Page 85 - JSOM Winter 2025

Committee on Tactical Combat Casualty Care (CoTCCC)

Position Statement on Grading of Evidence
for Tactical Combat Casualty Care (TCCC)

Harold R. Montgomery, ATP; Russ S. Kotwal, MD, MPH; Travis G. Deaton, MD

Background
The Committee on Tactical Combat Casualty Care (CoTCCC) • Level B: This level is divided into two sub-categories:
emphasizes the importance of evidence-based recommenda- o B-R: Evidence from a single RCT or a meta-analysis of
tions to ensure the effectiveness and safety of clinical practices moderate quality with randomized studies. This cate-
and interventions provided during Tactical Combat Casualty gory indicates moderate certainty but still provides valu-
Care (TCCC) and Prolonged Casualty Care (PCC). able insights from controlled experimentation.
o B-NR: Evidence from nonrandomized studies, obser-
A systematic approach is used to develop and update TCCC vational studies, lab evaluation in actual environment,
Guidelines and product reference lists based on research and as well as prospective and retrospective observational
performance improvement studies conducted and published studies with known limitations. While these studies lack
in the peer-reviewed medical literature. Clinical data and ob- the rigor of randomized trials, they still offer critical
servations from the field help to inform guideline recommen- information, particularly in situations where RCTs are
dations. Real-world performance evaluations conducted in impractical.
collaboration with subject matter experts, academic institu- • Level C: This is further subdivided into:
tions, and Department of Defense (DoD) and civilian research o C-LD: Limited data from retrospective observational
development, testing, and evaluation (RDT&E) programs are studies with limitations, chart reviews, case reports,
also used to inform recommendations for TCCC practices and and preclinical research (to include animal and non-
interventions. environmental studies). This level indicates areas where
evidence is scarce or methodologically weaker.
The CoTCCC is a multi-disciplinary committee composed o C-EO: Expert opinion based on clinical experience or
of military and civilian subject matter experts in the fields of consensus from subject matter experts, used in situations
trauma, emergency medicine, critical care, military medicine, where high-level evidence is unavailable or impractical.
prehospital medicine, and other areas. Guided by effectiveness,
safety, and operational suitability, the CoTCCC continuously Prehospital Performance Improvement
consolidates and interprets information, data, analyses, and and Research on the Battlefield
studies from published and unpublished sources in order to
provide recommendations and a consensus for the best prac- Documentation of prehospital care on the battlefield is para-
tices and products to be integrated into the TCCC guidelines. mount for performance improvement and optimization. The
Part of this process includes a formal grading of the evidence. operational cycle of performance improvement is key to the
To facilitate this process, the CoTCCC adopted a structured monitoring and assessment of TCCC metrics, procedures, and
system for grading evidence based on established methodolo- guidelines. Documentation helps to save lives and should be
gies to include systems developed by the American College of supported and enforced by DoD leaders and organizations at
Cardiology (ACC) / American Heart Association (AHA). all levels. Redundant, simple, and standardized solutions for
the initial documentation and after-action reviews of TCCC
should be mandated, trained, and enforced throughout the
Levels of Evidence (LOE)
DoD. Prehospital documentation, data consolidation, and per-
The grading of evidence is categorized into three main levels formance improvement studies provide evidence that guide
to reflect the quality and certainty of the data supporting each best-practice recommendations by the CoTCCC for TCCC
recommendation: Guidelines.
• Level A: Evidence derived from multiple randomized con- For casualties, documentation can improve care, facilitate the
trolled trials (RCTs) or high-quality meta-analyses with continuity of care, and provide a historical record and support
consistent findings. These studies provide a high degree of for disability. For providers, documentation can help to com-
certainty, making recommendations based on Level A evi- municate casualty status, injuries, and treatment. Documen-
dence robust and reliable. tation can also help to facilitate preventive medicine through

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