a rep licate test score of 100% (60/60) for all qRT-PCR as says. Results for LOD replicate test results are reported in Table 2. Positive and Negative Template Control Reactions Positive template control (PTC) reactions were prepared for each of the 4 assays at 10-fold LOD concentrations. Shigella Shigella son nei ATCC25931, respectively. The PTC reactions con template control (NTC) reactions consistently reported Sensitivity and Specificity Testing Using Reference Strains sults were concordant with reference strains (Table 3). In sensitivity testing, 3 reference strains representing each testing, 2 reference strains representing each pathogen at 1000-fold LOD concentrations. Cross-reactivity and inhibition of qRT-PCR were not observed. Throughout laboratory-based Field-evaluation Using Stool Samples (n=40)and Shig-ipaH (n=47) qRT-PCR assay sensitiv ( Shigella ) results (Table 5). Subsequent comparison of sequences of qRT-PCR amplicon indicated that all 4 as A FIELD-EXPEDIENT METHOD FOR DIRECT DETECTION OF ENTEROTOXIGENIC E COLI AND SHIGELLA FROM STOOL Table 2 Limit of detection replicate testing of qRT-PCR assays ex pressed as critical threshold (Ct). ETEC-STIa Ct (Mean/STDV) ETEC-STIb Ct (Mean/STDV) LT Ct (Mean/STDV) Ct (Mean/STDV) Replicate 1 34.07/0.49 33.66/0.77 34.94/0.59 36.03/0.65 Replicate 2 34.63/0.37 34.88/0.29 34.56/0.33 36.33/0.65 Replicate 3 35.94/0.35 34.07/0.69 34.93/0.43 36.32/0.48 Average 34.88/0.40 34.20/0.58 34.81/0.45 36.23/0.59 N= 20 for all qRT-PCR assays. Table 1 Linearity of qRT-PCR assay. STIa (AF-ETEC727) STIb (AF-ETEC771) LT (AF-ETEC966) (ATCC12022) Correlation coefficient 1.00 1.00 1.00 1.00 Slope 3.512 3.357 3.438 3.306 Error 0.0428 0.0793 0.0283 0.0787


October December 2015 55 as sequences of target pathogen at 90% or greater homology. Sequencing and qRT-PCR 100% (28/28), and Shig-ipaH 100% (15/15). Sample preparation, nucleic acid extraction, and analyses were conducted without provi sion for spatial separation. CO MM ENT Escherichia coli STIa, STIb, LT and Shig-ipaH qRT-PCR assay linearity and LOD test results were robust and reproducible. The established LOD of each qRT-PCR assay was validated in stringent replicate sample testing. Using a diverse panel of reference strains repre senting genotypically similar and clinically and LT and Shig-ipaH qRT-PCR assays proved to be highly sensitive and diarrheagenic E coli and shigellosis disease agents from stool samples. Sensitivity test results indicated that the qRT-PCR assays performed at evidenced by DNA sequencing. No false negative or false positive results were observed. Compared to qRTPCR amplicon sequencing, culture tivity levels and associated negative predictive values were not as robust as qRT-PCR. Furthermore, com and Shigella serotyping to qRT-PCR amplicon sequencing clearly showed that the qRT-PCR assays were more cence indicated that the assays re mained stable at ambient temperatures. Cross-over con tamination monitored by NTC consistently reported no Shigella and the risk of an outbreak situation is increased, especially where medical and public health resources are overbur dened or absent. In this study, our analytic system was rapidly deployed to an underdeveloped region and in tegrated into a community health program. In support of ongoing disease surveillance, 138 stool samples were diarrheagenic E coli disease and bacillary dysentery agents was accomplished in 3 days. Processing and analyses of a batch of 30 samples was completed in less than 3 hours. This has important clinical implications in decision-making of the necessity and appropriate selec tion of antibiotic therapy and time critical treatment. 22 Diarrheagenic E coli and bacillary dysentery symptoms are easily confused with those of other diarrheal dis eases as well as other common infectious diseases and Table 4 Results of ETEC and Shigella reference strains from culture. Strain Pathogen(s) ETEC-STIa qRT-PCR ( 1000 X LOD) ETEC-STIb qRT-PCR ( 1000 X LOD) ETEC-LT qRT-PCR ( 1000 X LOD) Shigella -ipaH qRT-PCR ( 1000 X LOD) AF-ETEC 929 ETEC STIa Positive Negative Negative Negative AF-ETEC 727 ETEC STIa Positive Negative Negative Negative AF-ETEC 877 ETEC STIb Negative Positive Negative Negative AF-ETEC 771 ETEC STIb Negative Positive Negative Negative AF-ETEC 966 ETEC-LT Negative Negative Positive Negative AF-ETEC 083 ETEC-LT Negative Negative Positive Negative ATCC 25931 Shigella sonnei Negative Negative Negative Positive ATCC 25922 Escherichia coli Negative Negative Negative Negative ATCC 70819 Campylobacter jejuni Negative Negative Negative Negative AF-SAL 0085 Salmonella gr. E 4 Negative Negative Negative Negative AF-SAL 445 Salmonella paratyphi A Negative Negative Negative Negative ETEC-STIa, STIb, and LT assay LOD= 1 5 10 4 cell/mL; Shigella /EIEC-ipaH assay LOD= 1 5 10 3 cell/mL. Table 3 Results of ETEC and Shigella /EIEC-ipaH qRT-PCR sensitivity testing using reference strains from culture. Strain Pathogen(s) PCR Assay Ct ( 1 X LOD) a (Mean/STDV) b Ct ( 1 X LOD) a (Mean/STDV) b AF-ETEC 929 ETEC STIa ETEC-STIa 37.36/0.26 33.91/0.09 AF-ETEC 727 ETEC STIa ETEC-STIa 35.81/0.07 32.09/0.16 AF-ETEC 721 ETEC STIa and LT ETEC-STIa 36.43/0.50 32.57/0.47 AF-ETEC 877 ETEC STIb ETEC-STIb 34.85/0.10 31.09/0.54 AF-ETEC 771 ETEC STIb ETEC-STIb 34.66/0.66 30.61/0.54 AF-ETEC 816 ETEC STIb and LT ETEC-STIb 34.09/0.28 30.79/0.09 AF-ETEC 966 ETEC-LT ETEC-LT 34.18/0.46 31.05/0.09 AF-ETEC 083 ETEC-LT ETEC-LT 33.81/0.50 30.34/0.11 AF-ETEC 816 ETEC-LT and STIb ETEC-LT 34.23/0.25 31.00/0.08 ATCC 12022 Shigella Shigella /EIEC-ipaH 36.32/0.61 33.01/0.32 ATCC 25931 Shigella Shigella /EIEC-ipaH 34.01/0.12 30.59/0.10 2457 T Shigella Shigella /EIEC-ipaH 35.57/0.29 32.67/0.21 a ETEC-STIa, STIb, and LT assay LOD= 1 5 104 cell/mL; Shigella/EIEC-ipaH assay LOD= 1 5 103 cell/mL b Samples were run in triplicate.


56 treatment is most effective when started 24 to 48 hours after the onset of diarrhea. 28-30 An accurate diagnosis is needed quickly for ef our qRT-PCR system, culture re quired one week of labor-intensive effort requiring advanced skills, and results showed lower sensitiv ity and positive predictive values compared to qRT-PCR. Current limitations in diagnostics drive the need for effective disease prevention and control. The results reported here and in previous studies indicate that di arrheal disease prevalence may be underestimated in epidemiological surveys conducting using culture meth odology versus more sensitive technologies. 7,10,13,19 Rapid tial to timely and focused implementation of priority in tervention measures directed at preventable conditions. This is especially important in socioeconomic develop ing regions during times of disaster when local public health resources are often overwhelmed. Human and environmental surveillance data collected in a spatially focused and expedient manner augment the predictive power of transmission risk. Correctly collected and in terpreted data on human infection and contaminated food, water, and environment integrated with other key transmission indicators (severity of cases, virulence of critical contamination control points, and climatic and geographical factors) provide for accurate transmission risk assessment. These data assist decision-makers in the appropri ate use of antibiotics to mitigate transmission and epidemiological approach, and the dedication of re sources for focused application of control measures such as potable water sources, hand washing sta tions, and monitoring food prepa ration and hygienic practices. Ag surveillance capability can provide valuable assistance to local public health practitioners by serving to alert and direct focus of preventive and control measures. detection of enterotoxigenic E coli and Shigella from health and potentially provide a valuable diagnostic aid. ACKNOWLEDGE M ENTS We thank the bacteriology section and molecular sciences for serotyping of Shigella spectively. We thank the Ministry of Public Health, Nepal, for providing valuable support throughout this study. This work was funded in part by the Diseases of the Most Im poverished Program, funded by the Bill and Melinda Gates Foundation, the Armed Forces Health Surveillance Centerof Modernization, Falls Church, VA. REFERENCES 1. Global regional and national causes of child mortality in 2008; a systematic analysis. Lancet 2010;375(9730):1969-1987. 2. Johnson TJ, Nolan LK. Pathogenomics Microbiol Mol Biol Rev 2009;73:750-774. 3. Schroeder GN, Hilbi H. Molecu lar pathogenesis of Shigella spp: control ling host cell signaling invasion and death by type III secretion. Clin Microbiol Rev 2008;21(1):134-156. 4. Pawlowski SW, Warren CA, Guer rant R. Diagnosis and treatment of acute or persistent diarrhea. Gastroenterology 2009;136(6):1874-1886. 5. simple polymerase chain reaction technique to detect and differentiate Shigella and en Diagn Microbiol Infect Dis 1997;28:19-25. A FIELD-EXPEDIENT METHOD FOR DIRECT DETECTION OF ENTEROTOXIGENIC E COLI AND SHIGELLA FROM STOOL Table 6 Analyses of real-time qRT-PCR and standard methods using DNA sequencing as the comparator test. Test Method Positive Specimens by Test Method/Sequencing Sensitivity (%) Sequence Homology (%) ETEC STIa real-time qRT-PCR 21 / 21 100 98 100 ETEC STIa hybridization DIG-labeled probe 13 / 21 72 4 ETEC STIb real-time qRT-PCR 28 / 28 a 100 91 100 ETEC STIb hybridization DIG-labeled probe 23 / 28 84 8 ETEC LT real-time qRT-PCR 40 / 40 100 98 100 ETEC LT hybridization DIG-labeled probe 20 / 40 66 7 Shig-ipaH real-time qRT-PCR 15 / 15 a,b 100 99 100 Shig-ipaH serotyping 8 / 15 a,b 68 2 a Positive samples from qRT-PCR with insufficient amplicon concentration for DNA sequencing were excluded from comparison testing (ETEC STIb (n= 30 2 excluded= 28 ) and Shigella-ipaH (n= 47-1 excluded= 46 ). b Positive samples from qRT-PCR but negative by culture were selected for sequencing (Shig-ipaH; n= 46-31 positive culture= 15 ). Table 5 and Shigella assays ( 138 samples) compar ing real time qRT-PCR results to hybridization of DIG-labeled probe (ETEC) and serotyping ( Shigella ) results. qRT-PCR Sensitivity % % ETEC STIa 100 92.4 ETEC STIb 100 92.6 ETEC LT 100 79.6 Shig-ipaH 100 81.6


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58 29. Abubakar I, Irvine C, Aldus F, et al. A systematic review of the clinical public health and cost-effec tiveness of rapid diagnostic tests for the detection gens in faeces and food. Health Technol Assess 2007;11(36):1-216. 30. Mandrekar J, Patel R. Three-hour molecular detec tion of Campylobacter Salmonella Yersinia and Shi gella species in feces with accuracy as high as that of culture. J Clin Microbiol 2010;48(8):2929-2933. AUTHORS Ms Silapong, Dr Neesanant, Ms Sethabutr, Dr Lertseth takarn, Dr Bodhitta, and Dr Mason are with the Depart tute of Medical Sciences (AFRIMS), Bangkok, Thailand. During the conduct of this work, Mr McAvin served as a Molecular Biologist with the 59th Medical Wing, Lack teric Diseases, AFRIMS, Bangkok, Thailand. A FIELD-EXPEDIENT METHOD FOR DIRECT DETECTION OF ENTEROTOXIGENIC E COLI AND SHIGELLA FROM STOOL


October December 2015 59 Much like the business world, todays combat environ ment is awash in data which is gathered for a variety of operating purposes. Healthcare in the deployed en vironment is not an exception. The Big Data move ment is largely about taking advantage of the data that is already resident in the various systems that a company operates and turning it into actionable information. 1 The key change over the last several years is an increase in volume, velocity, variety of data. 2 There is more data, it is coming in faster than ever before, and it is coming from different sources. This change is true both in civil ian and military applications. is rapid and subject to sudden and possibly violent turns. ronment is a data-driven process. Data allows decisionmakers to go beyond vague intuitions. 3 Data from vari ous systems can be used to improve leaders situational understanding, a critical part of the operations process. 4 In his book, Knight 5 distinguishes between risk and un certainty, allowing that risk was properly envisioned as those things which can be measured and thereby con trolled through proper planning. Unlike risk, uncertain ty is unmeasurable. It arises from conditions that could planned for, while preparing as best as possible for those things which are truly uncertain. What follows is a case study of decision-making under conditions of austerity. There are 2 sets of lessons to be learned from this case study: (1) despite limitations, authors Mellott and Mapes devised a reasonably useful (2) the process they used illustrates good principles for future leaders to follow when faced with the problem of developing similar heuristic approaches. METHODS Background 2nd Medical Brigade deployed to Afghanistan as part of had the mission to provide world-class health support to Coalition Forces conducting operations in coordination elon Above Brigade Combat Team level. 6 This meant TF operations between US military units from all 3 servic es, as well as coordinating with allied coalition forces and their respective medical elements to provide medi cal support for the entire Afghan theater. The Coalition the process of transferring control of military operations to the Afghan government and withdrawing from the country. This process required continuous adjustment as troop levels and operations changed throughout the theater in response to the withdrawal, making command and control of medical assets more complex. surgical care in remote locations. The majority of this could provide forward surgical support. The FST is a 20-man team which provides far forward surgi cal intervention to render nontransportable patients suf III hospital. 7 Data Analytics Under Deployed Conditions: A Case Study LTC Mark D. Mellott, MS, USA Mark J. Bonica, PhD, MBA, MS LTC Matthew J. Mapes, MS, USA AB STRACT of transforming data into actionable information. Not all data is useful for decision-making and not all data comes neatly packaged. In this case study, the authors present an effort to collect and analyze data about forward surgical team utilization. The article shares the variety of data collected and the process of analysis, and


60 ing the same surgical capability, but with less depth in personnel and equipment. An FST may be separated average patient load. However, over half of the larger hospitals in theater were run by Coalition partners such as the British, Spanish, French, and Germans, and some of the forward surgical support was provided by Coali tion partners not under the command and control of TF commands, with some of the regions commanded by Coalition partners. Coordinating with Coalition partners process. Some of those challenges were the result of lan guage, cultural, and organizational barriers. A critical impediment was that Coalition partners and US forces did not share a robust medical information system. The US-operated Medical Situational Analysis in the Theater (MSAT) is a robust platform that brings togeth er a number of data feeds, some of which are addressed later in this article. The MSAT is designed to integrate medical information about US forces into a single sys tem. 8 However, the MSAT includes information about the disposition of US forces and personnel that is not shared with Coalition units. Furthermore, the MSAT only runs on the US Secret Internet Protocol Router Network (SIPRNet), to which Coalition forces are not allowed access. To share information with Coalition rate system designed to be shared with Coalition part ners. Using the full functionality of MSAT would cause double reporting: once for the International Security once for US forces only, in MSAT. The reality was that both systems were partially used. Leaders had to look across 3 computer systems searching for information to develop an understanding of the medical situation, and to acquire data necessary to facilitate decision-making. problem of incomplete data in the MSAT. Some mea sures that could have been captured in MSAT were not, decision-making purposes. For example, the Triage Re vised Trauma Score (T-RTS) is commonly used to mea sure trauma workload. The T-RTS is an aggregated mea sure of 3 physiologic scores: the Glasgow Coma Scale, systolic blood pressure, and respiratory rate. These 3 scores were not captured across the theater in the elec T-RTS measure was not available from MSAT. The military medical facilities, and often asks for more in Operating in a coalition environment also presented a included rules for the medical care of contractor, Af ghan military partners, and local national healthcare in deployed US military treatment facilities. The multiple classes of individuals who could be treated at a medical facility, and how they were either evacuated or trans ferred depending on their status further complicated the analysis of the medical situation. PRO B LE M sented with an economic problem: he was required to provide forward surgical support in the many remote sources were limited, he had to leave some areas with out coverage or with a lower level of coverage than he would have preferred. Like any commander, his goal was to reduce risk by increasing his knowledge of the situation. 9 As a result, he needed a metric or metrics to guide his decision-making. He needed metrics that could measure the activity of an FST to determine if the had dropped enough, possibly as a result of withdrawal and transfer activities, that it could be reassigned else where in theater. In a civilian or military hospital in the United States, the most common measures of clinical workload are rela tive value units (RVU) and relative weighted products (RWP). 10 These measures are commonly accepted as representative of the amount of effort engaging a pro vider and an organization. The RVU and RWP weight outpatient encounters and inpatient admissions, respec tively, to allow cross-comparison of work between pro viders and facilities. In addition to the complexity and ric exists for the medical commander in theater to help him/her make decisions. ed that authors Mellott and Mapes develop a method of port planning for reduced personnel numbers, in particu Process Improvement Goal DATA ANALYTICS UNDER DEPLOYED CONDITIONS: A CASE STUDY


October December 2015 61 Metrics Development Process commanders intent. Any metric be both valid and reliable. 11 The metric is valid if it actually measures what it was supposed to measure. The metric is reliable if it returns the same results each time it is used in similar circum stances. There can be a tradeoff between validity and reliability, especially when trying to measure something as complex as the need for forward sur gical capability. A very good measure for validity may require time and effort to appropriately cap ting, medical personnel are primarily worried about saving patients lives. Time-consuming measures are unlikely to be treated as important, and there fore compliance is likely to be low. Low compli ance will result in low reliability of the measure. A simple measurement process is likely to get better compliance and more accuracy. Recognizing the trade-off between validity and reliability and an unwillingness to move resources from patient care to measurement, the authors em phasized using existing data sources. By limiting the measurements to existing data, no additional compliance/reliability issues were reduced. Given the 2 baseline requirements above, the met rics still had to account for the complexity of the in tervention. Any attempt to measure workload must allow for some form of weighting, so, for example, that sick call workload is not treated the same as trauma. Furthermore, not all traumas the same. In an environment where evacuation is key, an ab dominal gunshot wound could consume much more time and resources than other traumas. Additionally, there should be an adjustment for surges in patients for a unit. For example, in a large hospital with a number of surgeons and operating rooms, multiple wounded may or may not mean a mass casualty event. However, 2 individuals with The metrics also must allow for the different types dictates how the treating units must deal with the patients they see, with different patient types hav ing different requirements for evacuation or trans fer, causing differences in workload, even for pa tients with the same diagnosis. Finally, there was a requirement to account for per sonnel numbers. As the presence of Coalition forces in Afghanistan was reduced, medical coverage and the number of medical personnel also needed to decrease. With these requirements, the authors searched for exist ing data sets that could potentially provide workload in formation that could be used to reliably model forward surgical capability requirements. Two data sets, the In addition to these data sets, surgical data, evacuation data, and personnel data were pulled from other existing reports. Mellott and Mapes recognized that there was a trove of data already being collected, and in the fol lowing sections, the variables selected and the reasoning behind their selection are discussed. Ultimately the goal was to take existing data already resident in available systems and processes and transform it into useful in formation for decision-making. MSAT Electronic Medical Record level data about workload at each unit. For the purpose of the analysis, 3 months of medical records were extract ed directly from MSAT. The variables the authors drew Encounters count of the number of times providers gave care to patients. It serves as a partial proxy for workload. Because of its unweighted nature, it gives an in complete picture by itself since it does not differen tiate the level of care provided during the encounter. Injury Type Injury type included 3 possible entries: disease, nonbattle injury, and battle injury. Since surgical capability, the authors wanted to identify whether the units were being used for surgery or for general medical support. Visit Type This was a simple binary choice of new visit or follow-up. The authors would not expect a high level of follow-up care, which could also indi cate misuse of the unit. Disposition There were 3 possible dispositions: pa tients were admitted (held for over 12 hours within the facility), evacuated, or returned to duty. Al minimal holding capability is sometimes a neces sity due to austere conditions. ICD9 Diagnosis The ICD-9 code allows for greater clarity regarding the type and severity of injury. Di agnosis codes would allow an analysis of the kind and intensity of care being provided at the unit. Patient Branch of Service Within MSAT, this vari able would allow the authors to decipher the status


62 included codes for US service member, Coalition member, contractor, DoD civilian, member of the Afghan National Security Forces, or a local national. ing similar information, the researchers found clini cians most consistently used this particular variable. use in modeling because the MSAT is the system of re particularly concerning data quality. Field patient re cords, especially during high volume periods, were fre quently left incomplete or were only partially completed by providers. Failure to complete the record arose from 2 factors: Complexity of the Record the system of record, it was more appropriate for a hospital/clinic setting because it required excessive granularity of data and offered too many choices to providers. Furthermore, the complexity made it un it was designed as a patient record, not for aggrega tion and decision-making. General Provider Compliance and Completion Pro focused on immediate lifesaving activities, not on data quality could be of concern. This would be es pecially so if a provider is completing the record from memory after the fact, days, weeks, or months after the encounter. ful in modifying the encounter data to provide weight ing, much as RVU weights are assigned to encounters in a nondeployed healthcare setting. MSAT Blood Usage Blood usage is also tracked in the MSAT and this data was extracted. Blood usage was conceived of as a mea sure of acuity, with the thought that more serious surgi allocated would require more blood. Thus, a higher level of blood use would be a good proxy for a higher level of surgical acuity. If this was an accurate proxy, it would provide a simple and objective measure for decid ing which units were being used appropriately for their surgical capability. For measures, the authors used the monthly number of blood transfusions per facility. Us ing blood as a measure is a good example of the tradeoff between validity and reliability. The accuracy of the blood usage data was high because it is tracked through the logistics ordering system and requires no further manipulation. However, this measure did not provide information about how much blood was used per patient. Consequently, usage per month could look the same for a facility that treated several patients with a few units of blood and another facility that treated one patient with many units of blood. Surgical Data Surgical data variables were derived from the Interna tional Security Assistance Force (ISAF) Joint Command Medical Assessment Report. This report was updated every 3 hours by each Coalition medical facility in Af gical data measures drawn from the data set included: Number of Surgeries An unweighted count of the number of surgeries, not unlike patient encounters. Number of Surgical Hours An unweighted count of the number of surgical hours reported. Surgi cal hours did not differentiate among the number of personnel involved in providing the surgical intervention. Average Hours per Surgery As with the two above, an unweighted average not adjusted for acuity, equipment, or personnel. The variables drawn from this dataset were envisioned as possibly serving as proxies for acuity. There were 2 main, known concerns with this dataset. First, there was or underreported. Secondly, the numbers reported in this dataset were aggregates not connected to particular surgeries. As a result, the information in this system is not directly helpful for the sick and wounded US service member as numbers of hours per surgery and related in formation are not applied to an individual patient record. Although not helpful to the individual deployed service members record, it is a measurement across the Com bined Joint Operations AreaAfghanistan and includes information from Coalition partners. Further, as this is an online spreadsheet in SharePoint, it is easy to update as mandated. Lastly, this metric is commander-friend ly. Commanders rely on metrics like these and others such as bed status and availability of operating rooms to make medical-operational decisions. Evacuation Data was updated in near real-time and monitored by each re gional command, and was serving as the central reposi tory for casualty evacuation data in theater. The data was maintained in an online spreadsheet, making it easy DATA ANALYTICS UNDER DEPLOYED CONDITIONS: A CASE STUDY


October December 2015 63 ation data measures drawn from the data set included: The average number of patients per evacuation gives trend data on the intensity coming from each loca tion. Higher average numbers per evacuation indi cates more intense rates of casualties per incident. Number of patients evacuated to/from each location. One of the purposes of the report was to keep command ers informed of nonstandard evacuations. Nonstandard evacuations are evacuations of patients by nonmedical transport. One of the goals of the medical system was to minimize nonstandard evacuations to ensure quality of patient care. The evacuation data in this report was cross-checked systematically against monitored helicop Data Gathering were pulled from each of the data sets listed above to perform the analysis. The advantage of this method ology is reliance on historical data already resident in the systems discussed without the burden of collecting additional data on units being studied. In some cases where units were outliers, a follow up with the unit com Otherwise, the organizations were not further burdened in the production of the information. ANALYSIS AND RESULTS The review of the listed data sets yielded extensive raw data from each. The mission was to take that data and turn it into actionable information for the commander. To that end, the data was analyzed from the perspec tive of the surgical team mission in support of the wider was far-forward surgical treatment of trauma, although inevitably the team treated other forms of injuries and illnesses. 12 Since the commanders priority was to allocate surgi cal resources where they were most needed, the authors determined that the core measure for determining team weighted measure alone could potentially be mislead ing, depending on the business processes and local uti lization of each surgical element. While the mission of a surgical team is trauma surgery for Coalition forces, providers will generally perform other medical missions experience, they will also provide care for Afghan sol diers and local nationals on occasion. These latter func tions happen, but are not part of the primary mission making decisions about allocation of medical resources patient category, excluding patients who should not have Since care for these patients was not the mission of the team, and this workload should not have been used in determining future resource allocation. ing those with ICD-9 codes that indicated the encounter did not represent treatment that was part of the surgical counters with ICD-9 codes in the 800-999 range (injury and poisoning categories) were included, and further ther elimination of nontrauma encounters. All trauma, including nonbattle trauma such as accidental vehicle rollovers, were included. workload spread over the 19 sites. A sample of the data At this stage, the remaining workload was aggregated by site and by month for an initial review. The goal of any decision-making model matches the logic of Occams Razor: it is best to seek the simplest model possible. 13 If one data point is capable of providing the informa tion that a commander needs to make a decision, it is data requires resourcesmanpower and time at a mini mumand there are certainly diminishing returns to search. 14 Table 1 presents the array of workload by unit. In terms of average workload, there appears to be 3 clusters, with one outlier at the top of the distribution. As noted pre viously, this data is unweighted, with each encounter counted the same as any other, even though some of the encounters may have represented much more seri ous injuries. Nevertheless, this distribution provides the framework for further analysis. The low number of encounters seen among the units at the bottom of the distribution supported a recommenda tion to have those units relocated to areas with a heavi er medical mission. One of the units was ultimately moved; 2 were left in place despite their low utilization. Of the 2 left, one was providing support to very remote


64 carious at best, and, although there were relatively few commander deemed the mission valid. The second unit was left in place despite low utilization for other consid erations, which are not within the scope of this article. These examples show that a quantitative model must still be tempered by mission requirements. At the top of the distribution, policy was adjusted for FST D, the high ing some proxy for acuity was important to generate a more robust representation of actual medical need. To that end, other data sets were reviewed. Surgical workload was examined in terms of the number of surgeries, the total number of surgical hours, and the average number of hours per surgery. The authors found that the number of surgeries correlated strongly (0.85) with the number of surgical hours, as might be expected. number of surgeries correlated with the average number of hours per surgery. If average surgical hours are a mea sure of the acuity of the work done at the site, it would seem that the acuity was somewhat arbitrary. This could be a result of a random distribution of injuries through out the theater and among the sites. However, further qualitative analysis through discussions with the units practice by the individual surgeons. Some surgeons at tempted to do more at the site, extending the duration of the surgery, while other surgeons primarily stabilized seriously injured patients for further evacuation. The number of transfusions is an objective measure and is moderately correlated with the number of surgeries (0.48) and number of surgical hours (0.56). Because this measure is objective, it was looked at favorably for in clusion as a measure of acuity. correlated with surgical hours per surgery. Table 2 presents correlations among data variables. Many of the variables show low correlation with each other. High correlation between/among variables would suggest a relationship, and in some cases it appears that we do see higher levels of correlation. DATA ANALYTICS UNDER DEPLOYED CONDITIONS: A CASE STUDY Encounter Date Initial Visit Flag Injury Type Patient Branch of Service Disposition ICD9 Diagnosis Primary ICD9 Facility Description ICD93 Code Facility Branch of Service All ICD9 Encounter Timestamp Patient Category J Y Nonbattle Injury CIV Returned To Duty Traumatic Amputation of One Leg Below Knee Complicated: Right leg traumatic BKA 897.1 FSE H 897 USA 897.1 41075.2939 K92 J Y Battle Injury UNK Returned To Duty Gunshot Wound of the Thorax 879.8 FSE H 879 USA 879.8 41088.5754 null M Y Nonbattle Injury UNK Limited Duty Closed Fracture Neck of Femur Intertrochanteric Left 820.21 FSE H 820 USA 820.21 41056.3121 null M Y Nonbattle Injury UNK Limited Duty Cerebellar Contusion With Concussion 851.49 FSE H 851 USA 851.49 41053.4527 null M Y Battle Injury FMIL Evacuation Burns: <10% BSA mixed full and partial thickness burns of post neck right ear, and upper back 949.0 FSE H 949 USA 949.0 41059.5045 K74 M Y Battle Injury FMIL Limited Duty Injury Due to War Shrapnel Grenade: face, right arm and right thigh E991.4 FSE H E991 USA E991.4 41059.3609 K74 A Y Battle Injury FMIL Evacuation Gunshot Wound of the Forearm Left: through and through L forearm 881.00 FSE H 881 USA 881.00 41017.2738 K74 A sample of the extracted electronic medical record data appropriate to the study.


October December 2015 65 For this kind of effort, low correla tion between variables is actually potentially useful. If 2 variables have low correlation, it could be that these variables are capturing unre lated aspects of the unit operation. If all the data shared high correlations, we could ignore it most of it for the purpose of developing decisionmaking metrics. The fact that trans fusions are not perfectly correlated tells us that the transfusions data has additional information captured encounters data. This is congruent encounters represent a very incom plete picture. Managers looking for data to guide decision-making do not necessarily want data with high correlation. For decision-making purposes, data with high correlation with low correlation likely provides a different perspective. used as the primary measure of workload. Transfusions, surgical hours, and evacuations from the site were used as secondary measures of acu ity to make resourcing decisions. This combination of metrics helped to meet the requirements for metrics de valid. The fact that it was incomplete in itself was offset by using the other measures in a dashboard approach. positioning of assets due to other considerations played into the anal ysis as well, but the metrics identi ric for decision-making. Because they lacked weighting, other metrics were used alongside the encounters data to provide a more nuanced un derstanding. The authors considered combining the supporting metrics into some sort of weighted value, like an RVU, thus creating a single number. However, the idea was not pursued because the process of combining the data into one number would diminish the informational value of the metric. CO MM ENT While imperfect, the measures Mel lott and Mapes developed were us able. The primary strength of the ap proach was that they relied on exist ing data streams, without imposing additional reporting requirements on subordinate units. It is recognized that there are many weaknesses to this effort. Some of them arise from Military operations in theater are always austere, and resources are limited. Furthermore, in this case, data re porting that was split over multiple networks and report ing systems as a result of working with Coalition and Afghan forces, requiring the authors and many of their colleagues to maintain 3 computers at any given time in order to switch between networks. Table 2 Correlations Among Data Variables. Number of Transfusions Number of Surgeries Number of Surgical Hours Average Hours per Surgery Average Patients per Evac Mission Number of Locations Flown From Surgeons per Team Average Hours per Surgeon Manning Workload to Team Member EMR 0.4637 0.7084 0.565 0.2067 0.0316 0.7641 0.5529 0.3413 0.3789 0.9292 Number of Transfusions 0.4793 0.564 0.3048 -0.0027 0.5325 0.3619 0.4819 0.2707 0.3815 Number of Surgeries 0.8468 0.1175 0.0245 0.7478 0.4476 0.7234 0.1342 0.6994 Number of Surgical Hours 0.4112 0.085 0.5438 0.4328 0.9209 0.2094 0.5395 Average Hours per Surgery -0.0204 0.0269 0.3667 0.3958 0.5105 0.1041 Average Patients per Evac Mission -0.066 -0.0057 0.0712 -0.0524 0.051 Number Locations Flown From 0.5559 0.3138 0.2301 0.7171 Surgeons per Team 0.1582 0.5762 0.387 Average Hours per Surgeon 0.058 0.3741 Manning 0.0703 Table 1 FST/FSE Workload. Location Encounters Month 1 Month 2 Month 3 Average FST D 71 127 164 120.7 FST E 78 46 37 53.7 FST C 38 69 40 49 FST K 49 41 51 47 FST G 34 65 49 49.3 FST H 49 39 32 40 FST J 32 54 32 39.3 FSE A 50 18 7 25 FSE H 24 18 17 19.7 FST F 1 25 23 16.3 FST B 16 20 13 16.3 FSE G 1 28 20 16.3 FSE F 19 12 12 14.3 FST A 6 16 16 12.7 FSE C 10 10 6 8.7 FSE E 0 8 9 5.7 FSE B 0 10 0 3.3 FST I 1 5 1 2.3 FSE D 2 0 0 0.7 Moments N= 57 Mean= 18.37 SD= 9.44 Standard error of the mean= 1.25 Upper 95% Mean= 20.87 Lower 95% Mean= 15.86


66 In a more stable environment with more robust report ing, higher quality variables might have been captured for analysis. Some things that would have been avail able in the more robust civilian environment would have included measures such as the Triage-Revised Trauma Score, Glasgow Coma Scale, vital signs, etc, for quanti was not readily available, and gathering such informa tion would have imposed additional data collection re quirements on the subordinate units. One question worth further consideration is whether sur gery unrelated to trauma, such as appendicitis, should be included in the analysis. At the time, the decision was made to exclude surgeries of that type since they be treated farther back in the lines of evacuation. The actual incidence of such surgeries could be analyzed for discussion in future research to determine if some amount of additional manpower should be allocated to the FST in order to support that function. CONCLUSION for the allocation of forward surgical resources. It is an under austere and shifting circumstances. This article provides an examination of the process whereby staff cision-making while minimizing information costs on subordinate units. The use of data analytics to guide decision-making in theater will continue to grow as the information systems continue to be integrated into all aspects of operations. The civilian sector has only recently begun to recog nize the value of the data that is often captured during ordinary business operations. If it is analyzed properly, study has shown how Mellott and Mapes examined data cessed the data into information for command decisionmaking. Despite limitations, they devised a reasonably that did not require additional resources to sustain. The process illustrates good principles for future leaders to follow when faced with the problem of developing simi lar heuristic approaches. The process steps are as follows: 1. Identify existing data sources that have data po tentially bearing on the problem. 2. Identify which variable(s) is(are) core to decision-making. 3. 4. Identify supporting variables. 5. Filter out redundant supporting variables by ex amining correlations. Further focus on the process of developing command decision-making metrics should be integrated into mili tary medical leadership training, integrating the prin ciples shown in this case study. REFERENCES 1. Roski J, Bo-Linn GW, Andrews T. Creating value in health care through big data. Health Aff 2014;33(7):1115-1122. 2. Schultz JR. Big data are, after all, just data. Perfor mance Improvement 2014;53(5):20-25. 3. ment revolution. Harv Bus Rev 2012;90(10):60-68. 4. Army Doctrine Publication 5-0: The Operations Process Washington, DC: US Dept of the Army; 2012. Available at: trine/DR_pubs/dr_a/pdf/adp5_0.pdf. Accessed August 27, 2015. 5. Knight F. Boston, 6. Field Manual 4-02: Army Health System. Washing ton, DC: US Dept of the Army. 2013. Available at: pdf/fm4_02.pdf. Accessed August 27, 2015. 7. Army Techniques Publication 4-02.5: Casualty Care. Washington, DC: US Dept of the Army; 2013. Available at: trine/DR_pubs/dr_a/pdf/atp4_02x5.pdf. Accessed August 27, 2015. 8. Defense Health Agency. Maintaining Medical Situational Awareness in Theater. Military Health System Website. Available at: taining-Medical-Situational-Awareness-in-Theater. Accessed June 15, 2015. 9. Army Doctrine Reference Publication 3-90: Of fense and Defense Washington, DC: US Dept of the Army. 2012. Available at: http://armypubs. pdf. Accessed August 27, 2015. 10. Dummit LA. Relative Value Units The Basics. Washington, DC: The George Washington Univer sity; National Health Policy Forum. February 12, 2009. DATA ANALYTICS UNDER DEPLOYED CONDITIONS: A CASE STUDY


October December 2015 67 11. Reliability and Validity Assessment. Beverly Hills, CA: Sage Publications; 1979. 12. combat casualty care by forward surgical teams de ployed to Afghanistan. Mil Med 2011;176(1):67-78. 13. Gribbs P, Hiroshi S. What is Occams Razor? [in ternet]. 1997. Available at: home/baez/physics/General/occam.html. Accessed June 15, 2015. 14. Stigler GJ. The economics of information. J Polit Econ 1961;69(3):213-225. AUTHORS vation and Advanced Technology Development Division, Defense Health Agency, Washington, DC. Dr Bonica, a retired Army Medical Service Corps of Policy, University of New Hampshire, Durham, New Hampshire. Regional Medical Command, Sembach, Germany.


68 The 1999 report from the Committee on Quality Health Care in America of the Institute of Medicine, To Err is Human: Building a Safer Health System 1 brought the is sues of medical quality to national attention. The report revealed that between 44,000 and 98,000 Americans die each year as a result of medical errors in hospitals, resulting in an annual loss of $17 to $29 billion. 1(pp1-2) By nature of their duties, healthcare workers are often charged with managing several competing demands, in cluding caring for multiple patients simultaneously, data entry, and data interpretation. In healthcare administra tion, processes, protocols, and regulatory requirements exist to guide, assist, or direct staff in the execution of these duties, however it must be recognized that there are limits to human ability. Heavy reliance upon the hu man factor, at some point, leads to error. In a healthcare setting, error is a leading cause of reduced healthcare tient safety, including omission of important informa tion, duplicative and/or unnecessary testing, incorrect data interpretation, and increased costs. The Agency for Health Care Policy and Research was established in 1989 with the mission to improve the quality of health care in America. In 1999, congress reauthorized and Leveraging Health Information Technology to Improve Quality in Federal Healthcare MAJ Fred K. Weigel, MS, USA LTC Timothy L. Switaj, MC, USA LT Jessica Hamilton, USCG AB STRACT Purpose: Healthcare delivery in America is extremely complex because it is comprised of a fragmented and nonsystematic mix of stakeholders, components, and processes. Within the US healthcare structure, the federal healthcare system is poised to lead American medicine in le veraging health information technology to improve the quality of healthcare. We posit that through developing, form federal healthcare quality by managing the complexities associated with healthcare delivery. Although have yet to be adopted in federal healthcare settings. The use of health information technology is fundamental in providing the highest quality, safest healthcare possible. In addition, health information technology is valu able in achieving the Agency for Healthcare Research and Qualitys implementation goals. Methods: We conducted a comprehensive literature search using the Google Scholar, PubMed, and Cochrane databases to identify an initial list of articles. Through a thorough review of the titles and abstracts, we iden criteria of currency of the article, citation frequency, applicability to the federal health system, and quality of Results: curate medication dosage and decreased medication errors. The use of clinical decision support systems have challenges for implementation. Comment: The Veterans Administration is the only entity within the federal health system that has published research on the use of health information technology to improve quality. The federal healthcare system has existing systems in place with computerized physician order entry systems and clinical decision support sys tems, but these should be advanced. Conclusion: Particular focus and attention should be placed on data mining capabilities, integrating the elec tronic health record across all aspects of care, using the electronic health record to improve quality at the point of care, and developing interoperable and usable health information technology.


October December 2015 69 redesignated it as the Agency for Healthcare Research and Quality 2 to address the growing quality concerns brought to light by the Institute of Medicine report. 1 Alongside the increased focus on healthcare quality was the rise in health information technology and its imple mentation across America. With the advent and expan sion of health information technology, the Agency for formation technology to achieve its goal of improving healthcare quality. In 2009, the Agency for Healthcare Research and Quality published 5 goals to help health care institutions implement health information tech nology toward meaningful use and improving quality. These goals are to ( a ) improve patient safety by reduc ing medical errors; ( b ) increase health information shar ing between providers, laboratories, pharmacies, and patients; ( c ) help patients transition between healthcare settings; ( d ) reduce duplicative and unnecessary testing; and ( e ) increase our knowledge and understanding of 3 In this study, we examine the existing body of literature on health information technology and healthcare quality to provide recommendations for using health information technology toward those goals. The federal healthcare system, comprised of the Vet erans Administration (VA), Department of Defense (DoD), and the Indian Health Service, is a complex sys tem in which the implementation of health information technology could be easily accomplished. Despite be ing separated among the different entities, the federal healthcare system is closed and existing command and control channels can directly affect it, thus making it easier to perform improvements than can be accom plished on most civilian health systems. The federal DoD, have placed renewed emphasis on quality of care practices over the past few years. With the current state cus on quality, the federal healthcare system is primed to be the lead toward integrating and leveraging health information technology to meet quality goals. METHODS To gain the fullest appreciation for current literature on the topic of health information technology and quality, we began our analysis with a broad search strategy; we review. We conducted a systematic literature review with 2 primary objectives: ( a ) examine results from studies of existing and emerging health information technologies and their potential to improve quality and ( b ) identify the challenges of widespread adoption of health information technology. We performed our searches using the Google Scholar, PubMed, OVID, and Cochrane databases. 4 we selected Google Scholar as part of our search strategy. Although using Google Scholars metasearch capability is more time-consuming for researchers because of the excess nonrelated information that it frequently yields, we desired Google Scholars expansive web-crawling capability as it returns a greater number of literature re sults than that provided by a single academic database. 4 We used PubMed because of its advantage over Google Scholar in that it is human-curated, meaning literature review committees select which literature is included in the PubMed database. 5 PubMed focuses on clinical and biomedical journal publications, which are the focus ar eas of our study; hence, a PubMed search yields highly rigorous results. Additionally, since the information about each article is entered into the PubMed database in a tightly organized method, the likelihood of receiv ing spurious results is substantially decreased. The advantage of using OVID lies in the web-searching software that Ovid Technologies created and the pur view of the search engine. In other words, OVID pro vides an extensive search across multiple databases albeit, not as expansive as what Google Scholar pro vides and focuses on healthcare-related literature and databases. Using OVID, researchers can select multiple databases in which to simultaneously execute the search the use of Boolean operators to return a limited set of applicable articles. Additionally, based on the high level of research-based clinical evidence it provides, we chose to perform a search within the Cochrane database. The Cochrane database is derived from the Cochrane Library. It is a highly regarded compilation of databases that house su perior evidence-based healthcare research designed to aid healthcare decision making. We performed our search using the Boolean search terms and syntax: health information technology OR electronic health record OR federal health system AND quality OR patient safety OR AHRQ OR usability OR transition of care OR patient safety


70 Initially, our search strategy returned excessively high numbers of results; therefore, we refocused our search on review articles since 2005 and research articles since 2010 to try and identify the most current literature avail of the title and abstract as having relevance to health information technology and quality. Since many articles reduced the list from 42 to 20 by taking those articles that were the most current, most frequently cited, and fessional journals. Review articles since 2005 were given stronger consideration as they provided the most current overview of health information technology as it based on the factors of generalizability to the topic, ap plicability to the federal healthcare system, and quality of research conducted as related to our topic. After ap article selection, we selected 11 references from which we performed our analysis. RESULTS The vast majority of studies show some positive effects of health information technology on quality measures; how ever, it is mostly in the context of provider adherence to guidelines and not outcome measures, of which there is a paucity of research. 6 sively shown that the use of a fully-integrated electronic health record has led to improved adherence to clinical guidelines and a reduction in medication errors, but no following electronic health record implementation. 7 The focus on computerized physician order entry and clinical decision support system tools, though not evalu ating the relevance to consumers or interoperability, has 8 however, emphasis is still lacking in key information regarding implementa tion and usability. The body of research is limited to the evaluation of proper medication dosing and the reduc tion in medication errors, even though there are stud ies that show a slightly negative effect of computerized physician order entry systems due to alert fatigue, 9 the phenomenon by which alerts lose all effectiveness due to the sheer number of alerts with which the physician is inundated. Research is ongoing into the effect of other common uses of computerized physician order entry sys tems such as within radiology and laboratory ordering; Another concern related to, and in some cases, caused by, excessive alerts is that of healthcare practitioners creating workarounds. 10,11 When the number of alerts becomes excessive from the perspective of the user of the health information system, the user may create a workaround to compensate for the excessive alerts. On one hand, workarounds can be assistive tools for health maneuver through different areas of the health infor mation technology user interface. On the other hand, workarounds may be detrimentaleven dangerousif they are methods of disabling or bypassing patient safe ty protections built into health information technology systems. 10,11 information technology to improve quality have been undertaken. 6,12-14 The current literature on health infor mation technology reveals that it has positive outcomes in a healthcare setting. One particular review that in cluded 105 studies noted that: pact on quality of care from health information technol ogy. Among the more frequently studied types of health information technology, computerized reminders (91%) and patient self-management applications (88%) had high lower for CDSS (74%) and for order entry (71%). 13 In another systematic review: Of the 154 included studies, 96 (62 percent [sic]) were positive, indicative of associated improvement in 1 or more aspects of care of health information technology, with no aspects worse off; and 142 (92 percent [sic]) were either positive or mixed-positive. 14 The Jamal et al 6 and Sukh et al 12 studies focus on us ing clinical decision support systems functions that can be implemented within health information technology, which has been shown to reduce medical errors through the reinforcement of clinical practice guidelines. Dur ing our search, we found that the VA is the only enti ty of the federal healthcare system that has published research on quality improvements through the use of health information technology. 15 The VA found that ad implemented as a set of reminders within the electronic health record. 15 This effect is particularly prominent in the care of diabetic patients, wherein the use of elec tronic health records with clinical decision support sys outcome measures. 16 Within inpatient care settings, re search literature has shown a reduction in unnecessary blood transfusions, although we found no documented effect on mortality rates. 14 LEVERAGING HEALTH INFORMATION TECHNOLOGY TO IMPROVE QUALITY IN FEDERAL HEALTHCARE


October December 2015 71 decision support systems tools and the improvement in asthma care and hospital complications. Patient records include a variety of data in a wide range of formats in cluding images, numbers, text, and videos. Such data may suffer from problems of inaccuracy or incomplete ness, complicated by different coding schemes and a lack of interoperable frameworks. If developed and im plemented, data and transaction standards could be used to enhance the accuracy of data exchanged. 13 In addition to evaluating the effect of health information technology on clinical quality measures, researchers have looked into the use of health information technol ogy in the actual performance of quality management tasks. Health information technology can be useful in addressing process complexity and process improve ment. Currently, there is high variability in care pro cesses. To be improved, processes must be managed and measured, and these measurements must be derived from data. Health information technology is a tool that can be used to collect and analyze the data needed to measure performance and outcomes for process im provement. Health information technology can also be leveraged to document processes and identify and incor porate lessons learned. 17 mance of hospital quality practices directly attributable to the implementation of health information technol ogy. 18 By implementing health information technology, it would seem intuitive to automate the quality mea surement process. Studies have shown a methodologi cal challenge with using health information technology to acquire the data to track quality. 8 For example, of the 257 articles that comprised the Chaudhry and col leagues study, 8 3 papers from the VA addressed using health information technology to automatically capture quality-of-care metrics. The study found that although the workload to capture quality metrics was lowered when an automated approach was introduced, the ma jority of the studies (2 of the 3) yielded validity limita tions with the automated methods, that is, inaccurate/ underestimated database query results and biased re sults caused by false positives. 8 Although the preceding challenges are shortcomings of health information technology, these inadequacies will likely dissipate as health information technology is fur ther developed to provide useful tools to perform, track, monitor, and report on quality processes. However, the full realization of optimal, integrated health informa tion technology will likely be a lengthy process. 19 As an example of the positive potential of health information technology, and contrary to the troubling VA system tion technology: increased adherence to guidelinebased care, enhanced surveillance and monitoring, and decreased medication errors. 10 ter, access, and translate patient data into meaningful, real-time information such as patient history, pattern tocols for providers. This capability can shield provid ers from data overload and help them to make timelier, informed decisions in patient care. In general, a major ity to reduce data complexity while improving its ac curacy, timeliness, consistency, interoperability, and comprehensiveness. In federal healthcare, the Veterans Affairs Medical Center has been a leader in 1 form of health information technology; their medical records are recognized as one of the most comprehensive and integrated electronic health systems to date. 20 As of late, Veterans Affairs Medical Center records have limited interoperability with the records in the Military Health System. CO MM ENT There is limited literature and research on the use of health information technology within the federal health system; however, some themes can be taken from pub lished literature and applied to federal healthcare. The VA is the only federal healthcare entity we found with tronic health record on quality measures. Computer ized physician order entry is fully integrated within all federal health system components including medica tion, laboratory, and radiology ordering. Although re search has not been reported, anecdotal reports indicate these systems have reduced errors similar to that noted throughout the reviews referenced in this article. The highest barriers of health information technology adoption arise from the human element. In a healthcare setting, there are often resource constraints and the introduction of health information technology can ini 13 Learning curves involved with implementation of new technology, as well as possible resistance from employees, can pose a challenge for managers who are balancing many competing demands. Simply investing in health information technology is not enough; a manager must be able to promote a culture of improvement and growth in technology. Otherwise, they may not get the buy-in they need from their staff. There are several areas in which managers may be able


72 and colleagues 21 found moderate, positive correlations between the relative advantages of the new technology and the likelihood the user will be interested in adopt ing the technology. Likewise, they found that degree to which someone can experiment with a new technology also has a moderate, positive correlation to the likeli hood the user will be interested in adopting the technol ogy. 21 With that information, managers can focus on ex plaining the advantages of the new system and provide experimental systems for the employees. the aforementioned alert fatigue and workarounds com bined with the human factor that is part of medicine exist, and errors continue. Clinical decision support systems tools are more frequently found within the VA system than in the DoD and Indian Health Service (IHS) systems. Clinical decision support systems tools, in the form of the integration of clinical practice guidelines into the electronic health record at the point-of-care, have been steadily increasing over the past few years. Several studies have shown that these clinical decision support systems tools positively affect quality outcomes, 16 In our view, the areas in which the federal healthcare system is most lacking in the implementation of health information technology toward improving quality are no different from what is noted repeatedly as weak nesses by national studies. These factors are usability, interoperability, full integration, and data mining. Spe order entry, outpatient electronic health records, inpa tient electronic health records, and surgical electronic exists, it does not transfer between systems and thus, is not interoperable. Interoperability includes the spread of the information across the federal healthcare sys a combination of the VA, DoD, and IHS systems, and therefore, receive portions of their care among different agencies. However, as previously mentioned, the health information technology systems among the 3 systems have limited interoperability between one another. This limited interoperability poses substantial quality and patient safety concerns. In its 2012 report on health information technology and patient safety, the Institute of Medicine called for the establishment of an independent federal entity for monitoring and analyzing patient safety data. 22 Oth erwise known as the Health Information Technology Safety Center, this entity is envisioned to be the central exchange of health information technology subject mat ter expertise and best practices. While budgetary con straints have prevented the creation of the Health Infor mation Technology Safety Center as of yet, it is clear that as a nation we are making strides and moving toward universal adoption of health information technology. Although new tools have been created to improve the usability of the health information technology within the federal healthcare system, these tools have not been fully integrated across all platforms. Therefore, most the health information technology does not yet offer the usability necessary at the point-of-care to improve pro all quality outcomes. Lastly, although there is much data within our health information technology systems, the vast majority of it still must be compiled manually. Although a data min ing tool was designed into the DoD electronic health record, its capability to monitor, mine, analyze, and re port on quality measures is lacking. Having to manually compile all quality measures creates human error and CONCLUSIONS Despite the fact that the federal healthcare system has successfully implemented several health information care, more work still must be done to raise the system to the Agency for Healthcare Research and Qualitys goals. To meet the goal of improving patient safety by reducing medication errors, a health information technology sys tem with full integration of the electronic health record and patient safety reporting systems must be developed and implemented. The ability to enter the patient safety reporting immediately with direct connection to the pa tient electronic health record would drastically improve reporting percentages and lead to better safety pro cesses. Information sharing and transition of care would information technology system across all aspects of care. Although duplicative testing is markedly reduced with the current computerized physician order entry system within federal healthcare, having the health information technology system interoperable across the VA, DoD, and IHS would further reduce this concern. Qualityto increase our knowledge and understanding ogycan only be accomplished through full integration, ease of use, and education. Federal healthcare system LEVERAGING HEALTH INFORMATION TECHNOLOGY TO IMPROVE QUALITY IN FEDERAL HEALTHCARE


October December 2015 73 employees would be more inclined to use the health in formation technology systems if they provided improved clinical decision support systems tools, incorporating clinical practice guidelines at the point-of-care. Addi tionally, if healthcare information technology systems had the capability for employees to report concerns di rectly through the electronic health record that produced actionable and timely data, and were easy to use, adop tion would be more widespread. After a full implemen tation of these criteria and integration into all aspects data will promote further knowledge and understanding. These goals are attainable, albeit not immediately. The continued perseverance of federal healthcare system in formation technology experts, combined with the contin ued improvement in health information technology and drive toward quality of care provides the federal health system the potential to be the preeminent organization to leverage technology toward quality improvement. REFERENCES 1. Kohn K, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System Wash ington, DC: National Academy Press. 1999:1,2. Available at: php?record_id=9728&page=R1. Accessed Sep tember 11, 2015. 2. Agency for Healthcare Research and Quality: Re authorization Fact Sheet [internet]. Available at: Ac cessed September 11, 2015. 3. Abdelhak M, Grostick S, Hanken MA. Health In formation: Management Of A Strategic Resource. 4. Sturm B, Schneider S, Sunyaev A. Leave no stone unturned: introducing a revolutionary meta-search ference on Information Systems; Mnster, Ger many; May 26-29, 2015. Available at: http://www. No_Stone_Unturned_Introducing_a_Revolution cient_Systematic_Literature_Searches. Accessed September 11, 2015. 5. Michigan State University. PubMed, Web of Sci ence, or Google Scholar? A behind-the-scenes guide for life scientists. So which is better: PubMed, Web of Science, or Google Scholar? [internet]. 2014. Available at: vsgooglescholar Accessed August 20, 2015. 6. Jamal A, McKenzie K, Clark MJ. The impact of health information technology on the quality of medical and health care: a systematic review. HIM J 2009;38(3):26-37. 7. impact of electronic health records on healthcare quality: a systematic review and meta-analysis. Eur J Public Health June 2015: epub ahead of print. 8. Chaudhry B, Wang J, Wu S, et al. Systematic re view: impact of health information technology on Ann Intern Med. 2006;144(10):742-752. 9. Jones SS, Rudin RS, Perry T, Shekelle PG. Health information technology: an updated systematic re view with a focus on meaningful use. Ann Intern Med 2014;160(1):48-54. 10. Vogelsmeier AA, Halbesleben JRB, ScottCawiezell JR. Technology implementation and workarounds in the nursing home. J Am Med In form Assoc 2008;15(1):114-119. 11. Weigel FK, Landrum WH, Hall DJ. Human-tech presented at: Twelfth Annual Conference of the Southern Association for Information Systems; Charleston, SC. March 12-14, 2009. Available at: 2009.pdf/Weigel,Hall,Landrum.pdf. Accessed September 11, 2015. 12. Sheikh A, Sood HS, Bates DW. Leveraging health information technology to achieve the triple aim of healthcare reform. J Am Med Inform Assoc 2015;22(4):849-856. 13. Millery M, Kukafka R. Health information tech nology and quality of health care: strategies for re ducing disparities in underresourced settings. Med Care Res Rev. 2010;67(5 suppl):268S-298S. 14. Buntin MB, Burke MF, Hoaglin MC, Blumenthal review of the recent literature shows predominant ly positive results. Health Aff. 2011;30(3):464-471. 15. AG, Johnston DS, Middleton B. The value from investments in health information technology at the US Department of Veterans Affairs. Health Aff. 2010;29(4):629-638. 16. ic health records and quality of diabetes care. New Engl J Med 2011;365(9):825-833. 17. Barton B. Critical lessons learned in healthcare information technology. J Qual Participation. 2014;37(2):22-24,33. 18. Restuccia JD, Cohen AB, Horwitt JN, Shwartz M. Hospital implementation of health information technology and quality of care: are they related? BMC Med Inform Decis Mak 2012;12:109.


74 19. McCullough JS, Casey M, Moscovice I, Prasad S. The effect of health information technology on qual ity in US hospitals. Health Aff. 2010;29(4):647-654. 20. Russ AL, Saleem JJ, Justice CF, Woodward-Hagg health information in use: characteristics that sup Health Informatics J. 2010;16(4):287-305. 21. Weigel FK, Hazen BT, Cegielski CG, Hall DJ. Dif fusion of innovations and the theory of planned behavior in information systems research: a meta analysis. Comm Assoc Inform Syst. 2014;34(1):31. 22. Sittig DF, Classen DC, Singh H. Patient safety goals for the proposed Federal Health Information Technology Safety Center. J Am Med Inform Assoc. 2014:22(2):472-478. AUTHORS MAJ Weigel is Chair, Research and Faculty Develop ment Committee, and Associate Professor, Army-Baylor University Graduate Program in Health and Business Texas. LTC Switaj and LT Hamilton are students in the Masters of Health Administration/Masters of Business Adminis tration Joint Degree Program, Army-Baylor University Graduate Program in Health and Business Administra lence, Joint Base San Antonio Fort Sam Houston, Texas. LEVERAGING HEALTH INFORMATION TECHNOLOGY TO IMPROVE QUALITY IN FEDERAL HEALTHCARE


October December 2015 75 When a health care system deals with complex trauma patients while simultaneously serving as an educational platform, teamwork and clear communication are im perative. 1 The San Antonio Military Medical Center is the largest inpatient medical facility in the Department of Defense (DoD) and is one of only 31 hospitals in the United States (the only one in the DoD) that holds the American Burn Association. The hospital sustains over 89 accredited educational programs including 38 graduate medical education programs, 6 nursing pro grams, 25 allied health education programs, 18 enlisted allied health programs, and programs in administration and allied health specialties. The San Antonio Military Medical Center (SAMMC) is the result of the consoli dation of the inpatient missions of the Brooke Army Medical Center and the (USAF) Wilford Hall Medical Center as a result of recommendations by the 2009 Base Realignment and Closure Commission (BRAC). 2 The pressure inherent in the BRAC-mandated integration of these large military treatment facilities run by separate services was accompanied by an expectation to increase This mandate occurred during a period of ongoing glob casualties in need of multidisciplinary care, in addition to the number of civilian trauma patients typical in a large urban environment as well as the broad spectrum of elective cases. Improved teamwork, communication, and operative processes within this complex surgical environment were clearly needed to continue to meet the mission of quality patient care. Implementation of TeamSTEPPS at a Level1 Military Trauma Center: The San Antonio Military Medical Center Experience Michelle M. Fischer LTC(P) Creighton C. Tubb, MC, USA Col Joseph A. Brennan, MC, USAF COL Douglas W. Soderdahl, MC, USA AB STRACT Context: When a health care system deals with complex trauma patients while simultaneously serving as an educational platform, teamwork and clear communication are imperative. While there are numerous tools at the most complex and busiest tertiary military trauma center in the Department of Defense in the midst of the longest period of continuous combat operations in US history. Methods: Data were collected from December 2013 through March 2014 on the number of total cases per formed by month, number of debrief surveys submitted for those months, and associated percentage of surveys completed based on case category. Results: completion) was 75.1%. Responses showed a decrease in concerns in all areas during the period of observation. decreased by 53.3%; personnel issues decreased by 90.5%; case scheduling issues decreased by 35.7%; and preference card issues decreased by 72.1%. Conclusions: level-1 trauma center in the midst of combat casualty care with a greater than 75% overall compliance with


76 Transforming to a culture of safety and high reliability is a challeng ing task when there are an increas ing number of quality metrics being measured and the hospital leader ship is focused on many laudable yet diverse priorities. While there are numerous tools and resources avail able to address the concerns sur rounding patient safety, one in par ticular emphasizes a team approach to improve communication among all caregivers. Team Strategies and evidence-based approach developed on the basis of 20 years of research by the Agency of Healthcare Re search and Quality of the Depart ment of Health and Human Services designed to improve patient safety through improved communica tion. 3-5 of 5 core principles: team structure, leadership, situation monitoring, mutual support, and communica tion, with implementation based on Kotters Principles of Change, which uses a holistic approach to change that allows organizations to continuously adapt and thrive. 6,7 In response to a May 2011 US Army Medical Command-wide direc in May 2012, the Commander of Brooke Army Medical Center di rected all departments to implement implementation by October 1, 2012. tion and participated in a multiple day, off-site train the trainer event. The champions then trained the staff with a 4-hour combined didactic and participatory training event. During this period, the hospitals operating rooms were experiencing a multitude of disruptions in daily opera tions due to the BRAC-driven integration that impeded been implemented successfully both at the combat support hospital in Baghdad, Iraq (and spread throughout the combat theater of operations), and Madigan Army Medical Center in Washing ton state, it was unclear whether implementation would succeed at SAMMC in such a tumultuous set ting, especially within the highly complex operative environment. 8 This article describes the interim tation in the operating rooms at the most complex and busiest tertiary military trauma center in the DoD, while in the midst of the longest period of continuous combat opera tions in US history. METHODS In November 2013, after additional multidisciplinary team training environment, SAMMC implement ing rooms. The team consisted of surgeons, anesthesiologists, nurses, information technology personnel, and key administrative leaders in the surgical departments. The team used 2 of the key tenets of the Team Debrief, to develop the concept of cases scheduled during the normal business day, staff surgeons were required to be present for a morn ing Brief with the entire operative team (staff surgeon, staff anesthesia provider, operating room nurse, and scrub technician). The topics dis cussed at this morning meeting were standardized (Figure 1), and all of the scheduled cases for the day were covered during this initial Brief (no requirement to repeat the Brief prior to each case). After the completion of each case, the entire team would participate in a Debrief using a standardized Debrief were electronically captured using a Debrief survey instrument (Figure 3). For emergent, urgent, and timeand space-available cases, an informal Huddle (same IMPLEMENTATION OF TEAMSTEPPS AT A LEVEL1 MILITARY TRAUMA CENTER: THE SAN ANTONIO MILITARY MEDICAL CENTER EXPERIENCE Brief Checklist Team Introductions Surgeon Procedures and plan for the day Instruments/supplies not normally used Implant verification Anticipated complications/blood loss Special requests (x-ray, reps, etc) Postop plan (PACU, ICU, etc) Concerns Anesthesia Antibiotics/allergies Anesthesia plan/regional anesthesia Blood availability Concerns Nurse/Technician Equipment/instrument/supply/implants Contact precautions Correct bed/positioning Concerns Figure 1 Standardized topics discussed at the morning brief. All scheduled cases for the day are covered during the initial brief. Debrief Checklist Surgeon Procedures performed Verify specimens Verify implants What went right What went wrong Concerns Anesthesia Verify postop plan Concerns Nurse/Technician Counts correct Medications Concerns Complete debrief tool Figure 2 Standardized topics discussed at completion of each case.


October December 2015 77 checklist as the Brief) was recommended (but not required) as the team felt that this added communication would enhance patient safety gent situations. The Huddles were not consid ered in the data analysis in this study which only included the process completion on elec tively scheduled cases. morning Brief to Debrief survey completion on all regularly scheduled cases. Nonadher ence to any portion of the process was consid ered a failure. The measures for effectiveness included elective surgery workload and the Debrief survey contained questions surround ing issues or concerns that potentially caused a case delay. Data were collected from December 2013 through March 2014 on the number of total cases performed by month and the number of cases performed during the normal business day for each month. Case counts were obtained from the Surgery Scheduling System. A nor were performed between 7:30 AM and 3:30 PM Monday through Friday, excluding holidays. Data were also collected on the number of De brief surveys submitted for those months and associated percentage of surveys completed. RESULTS The overall compliance rate for the Team to the Debrief survey completion) was 75.1% (Table 1). While the total number of routine cases increased 7.2% centage of completed Debrief surveys dropped by an av erage of 24.2% (Table 2). Responses showed a decrease in concerns in all areas during the period of observa instrument-related issues decreased by 29.9%; supply issues decreased by 53.3%; personnel issues decreased by 90.5%; case scheduling issues decreased by 35.7%; preference card issues decreased by 72.1% (Table 3). CO MM ENT cessfully implemented in an integrated level-1 military trauma center in the midst of combat casualty care with cess greater than 75%. While this leaves much room for improvement, this result is promising given the amount of personnel turnover at the largest medical training fa cility in the DoD. In fact, orthopaedic surgeons, a popu literature, completed the process 98% of the time. 9,10 While demonstrating promising results, our study does have several limitations. First, as an analysis of interim data, the generalizability of our results is admittedly tary trauma center during any period, so data generated during a period of active warfare are especially impor tant. Second, we did not conduct any type of survey to gauge the degree of acceptance from the perioperative Debrief Survey Questionnaire Q 1 : Was a satisfactory brief/huddle completed prior to the case? If no, please comment. Q 2 : Was there a delay in the first time start or the expected 30 minute turn over between cases? If yes, please provide delay reason. Q 3 : Was there a delay during the case? If yes, please provide delay reason. Q 4 : Was the case scheduled correctly? If no, please provide details. Q 5 : Was there a preference card issue? If yes, please provide specific details to fix: Staff Surgeon (if other than the one listed), specific procedure name, specific problem/correction Q 6 : Were there any equipment issues? (equipment means something plugged directly into the wall) If yes, please provide specific information: name, ECN#, specific problem, whether or not it has already been reported for a work order. Q 7 : Were there any instrument issues? (instrument means something reus able that is sterilized) If yes, please provide specific information: initials, load number, etc. Q 8 : Were there any supply issues? (supply means nondurable, sterile pack aged, single use item) If yes, please provide details: product name, number, specific problem, whether or not the packaging/product was saved and reported to the operating room or Medical Supply. Q 9 : Were there ancillary support issues? (radiology, pathology, pharmacy) If yes, please describe the problem(s). Q 10 : Was there a staffing issue? If yes, please describe the issue. Q 11 : Was a patient safety issue identified? If yes, please complete a Patient Safety Report (PSR). Q 12 : Please describe any quick wins (issues that were identified and fixed today). Q 13 : Suggestions for ideas/comments/improvements. Figure 3 using the 13 question Debrief Survey questionnaire with the ability to free text responses on each question if necessary.


78 staff to assess what role this may have played in the non compliant cases. As the im was a command-directed pro cess, perioperative staffs were required to participate, re gardless of degree of personal acceptance. Thus, there is the potential that the completed could be incomplete or erro neous as an effort to simply check the box. This could explain some of the drop in the overall rate of problems that were reported over reported issues simply because of the additional time required to complete a Debrief survey when issues are sures of operating room quality such as administration of prophylactic antibiotics 60 minutes prior to incision, or the administration of perioperative beta blockers. Al though there has been some suggestion that the process decreased the historical surgical case times in some ser vice lines following implementation, our data set does not answer that question; this claim requires further study. CONCLUSION Our results demonstrate that fully implemented in an inte grated level-1 trauma center in the midst of combat casualty care with overall compliance process greater than 75%. Further study on the sustain ability of these results as well as validation of effects on quality measures is necessary. REFERENCES 1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human Washington, DC: National Academies Press; 1999. Available at: book.php?isbn=0309068371. Accessed July 31, 2015. 2. Military Base Realignments and Closures: DoD Faces Challenges in Implementing Recommenda tions on Time and Is Not Consistently Updating 09-217. Available at: items/d09217.pdf. Accessed July 31, 2015. IMPLEMENTATION OF TEAMSTEPPS AT A LEVEL1 MILITARY TRAUMA CENTER: THE SAN ANTONIO MILITARY MEDICAL CENTER EXPERIENCE Table 1. Tabular data of the TeamSTEPPS compliance rate by month. The overall compliance rate throughout the data collection period is 75.1 %. Month Debrief Surveys Completed (A) Total Cases (B) % Debrief Surveys Completed (A/B) Total Cases (NBD, Mon-Fri) (C) % Debrief Surveys Completed (A/C) Total Routine Cases in NBD (excluding TSA, urgent, emergent, after hours) (D) % Debrief Surveys Completed (A/D) December 2013 859 1285 66.8% 1226 70.1% 1059 81.1% January 2014 874 1405 62.2% 1354 64.5% 1148 76.1% February 2014 972 1381 70.4% 1300 74.8% 1129 86.1% March 2014 651 1372 47.4% 1290 50.5% 1135 57.4% Totals 3356 5443 61.7% 5170 64.9% 4471 75.1% NBD indicates normal business day. TSA indicates timeand space-available. Table 2 Total number of routine cases increased 7.2% percentage of Debrief Survey completions dropped by an average of 24.2% Months Change in Case Volume % Change Change in Number of Debrief Surveys Completed % Change Dec to Jan 89 8.4% 15 1.7% Jan to Feb -19 -1.7% 98 11.2% Feb to Mar 6 0.5% -321 -33.0% Dec to Mar 76 7.2% -208 -24.2% Table 3 Comparison of number of complaints between beginning and ending months of TeamSTEPPS implementation. Responses showed a decrease in concerns in all areas during the period of observation. Complaint Category December March % Change Number of Debriefs Number of Complaints Complaint Rate Number of Debriefs Number of Complaints Complaint Rate Equipment 859 43 5.0% 651 17 2.6% -48.0% Instrument 859 75 8.7% 651 40 6.1% -29.9% Supplies 859 26 3.0% 651 9 1.4% -53.3% Personnel 859 18 2.1% 651 1 0.2% -90.5% Case Scheduling 859 12 1.4% 651 6 0.9% -35.7% Preference Cards 859 37 4.3% 651 8 1.2% -72.1%


October December 2015 79 3. Team strategies and tools to enhance performance and patient safety. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approach es Vol 3. Washington, DC: US Dept of Health & Human Services Agency for Healthcare Research and Quality. 2008. Available at: http://www.ahrq. gov/professionals/quality-patient-safety/patientsafety-resources/resources/advances-in-patientsafety-2/vol3/Advances-King_1.pdf. Accessed July 31, 2015. 4. Thomas L, Galla C. Building a culture of safety through team training and engagement. Postgrad Med J 2013;89:394-401. 5. improved communication and teamwork. Orthop Nurs 2012;31:190-192. 6. Agency for Healthcare Research and Quality. Team STEPPS 2.0 Instructor Guide. Rockville, MD: Uni formed Services University of the Health Sciences; 2007. 7. Kotter J, Rathgeber H. Our Iceberg is Melting: Changing and Succeeding Under Any Conditions. NY: St Martins Press; 2006. 8. Deering S, Rosen MA, Ludi V, Munroe M, Pocr nich A, Laky C, Napolitano PG. On the Front Lines of Team Training in Iraq. Jt Comm J Qual Patient Saf 2011;37(8):350-356. 9. Tongue JR, Jenkins L, Wade A. Low-touch sur geons in a high-touch world. AAOS Now May 2009. Available at: may09/cover1.asp. Accessed July 31, 2015. 10. Frymoyer JW, Frymoyer NP. Physician-patient communication: a lost art? J Am Acad Orthop Surg. 2002;10:95-105. AUTHORS Ms Fischer is Administrator, Christus Santa Rosa Physi cians Ambulatory Surgery Center Stone Oak, San An tonio, Texas. During the project described in this article, she was the Department of Surgery Administrator, San Antonio Military Medical Center, Joint Base San Anto nio Fort Sam Houston, Texas. LTC(P) Tubb is Vice-chairman and Chair of the Perfor mance Improvement Committee, Department of Ortho paedics and Rehabilitation, San Antonio Military Medi cal Center, Joint Base San Antonio Fort Sam Houston, Texas. Col Brennan is Chief, Department of Surgery, San An tonio Military Medical Center, Joint Base San Antonio Fort Sam Houston, Texas. COL Soderdahl is Deputy Commander for Acute Care, San Antonio Military Medical Center, Joint Base San Antonio Fort Sam Houston, Texas. LTC(P) Johnson is Chairman, Department of Orthopae dics and Rehabilitation, San Antonio Military Medical Center, Joint Base San Antonio Fort Sam Houston, Texas.


80 Preventable diseases such as cholera, typhoid, malaria, and dengue often thrive in the aftermath of societal, eco nomic, or natural disruptions. It is into these situations that members of the US armed forces are often called to assist in the provision and distribution of relief sup plies, restoration of essential services, and assisting the host nation government to return to normalcy. It is criti cal for both US force health protection concerns and the contribution to the host nation public health campaign that preventive medicine assets across the spectrum of participating organizations coordinate their efforts. erations as: An overarching term encompassing various military missions, tasks, and activities conducted outside the United States in coordination with other instruments of national power to maintain or reestablish a safe and secure environment, provide essential governmental services, emergency infrastructure reconstruction, and humanitarian relief. 1(p230) Further, the DoD policy regarding stability operations is stated as: Stability operations are a core US military mission that the Department of Defense shall be prepared to conduct 2(p2) DoD Instruction 6000.16 refers to medical health sup port for stability operations as medical stability opera tions (MSOs). 3(p1) It also states DoD policy regarding MSOs as: MSOs are a core US military mission that the DoD Mili tary Health System (MHS) shall be prepared to conduct military operations, including in combat and non-combat environments. MSOs shall be given priority comparable to combat operations and be explicitly addressed and in tegrated across all MHS activities including doctrine, or ganization, training, education, exercises, materiel, lead ership, personnel, facilities, and planning in accordance with Reference (b) [ DoDI 3000.05 2 ] 3(p1) operations is that MSOs will often be key components of such operations. Moreover, DoD policy for the plan DoD shall: collaborate with other US Government agencies and with foreign governments and security forces, interna tional governmental organizations, nongovernmental plan, prepare for, and conduct stability operations. 2(p2) The operating environment following a natural disaster or societal upheaval is inevitably complex and confus ing. The nuances of each situation will vary with geog raphy, local customs and history, and the level of preincident development. What is constant is the presence of host nation governmental agencies, international gov ernmental and nongovernmental organizations (NGOs), media, and multiple agencies of the US government os tensibly working towards the same goal. It is clear that all organizations involved in relief operations need a ly use available resources. This is especially true for dis ease control operations as preventive medical assets are often limited and at best a tertiary concern regarding re source allocation. An additional challenge is the nature of preventive medicine and public health programs in general, which often require years of development and decades of sustainment. Consequently, the US military role in these efforts is typically limited both temporally and materially; collaborations must be a priority for that role to be effective. In application and practice, MSOs broadly encompass both foreign disaster relief and foreign humanitar Joint Publication 1-02 1(pp93,94) The formal lines between the two are often blurred (even within doctrine). While both responses Integration and Coordination of Governmental, Nongovernmental, and Host Nation Preventive Medicine Assets During Medical Stability Operations CDR Jeffrey Stancil, MSC, USN Domestic civil support, addressed by Joint Publication 3-28 4 is outside the scope of this article.


October December 2015 81 to consider them separately when discussing the role of military preventive medicine assets and coordination of effort. Foreign disaster relief, particularly in the acute phase, evolves rapidly with multiple entities trying to restore some semblance of order, few of which can rival the lo gistical and organizational capabilities of the DoD. In a foreign disaster relief scenario (such as the response to DoD Directive 5100.46 5 in Joint Publication 3-29 6 start with the responsible (in the case of Haiti, the remaining) elements of the host na tion government requesting assistance from the United ment representation in that country. If approved, DoD preparation and coordination is led by the Assistant Sec retary of Defense for Special Operations/Low-Intensity responsible for developing planning guidance for the appropriate combatant commander, often leading to the establishment of a joint task force. The joint task force, by doctrine, functions in a supporting role to the lead US government entity (often the United States Agency for International Development (USAID)) and must co ordinate operations to maximize relief efforts. The US government response occurs at the request and approval of the host nation government and must be coordinated with that countrys responsible agencies and any United Nations coordination elements as well. Reasonably clear in doctrine but often less so in execution, the effect of the disaster and visible human suffering will add to the fog of war, combined with limited communications often conducted in multiple languages, a host nation government directly affected by the disaster, and a lit companies, and disaster touristsall converging on the same affected location to create an exceptionally chal lenging operational environment. In this phase of the response, military preventive medi cine assets should be primarily concerned with force health protection and ensuring responders do not be come victims, either to natural or manmade environ mental risks, including preventable diseases The Armys noteworthy success in the prevention of ebola and ma laria infection in Soldiers during Operation United As sistance* is a great example of this. Operational coordi nation is often largely internal and the primary mission focus is on areas such as mortuary affairs; delivery of palliative medical care; and provision of basic water, food, and shelter needs; with secondary or tertiary focus on preventable diseases. However, coordination with US government, host nation, and NGO stakeholders at this stage will serve to solidify medical intelligence avail able prior to the incident, perhaps provide opportunities to assist in the location for and inclusion of sanitation and hygiene considerations in relief camps, and will as nation will be learning who the players are and estab lishing personal relationships that will ideally engender trust and create opportunities for additional assistance during the recovery phase. As foreign disaster relief efforts move from response to recovery, they begin to resemble or in fact become Joint Publication 3-29 6 in the form of a Humanitarian Assistance Coordination Center, a CivilMilitary Operations Center, or a Humanitarian Opera tions Center (HOC). Large scale stability programs will be guided at some level by the stakeholders represented in the HOC, includ ing preventive medicine and public health programs. In the Haiti earthquake response, the coordination of most preventive medicine programs fell under the United Na tion cluster which brought together United Nations, host nation, and foreign governmental representatives with NGOs, academia, and private industry to address mul tiple issues including preventable water-borne, foodborne, and vector-borne diseases. A HOC will not exist in programmed FHA operations that are conducted under the purview of the geographic combatant commander, and the overall coordination process is less formal. The allocation of military as sets and funding lines are also different, but whether conducted as part of a foreign disaster relief recovery process or a more routine FHA mission, public health programs will have short-term and long-term goals in which the US military can play a role. Short-term and long-term efforts in both recovery and routine FHA operations should be conducted in close coordination with or perhaps under the direct guidance of USAID or the designated Department of State repre sentative. For their part, USAID should be coordinating Operation United Assistance (September 2014 May 2015 ) was the US military participation in the international effort to as sist the west African countries of Guinea, Liberia, and Sierra Leone contain the serious ebola virus outbreak in those countries. Source:


82 efforts with the host nation as well as established, re liable NGOs and other agencies for which the military rapid progress by virtue of its inherent logistical and organizational acumen. This close coordination and of FHA missions where it may be expected that host nation, USAID, and NGO partners are trusted within the community in need, are local subject matter experts, and can provide expert guidance in the most effective utilization of military capabilities. Planning should also to establish goals and document progress in achieving these goals to justify resource allocation. In summary, the US militarys ability to respond to the requirements of foreign disaster relief and foreign humanitarian assistance is unrivaled by other govern ment or nongovernmental agencies, and is the epitome military is not a humanitarian organization, it is capable of remarkable humanitarian acts and assistance. This assistance, including preventive medical efforts, must (by doctrine) and should be conducted in support of and in coordination with other US government, host nation, international, NGO, and private entities to maximize ef forts and optimize use of resources to best help those in need. REFERENCES 1. Joint Publication 1-02: DoD Dictionary of Military and Associated Terms Washington, DC: Joint Staff, US Dept of Defense; November 8, 2010 [amended March 15, 2015]. Available at: doctrine/new_pubs/jp1_02.pdf. Accessed June 30, 2015. 2. Department of Defense Instruction 3000.05: Sta bility Operations Washington, DC: US Dept of Defense; September 16, 2009. Available at: http:// pdf. Accessed June 30, 2015. 3. Department of Defense Instruction 6000.16: Mili tary Health Support for Stability Operations Washington, DC: US Dept of Defense; May 17, 2010. Available at: tives/corres/pdf/600016p.pdf. Accessed June 30, 2015. 4. Joint Publication 3-28: Defense Support of Civil Authorities Washington, DC: Joint Staff, US Dept of Defense; July 31, 2013. Available at: http://www. Accessed June 30, 2015. 5. Department of Defense Directive 5100.46: Foreign Disaster Relief Washington, DC: US Dept of De fense; July 6, 2012. Available at: http://www.dtic. mil/whs/directives/corres/pdf/510046p.pdf. Accessed June 30, 2015. 6. Joint Publication 3-29: Foreign Humanitarian As sistance Washington, DC: Joint Staff, US Dept of Defense; January 3, 2014. Available at: http://www. Accessed June 30, 2015. AUTHOR cellence, US Naval Air Station, Jacksonville, FL. Articles published in the Army Medical Department Journal are indexed in MEDLINE, the National Library of Medicines (NLMs) bibliographic database of life sciences and biomedical information. Inclusion in the MEDLINE database ensures that citations to AMEDD Journal content will INTEGRATION AND COORDINATION OF GOVERNMENTAL, NONGOVERNMENTAL, AND HOST NATION PREVENTIVE MEDICINE ASSETS DURING MEDICAL STABILITY OPERATIONS


October December 2015 83 A vital component of United Nations (UN) peacekeep ing operations (PKOs) is provision of health services for mission personnel. 1,2 The aim of medical support is the physical and mental welfare of deployed personnel, preservation of human resources, conservation of life, and minimizing residual physical and mental disabili ties. Arguably, peacekeepers function better when they are healthy and know that high-quality medical treat ment is there in case of injury or illness. Also, UN PKOs must meet various multidimensional mandates, all while 3,4 Furthermore, in the Post-Cold War era they operate increasingly in safety. The hope is that UN PKOs will become streamlined, more effective, quicker to respond, and more capable in order to be involved in more wide-ranging, multifaceted operations conducted over large, diverse, and remote geographies. 5 Consequently, the expectation for medi cal support is that it will likewise adjust to the larger cal support to the demands of post-Cold War UN PKOs requires informed planning that considers all medical aspects, including those supplementary to operations but nonetheless important to mission success. Just as can quickly turn into big things if not considered and accounted for. No accounting exists for such medical aspects, though the literature contains comprehensive pieces that consider paramount or pivotal medical as pects of post-Cold War UN PKOs related to operations and medical planning. 6 UN PKO medical support for post-Cold War UN PKOs is a comprehensive understanding of all medical aspects personnel confront (whether great or not so great, but just as important), this article reports on an inventory of those less pivotal medical aspects. These aspects were gleaned through iterative probing into open-source ar ticles in the medical literature for useful conceptual categories and themes across peacekeeping missions re the futurepeacekeeping missions and their analogs North Atlantic Treaty Organization (NATO) members plemental aspects include: Humanitarian assistance/military humanitarianism Womens health A Review of Supplementary Medical Aspects of Post-Cold War UN Peacekeeping Operations: Trends, Lessons Learned, Courses of Action, and Recommendations LTC Ralph J. Johnson III, MS, USAR AB STRACT Post-Cold War United Nations Peace Keeping Operations (UN PKOs) have been increasingly involved in dan and disregard on the part of some local parties for peacekeepers security and role. In the interest of force protection and optimizing operations, a key component of UN PKOs is healthcare and medical treatment. The expectation is that UN PKO medical support will adjust to the general intent and structure of UN PKOs. To do so requires effective policies and planning informed by a review of all medical aspects of UN PKO operations, including those considered supplementary, that is, less crucial but contributing nonetheless. Medical aspects considered paramount and key to UN PKOs have received relatively thorough treatment elsewhere. The intent of this article is to report on ancillary and supplemental medical aspects practical to post-Cold War UN PKO operations assembled through an iterative inquiry of open-source articles. Recommendations are made about possible courses of action in terms of addressing trends found in such medical aspects of PKOs and relevance


84 Quick reaction force concept Medical command structure The fundamental aspect that altered the planning re quirements and set the stage for these supplemental as pects was the changed nature of UN PKO missions. The hope is that this report will assist planners and policy makers to enhance well-rounded medical support to UN PKOs (and non-UN PKOs) and better ensure the health and well-being of UN PKO members. This is the ideal of medical support incorporated in the UNs medical mis sion statements. 1 Some basic assumptions apply. This review emphasizes deployed military peacekeeping personnel, even though all civilian and military personnel assigned to a UN PKO are entitled to medical care. Underlying trends will continue or accelerate. This article explicitly addresses the expanded post-Cold War era UN peacekeeping mis sions and supplemental medical aspects found in the lit MEDICAL ASPECTS Changed Nature of UN PKOs During the Cold War, UN PKOs were relatively benign affairs with impartial unarmed peace observers or light ly armed peacekeepers interposed to separate former a peaceful settlement (an exception was the UN mission in the Democratic Republic of the Congo in the early 1960s). 4,7 The nature of UN PKOs dictates their medical needs, which in turn prescribe their medical support re quirements and planning. For example, McKee et al re ported that peacekeepers deployed in a classic Cold War UN PKO observer-interposition role on the Bosnia-Her zegovina mission (UNMIBH) had minor medical ail ments typically associated with noncombat deployment, such as orthopedic conditions and respiratory diseases. 8 Post-Cold War, the nature of UN PKOs changed dra phisticated, complicated, and dangerous operations de signed to enable security, stability, and reconstruction of failed or decompensating nations. 4,9 There have been nearly as many deaths among peacekeepers post-Cold War as in all previous UN PKOs. 7,10,11 of UN peacekeeping had 13 missions, all of which were relatively temperate, except for the 1960s mission to the Democratic Republic of the Congo. However, over the and complicated missions were undertaken in hazard ous environments. Logically, medical events would sub stantially consist of emergency trauma (eg, high-velocity penetrations, multiple deep lacerations, blast and blunt force injuries, complicated fractures) along with indig in changes in the nature and probability of casualties governmental organizations (NGOs) and humanitarian organizations (HOs) working alongside UN PKOs. 12-17 underreported. Two reasons have been cited for the greater danger to UN PKOs and resulting fatalities: (1) the increased num ber, scale, and coverage of UN PKOs and (2) their more robust operations (ie, combat-like) in more remote areas with questionable consent from former belliger ents. 18 Durch and Berkman 19 and Pugh 14 all argued that these operations have assumed only the veneer of clas sic consensual peacekeeping. The greatest overall risk factor in terms of wounded and casualties were com plicated robust missions in failed states in Africa that included humanitarian assistance operations, or what is termed military humanitarianism. 7,14 Despite what side they are on, some belligerents may target peace keepers for aggression, perceiving and portraying them cally, Seet states 7 : peacekeepers are being deployed into hostilities be tween belligerents where not all belligerents may feel they consented to the peace process, and, with no real with dire (medical) consequences. Holt et al 20 cited the post-Cold War mission (circa 2005) to the Democratic Republic of the Congo, where con groups planning to attack innocent villages and even vulnerable UN installations and personnel. 2,9 As the missions mandate permitted protection of civilians in immediate danger, preemptive robust, combat-like op erations were required to check the imminent threat. Humanitarian Assistance/Military Humanitarianism Humanitarian assistance or military humanitarianism are subjects in their own right. Consequently, their brief and broad brush treatment herein only speaks to how they pertain to medical aspects and operational/medical planning for PKOs. To promote civil-military cohesion and improve public relations, UN PKO medical com ponents are increasingly tasked with providing general/ family practice clinical services to civilian nationals in the most remote and rugged areas (ie, military medi cal humanitarianism). Note that Kevaney et al 21 found medical resources for helping the local population in the building at the local level and A REVIEW OF SUPPLEMENTARY MEDICAL ASPECTS OF POST-COLD WAR UN PEACEKEEPING OPERATIONS: TRENDS, LESSONS LEARNED, COURSES OF ACTION, AND RECOMMENDATIONS


October December 2015 85 use of mission assets (such as construction engineers or medical resources) for appropriate local public health and medical outreach projects will also contribute (1) to building good relations with the local population and authorities, (2) contribute to restoring the national infra structure, (3) have a normalizing and stabilizing effect, and (4) may be part of the mission. 21 Through ingratiation with the local population with the simplest of help, as Reade pointed out about the Kosovo mission, 22 these medical humanitarian relief ef forts have treated substantial volumes of patients with minimal medical resources. However, these efforts further expose personnel to both the physical dangers psychological conditions. 23,24 For example, Outram 13 African States, that despite the relatively large number of military peacekeeping personnel, without consent to defend and protect humanitarian assistance distribution sites. Thus, peacekeepers were further exposed to risk. 17 Pugh maintained that in situations where consent to the peace process was questionable, providing humanitar ian assistance blurred the pre-Cold War UN concepts on which all UN PKOs are supposedly based: impar tiality, neutrality, and assistance based solely on need without political discrimination. 14 Thus, eventually one side or the other, or both, come to view peacekeepers as helping their enemies and, therefore, peacekeepers also become the enemy and targets for armed aggres sion. For example, although Japan did not participate in the Rwanda mission directly, it did provide a small contingent of medical support to Gome Zaire to attend Ministry for Foreign Affairs reported that humanitar ian assistance was exceptionally popular with the local population and authorities. 25 However, the local ongoing work and workers into targets for renegade belligerents from Rwanda whose consent to the peace process was questionable. Therefore, the need for cooperation with local authorities and the UN, particularly for security, became paramount for ensuring smooth operations. The Japanese report also supported Pughs contention re garding the newer post-Cold War UN PKOs in that hos tilities do not respect national boundaries. 14 The trend toward including military medical humanitarianism in UN PKOs has grown, and the number of such PKO missions is predicted to rise. 26 This aspect of medical support to UN PKOs lends credence to the contention that deployment of medical support and evacuation is not simply a question of distance and time, but security must also be a consideration. 27 Womens Health Milosevic reported that the shift in peacekeeping from relatively benign to more robust operations has resulted in a consequent shift in the protection of civilians, partic ularly women and children. 2(pp171-177),26,28 Thus, since 2002, women have constituted a greater percentage of UN PKO forces. He drew on the example of the Chad mis sion, noting that the increased inclusion of women over all in the medical component of that UN PKO was not new. 28 However, the increased representation of women in roles traditionally considered the province of males was new. In turn, female peacekeepers in UN PKOs provide new possibilities to effect peace as women can engage women, particularly where cultures forbid manto-woman contact. Furthermore, female health providers have offered medical treatment to women (and children) as the humanitarian medical aspects of UN PKOs have increased. He suggested that planners give more consid eration to female healthcare (and family practice) provid ers on missions and deployment considerations. Electronic Medical Documentation Universal and fully integrated electronic medical doc umentation is an ideal that is probably unworkable, if not unrealistic. However, regarding the Kosovo mission, Reade reported that a secure, but operationally integrat ed, computerized medical records system enabled the expedient transmission of peacekeepers medical infor mation. 22 This was especially true in cases of emergen mensely useful and practical for intramission retention and transfer of peacekeepers medical treatment, stock control and resupply, summary statistics for epidemio logical analyses of trends and quality assurance, and information transfer to civilian care and quick resolu tion of any postdeployment disability claims. Regarding medical imaging for the Kosovo mission, Mun et al also observed that adoption of electronic systems was prac 29 These medical systems elimi nated shipping and storage of bulky new and unexposed and water, and toxic discharge that had to be collected and transported out of the deployed area. The same can be true for medical records and documentation in that electronic systems dispense with the storage, retrieval, transport, and eco-unfriendliness of bulky paper copies, as well as the expense and encumbrance of paper, print ers, ink and printing, and upkeep. Medical Professional Personnel Backfill Concerning the mission in Kosovo, Reade reported that the medical service component was severely under staffed, mainly lacking physicians. 22 Thus, it was nec essary to draw on reservists for short deployments to


86 augment their active service counterparts. He reported that use of reservist medical personnel caused no loss in quality or standards of medical care due to consistent dividual augmentees in previous UN PKOs have a sub stantially higher risk for mission-related psychological stressors and morbidities, possibly due, as Mehlum et al 30 also noted, to the absence of preventive prophylaxis in the form of social support found in being deployed as integral parts of cohesive units. Quick Reaction Force Concept Few people familiar with UN or regionally led PKOs think they can operate at the level of a quick reaction force. 2(pp285-290),26,31 However, the UNs goal has been to be in a position to launch a multidimensional PKO mis sion within 90 days. 16(pp255-279) time to crises and streamline the slow and cumber some redress of emergent crises, advocates have con tended that UN PKOs should shift to a quick reaction force concept (eg, a standby, high-readiness brigade (SHIRBRIG)). 16(pp255-279),31 increased emphasis on predeployment planning, mobil ity, prepositioning of supplies in regional depots, pre arrangement of transport, improved intelligence, and enhancement of early warning systems. 25 This includes similar efforts in coordination and consistency within various UN departments and agencies that deal with UN PKOs and member nations. This concept also extends to aspects of UN PKO medical support. The precedent for advancing this concept was the Kosovo resolution that asserted that human rights abuses and crimes against humanity coincident with the rapid collapse of a state merit international intervention with all due speed. 1,4 Despite calls for the quick response force concept at the West African States-UNDPKO, 2005) reported an ab sence of vital medical capabilities early in the mission concerning effective communications, capable medical support, and adequate life support. 31 A tight timeline compounded these shortages and led to recommenda tions for improvements in prepositioning and preplan ning. These concerns were also voiced regarding the post-Cold War mission (circa 2005) to the Democratic Republic of the Congo with regard to inadequate medi cal supplies hampering offensive operations, and the rapid response necessary to protect citizens and UN PKO installations from rogue belligerents. 16 Indeed, the UN all but abandoned the SHIRBRIG 6 years ago, a symbolic capitulation that a quick response peacekeep ing force was an unworkable ideal at the time. 32 But this did not signal the end to the calls for more rapid and responsive UN PKO missions, including their medical support elements. M edical Command Structure Reade 22 and Joshi 33 both described problems related to the separation of medical command and medical authority common to military components supporting UN PKOs. Indeed, Reade 22 argued this separation is in medical authorities were physicians, whereas medical commanders were professional administrators. He re because they had little familiarity with the practical pro vision of medical treatment. On the other hand, medical authorities who were physicians knew the ins and outs of patients but not the ins and outs of the administrative medical decisions that effectively usurped their units medical administration. Unfortunately, Reade offered no solution. Without a viable alternative, this state of af fairs is expected to continue at least for the foreseeable future. Yet, there must be an ongoing awareness of its dysfunctional effects on medical support to UN PKOs. CO MM ENT The literature of expanded and more robust post-Cold War UN PKOs highlighted several trends and recom mendations in their medical aspects, in particular, the less pivotal or supplementary aspects: 1. UN PKOs are no longer classic observer-interpo sition missions of small numbers of peacekeepers in 2,15 They cated, and dangerous paramilitary operations designed to enable security, stability, and reconstruction of failed or decompensating nations. 4,9 This also means that the nature and extent of medical events has transformed and consequent medical support must in turn adapt for para mount or pivotal medical aspects, as well as ancillary or supplemental ones. 2. As such, planners should consider that the demand for civil/military-driven humanitarian medical outreach far into the margins of already risky and dangerous situations adds a new and even more risky dimension to UN PKO missions and their medical components. particular women and children, also creates a need for generalist/family practice medical professionals along with other medical subspecialties in particular surgical subspecialties. A REVIEW OF SUPPLEMENTARY MEDICAL ASPECTS OF POST-COLD WAR UN PEACEKEEPING OPERATIONS: TRENDS, LESSONS LEARNED, COURSES OF ACTION, AND RECOMMENDATIONS


October December 2015 87 3. Planners should therefore provide for womens (and family) health and include female medical providers. This is particularly true if the mission has a humanitar ian aspect and/or a need to be sensitive to local cultures customs. Humanitarian outreach, military humanitari anism, and womens/family health may need to be fac tored into security considerations. 4. There should be some degree of employment of electronic medical information systems that can reliably, ceive, and integrate data, in particular medical records data. Note: this recommendation must be balanced against the notion that, though universal electronic medical records would be ideal in a perfect world, this is probably unrealistic and unworkable. 5. The length of UN PKO missions and the require ment for scarce medical treatment providers suggests replacements. 6. Consequently, reliance on individual augmentees, along with the changed nature of UN PKO missions, the fact that they are lengthy, and humanitarian assistance or military humanitarianistic components all increase the risk for psychological morbidities. 23,24 Therefore, there is a requirement for the mission-wide incorpora tion of mental health personnel to monitor and address attendant psychological morbidities that emerge conse quent to peacekeepers mission involvement. 22,34 7. A quick reaction force concept is probably unwork able in the near future. But there is gravitation toward missions that require increased rapid responsiveness. Supporting a shift in UN PKO medical care to further rapid deployment would require prepositioning of de pot, cache, tracking and management, maintenance of assist. This might require an extra inventory or a spe cialized inventory for plug-in-and-play, depending on operational requirements. This also would require a redundancy of material that has proven to be useful in previous and prolonged operations that generated a need for maintenance and replacement of worn and broken equipment. 1,27 8. Previous critiques of the system of separation of medical authority vs command have offered no viable resolution. Without a more appealing alternative, these systems that are so much an ingrained part of the culture of western military medicine should remain in place for now. Nevertheless, there should be improved awareness that this bifurcation exists, which, if unchecked, can be high-quality medical care. ble of moving itself, while retaining the ability to deliver care throughout a UN PKO theater. This must be ac complished to provide medical treatment in far forward areas of operations. This is especially true for trauma care, which sustains extended and comprehensive op erations, peacekeeper maneuvers, and humanitarian outreach and womens/family care. 27 10. Given the experience of past UN PKOs, in addi PKOs will need to adopt a medical support planning of modules to purpose-build medical care to UN PKO requirements. This mindset should incorporate consid whether great or not so great. 11. The near absence of peer-reviewed articles on medical aspects of UN PKOs, especially on less central medical aspects, calls for more peer-reviewed research in these areas. Nevertheless, it should be noted that both the US military, in particular the US Army, and NATO/ porting facts of which should be examined more closely: Undoubtedly, both the United States and NATO/ in combat and military/security operations. Those operations include other than war operations on par with the recent change in UN PKOs, especially regarding deployment and responsive and adaptive modular development of medical support. 1,35-40 tinely include military humanitarian outreach into their operations and insert medical practitioners deep in the periphery, including a high percentage of women. 41-48 es also factor in commensurate security and psychi atric care considerations. The US military has a proven track record for vet ting, using, and deploying highly effective electron ic medical documentation systems in such capac ity that they can easily adapt these systems to the degree necessary for the parallel incorporation of non-US multinational partner nations embedded in US operations. 50-54 United States forces have extensive documented experience with a standing reserve medical person


88 provider shortfalls. 55,56 The US military and NATO/ dress psychiatric morbidities early on, especially for missions with humanitarian outreach, substan tial individual augmentees, and women service members. 22,57,58 The US military in particular has standing quick response forces including medical support with all the implied attendant worldwide logistical and sustainment infrastructure, to the extent it is often taken for granted. 59-62 similarly structured forces as well. Nevertheless, the established command and control forces probably will remain in place into the fore seeable future. However, there are initiatives in US military medical forces toward adoption of more of a team and collegial approach. 63-66 matter expertise and adaptable models of medical sup port that can be lent to UN PKOs regarding supplemen tary medical aspects. Furthermore, they have conducted substantial research into the feasibility and workability of those models, 67,68 but there is still much to be done in terms of their applicability to the contexts and con straints of the UN system and UN PKOsnot just for the little things, but the big ones as well. ACKNOWLEDGE M ENTS The author thanks COL (USA Ret) Karl Farris and COL (USA Ret) George Oliver for their advice, guidance, and encouragement on that culminated in this manuscript. The author gratefully acknowledges COL S. C. Nessen for his work that provided the inspiration to test the ideas of his hypothesis on UN PKOs. REFERENCES 1. United Nations Department of Peacekeeping Op erations. Medical Support Manual for United Na tions Peacekeeping Operations 2nd ed. New York, NY: United Nations; 1999:3-21. 2. Dammen Core Predeployment Training Materi als Williamsburg, VA: Peace Operations Training Institute; 2014:35-45. 3. Balanzino S. Lessons Learned in Peacekeep ing Operations. Ad Hoc Group on Cooperation in Peacekeeping; NATO; 1997, 20. Available at: peacekeeping-lessons-eng.pdf. Accessed Septem ber 3, 2015. 4. peacekeeping operations in the post-cold war era. Perception. J Int Aff 2000;IV,4:3-8. 5. United Nations. Report of the Special Committee on Peacekeeping Operations: 2012 Substantive Session New York, NY: UN General Assembly No. 19; 2012:13-17. 6. Johnson RJ. A literature review of medical aspects of post-cold war UN peacekeeping operations: trends, lessons learnt, courses of action, and rec ommendations. J R Army Med Corps June 17, 2015 [epub ahead of print]. 7. Seet B, Burnham GM. Fatality trends in United Na tions peacekeeping operations, 1948-1998. JAMA 2000;284(5):598-603. 8. McKee KT, Kortepeter MG, Liaamo SK. Disease and non-battle injury among United States soldiers deployed in Bosnia-Herzegovina during 1997: summary primary care statistics for Operation Joint Guard. Mil Med 1998;163(11):733-742. 9. Gordon R. Principles and Guidelines for UN Peacekeeping Operations Williamsburg, VA: Peace Operations Training Institute; 2010:25-48. 10. Ram S. History of United Nations Peacekeeping Operations During the Cold War: 1945 to 1987 Williamsburg, VA: Peace Operations Training In stitute; 2008:33,35-37,42. 11. Leslie D. Operational Logistical Support of UN Peacekeeping Missions: Intermediate Logistics Course Williamsburg, VA: Peace Operations Training Institute; 2011:109. 12. Posen BR. Military response to refugee disasters. Int Secur 1996;21(1):72-111. 13. Outram Q. Cruel wars and safe havens: hu manitarian aid in Liberia 1989-1996. Disasters 1997;21(3):189-205. 14. Pugh M. Military intervention and humani tarian action: trends and issues. Disasters 1998;22(4):339-351. 15. Ram S. History of United Nations Peacekeeping Operations During the Cold War: 1988 to 1996 Williamsburg, VA: Peace Operations Training In stitute; 2008:17-18,38-46,99-101,225-228. 16. Ram S. History of United Nations Peacekeeping Operations During the Cold War: 1997 to 2006 Williamsburg, VA: Peace Operations Training In stitute; 2008:85-129. 17. Sheik M, Gutierrez M-I, Bolton P, Spiegel P, Thie ren M, Burnham G. Deaths among humanitarian workers. Br Med J 2008;321(7254):1,66-68. 18. Hannum J, Charmy JR. The Role of the US in UN Peacekeeping Operations [internet]. Washington, DC: InterAction; 2013. Available at: keeping.pdf Accessed September 3, 2015. A REVIEW OF SUPPLEMENTARY MEDICAL ASPECTS OF POST-COLD WAR UN PEACEKEEPING OPERATIONS: TRENDS, LESSONS LEARNED, COURSES OF ACTION, AND RECOMMENDATIONS


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90 42. manitarian assistance. Arch Facial Plast Surg 2012;14(3):220. Available at: http://archfaci.jama Ac cessed September 3, 2015. 43. rolling along.... Maximizing care through dental assistant expanded functions in a humanitarian mission. Dent Assist 2003;72(3):28-33. 44. jden S. Humanitarian assistance in UN operations: laboratory and consultative support of a local hos Mil Med 2002;167(8):653-656. 45. N Engl J Med 1989;321(16):1136-1140. 46. Pannell D, Poynter J, Wales PW, Tien H, Nathens AB, Shellington D. Factors affecting mortality of pedi atric trauma patients encountered in Kandahar, Af ghanistan. Can J Surg 2015;58(3suppl3):S141-S145. 47. Donev D, Onceva S, Gligorov I. Refugee crisis Croat Med J 2002;43(2):184-189. 48. Burreli DF. Women in Combat: Issues for Con gress. Washington, DC: Congressional Research Service; May 9, 2013. Available at: http:// www.dtic. mil/cgi-bin/GetTRDoc?AD=ADA590333. Accessed September 3, 2015. 49. Goldman N. The changing role of women in the armed forces. Am J Sociol 1973;78(4):892-911. 50. Do NV, Barnhill R, Heermann-Do KA, Salzman KL, Gimbel RW. The military health systems personal health record pilot with Microsoft Health Vault and Google Health. J Am Med Inform Assoc 2011;18(2):118-124. 51. Charles MJ, Harmon BJ, Jordan PS. Improving Lewin DI, eds. Advances in Patient Safety: From Research to Implementation (Volume 3: Imple mentation Issues) Rockville, MD: [US] Agency for Healthcare Research and Quality; 2005. Avail able at: NBK20562/. Accessed September 3, 2015. 52. Bohnsack KJ, Parker DP, Zheng K. Quantifying temporal documentation patterns in clinician use of AHLTA-the DoDs ambulatory electronic health record. Paper presented at: American Medical In formatics Association 2009 Annual Symposium; November 14-18, 2009; San Francisco, CA. Avail able at: Accessed September 3, 2015. 53. US Army Med Dep J 2008; Oct-Dec:63-67. 54. Smith B, Chu LK, Smith TC, et al, and the Mil lennium Cohort Study Team. Challenges of selfreported medical conditions and electronic medical records among members of a large military cohort. BMC Med Res Methodo l. 2008;5(8):37. 55. ing and retention. Mil Med 1992;157(3):149-153. 56. Im proving the Deployment of Army Healthcare Pro fessionals: An Evaluation of PROFIS Santa Moni ca, CA: RAND Corporation; 2013. 57. Castro CA. The US framework for understanding, preventing, and caring for the mental health needs of service members who served in combat in Af ghanistan and Iraq: a brief review of the issues and the research. Eur J Psychotraumatol 2014;14(5) [eCollection 2014]. 58. Deployment-related mental health support: com parative analysis of NATO and allied ISAF part ners. Eur J Psychotraumatol 2014;14(5) [eCollec tion 2014]. 59. Dahlburg JT. NATO is setting up an ultra-rapidreaction force to deter Russia. Associated Press Business Insider [serial online]. January 6, 2015. Available at: nato-is-setting-up-an-ultra-rapid-reaction-forceto-deter-russia-2015-1#ixzz3fz6Vcfol Accessed September 3, 2015. 60. Burke RL. One health and force health protection during foreign humanitarian assistance operations: US Army Med Dep J 2013; Jan-Mar:81-85. 61. Chapman D, Palaschak KL. Health facilities planning: determining infrastructure require ments for form and function from clinical and op erational capabilities. US Army Med Dep J 2008; Oct-Dec:79-87. 62. US Marine Corps Forces. Chemical Biological Incident Response Force [internet]. Available at: Accessed September 3, 2015. 63. Hetz SP. Introduction to military medicine: a brief overview. Surg Clin North Am 2006;86(3):675-688. 64. port of the Department of Defense external civilian peer review of medical care. JAMA 1988;260(18):2690-2693. 65. Mil Med 1992;157(1):40-46. A REVIEW OF SUPPLEMENTARY MEDICAL ASPECTS OF POST-COLD WAR UN PEACEKEEPING OPERATIONS: TRENDS, LESSONS LEARNED, COURSES OF ACTION, AND RECOMMENDATIONS


October December 2015 91 66. tive practice model: Madigan Army Medical Center. Obstet Gynecol Clin North Am 2012;39(3):399-410. 67. Deering S, Rosen MA, Ludi V, Munroe M, Pocr nich A, Laky C, Napolitano PG. On the front lines of patient safety: implementation and evaluation of team training in Iraq. Jt Comm J Qual Patient Saf. 2011 Aug;37(8):350-356. 68. combat trauma care: converting data and experi ence to practical guidelines. Surg Clin North Am 2012;92(4):1041-1054. AUTHOR LTC Johnson is an instructor, medical subject matter Southern Training Division, 75th Training Command in Houston, Texas. He is also the US Military Academy Admissions Field Force Representative, and liaison to the cy Management Agency, and the US Northern Command. In his civilian pursuits, Dr Johnson (PhD, MAHS, MAT) is a medical researcher, data analyst, and professor.


92 Nursing in the 8 th Evacuation Hospital, 1942-1945 LTC William J. Brown, AN, USA AB STRACT Hospital during World War II. In addition, it examines gender and role differences within the Army Medical Department, and how nurses contributions helped shape the profession. This research used traditional historical methods of inquiry to include both primary and secondary sources of information. Primary sources include Hospital located in the University of Virginia Historical Collections and Services, Charlottesville, VA, and suggests that advances in the chain-of-evacuation, antibiotics, dissemination of blood products, and nurses expanded roles all contributed to increased survival of the wounded. Nurses performance garnered an enduring they worked on a daily basis. Collaboration, mutual respect, and coordinated teamwork were critical for mission success. Army nurses demonstrated that they had the mettle to go into a war zone and perform in an exemplary manner. Thousands of nursing students in schools across the country would graduate in 1940, the last year before America entered World War II. Many new graduates hospitals, while others would deploy to evacuation hospitals in austere environments directly supporting troops. The declaration of war required mass mobiliza tion of not only troops, but also of all facets of private and public industry to support the war effort. Nursing in the private sector and in the military would undergo nurses had answered the call to active duty, but tens of thousands more would be required. This article describes the experiences of Army nurses Hospital during World War II. In addition, it examines gender and role differences within the Army Medi cal Department, and how nurses contributions helped challenges and extremes in terrain and weather, from the oppressive heat in the North African desert to the mountainous and snow-laden Italian peninsula. 1 BACKGROUND With Japans premeditated attack on Pearl Harbor on December 7, 1941, the United States was at war. At the onset of hostilities there were less than 1000 active duty 2 The superintendent at that time was MAJ Julia Flikke who had held this key leadership position since 1937. Prior to that role, she had been the Assistant Superintendent for 10 years. Flikke demanded much of her nurses in the Corps and certainly set the bar high. In a letter to a newly accessioned Army nurse, she writes: No one appreciates a nurse who shirks her duties, and her, for someone else to do; who is always surly and dis agreeable on duty, in the home or at play; who delights in gossip and criticism of others who complains of the food, the hospital management and her sister nurse. To us such a nurse is a great disappointment and her continuation as a member of the ANC is not desired. In accordance with Army regulation 40-20 she may be dropped. 3(p159) The sudden demand for nurses put increased stress on the Army to recruit more nurses. Alumnae of the Army School of Nursing, which had been closed in 1931 due to budget constraints, advocated for its reopening. 3 Flikke did not see it as a viable and cost effective op schools that could meet the demands for nurses. 4 In a relatively short time, the Corps quickly grew to 12,000 in 6 months, peaking at 57,000 nurses at the end of the war. 5 However, throughout the war there were supply vs demand issues as the ANC attempted to grow its force. RACE AND GENDER Racial and gender issues posed barriers that hindered recruitment of skilled nurses. African American nurses were available but largely underutilized despite vocal proponents such as Mabel Staupers, a representative of the National Association of Colored Graduate Nurses, who had corresponded with President Roosevelt to end


October December 2015 93 segregation. These efforts were unsuccessful and there was minimal use of African American nurses through out the war. Similarly, male nurses were not eligible to be commis Army Medical Department eventually let men join the Red Cross Reserve, but the Army never intended to use them within their assigned role. Collectively, they were too few in number to bridge any gender gaps within the Nurse Corps and lacked the political and organizational power base to affect or change policy. 3 Similar to World War I, exaggerated gender differences were common in both society and the military. Simply, 6 Female nurses did serve in World War I, but there were no female military surgeons. This policy continued until Congress passed the Sparkman Act in 1943. The Act authorized the commissioning of female physicians 7 Although nursing was a recognized and valued profes sion within society, gender discrimination was evident. Women were not treated with the same respect and stat ure that were afforded to men. Just as there was much inertia to overcome in order to change societys views of the roles and status given to women in various profes sions, change within the Army presented its own special challenges. A key and potentially divisive issue was that of rescinding the order of relative rank. The ANC had stringent requirements for appointment to the active or reserve component. Yet, nurses did not have the same power and authority as other military personnel because nurses ranks were relative. Relative rank meant that women in the Nurse Corps (Army and Navy) carried of their male counterparts. 8 Nurses were the second line right of command. 3 There was much debate among the lawmakers on Capi tol Hill, and the War Department had long been opposed to the idea of permanent commissions for Army Nurses the new Surgeon General, MG Norman T. Kirk, and among many Congressmen. Permanent commissioning the Army only granted temporary commissions for the remaining years of the war, plus an additional 6 months. Nursing personnel would not be granted permanent years after the war had ended. 3 THE CHANGING NATURE OF WAR The Second World War would see the mobility of armies 9 This type of warfare was exhibited in the most ferocious way with the German military forces (Wehrmacht) use of the Blitzkrieg or lightening war during its attack on Poland in 1939, and later again against France, Russia, and oth this strategy were coordinated deep armor thrusts with support of mobile infantry units, in conjunction with close and intense air support. 10 The Allies recognized the importance of mobility as well. To meet this threat, US Army armor doctrine developed broad maneuver ca pabilities, becoming synonymous with combined arms operations. 9 Consequently, those medical assets that supported the Allied armies had to be mobile to keep pace with rapidly advancing forces. RECRUITING THE STAFF In late 1941, Staige D. Blackford was Chief Medical Of He convinced the University to provide a medical unit as it had done in World War I. On February 27, 1942, the Secretary of War granted approval. It would be desig sponsibility of recruiting all the personnel. 11 Blackford immediately recognized the need for a skilled nurse to for the newly forming hospital unit. Blackford previous ly met Ms Ruth Beery, RN, then a science instructor in the School of Nursing at the University. In a letter dated February 16, 1942, Blackford writes 12 : Dear Ruth: Unit here, which requires 52 Nurses. Nurses to be eli gible must be in the American Red Cross First Reserve, which means that they are single, between 21 and 40 and and 5 months. I think we might possibly get a special ruling on your age if you could pass a physical examina tion and would be interested in accepting the position as chief nurse. Drop me a line as soon as you can and let me know what you think about it. Sincerely yours, Staige D. Blackford, MD Several weeks later on March 2, Blackford advocated for Ms Beery to be granted entry to active duty service, tendent of the Army Nurse Corps 12 :


94 I am very much interested in having Miss Ruth Beery, who has been on staff here, made Chief of Nursing Ser viceshe has passed her physicalbut she was forty years old last May, and the purpose of this letter is to ask you if there is any way in which her age can be waived so that we can get her as Chief of our Nursing CorpsMiss Beery is the only person that I have been able to think of position satisfactorily. With kindest regards, Staige D. Blackford, MD Recognizing the importance of having experienced The Surgeon General raised the age limits for nurses policy change, 13 which was instrumental in bringing ex perienced nurses to the battlefront. Further recruiting was required to obtain the necessary personnel to staff the hospital. The Army Medical De required 417 personnel: 47 physicians, 52 nurses, and and age determined initial rank structure for the physi cians. However, these rules did not apply to nurses as the Chief Nurse held only the rank of 1st lieutenant. The policies suggest that the male physicians held power and authority within the military hospital, paralleling soci etal norms. 1 CHIEF NURSE In early 1942, Ruth Beery returned to the University of Virginia to assume the role of Chief Nurse in the new choice for the position of Chief Nurse due to her calm and composed disposition, and the focus she placed on the welfare of her staff and her hospitals reputation. 1 Beerys task of recruiting nursing volunteers was much spent a great deal of time on correspondence and travel, to ensure that all potential recruits were fully quali to nursing groups in Roanoke, Harrisonburg, and Rich mond in an effort to recruit nurses. 12 During a talk in Winchester, Beerys sense of duty and patriotism were quite evident 12 : Nurses of America are now needed in increasing num bers to care for the Nations armed forces, whether at home or overseasThousands who are needed are not responding as rapidly as might be wished. Fifty-two will render emergency service as a mobile unit. If Amer ican boys are going into danger, it is up to Americas nurses to care for them. That is our duty and we cannot escape it. PREPARATION FOR DUTY The need for realistic military training was essential to mold the new members into a cohesive team. Nei Army nurses were prepared for the military. The units 1942, in Pageland, SC, where it participated in maneu additional training at Fort Benning, Georgia. Personnel kept busy with physical training including road marches, and with lectures on a variety of subjects including ba sics such as military courtesy, administration, bivouacs, 1 at Camp Kilmer, NJ, where it waited for new orders. On es would not deploy overseas. Despite Blackford and Beerys several trips to Washington, DC, orders for the nurses to accompany the troops were not forthcoming until the corps surgeon considered it safe and expedient for them to rejoin the unit overseas. Meanwhile, a group of corpsmen would serve as nurses. 1 An Army colonel stated his concerns and the importance of female nurses: Theres no argument about it. We cant do without nurs es, even in the combat zone. We have good corpsmen, but you cant make a doctor or a nurse out of a layman in one year. It takes training to develop the inborn sense of sterility a nurse has. In the operating room every tray to her is an individual problem. She doesnt have to look for an instrument. She knows where it is. If she didnt have anything more to do than mingle with the patients shed be doing a great service. The patients morale goes up 100 percent when they know a woman is looking after them. 14(p268) THE SANTA PAULA On the morning of November 1, 1942, members of the deploy overseas, boarded the troop transport ship Santa Paula which departed at 4 AM on November 2, 1942. Members of the unit awoke to a large formation of 35 to 40 ships, including a battleship, aircraft carrier, and numerous destroyers, which zigzagged as it crossed the Atlantic Ocean. This convoy eventually merged with the massive Western Task Force on November 8, 1942, which encompassed over 500 warships and 350 trans ports, and would spearhead the attack on North Africa. 1 NURSING IN THE 8TH EVACUATION HOSPITAL, 1942-1945


October December 2015 95 The Captain of the Santa Paula had concerns about the transportation of such a large party of women aboard his ship. However, these fears were unfounded. Upon completion of the journey, he sent a memorandum for the Commanding General, Atlantic Base Section 12 : duct and excellent discipline on shipboard of the group of 52 nurses of your organization, which came to Africa on this vessel under the command of 1st Lt Ruth Beery, tion hospital. 2. In my experience a transport commander is inclined to look forward with some anxiety to having a large number of nurses aboard, fearing that they might present problems outside of his range of experience and hence 3. They were no problem on this ship. They were model passengers, competently commanded a splendid group of women it was a pleasure to have aboard. They were an asset to ship life as well as valuable assistants in the hospital, and if there were any problems connected with of the groups without coming to my attention. If there your unit has to perform. 4. A similar letter is being sent to the Commanding Of Ward L. Schrantz Colonel, T.C. Transport Commander The leadership of Beery and the exemplary conduct of group who only 8 months earlier were civilians. This professionalism would serve them well in their immi nent deployment. NORTH AFRICA offensive military operation and was the best alternative to an invasion of France. 15 The purpose was to defeat the Axis powers and provide a staging platform for future operations. The Army organized a new experimental sion. The ensuing success of the new chain of evacua tion resulted in the same procedure being employed in every theatre of operations during the war. 2 When a Soldier was injured or wounded in combat, a series of events would transpire in evacuating the Sol dier rearward. Aid men treated the casualtys initial wounds and called for a litter squad to transport the ca sualty back to battalion aid stations (BAS). At the BAS, a battalion surgeon would provide additional care as necessary. The casualty was then sent to a collecting station, and then to a division clearing station, for trans port rearward. Unstable casualties would have surgery Stabilized casualties were moved to evacuation hospi lifesaving procedures, and allowed additional recovery time. 16 Soldiers recovering from chest or postoperative abdominal wounds would stay from 5 to 10 days respec tively, before being sent to station or general hospitals. 2 NURSING CARE OF THE WOUNDED Depending on the tactical situation, a Soldier may have travelled from 3 to 30 miles before reaching the units if disease or infection were present, or to surgical units if medically stable. Soldiers with serious injuries and wounds were triaged to the shock tent, the equiva lent of an emergency room. There were no gurneys, but simple sturdy sawhorses upon which the Soldiers lit ter (stretcher) would be placed. 1 For many Soldiers, this Nurses in the shock tent typically worked 12-hour shifts ties. Boundaries between medicine and nursing blurred tomarily performed by physicians. Nurses performed plasma infusions and blood transfusions, as well as administering antibiotics and tetanus toxoid injections. There were 3 wards; one for the serious and 2 for those with less serious injuries. Overall, the entire section could hold 100 patients during any given time. 1 care of injured and wounded, disease put the greatest treated Soldiers medical conditions including upper respiratory, gastrointestinal, and nonsurgical musculo skeletal disorders like trench foot, which affected 5,700 Soldiers in the Fifth Army over a 6-month period. 17 Medical cases went to the 36-bed ward where enlisted personnel assisted them. As in the shock tent, nurses worked 12-hour shifts with 22 nurses working days and 12 nurses working nights. 1 FOLLOWING THE FIFTH AR M Y Working as a team, the nurses and physicians of the 8th out the North African and Italian Campaigns. While de North Africa to Sicily, and all the way up the Italian


96 Garda) in the northeast part of the country. During one arduous move, MG Joseph Martin commended the unit for the speed in which it had transferred a working hos pital from one area to another. It was the longest move and the most rapidly effected setup so far in Fifth Ar mys medical record. 18 In December 1943, the hospital served near Teano, Italy, It was a mountainous region with rain, sleet, and snow. The hospital saw its worst casualties after the 36th In fantry Division assaulted German positions across the 1 This period marked a critical change in the treatment of wounded Soldiers with the widespread use of penicillin, and the establishment of a blood blank in Naples, Italy, in February 1944. Gas gangrene from infected wounds practically ceased with the use of penicillin. The blood banks dissemination of blood products resulted in re duced mortality rates following injuries, enabled per formance of longer and more complex surgeries, and decreased the incidence of transfusion reactions. 1 The earlier campaigns in Tunisia as part of Operation Torch had shown blood transfusions to be more effective in reducing mortality rates than plasma. 16 As is the nature of warfare, having adequate supplies, The ANC anticipated the need for additional nurse anes thetists, and from 1939 to 1941, it increased the number of nurses attending educational courses. However, more were required than could be trained in the initial phases of the war. 3 Shortages of trained anesthesiologists also persisted through 1943. 19 CPT Linus Miller, a trained anesthesiologist and 2 previously trained nurse anesthe that more staff was needed to administer anesthesia, particularly in mass casualty situations. To meet the de mand, 3 additional ANC lieutenants were trained while in theatre to administer anesthesia, including intrave nous sodium pentathol and nitrous oxide. 1 SURGERY As the Chief Nurse, CPT Beery had numerous adminis trative and personnel tasks to attend to, as did her Assis tant Chief, 1LT Mary J. McCone. However, this did not was most often in the auxiliary shock wards. The nurses in the unit served in almost all the professional services. The surgical area represented the most essential aspect of the evacuation hospital. Nine sections of tent were utilized, which included a dirty surgery annex and covered entrances which ensured protection against to conceal the hospitals location from the enemy. The completed operating room was 90 ft long, 17.5 ft wide, and 6 ft high at the sides. 1 The surgical teams operated on one of the 8 available nurse, an anesthetist, and a surgical technician made up the teams. The nurse kept the sterile supplies stocked, circulated, and scrubbed in when needed. The nursing supervisor along with 5 circulating nurses and 5 corps men worked 12-hour shifts, but in times where there were increased casualties it was common to work 20 or more hours. Despite experience, skill, and coordinated 2 LT Dorothy Sandridge, Nurse Anesthetist, 8 th Evacuation Hospital, in theater circa 1943-1944 In the Italy Theater, circa 1943-1945 From left: CPT Ruth Beery, 8 th Evac; Congresswoman Edith Rogers; CPT Helen Wharton, RN, Fifth Army. NURSING IN THE 8TH EVACUATION HOSPITAL, 1942-1945


October December 2015 97 in a 24-hour period. 1 Nurses played a key role in the preparation and main tenance of the operating room as well as preoperative and postoperative care of wounded Soldiers. This was critical, as thoracic surgery was a key intervention per formed in the surgical unit of evacuation hospitals like the 8th. The nature of modern warfare resulted in se on Soldiers with severe open chest, thoraco-abdominal, and cardiac wounds. Wounds that prevented adequate ventilation such as sucking chest wounds or hemothorax required urgent surgical intervention. Often these re quired chest wall debridement, placement of chest tubes, thoracentesis, nerve blocks, and bronchoscopies. Nurses required to ensure success in these types of procedures. Preparation was important and nurses were instrumen potential uncertainties. 20 VICTORY IN EUROPE On May 8, 1945, Nazi Germany unconditionally surren It would not be long until Japan also surrendered on Au gust 13, 1945. World War II, the bloodiest war in human superbly in support of the Fifth Army for over 2 years, and its personnel had cared for over 48,047 patients in the hospital; 31,057 with disease, 10,487 with wounds, and 7,563 with injuries. Another 45,000 were seen in outpatient departments. 1 These accomplishments gar nered considerable recognition, as both the unit and its members would receive numerous awards and citations, including the Legion of Merit (6), Silver Star (1), Sol diers Medal (2), Bronze Star (28), Air Medal (1), and Purple Heart (7) awards. 11 CONCLUSION More than 57,000 American nurses served in the ANC during World War II, over 201 of whom died while in service to their nation. 2 Aided by nurses, over 60% of the 500,000 Soldiers wounded in battle returned to ac tive service. 21 chain-of-evacuation, antibiotics, dissemination of blood products, and the expanded roles of nurses all contrib uted to increased survival. Nurses received enduring respect from combatants who Soldiers with whom they worked on a daily basis. Col laboration, mutual respect, and coordinated teamwork evolutionary aspect in which necessity, innovation, and technology combined to bring about important practice changes. The performance of nurses garnered recogni tion among many facets of society for their unique and valuable contributions during the war, and pushed the boundaries of what women could achieve. Army nurses would again answer the call to duty during the many en change, but the critical need for nursing care of Soldiers will not, and this proud legacy of service continues today. ACKNOWLEDGE M ENTS I thank Dr Arlene Keeling, Centennial Distinguished Bjoring Center for Nursing Historical Inquiry at the University of Virginia, and Leigh McGraw, PhD (LTC, ANC, Ret) for their assistance in editing this manuscript. REFERENCES 1. Leavell BS. The 8th Evac: A History of the Uni versity of Virginia Hospital Unit in World War II Richmond, VA: Dietz Press; 1970. 2. Bellafaire JL. The Army Nurse Corps: A com memoration of World War II Service Washington, DC: US Army Center of Military History; 2008. Available at: pubs/72/72-14.html. Accessed September 1, 2015. 3. Sarnecky MT. A History of the U.S. Army Nurse Corps. Philadelphia: University of Pennsylvania Press; 1999. 4. Kalisch PA, Kalisch BJ. American Nursing: A His tory 4th ed. Philadelphia, PA: Lipincott Williams & Wilkins; 2004. Evacuation Hospital surgical teams in the European theater, circa 1943-1945

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98 5. Highlights in the History of the Army Nurse Corps Washington, DC: US Army Center of Military History; 1981. 6. Byerly CR. in the US Army During World War I New York, NY: New York University Press; 2005. 7. US National Library of Medicine. Changing the [internet]. Available at: changingthefaceofmedicine/physicians/biogra phy_23.html. Accessed September 1, 2015. 8. Bullough B. Nurses in American history: the last ing impact of World War II on nursing. Am J Nurs 1976;76(1):118-120. 9. Cameron RS. Mobility, Shock, And Firepower: The Emergence Of The US Armys Armor Branch, 1917-1945 Washington, DC: US Army Center for Military History; 2008. Available at: http://www. and_Firepower/CMH_30-23-1.pdf. Accessed Sep tember 1, 2015. 10. Fitzsimonds JR, Van Tol JM. Revolutions in military affairs. Joint Force Quarterly 1994(Spring):90-97. Available at: pdf. Accessed September 1, 2015. 11. 8th Evacuation Hospital Unit History Historical Collections and Services, University of Virginia. Available at: evac_hosp.php. Accessed September 1, 2015. 12. Beery R. Ruth Beerys Scrapbook 1942-1945. His torical Collections and Services, Claude Moore Health Sciences Library; University of Virginia, 1942. 13. In: Beery R, ed. A letter from CPT Florence Corps to Miss Ruth Beery. Washington, DC: War 14. Jose M. Hi, angels. Am J Nurs 1945;45(4 ):267-269. 15. Tavares S, Faruk Khan M, Arnold A, et al. Op eration Torch: North African Campaign Fort Leavenworth, KS: Combat Studies Institute, USACGS;1984. 16. Wiltse CM. The Medical Department: Medical Service in the Mediterranean and Minor Theaters Washington, DC: US Army Center of Military His tory; 1965. Available at: html/books/010/10-8/index.html. Accessed Sep tember 1, 2015. 17. Surgeon to Soldiers: Diary and Records of the Surgical Consultant, Allied Force Headquarters, World War II Philadelphia, PA: J B Lippincott Company; 1972. 18. Wolff LH. Forward Surgeon: the Diary of Luther H. Wolff, M.D., Mediterranean Theater, World War II, 1943-45 New York, NY: Vantage Press; 1985. 19. thesia. In: Zajtchuk R, Grande CM, eds. Anesthe sia and Perioperative Care of the Combat Casu alty Fort Sam Houston, TX: The Borden Institute; 1995:855-896. 20. Brooks VA. Thoracic surgery: the duties of the nurse in a thoracic surgical team. Am J Nurs 1945;45(4):275-280. 21. Am J Nurs 1945;45:683. AUTHOR LTC Brown is the Deputy Chief, Research at the Cen ter for Nursing Science and Clinical Inquiry, Womack Army Medical Center, Fort Bragg, North Carolina. NURSING IN THE 8TH EVACUATION HOSPITAL, 1942-1945

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October December 2015 99 Y ou are holding a unique book, one that demonstrates the commitment of the Army and the Nation to its Soldiers. Inside, the reader will nd medical doctors and scientists reaching conclusions that are at odds with each other. This book puts these contradicting learned opinions under one cover, for it is important that readers absorb these writings and come to their own conclusions. LTG Patricia D. HorohoThe Surgeon General of the US Army Commanding General, US Army Medical CommandIn October 2011, the Institute of Medicine issued the report Long-Term Health Consequences of Exposures to Burn Pits in Iraq and Afghanistan. The report identi ed and measured the toxic components released from the burn pit at Joint Base Balad in Iraq, and it addressed the potential adverse respiratory health effects associated with these exposures. Although most pollutants detected were present in amounts less than those measured in typical urban areas in the United States and below values thought to cause injury, the amount of particulate matter in the air exceeded values thought to be safe. In the end, the Institute of Medicines ndings were considered to be inconclusive, and a call for additional research was made. Despite the inconclusive nature of the reports ndings, the reports contents prompted the Department of Defense and the Veterans Administration to join forces. As a team, they devised a plan to identify both the population and individuals who had been exposed to the pollution of burn pit res and were at risk through the use of a registry. The intent was to provide healthcare for those with health effects associated with burn pit exposure. To that end, a research agenda was developed to identify and care for those with respiratory impairment attributable to deployment, in general. As a part of this effort, the Veterans Administration and the Department of Defense hosted the Joint Airborne Hazards Symposium in August 2012. This monograph summarizes the content of the symposium, and also includes additional perspectives from other experts who have published research relevant to deployment-related airborne hazards. Published by the Borden Institute and endorsed by The Surgeon General, this monograph comprises 33 chapters outlining important issues that remain to be considered in addressing Soldier respiratory health. The issues include the following: Although a comprehensive health assessment is provided to each Soldier prior to deployment, lung function tests are not part of that assessment. Although adding to the cost of care, this approach would be useful to better understand the effects of deployment on respiratory health. Chapters in this book provide considerable discussion as to whether this would be a useful approach to understanding changes in lung function associated with deployment. The pros and cons of a registry identifying those with an adverse respiratory exposure while deployed are debated. Although it is attractive to undertake epidemiological studies on a population of Soldiers with a common exposure to areas recognized to cause lung disease, the value of such a registry is less clear when the criteria for enrolling in the registry is solely based on the Soldiers recollection, and no clear quanti cation of the extent of exposure to adverse agent(s) is available. Furthermore, A New Monograph From the Borden InstituteAirborne Hazards Related to DeploymentEditors: Coleen P. Baird, MD, MPH Deanna K. Harkins, MD, MPHUS Army Public Health Command Aberdeen Proving Ground, Maryland LTC Daniel E. Banks, MC, USA

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100 some Soldiers, the effects of confounding exposures, speci cally cigarette smoke, may make it dif cult to understand outcomes associated with an exposure that may cause lung injury, such as those that occurred in association with burn pit exposure. The clinical illness constrictive bronchiolitis is described in a population of Soldiers who were short of breath after their deployment, some with clearcut burn pit exposures and some without. Most were without airway obstruction as measured by lung function tests or abnormalities on the chest radiograph or chest computerized tomography scan. Yet, a large number of these individuals had a lung biopsy with changes in the lung consistent with this pathologic entity. This is a very different clinical presentation than that described in nearly all cases associated with other toxic exposures resulting in these pathologic lung changes. In many cases where this pathologic entity was previously reported as caused by other exposures, lung function approached end-stage, and dramatic changes were apparent on chest imaging. This description of disease, as well as the lung biopsy in the absence of lung function or abnormities in lung imaging, has engendered considerable discussion in the pulmonology community about how to understand this illness and how to relate this presentation to our previous understanding of this disease. Although the cases show pathologic features in the lung of constrictive bronchiolitis, what is missing is a serial follow-up of these individuals. In previous reports of individuals with this illness, the great majority fail to improve with therapy. In this instance, there are no reports addressing the clinical outcomes of these Soldiers once the diagnosis of constrictive bronchiolitis was made. Of particular relevance would be the response of symptoms to therapy, as well as a serial assessment of lung function and chest imaging to address progression of the disease over time. The nal aspects of the discussions in the report related to the ways doctors should evaluate those Soldiers who return from deployment with respiratory complaints. Authors propose and detail clinical steps to address and explain why the Soldier has complaints prior to lung biopsy. What investigations are ongoing to better understand the health of Soldiers as they progress through their careers? The Department of Defense and the Veterans Administration have worked together to provide information on the shortand long-term health and well-being of US military veterans and Soldiers. The Millennium Cohort Study was initiated after the 1991 Gulf War and launched a large longitudinal health survey of US service members beginning in 2001immediately prior to the Iraq and Afghanistan con icts. The intent was to evaluate the effect of military service, including deployments, on the long-term health of service members. The study, originally planned to last 21 years, was extended to last 67 years, the life span of a generation of veterans. The cohort consists of more than 200,000 service members from all branches of the service enrolled in 2001, 2004, 2007, and 2011. Evaluations are scheduled at 3-year intervals. Participation is by invitation of a randomly sampled population. Additional enrollment and continued follow-up are scheduled to continue for several decades. The survey is mailed or emailed to the participants and responses collected from more than 1,000 questions. Topics include mental and physical health, military experiences, and lifestyle. An interesting aspect of this survey is the linkage of the individual responses to the TRICARE database (addressing ICD-9 codes for illness) and the Pharmaceutical Data Transaction Service, a way to follow prescription drug therapy. A second, smaller, and much more focused study is the Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures (also known as STAMPEDE). This study was designed to assess and explain new onset of respiratory symptoms occurring relatively soon after returning from deployment in southwest Asia. Of the 50 Soldiers initially studied, 21 were not diagnosed with lung disease; yet, 6 of these Soldiers had cellular abnormalities in the lung, thus implying a subclinical illness. Lung biopsies were not performed. Among those with identi able respiratory illness, the most common explanation was the development of asthma while deployed. The rst manuscript describing the investigations and outcomes in this population can be viewed at pdf/10.1164/rccm.201402-0372OC. Similar studies on a larger population of deployed Soldiers returning with respiratory complaints are ongoing. In summary, the comments by LTG Horoho at the beginning of this review re ect the presentation of information in this monograph. The full story of the outcome of respiratory health of the Soldiers who were deployed to southwest Asia is not yet understood. The editors of this book, Dr Baird and Dr Harkins, have presented a fair perspective on the current state of our understanding of these health effects. They have made a great effort to include both Department of Defense and Veterans Administration representatives, as well as those in the practice of academic medicine, to present what information is available and spur their colleagues to better understand AIRBORNE HAZARDS RELATED TO DEPLOYMENT A NEW MONOGRAPH FROM THE BORDEN INSTITUTE

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October December 2015 101 the respiratory effects of the exposures. These efforts are a very important step forward in better understand ing the adverse respiratory health effects associated with deployment in southwest Asia. LTC Banks is a former Director and

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102 The US Army Health Readiness Center of Excellence The Army Medical Department Center and School ENVISION, DESIGN, TRAIN, ED UCA TE, INSPIRE Joint Base San Antonio Fort Sam Houston, Texas

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October December 2015 103 THE US ARMY MEDIC A L DEP A R T MEN T REGIMEN T The US Army Medical Department was formed on 27 July, 1775, when the Continental Congress authorized a Medical Service for an army of 20,000 men. It created the Hospital Department and named Dr Benjamin Church of Boston as Director General and Chief Physician. On 14 April, 1818 the Congress passed an Act which reorganized the staff departments of the Army. The Act provided for a Medical Department to be headed by a Surgeon General. Dr Joseph Lovell, appointed Surgeon General of the United States Army in beginning of the modern Medical Department of the United States Army. Throughout its early history, the size and mission of the US Army Medical Department would wax and wane in response to military events around the world. There was, however, no formal regimental organization until World War I. Then, in the late 1950s, the brigade replaced the regiment as a tactical unit. In the reorganization that followed, some Army units lost their identity, their lineage, their history. This loss did not go unnoticed. The US Army Regimental System was created in 1981 to provide soldiers with Army Regimental System, states the mission of the regiment is to enhance combat effectiveness through a The Regimental web site ( is designed to provide useful information about the US Army Medical Department (AMEDD) Regiment. Through the web site, you can learn the history of the AMEDD Regiment, the symbolism behind our heraldic items, how to wear the Regimental Distinctive insignia, and various programs available to you and your unit. Texas. The Regimental staff can provide further information pertaining to the history of the Army Medical Department and the AMEDD Regiment, and also to assist with any of the services described in the web page. address: Commander US Army Medical Department Regiment

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SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewed print medium to encourage dialogue concerning health care issues and initiatives. REVIEW POLICY All manuscripts will be reviewed by the AMEDD Journal s Editorial Review Board and, if required, forwarded to the appropriate subject matter expert for further review and assessment. IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST 1. Related to individual authors commitments: tionships that might bias the work or information presented in the manuscript. 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A complete list of references cited in the article must be provided with the manuscript, with the following required data: Reference citations of published articles must include the authors surnames and initials, article title, publication title, year of publication, volume, and page numbers. Reference citations of books must include the authors surnames and initials, book title, volume and/or edition if appropriate, Reference citations for presentations, unpublished papers, conferences, symposia, etc, must include as much identifying information as possible (location, dates, presenters, sponsors, titles). 4. Either color or black and white imagery may be submitted with the manuscript. Color produces the best print reproduction quality, but please avoid excessive use of multiple colors and shading. Digital graphic formats (JPG, TIFF, GIF) are preferred. Editable versions with data sets of any Excel charts and graphs must be included. Charts/graphs embedded in MS Word cannot be used. Prints of photographs are acceptable. If at all possible, please do not send photos embedded in PowerPoint or MS Word. photographic print on the back. Tape captions to the back of photos or submit them on a separate sheet. Ensure captions and photos are indexed to each other. Clearly indicate the desired position of each photo within the manuscript. 5. information must be included on the title page of the manuscript. Submit manuscripts to: DSN 471-6301 Comm 210-221-6301 Email: EDITOR, AMEDD JOURNAL AHS CDD AMEDDC&S 3630 ST ANLEY RD STE B0204 JBSA FORT SAM HOUSTON, TX 78234-6100

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