Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary (2009)

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Appendix B Issues Raised by Stakeholders about the Military Care of Patients with Traumatic Brain Injury Caring for patients with traumatic brain injury (TBI) entails many challenges. Clearly, there are two TBI populations of concern, patients with moderate/severe TBI and patients with mild TBI (mTBI). Patients with moderate/severe TBI must navigate a complex and lengthy path through many military, Department of Veterans Affairs (VA), and civil- ian facilities where they receive acute care, rehabilitation, and chronic care by many providers and case managers. The much larger, but less obvious, population of service members who have had mild ­concussive injuries (mTBI) must be identified, treated acutely (if identified), t ­ riaged, tracked, and assessed for long-term outcomes and needs. The following list of issues raised by stakeholders in the Military Health System (MHS) during the planning phase of the workshop addresses both mTBI care and moderate/severe TBI care. Following a meeting in February 2008, the workshop planning committee re- c ­ ategorized the issues on this long, though by no means comprehen- sive, list to correspond with five major challenges for TBI care: (1) the development of new TBI knowledge; (2) detection and screening of TBI conditions; (3) TBI care coordination and communication; (4) TBI care demand; and (5) TBI care system capacity, organization, and resource allocation. The committee then selected up to three ­issues from each of the five categories that were considered particularly well suited to illustrate the potential benefits of operational systems engi- neering (OSE) tools and techniques to TBI care management in the 135 

136 Systems Engineering to Improve Traumatic Brain Injury CARE Military Health System (MHS). The selected issues are explained in detail in a separate guidance document that was developed for the five working groups. (See Appendix C). All of the issues raised by stakeholders (grouped by stages of medical care) are listed below to inform workshop participants of the wide range of issues that were considered by the planning committee. Screening and Prevention • There is no baseline cognitive screening tool – upon entry into the military – for pre-deployment screening • There is no systematic follow-up assessment for those suspected or known to have a TBI—and no post-deployment screening. • There should be a consistent, highly trained team to evaluate individuals with positive post-deployment screening. • Personal protective equipment should be improved. • Education of service members and their families about TBI symptoms and appropriate interventions is inadequate. Diagnosis and Case Management • No efficient, effective means of documenting trauma associated with a TBI (data on the type and severity of the exposure leading to the injury) has been developed. • There is no gold-standard test for the presence or severity of TBI (no known biomarker, for example). • Standard methods for assessing TBIs in the field or distinguishing when a concussion requires more intensive medical intervention are not used for all service members involved in a blast incident (MACE algorithm tool is currently used). • Gaps should be addressed in identification and subsequent treat- ment of soldiers with mTBI resulting from exposure to roadside bomb blasts—cases of mTBI may be overlooked. • Differences between TBI symptoms caused by blast exposures and other traumatic exposures should be identified.  MACE stands for Military Acute Concussion Evaluation. For more infor- mation, see http://www.dvbic.org/pdfs/DVBIC_instruction_brochure.pdf. 

appendix B 137 • DOD does not have a system-wide approach for properly identi- fying, managing, and monitoring individuals who sustain a TBI, particular mTBI. • We need a better way of determining the incidence of brain i ­njury and a secondary goal of tracking former soldiers who may have experienced brain injury but have since left active-duty military service. • Missed diagnoses or premature return to duty may result in r ­ epeated concussions with long-term consequences. • Only a limited network is in place to document and track service members from point of injury/diagnosis through post-military service care in the VA health system. • There is no consistent disposition assessment for determining when/if a service member who has sustained a TBI should return to duty or at the time of discharge from service. • Limited resources are available in theater (e.g., imaging). Treatment • Multidisciplinary treatment (physical, psychological, cognitive) is not available or used at all military/VA treatment facilities. • No standardized care/treatment is provided at all military h ­ ospitals. • Identified best practices are not uniformly implemented across the continuum of care for patients with all degrees of TBI. U.S. Department of Defense (DOD) does have a clinical practice guideline. • Adequate treatment is lacking for patients in rural, non-urban, and underserved areas, who live too far from designated TBI centers or other VA treatment facilities to receive treatment from them. • Problems in coordinating care between DOD and VA facili- ties—especially in transferring electronic records from DOD to the Deaprtment of Veterans Affairs—should be addressed. • Communication and coordination among care pro­viders at differ- ent levels of care and at different medical facilities is ­inefficient. • There is no validated follow-up with appropriate clinical assess- ment techniques to recognize neurological and behavioral effects following acute injury other than MACE. 

138 Systems Engineering to Improve Traumatic Brain Injury CARE • We need more knowledgeable care providers with expertise spe- cifically in TBI—many care providers currently have little or no experience in treating blast-related brain injuries. • A challenge in treating mTBI is the co-morbidity of post- t ­ raumatic stress disorder (PTSD) and other psychiatric disorders, and some overlap of symptoms; PTSD associated with TBI may be different than non-TBI-related PTSD; understanding how TBI symptoms and psychiatric symptoms exacerbate and medi- ate one another. • TBI may be harder to recognize in cases where there are no out- ward signs of injury. Rehabilitation and Chronic Care • Rehabilitation care is not standardized and is not always initi- ated when clinically indicated, nor has an optimal rehabilitation program been determined. • Patients cared for in VA facilities who are still on active duty may complicate rehabilitation regimens. • Excessive delays in establishing necessary services—mostly as a result of problems in transferring records from DOD to VA and/or in obtaining military health care benefits—should be eliminated. • There are no objective measures for what constitutes recovery from a TBI, making the determination of fitness for return to duty problematic. • Long-term case management is inadequate for service members/ veterans who are impaired but not hospitalized; tracking of changes in health or mental status, quality of life, adherence to therapy/medication, etc. are spotty, at best. • We need new programs to focus on coordinating care, such as a federal care-coordinator system (polytrauma) and Defense and Veterans Brain Injury Center (DVBIC) regional care- c ­ oordination systems. • Support for families caring for TBI patients is insufficient or nonexistent. • Ongoing efforts are being made with congressionally mandated Family Caregiver Curriculum. 

appendix B 139 • Role of community-level TBI-relevant services is not well defined or coordinated. General Issues • Additional TBI research is necessary along entire continuum of care, as well as a mechanism to collect data on the frequency, severity, care, and outcomes of TBI patients. • The lack of data impairs analysis of the operation, cost, and effec- tiveness of TBI care; DOD and VA should systematically collect, code, retain, share, and analyze data in a way that respects the privacy of patients and the confidentiality of their information. • The challenge in understanding, diagnosing, and treating military personnel is greater for mTBI than for moderate or severe TBI. • No single medical discipline addresses TBI issues.