NATO Trauma Registry – evidence based military medical care for the Alliance

Introduction

When troops are being put in harm’s way, there is always social expectation to minimize the impact of sustained injuries and provide same quality of health care outcome in the combat area than in the home-country. Since the peace time trauma care regime is not fully applicable in the area of military operations, the adaptation of the system is required. 

Nations with larger number of combat casualties established a military trauma registry to find answers for the challenges of combat casualty care. These databases have many similarities and differences, according to the national concept of casualty management, but all the systems have proved their benefit and committed to the evolution of the current state of the art military trauma care.

The idea of founding a common NATO Trauma Registry came out several years ago. It is apparent that there is a particular limitation for nations whose casualty numbers and case loads are not sufficiently large to allow scientifically and statistically robust analysis. Furthermore there is no standardized means of communication or exchange of information. These factors limit the systematic exploitation of lessons learned. The solution might be a centralized data pool and consecutive analysis and reporting capability on trauma patient care, what would facilitate performance improvement for all troop contributing nations of the Alliance.

NATO Research and Technology Organisation has conducted the first relevant research project on NTR and published the results in 2008. The report provided firm advises how to establish the registry and detailed analysis of the possible constrains. The final recommendation was to establish a common NATO Trauma Registry with the subsequent national databases - where not in place yet - and set up a central place for data management and analysis support. Due to the different national legal regulations only anonymized data should be transmitted and handled.

The COMEDS noted the report and tasked the working group structure to initiate the work; Military Health Care Working Group (MHC WG) received the overarching function of the development. Emergency Medicine and Medical Communication and Information Systems Expert Panels were involved in the construction of the minimum dataset required to be exchanged. Belgium assumed the custodianship of the NATO Trauma Registry project.

In 2010, acknowledging the comprehensive work done by the custodian, the NATO Trauma Registry project was reaffirmed. A NTR Task Force (TF) was established under the umbrella of MHC WG, with the Centre of Excellence for Military Medicine (MILMED COE) as coordinating secretary supported by volunteer participating nations (BEL, CZE, DEU, FRA, GBR NLD, USA). NATO Communication, Command and Control Agency (NC3A) was tasked by Allied Command Transformation (ACT) to support the project and facilitate the project development. The TF has the mandate from COMEDS to accelerate the process and validate progress through the use of a pilot study. 

NTR Pilot Study

The pilot study meant to provide further guidance for nations how to coordinate their efforts and develop their national trauma registries. This study was a descriptive study, and also aimed to assess the feasibility of NTR. Furthermore the study examined the NTR Minimum Core Data Elements and the features of the available military trauma registries. 

Data exchange of the parallel developed NTR prototype and the already existing UK and US Joint Theatre Trauma Registry was also in the scope of the experimentation. 

Pilot Objectives

Goals/Overall Objectives:

• To assess the feasibility of the NTR.

Purpose:

• To develop a working model of NTR; to merge the numbers of national cases into a single database and henceforth provide a scientifically robust pool of information for studies and analysis. 
• To encourage nations to exchange and share anonymous data. 

Output:

•  Functional interface among national trauma registries established 
• Communication strategy among NATO TF Nations developed and accepted.

Activities:

• To identify a limited number of parameters for a descriptive study design based on NATO TRAUMA REGISTRY CORE DATA ELEMENTS
• To identify participating nations and their current systems (internal system model compared to NTR model)
• To utilize the UK/US JTTR as template of national trauma registries
• To develop a Trauma Registry System Data Model in order to exploit the trauma registry data
• To develop an NTR Data Exchange Model to enable core data elements exchange 
• To utilize algorithm for Global NTR ID in order to avoid data redundancy
• To design the preliminary rules and procedures to support the NTR model
• To do a test run for import / export based on available systems
• To define communication media and periodicity for the data exchange (CD, mail, attachments, etc.)

Field data collection and data exchange

Field trip

Data process to NTR

The field deployment to ISAF was a pivotal activity; two medical staff officers from MILMED COE executed the data collection in real field hospital environment.

The two weeks period of deployment was split into two parts. In the first week the team visited the FRA Role3 hospital in Kabul International Airport (KAIA), the second week was spent in the DEU Role3 hospital in Mazar-e-Sharif (MeS), ISAF Regional Command North.

The team tested the clinical data availability and compliance with the NTR Core Data Elements, the UK and US trauma collection forms. The registered trauma data were later populated to all three registries (NTR, UK, US) respectively.

Due to the limitation of this article detailed discussion of the field collection experiences is only available in the NTR Task Force final report.

Data exchange

Parallel effort was carried out by NC3A and UK, US to try out the data exchange. The first step for the existing database owners was to compare their dataset with the minimum required Core Data Elements. Then later to select those data elements which fit most to the NTR dataset. 

NC3A was the leading member of the Task Force for coordinate the data transmission and to receive the data messages. To allow NC3A to store the sent data, they constructed an NTR prototype and also a schema. This schema worked as an interface/filter in the identification of the transmitted data. Figure 1. depicts the basic outline of the future relation between  the national registries and the NTR.

Results/Recommendations

The final chapter of the article is briefly summarizing the results of the theatre data collection trip and the IT related experiences and finally provides recommendations.

Results of the field data collection

1. Due to the low sample size statistical analysis on captured data was not carried out. Efforts were focused on practical observations regarding data collection in clinical environment where trauma registry has not been introduced yet. Additional findings were made from the parallel utilization of the three datasets. 
2. Entering the same cases there was different compatibility achievable with the UK and US data form. As far as all three forms are considered there are major variances in inclusion criteria, data sets and data dictionaries as well. The current NATO Trauma Registry Core Data Elements main deficiency is the lacking data dictionary and missing specifications of numerous data entries. 
3. The available registries focus on hospital care and do not fully capture pre-hospital data. 

Results of the data exchange procedure

Data exchange was tested with 74 test patient from UK and US trauma registry. The direct data export from both existing trauma registries into the NATO TR prototype failed because of the incompatibility of the systems and the inappropriate level of the data standardization. The NTR Prototype I. need significant re-arrangements to ensure a standardized data import.  

Recommendations

Further research recommended: 

1. Data dictionary for all entry fields needs to be worked out. It is advised to take over data definitions from UK/USA trauma registry if available.
2. Explore NTR related Quality Improvement and Epidemiological Surveillance aspects and assess the linkages between Clinical Governance in Trauma Care and Force Health Protection.
3. Survey the NTR tactical level users’ operational requirements and support the development of the System part. (collecting, analysis, reporting and dissemination)
4. Evaluate the deliverable products in regard of simplicity, flexibility, data quality, acceptability, representativeness, and timeliness.

Figure 2. is a proposed cycle for the NATO Trauma Registry related system development and also provides guidance for nations if they wish to establish their new trauma system.

Date: 01/21/2019

Source: Medical Corps international Forum (2/2012)