title: Potential benefits of an integrated military/civilian trauma system: experiences from two major regional conflicts.
abstract: BACKGROUND
  Although differences of opinion and controversies may arise, lessons learned from military conflicts often translate into improvements in triage, resuscitation strategies, and surgical technique. Our fully integrated national trauma system, providing care for both military and civilian casualties, necessitates close cooperation between all aspects of both sectors. We theorized that lessons learned from two regional conflicts over 8 years, with resultant improved triage, reduced hospital length of stay, and sustained low mortality would aid performance improvement and provide evidence of overall trauma system maturation.
  
  
  METHODS
  We performed an 8 year, retrospective analysis of the Israeli National Trauma Registry prospective data base for all casualties presenting to level 1 and 2 trauma centers nationwide during an earlier conflict (W1) (7/12/06-8/14/06) and sought to compare results to those of a more recent war(W2), (7/08/14-08/26/14), as well as to compare our results to non-war civilian morbidity and mortality during the same time frame. Of particular interest were: casualty distributions, injuries/ISS, patterns of evacuation/triage, hospital length of stay, and mortality.
  
  
  RESULTS
  Data on 919 war casualties was available for evaluation. Of 490 evacuated during W1, 341 (70%) were transferred to Level 1 centers, compared with 307 (72%) from the 429 casualties in W2. In W2, significantly more severe injuries (ISS ≥16) were evacuated directly to level 1 centers (42, 76% vs. 20, 43% respectively; p = 0.0007). W2 vs. W1 saw a significant increase in evacuations using helicopter (219,51% vs. 180,37%; p < 0.0001) and increase in ISS ≥16: (66; 15.5% vs. 55; 11%, p = 0.057). In W2 vs. W1, less late inter-hospital transfers occurred: (48, 11% vs. 149, 30%, p < 0.0001); and there was a reduction in admission ≥ 7 days (90,22%vs 154,32%, p = 0.0009). These results persisted in logistic regression analyses, when controlling for ISS..Mortality was not significantly changed either overall or for injures with ISS ≥ 16: (1.2%in W1 vs. 1.9% in W2, p = 0.59, 10.9% in W1 vs. 10.6% in W2, p = 1.0, respectively). When compared to civilian related, (non-war) mortality during the same 8 year time frame, overall mortality was unchanged (1.6% vs. 1.8%, p = 0.38), although there was a noteworthy significant decrease in mortality over time for ISS ≥ 16: 12.1 vs. 9.4 (p = 0.012), and a concomitant reduction in late inter-hospital transfers (9.8 vs. 7.5, p < 0.0001).
  
  
  CONCLUSIONS
  Despite more severe injuries in the most recent regional conflict, there was increased direct triage via helicopter to level 1 centers, reduced inter-hospital transfers, reduced hospital length of stay, and persistent low mortality. Although further assessment is required, these data suggest that via ongoing cooperation in a culture of improved preparedness, an integrated military/civilian national trauma network has also positively impacted civilian results via reduced mortality in ISS ≥ 16 and reduced late inter-hospital transfers. These findings support continued maturation of the system as a whole.
authors.affiliation: Assia Medical Group, Barzel 20, Tel Aviv, 96303, Israel. jeffrykashuk@gmail.com.
authors.forename: Jeffry L
authors.initials: JL
authors.lastname: Kashuk
authors.affiliation: Disaster Medicine Division, Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.|National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel.
authors.forename: Kobi
authors.initials: K
authors.lastname: Peleg
authors.affiliation: Israel Defense Forces, Jerusalem, Israel.
authors.forename: Elon
authors.initials: E
authors.lastname: Glassberg
authors.affiliation: National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel.
authors.forename: Adi
authors.initials: A
authors.lastname: Givon
authors.affiliation: National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel.
authors.forename: Irina
authors.initials: I
authors.lastname: Radomislensky
authors.affiliation: Rambam Health Campus, Haifa, Israel.
authors.forename: Yoram
authors.initials: Y
authors.lastname: Kluger
mesh_terms: D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D007557:Israel; D008297:Male; D008887:Military Medicine / Q000458:organization & administration*; D012042:Registries; D012189:Retrospective Studies; D014193:Trauma Centers; D014194:Traumatology / Q000458:organization & administration*; D014218:Triage; D014857:Warfare; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy*