Another important point to highlight is that the landscape of prehospital medical care is constantly changing and evolving. As we enter an era where we may be involved in more anti-access and area denial missions that use units with smaller footprints in environments that are less permissive, the need for prolonged field care will likely become more important with longer evacuation times. New technologies will continue to be developed that enhance forward delivery of medical care. In this ever-changing environment, guidelines and recommendations will need to adapt and change.

CoTCCC and the JTS have a process to ensure the TCCC Guidelines remain relevant and stay updated. The first step is the identification of issues that could be considered for a formal review. These range from the advent of new technologies and equipment, to the findings of combat casualty care reviews through the DOD Trauma Registry or other research efforts, to lessons identified in current operations, to routine reviews of existing recommendations to ensure they are founded on sound evidence-based guidance. Often this comes through CoTCCC members at routine meetings, but it can certainly be identified by other medics based on their knowledge, experiences or research.

Potential issues are then identified to select CoTCCC members for consideration. Sometimes, the need to pursue the issue further is very obvious, and it will move to the next stage without being introduced to the entire CoTCCC membership. Other times, the issue will be forwarded to the larger membership body for consideration as a new project (either at an in-person meeting or through a less formal process of reaching out to the members individually). Based on the collective response, the issue may move to the next stage, but sometimes the choice is to not pursue the issue further at that time, leaving room open to readdress the issue at a later date.

The next stage involves the selection of a small group of people, led by a champion, to address the issue and prepare a course of action and recommendations for the CoTCCC membership. This stage could involve doing a retrospective review of literature, it might require some deliberate research (particularly in the cases of new technology recommendations), and it almost always involves coordination with subject matter experts inside and from outside of CoTCCC membership. The end result of this most complicated phase is a set of recommendations for the CoTCCC membership to consider.

Once that information has all been gathered and put together, the issue is brought before the CoTCCC members for deliberation. This can be done at the routinely scheduled CoTCCC meetings (often held twice a year), but an ad hoc meeting can also be convened. A routine meeting either is limited in time or will not occur in time to address a time-sensitive issue. Read-aheads are provided, but there is an open discussion, and debate is encouraged prior to voting. The membership ultimately votes on anything that might result in a Guideline change or formal CoTCCC recommendation. The minutes from those meetings are openly available on the JTS website.

Changes to the Guidelines may be validated, but a completely new version might not be issued pending other outstanding issues, to prevent version changes from occurring too frequently (CoTCCC may choose to reissue the Guidelines once several changes are approved). In the interim, each pending change will be highlighted so anyone who might be affected can prepare for the upcoming modifications. Also, in the case of most changes, a formal change paper is written, providing a summary of the information that formed the basis for the CoTCCC discussions. These are often published in the Journal of Special Operations or in Military Medicine.