Page 57 - JSOM Summer 2023

Determining Clinical Priorities Using a
Clinical Practice Guideline Deconstruction Tool

COVID-19 in Austere Operational Environments

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Richard M. Caldwell, MSN, MBA *; Wayne Dickey, PhD ;
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Aaron Sawyer, PhD ; Elizabeth Mann-Salinas, RN, PhD ; Lawrence Crozier, RN, MSN ;
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Harold Montgomery, BBA, SO-ATP ; Giselle Moody, MBA, PhD 7
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ABSTRACT
The Joint Trauma System (JTS) publishes Clinical Practice hemodynamic monitoring parameters, specialized equipment
Guidelines (CPGs) used by military and civilian healthcare for managing airway/ventilation, and infection control mea-
providers worldwide. With the expansion of CPG development sures varied significantly from previously published guidance;
in recent years, there was a need to collate, sort, and deconflict and (3) deployed medical personnel may not fully understand
existing and new guidance using systematic methodology both guidance due to role-specific disease management and preven-
within and across CPGs. This need became readily apparent tion directions. JTS required a system for organizing clinical
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at the start of the COVID-19 pandemic when guidelines were guidance along with a dissemination and implementation strat-
rapidly developed and fielded in deployed environments. To egy to maximize awareness and ensure ready access to these
meet the needs of deploying units requesting immediate and recommendations.
concise guidance for managing COVID-19, JTS developed
the CPG entitled Management of Covid-19 in Austere Opera- JTS enlisted support from a team of implementation science (IS)
tional Environments. By applying a deconstruction process to experts within DHA’s Research and Engineering Directorate to
organize clinical recommendations across multiple categories, improve CPG organization and translation. Implementation
JTS was able to present clear clinical recommendations across science is the scientific study and application of methods and
“role of care” and “scope of practice.” The use of a deconstruc- strategies that facilitate the uptake of evidence-based practice
tion process supported the rapid socialization of the CPG and and research into regular use. The goals of this support were to
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may have improved clinical understanding among deployed
medical teams. 1. Develop a standardized framework for the rapid identifica-
tion, prioritization, and communication of changing clini-
Keywords: deployed medicine; COVID-19; implementation cal guidance within deployed medical environments.
science; dissemination; clinical practice guidelines; trauma 2. Identify and close gaps impacting CPG implementation, in-
care cluding developing and/or refining education and training,
supporting materiel, and policy.
3. Align trauma Knowledge, Skills, and Abilities (KSAs) to
specific groups of end-users according to personnel role
Introduction
and care team scope of practice.
The JTS is the Department of Defense Center of Excellence for
Trauma Care, dedicated to improving survivability for trauma Critical actions within a CPG are often different based on
patients in wartime and peacetime. JTS is a critical element in scope of practice and environment of care. The act of “decon-
the Defense Health Agency’s (DHA) role as a Combat Support structing” CPG organized content into manageable and dis-
Agency. It works closely with Combatant Command (CCMD) crete guidance is based on these factors. Deconstruction also
surgeons, developing trauma system contingency plans to sup- enabled JTS to cross-reference guidance across multiple CPGs.
port unique CCMD mission requirements. CPGs are essential
tools that support CCMD trauma systems by reducing un- CPG Deconstruction
wanted medical practice variations. Deconstruction first allowed stakeholders to collate and
cross-reference clinical information, hereafter referred to as
Managing clinical recommendations across JTS’ 77 CPGs clinical guidance components, across several CPGs by organiz-
is a Herculean task, especially for care delivered in evolving, ing them into discrete categories. Then, key recommendations
dynamic environments across a global footprint. The CPG were linked across categories, arranged in sequence like that
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entitled Management of COVID-19 in Austere Operational of Tactical Combat Casualty Care (TCCC). Subject matter
Environments had multiple challenges: (1) recommenda- experts (SMEs) used this process to systematically organize
tions embedded within the CPG that differed according to components of guidance into a framework to improve under-
role of care and scope of practice; (2) recommendations for standing and implementation by deployed medical personnel.
*Correspondence to the Research & Engineering Directorate Team: dha.ncr.j-9.mbx.isb@health.mil
1 Richard M. Caldwell, Dr Wayne Dickey, and Dr Aaron Sawyer are affiliated with Research & Engineering Directorate Contract Support,
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Defense Health Agency, Falls Church, VA. Dr Elizabeth Mann-Salinas, Lawrence Crozier, and Dr Giselle Moody are affiliated with the Joint
Trauma System Contract Support, Defense Health Agency, Joint Base San Antonio Fort Sam Houston, TX. Harold Montgomery is affiliated with
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the Tactical Combat Casualty Care Program, Defense Health Agency, Joint Base San Antonio Fort Sam Houston, TX.
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