Military Hospital’s Surgical Care Ranks Among Best in Nation

By Elaine Sanchez

Brooke Army Medical Center

WASHINGTON, July 24, 2015 – The San Antonio Military Medical Center here ranks among the top hospitals in the nation for surgical care, according to a recent report from the American College of Surgeons.

SAMMC earned an exemplary or average rating in 180 different surgical quality variables, placing the facility in the upper half of hundreds of esteemed hospitals throughout the nation.

The report is issued by ACS’ National Surgical Quality Improvement Program, or NSQIP, a voluntary program that gauges the quality of surgical programs across the nation. The aim is to help surgeons better understand their quality of care compared to similar hospitals with similar patients, according to the program’s website.

“The largest and best hospitals in the U.S. are part of this program, and our percentages place us in the top half of those hospitals,” said Air Force Col. Joseph Brennan, chief of SAMMC’s Department of Surgery. “We are very proud of that.”

Data Collection is Key

Data collection is key to the program’s success, Brennan noted. At SAMMC, a surgeon oversees the program and two nurses are dedicated to inputting preoperative through 30-day postoperative data into a secure, web-based platform. ACS analyzes rates of mortality and morbidity, such as pneumonia, surgical site infections, urinary tract infections, sepsis and readmissions.

“Blinded” information is then shared with all participating hospitals, offering a snapshot of how hospitals rank according to surgical outcomes.

This data offers priceless insight, noted Army Maj. (Dr.) George Kallingal, surgeon champion for NSQIP at SAMMC.

“NSQIP foremost offers us an internal metric to ensure our surgical quality outcomes continue to progress at SAMMC and sets in motion the process of continual analysis and improvement,” he said.

SAMMC’s surgical outcome data has been increasingly positive over the past three years, Brennan noted, an uptick he attributes to SAMMC’s care providers and infection control, quality and process improvement teams.

Improvements to Surgical Processes

“As a result of the data, we’ve made multiple improvements to our surgical processes,” he said, citing efforts to improve operating room preparations and catheter use. “And our exceptional staff did a great job pushing initiatives focused on better patient care.”

While NSQIP provided the framework for analysis, “the dedication of SAMMC personnel and their commitment to quality improvement is what fostered meaningful change,” Kallingal said. “It will continue to be an important tool to provide the framework for improving surgical quality outcomes in the future.”

The program is an easy sell at SAMMC, added Mariea Shelton, process improvement coordinator. The aim, she said, is to always strive for “great outcomes in surgical procedures.”

With an eye on further improvements, Brennan hopes to add a third NSQIP surgical clinical reviewer soon to enable more data to be inputted and more feedback to be gained. “The more numbers we can track, the better off we’ll be when it comes to gauging our strengths and weaknesses,” he said.

While the program is voluntary, the Defense Department requires all military hospitals to participate in NSQIP. SAMMC has been a voluntary member of the program since 2009.

“Participation in NSQIP means there is a total commitment to deliver the highest quality surgical patient care,” said Marilyn McFarland, a NSQIP surgical clinical reviewer.

Multiple Recent Successes

"Quality patient care is [the] priority here and it shows,” added Laura Van Dyk, surgical clinical reviewer.

Brennan praised the hospital’s exceptional care, citing recent successes on The Joint Commission reaccreditation survey, Level I trauma center reverification, and a Commission on Cancer silver designation for SAMMC’s cancer program.

“Our focus has always been on providing the best patient care,” the colonel said. “That emphasis has never wavered. This is just a great organization, from the leadership on down.”

New burn care center fully operational in San Antonio

SAN ANTONIO, Texas -- The U.S. Army Institute of Surgical Research began a new era in burn and combat casualty trauma care when the staff moved its patients into the burn intensive care unit recently.

They performed the first surgical procedure May 25, in one of two operating rooms of the new burn center in the San Antonio Military Medical Center, or SAMMC, consolidated tower at Joint Base San Antonio - Fort Sam Houston.

The completion of the move comes several weeks after the initial move of the burn rehabilitation center, the outpatient clinic, the administrative section, and the clinical studies branch.

"The new burn center challenges us to use all that we have learned during the war and improve care for the benefit of all future burn patients admitted to our center," said Col. Evan Rez, Burn Center director.

Renz said the move marks a monumental milestone for the only Department of Defense burn center.

"The long anticipated occupation of the new burn center highlights the organization's enduring commitment to combat casualty care and research," he said.

As the only burn center for the DOD for more than 50 years, it has been providing specialized care for casualties with severe burns, inhalation injury, and complex soft-tissue trauma, or BICU, sustained in combat or accidents.

In addition, it serves as the regional burn center for South Central Texas, providing care for hundreds of civilian emergency patients each year.

"Our role as a regional burn center is twofold," said burn center Chief Nurse Lt. Col. Louis Stout.

Stout said the first is to provide a critical service. The second is the necessity to remain clinically proficient in times of peace so that we can assume our mission rapidly in times of conflict.

"These are perishable skills that are not easily, or quickly, mastered and must be maintained" she said.

The center is located on the fourth floor of the new seven-story tower at SAMMC and is approximately 40 percent larger in size than the previous unit.

Some of the new features include two operating rooms with cameras installed in the surgical lights to transmit live videos of surgical procedures to monitors in the operating rooms and nurses' stations, and a conference room for educational purposes for medical students and staff.

The new facility also combines two eight-bed burn intensive care units into one 16-bed unit where each BICU room utilizes a 360-degree design in which most of the vital equipment is attached to a ceiling-mounted boom, allowing the patient's bed to rotate completely around the room.

"The successful transition to the new burn center has validated the integral value of a multidisciplinary approach to patient care," said clinical nurse Maj. Trinity Peak, BICU officer-in-charge.

It also reaffirmed staff that they have the skills and knowledge to accomplish their mission anywhere and at anytime, he said, while never losing sight of the the patient."

Since 2003, the burn center has cared for approximately 1,000 wounded warriors evacuated from Iraq and Afghanistan and 2,500 civilian patients from the South Central Texas region. The Burn Center employs approximately 300 staff members with multiple critical burn care skills from the Army, civil service, and contractors.

The United States Army Surgical Research is a subordinate command of the U.S. Army Medical Research and Materiel Command.

The mission to "optimize combat casualty care" is accomplished by conducting science and clinical research in the fields of damage control resuscitation, homeostasis, engineering, and tissue regeneration affecting combat casualties, including burns.

Vice Chief Visits San Antonio Wounded Warrior Support and Joint Force Training Facilities

By Lt. Cmdr. Chris Servello, VCNO Public Affairs

SAN ANTONIO (NNS) -- The vice chief of naval operations (VCNO) toured the San Antonio Military Medical Center (SAMMC) and visited Navy and joint training sites during a May 24 trip to the greater San Antonio area.

Adm. Mark Ferguson interacted with patients, staff and family members at the Center for the Intrepid (CFI) and Warrior and Family Supprt Center (WFSC), and then met with Sailors at the Medical Education and Training Campus (METC) and Naval Technical Training Center (NTTC) Lackland.

VCNO began his day with visits to CFI and WFSC to better familiarize himself with the wounded warrior care and family support offered at SAMMC.

The mission of the CFI is to provide rehabilitation to personnel who have sustained amputation, burns, or functional limb loss; to provide education to military and Department of Veteran's Affairs professionals on rehabilitation; and to promote research in orthopaedics, prosthetics and physical/occupational rehabilitation.

WFSC provides coordinated services to patients, next-of-kin and extended wounded warrior family members. Injured service members and their family visit the WFSC to receive emotional support, answers to their questions, and to extend their rehabilitation away from the hospital.

During his visit to METC and NTTC Lackland, Ferguson had the opportunity to address students, school officials and family members as he toured living quarters, recreational facilities, and various training classrooms at the two sites.

At all-hands calls at both locations, Ferguson discussed the Sailing Directions from the Chief of Naval Operations. He provided the audiences real-world examples of how today's Navy was putting the tenets of Warfighting First, Operate Forward and Be Ready into practice worldwide.

VCNO also thanked both groups of Sailors for their service and sacrifice. "You have all chosen to serve--to give up comforts and embark on a life of high standards--to be ready when the country is least ready."

In his METC remarks, Ferguson thanked Sailors training to be hospital corpsmen for their hard work, telling them that today's men and women were, "the best we have ever had. You are the most educated, intelligent and physically fit group of Sailors in the history of our Navy."

METC is the primary Department of Defense healthcare education campus and trains enlisted medical personnel in over 60 medical programs, graduating 24,000 joint service personnel annually.

At NTTC Lackland, Ferguson told an audience of Sailors training in the Master-at-arms (MA) rating, "you are making a difference because you make us safer--you protect us against terrorist and criminal threats."

Sailors attending the MA school are trained and tested in the areas of antiterrorism, security force fundamentals, and basic law enforcement.

Military Study Aims to Aid Troops With Mild TBI

By Elaine Sanchez
American Forces Press Service

SAN ANTONIO, Jan. 12, 2012 – A team of experts at San Antonio Military Medical Center here has launched a military study aimed at improving outcomes for service members suffering from a signature wound of today’s wars: traumatic brain injury.

The Study of Cognitive Rehabilitation Effectiveness, dubbed the SCORE trial, is examining cognitive rehabilitation therapy’s value as a treatment for service members with mild TBI.

The Defense and Veterans Affairs departments teamed up on this study to determine the best treatment for combat troops who are experiencing mild TBI symptoms -- such as difficulties with attention, concentration, memory and judgment -- three to 24 months post-injury, explained Douglas B. Cooper, the study’s lead and a clinical neuropsychologist for the center’s Traumatic Brain Injury Service.

“We have a lot of great interventions to help … in the first few days after concussion,” he said in an interview with American Forces Press Service. “We can pull them out, get them rest and get them better.”

However, “we don’t have as many good interventions later on --six months, 12 months or two years post-injury,” acknowledged Cooper, who also serves as the director of the Military Brain Injury Rehabilitation Research Consortium.

The trial’s aim is to determine if cognitive rehabilitation therapy improves chronic mild TBI symptoms and, if so, which interventions work best, on whom and why.

Cognitive rehabilitation, Cooper explained, involves a variety of interventions that help patients with brain injuries reduce, manage or cope with cognitive deficits. It’s commonly used to treat patients with brain injuries, whether from concussions, penetrating brain injuries or strokes.

With vast experience in the field, Cooper said, he and his colleagues knew anecdotally that the therapy works, meaning it helps to improve memory and focus in patients. However, he added, experts have cited a lack of evidence-based research tying cognitive rehabilitation to successful treatment of brain injuries.

With a lack of in-hand research, insurance companies began to balk on covering it as a stand-alone treatment. For example, TRICARE, the military’s health care plan, won’t cover cognitive rehabilitation programs that haven’t been proven as effective stand-alone therapy for TBI, according to a TRICARE fact sheet.

Rather than step away from the therapy, Congress directed a series of studies to explore cognitive rehabilitation and its effectiveness among troops, Cooper said.

The Defense and Veterans Brain Injury Center took on the challenge and soon enlisted the help of DOD and VA experts. They took a year to write manuals to serve as a trial guide and began enrolling patients in SCORE in July.

They had only a few enrollment criteria: troops must have suffered a mild TBI while deployed in support of operations Enduring Freedom, Iraqi Freedom or New Dawn, and be three to 24 months post-injury, Cooper said.

They had no shortage of available participants. A TBI database shows that more than 202,000 service members suffered a TBI between 2000 and 2010, with the majority experiencing a mild TBI or concussion, according to the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. The center cited blasts, fragments, bullets, motor vehicle accidents and falls as the leading TBI causes within the military.

The team plans to treat 160 participants in six-week cycles over the course of two to three years, Cooper said. While in the trial, patients participate two times a day, five days a week, and are entered into one of four treatment paths, or “arms,” he explained.

These treatment paths involve a variety of interventions, and may include individual appointments, group sessions, computer treatments and behavioral health -- or a combination of several intervention types.

For the computer exercises, Cooper explained, service members complete a series of commercially available computer programs touted to improve “brain fitness.” These sessions take place in hospital and are proctored by clinic staff.

The programs are presented in a game-like format, he added. As they progress, troops earn “brain bucks” that can be used to outfit a virtual apartment with big-screen TVs and stereos. This suits technology-savvy service members, he noted, who often fall into the under-25 age range.

The team also is looking at the effectiveness of various treatment combinations, such as mental health care and cognitive rehabilitation offered together. More than 50 percent of TBI patients have a coexisting psychological disorder, oftentimes combat stress, Cooper explained, so wrapping the two treatments together makes sense.

An exercise typical of this approach is to have service members listen to a tape and be asked to focus on certain things in their environment, he said. This exercise is first introduced as a cognitive rehabilitation skill, but troops later see its benefits as a tool to overcome combat-related stress.

This integrated treatment is particularly useful for service members who aren’t willing to seek behavioral health care on their own, Cooper noted.

“There’s still a large stigma attached to mental health care,” he explained. “They may not want to seek behavioral health to get care, but are willing to talk to a psychologist while here getting care for a concussion.”

Cooper said his team will look at each treatment arm to see which interventions have proven most successful and for whom. In general, they’re looking for improvements in several areas: working memory, which is holding on to information; prospective memory, which involves remembering to perform a planned action or intention at the appropriate time; and simple attention, which is being able to process what someone is saying at the moment and then remembering what was said.

“We hope to not only look at what interventions work, but then look at subsets of patients -- these particular people haven’t shown as much improvement or people with multiple concussions may be harder to treat and so on,” he explained.

As Cooper’s team works to improve attention and focus, a parallel study at the medical center here is delving deeper into their patients’ brains. Participants of the SCORE trial also are invited to participate in the Imaging Support for Study of Cognitive Rehabilitation Effectiveness, known as the iSCORE study. For this study, experts use cutting-edge imaging technology to scan patients’ brains at certain intervals: before the SCORE trial, halfway through, after the trial and at 12 to 18 weeks later.

Imaging experts are hoping to learn more about people’s white matter track pathways in the brain, Cooper explained. “Is there something about these that will tell us why individuals are changing?” he asked. “Why are they getting better, and which ones are not able to get better?”

The best clinical trials, he added, raise more questions than they answer.

If the SCORE trial proves successful -- meaning it proves cognitive rehabilitation’s efficacy -- the goal is to determine which interventions are the most effective and then disseminate that information to VA and DOD centers, Cooper said. Civilian providers also may glean ideas that can aid them in the treatment of noncombat-related brain injuries, such as those from a car accident or a stroke.

Meanwhile, Cooper is hoping the study will have a direct, positive impact on troops’ well-being and their ability to return to active duty, and, on a bigger-picture level, the health care system as a whole.

Above all, he added, “we want to make sure they’re functioning and doing OK.”

The nation has an obligation to ensure service members get the best care and treatment possible, Cooper said.

“They need to feel taken care of, that their complaints are valid, and that they’re not alone in going through this process,” he added.

The SCORE trial, he said, “is accomplishing that and more.”