CPGs are “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”1 To date, over 80 CPGs have been instituted to inform the standard of care for the US military in the deployed setting and are reflective of the current “state of the art” at the time of release.

CPGs are developed based on the best available evidence and SME consensus, providing clinicians with recommendations to improve the quality of care, standardization of care and serve as an educational resource while deployed. A systematic and operationally responsive approach to development, verification and implementation of CPGs is taken to ensure rapid field dissemination and provide quality indicators to measure effectiveness. Department of Defense (DoD) trauma cases worldwide are reviewed for CPG compliance by JTS in accordance with PI metrics specified at the end of each CPG.

JTS guidelines may be updated frequently based on operational need and clinical observations and have all been written by SME volunteers. CPGs undergo revisions when the clinical or operational need arises. The JTS CPGs currently do not meet the National Academies of Sciences Engineering and Medicine standards for CPG development1 to facilitate expediency, responsiveness to the military operational environment and rapid performance improvement. In some cases, there may be little published literature (military or civilian) to guide battlefield or operational medicine, requiring heavy reliance on SME opinion or unpublished analysis of military data. JTS CPGs are timely and reflect evolving threats, technologies, and current realities on the battlefield. The JTS recommends every deploying clinician in their respective Combatant Command (CCMD) who will be providing care for casualties becomes familiar with the CPGs posted on the JTS website.

Strong evidence demonstrates CPG compliance is associated with a reduction in mortality.2-4 The Donabedian Model for quality improvement in health care states that, besides patient characteristics, institutional structures and clinical practices determine patient outcome.5 Evidence-based CPGs are developed to avoid unnecessary variation and promote consistency in healthcare practice throughout the continuum of care to achieve optimal outcomes. JTS CPGs complement the deployed PI process. Since the early days of the U.S. Central Command (USCENTCOM) trauma system, the guidelines have been developed and implemented by clinical SMEs in response to needs identified in the CCMD Area of Operations (AOR). More recently, as the trauma system has matured, the process for identifying, developing, vetting, approving, and implementing CPGs has also matured.

To the greatest extent possible, JTS CPGs are evidence-based. The evidence is derived from the published literature, to include analysis of combat casualty data. When evidence is lacking or unclear, yet a CPG is needed, guidelines are developed based on the best available evidence and SME consensus. In order to ensure CPGs include the latest techniques and innovations, monitoring of all CPGs is essential. To ensure monitoring, each individual CPG will include a system-level PI monitoring plan. Monitoring specifics (e.g., timing, frequency, performance measures) are written in the PI monitoring plan for each CPG. This system-wide monitoring will be conducted by the JTS PI Branch. The PI plan will state the intent and minimum performance measures that will be utilized for monitoring. Trauma directors or their equivalents at the deployed military treatment facility level are expected to implement local PI processes to ensure appropriate adherence to the CPGs; the PI monitoring plan will help guide these efforts. Routine updates to CPGs occur every five years or as the operational need arises or as new evidence surfaces. SMEs include, but are not limited to, military and DoD civilian experts, deployed clinicians, Service specialty consultants, trauma medical directors, trauma program managers, JTS Branch Chiefs, and trauma PI nurse analysts.

Although the JTS CPGs were originally developed for USCENTCOM, they are no longer specific to any particular CCMD or contingency. JTS CPGs are patient-centric guidelines with the intent of keeping the medicine joint and agnostic of Service or location. Because CCMDs greatly differ in climate, terrain, and resources, the JTS CPGs are not representative of a specific CCMD or contingency. Services, unit organizations, and trauma directors may tailor to unit missions, deployed settings, and unique situations.