Patient Movement

Purpose of patient evacuation

-Minimizes mortality: by rapidly and efficiently moving the sick, injured, and wounded to an MTF. -Serves as a force multiplier: as it clears the battlefield enabling the tactical commander to continue his mission with all available combat assets. -Builds the morale: of Soldiers by demonstrating that care is quickly available if they are wounded. -Provides en route medical care: that is essential in improving the prognosis and reducing disability of the wounded, injured, or ill Soldiers.

3 types of patient evac

CASEVAC Casualty Evacuation: The movement of casualties aboard a nonmedical vehicle or aircraft without en-route medical care. MEDEVAC performed by dedicated, standardized medical evacuation platforms, with medical professionals who provide the timely, efficient movement and en route care of the wounded, injured, or ill persons from the battlefield and/or other locations to MTFs. Aeromedical Evacuation: specifically refers to USAF provided fixed-wing movement of regulated casualties using organic and/or contracted mobility airframes with AE aircrew trained explicitly for this mission. platforms being displayed: C-17, KC-135, and C-130

Patient movement continuum of care

CASEVAC/MEDEVAC -> Tactical AE -> Strategic AE First responder care -> Forward Resuscitative Care -> theater hospital care -> definitive care Intra-theater (tactical AE) -> inter-theater (strategic AE)

En Route Patient Staging Systems (ERPSS) (inter-theater travel)

ERPSS is designed to temporarily hold patients as they transit the AE system while providing short-term complex medical-surgical nursing care and limited emergent intervention. The ERPSS has a two-fold mission— -To provide support and continuity of medical care for patient movement -Serve as an integral patient interface to the en route care system. The ERPSS provides personnel and equipment necessary for 24-hour patient staging operations, patient transportation between the staging facility and the aircraft, and administrative processes for tracking patients transiting the en route care system worldwide. The ERPSS has no surgical, lab, dental, mental health, x-ray, or blood bank capabilities. Therefore, it is normally collocated with an MTF capable of providing required inpatient and outpatient services. Critically ill patients and inpatient psychiatric patients must be staged/held at the collocated or supporting MTF. ERPSS is designed to temporarily hold patients as they transit the AE system while providing short-term complex medical-surgical nursing care and limited emergent intervention. The length of stay in an ERPSS facility may be from 2 to 72 hours. If the staging facility is not collocated with an MTF that can provide the required clinical support, arrangements must be in place to meet the clinical support levels needed for patients transiting the facility.

International SOS

In the event a SM member is in a remote location where military transportation is not available, Tricare has a contract with a civilian agency called International SOS. This needs to be a coordinated effort with TPMRC for life, limb or eye sight. This is a cashless, claimless medical service through a proprietary network of providers credentialed and appointed by International SOS around the globe. Tricare contracted service utilized in the event a SM is in a remote location where military transportation is not available.

Inter vs Intra-Theater Aeromedical Evacuation

Intra-Theater Aeromedical Evacuation is the movement system by which patients are evacuated to or between medical facilities within the Area of Operation (AO) / Theater of Operations. Inter-Theater Aeromedical Evacuation is the movement system by which patients are evacuated from medical facilities within the area of operation to hospitals located in the theater support base or CONUS.

Patient Evacuation Coordinating Cell (PECC)

Joint entity tasked with coordinating the intelligent tasking process in support of Joint Theater Patient Evacuation (JTPE), integrating operational, clinical, and medical regulating considerations to inform PM activities throughout the joint operations area. Functions include coordinating with the appropriate Patient Movement Requirements Center (PMRC) to optimize integrated PM points of transition, enabling continuity of en route care. Receives MEDEVAC request -> determine EVAC platform -> launch FLA (field litter ambulance)

Global Patient Movement Trends

Patient Prep Issues: 146 events reported (#1 Category) •Top focus areas: oEquipment (34) a) No litter b) No litter pads c) No pulse ox oPaperwork (30) oOrders (30) a) Missing medication order b) Order discrepancy c) Transcription error • •Actions/Recommendations: oJPMRC is checking with sending facilities if AE crew needs to bring equip to add to the PMR. TRAC2ES trainer at JPMRC continues visiting & training sites throughout CENTCOM on PMI, PM and forms oImplement I-SBAR handoff form that includes patient prep checklist and references •Medication order issues trending out of LRMC oPrior orders crossed out or whited out & written over oNon-approved abbreviations used for medications oTranscription errors to med record (3899I) •Actions/Recommendations: oCASF VFS provided briefing & 3899 training at ProStaff oLRMC Chief nurse & LRMC PSM continue monitoring oRe-education to individual providers •EMS issue in CONUS where certain locations EMS will not accept narcotics or PCA oAwareness e-mail sent to Army POC and USTRANSCOM oSeeking resolution to this ongoing issue •Anti-hijacking Issues: 18-19 events/Qtr : oMostly involve CENTCOM and CONUS locations oAwareness e-mails sent to units

MEDEVAC evacuation procedure

Priority I—URGENT (1 hour) Is assigned to emergency cases that should be evacuated as soon as possible and within a maximum of 1 hour in order to save life, limb, or eyesight and to prevent complications of serious illness and to avoid permanent disability. Priority IA—URGENT-SURG (1 hour) Is assigned to patients who must receive far forward surgical intervention to save life and stabilize for further evacuation. Priority II—PRIORITY (4 hours) Is assigned to sick and wounded personnel requiring prompt medical care. This precedence is used when the individual should be evacuated within 4 hours or if his medical condition could deteriorate to such a degree that he will become an URGENT precedence, or whose requirements for special treatment are not available locally, or who will suffer unnecessary pain or disability. Priority III—ROUTINE (24 hours) Is assigned to sick and wounded personnel requiring evacuation but whose condition is not expected to deteriorate significantly. The sick and wounded in this category should be evacuated within 24 hours. Priority IV—CONVENIENCE (no time, simply convenience for MTF and/or PT) Is assigned to patients for whom evacuation by medical vehicle is a matter of medical convenience rather than necessity.

TRAC2ES

TRANSCOM Regulating and Command & Control Evacuation System (TRAC2ES) is a Department of Defense system used to create and track Patient Movement Requests (PMRs). TRAC2ES links the originating and destination MTFs with medical evacuation transportation assets and C2 infrastructure. This facilitates the patient movement planning and management process and allows continuous tracking of patient locations or In-Transit Visibility (ITV).

AE Evacuation Precedence

Urgent (12 hours) Patients requiring emergency evacuation to save life, limb, eyesight or to prevent serious complications of injury or existing medical conditions Psychiatric or terminal cases with a very short life expectancy are not considered urgent Priority (24 hours) Patients requiring prompt medical care not available locally Used when the medical condition could deteriorate and the patient cannot wait for routine evacuation Routine (72 hours) ***Recently changed to 7 days*** Patients requiring medical evacuation, but conditions are not expected to deteriorate significantly

Role III and Patient Administration Team (PAT) responsibilities

• Transporting them to and from airfields or AE staging facilities, when directed. • Obtaining and transporting the appropriate diet for the patient. • Providing appropriate personnel to accompany patients to the aircraft. • Helping load and unload patients and baggage. • Coordinates with any external or sponsoring agency (or company, in the case of civilian patients) to provide instructions on correct patient care. • Gets appropriate documentation (equivalent to AE patient orders) from the agency, including proper billing information. ** Identifying Medications, Supplies and Equipment. The attending physician writes orders for a 3-calendar-day (intratheater) or 5-calendar-day (intertheater) supply of all medications, IV fluids, tube feedings, and treatment supplies the patient requires. **

Theater Evacuation Policy

•The theater evacuation policy is established by the Secretary of Defense, with the advice of the Joint Chiefs of Staff and upon the recommendation of the theater commander. • •The policy establishes the length in days of the maximum period of non-effectiveness (hospitalization and convalescence) that patients may be held within the theater for treatment. • •This policy does not mean that a patient is held in the theater for the entire period of non-effectiveness. • •Begins upon arrival to role III. For example, a theater evacuation policy of seven days does not mean that a patient is held in the theater for six days and then evacuated. Instead, it means that a patient is evacuated as soon as possible after the determination is made that the Soldier cannot be returned to duty within seven days following admission to a Role 3 hospital. A shorter theater evacuation policy— •Results in fewer hospital beds required in the theater and a greater number of beds required elsewhere. •Creates greater demand for inter-theater USAF evacuation resources. •Increase the requirements for replacements to meet the rapid personnel turnover. A longer theater evacuation policy- •Greater accumulation of patients and a demand for larger CHS infrastructure. Decreases bed requirements elsewhere. •Increases requirements for medical supplies, equipment, and med maintenance. •Increases the requirements for hospitals, engineer support and all aspects of base development for CHS. •Provides greater proportion of patients to RTD within theater, thus reduces the loss of experienced manpower

Patient Tracking Systems

•Transportation Regulating Command and Control Evacuation System (TRAC2ES) • •Medical Communications for Combat Casualty Care (MC4) A Web-based application, Medical Situational Awareness in the Theater (MSAT) combines information from multiple communities to provide decision support and a common operating picture. MSAT links together information that encompasses disease and non-battle related injuries, physical and psychological trauma, patient tracking, chemical and biological threats, environmental and occupational health, intelligence, medical command and control (C2) data, personnel, unit locations and weather. • •Theater Medical Data Store (TMDS) web-based application used to view Service members' medical treatment information recorded in the combat zone. TMDS views and tracks ill or injured patients as they move through theater levels of care, sustaining base medical treatment facilities (MTFs) and those shared with the Department of Veterans Affairs (VA). • •HELP web-based, HIPAA-compliant, secure, asynchronous, teleconsultation system started up by Naval Medical Center Portsmouth (NMCP). It allows request for information in a secure and HIPAA-compliant format, continuous situational awareness for consults, appointments, and patient arrival