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Handoff Training for Combat Casualty Care (HTC3)



OBJECTIVE: Develop a training framework capable of working with current DoD systems that employs virtual, mixed, and/or live simulation training strategies capable of providing caregivers the opportunity to master handoff protocols from the point of injury through the continuum of care. 

DESCRIPTION: The Defense Health Agency (DHA) seeks to standardize baseline handoff protocols and associated tools across the services and to create a common approach to the training of these protocols and tools. Opportunities for the medical and non-medical individuals, teams, aircrews, and units to participate in collective training of patient evacuation and transport is often limited which can result in the atrophy of their patient handoff skills. Adding baseline handoff protocol training to current approaches will create a standard, service-agnostic approach to ensuring the transfer of responsibility for patients and their information is properly communicated and understood [1]. Providing care to those wounded in combat requires a coordinated effort from a team of teams which generally operate under suboptimal conditions and are separated by time and often great distances. In order to achieve the best possible patient outcomes, everyone involved in the process of transferring patients from one level of care to the next must receive and understands critical information. Unfortunately, while usually conducted, patient handoffs are error prone and have been shown to be frequently insufficient [2]. Handoffs are fundamental for patient care and should be an opportunity for shared cognition and situation awareness between transferring caregivers. To achieve the best possible coordination and continuity of care, training must ensure effective patient handoffs. Approaches to standardized handoff training across the military services must consider the complex nature of multi-trauma handoffs, interactions between team members [3], and how these factors can be objectively measured in a variety of conditions and settings (e.g. care under fire, assessment and treatment in austere environments, national and regional customs and language barriers, equipment differences). Compounding the opportunities for error, military healthcare providers often find themselves simultaneously handling several waves of multi-casualty handoffs with minimal preparation time before receiving the next series of casualties. These operating conditions amplify their need to be capable of quickly and accurately exchanging and understanding critical patient information. The handoff protocol training approach should implement an innovative framework that considers compatibility and integration within extant DoD computer network systems as well as interoperability with existing systems such as Virtual Battlespace 3 (VBS3), the Wide Area Virtual Environment (WAVE), and/or the array of technologies used by the Critical Care Air Transport Team (C-CAT1), Center for Sustainment of Trauma and Readiness Skills (C- STARS), and the Army Medical Support Training Centers (MSTC). A successful solution will take advantage of in situ performance data which can be collected and analyzed in order to provide objective assessments of individual and team performance for real time monitoring and feedback. Further, a successful system will need to be capable of providing certification, recertification training, and have the ability to support service-specific training for En Route Care (e.x. individual, team and crew tasks, in-flight aeromedical team communication). Additionally, data collected and analyzed during training will contribute to future approaches to Joint En Route Care. Ultimately, the result of this effort will be service members who are properly trained and certified in standardized handoff protocols in representative environments that will contribute to improved patient care and achieve the best possible patient outcomes [4]. 

PHASE I: The team will develop an approach for delivering, as appropriate, a virtual, mixed, and/or live simulation training framework to work within existing DoD systems (e.x. VBS3, C-CAT1, C- STARS, WAVE, MSTC, etc.) during a prolonged combat casualty care scenario. The framework will establish that the proposed concept can feasibly work within the selected system(s). Feasibility will be established through the modeling and analysis of specific simulation strategies and techniques which utilize unique training materials and meets the considerations provided in the description. The Phase I Option, if awarded, will include the initial design specifications and capabilities description to build a prototype in Phase II. 

PHASE II: Based on Phase I results and the statement of work for Phase II, a simulation training framework solution will be developed and delivered. The prototype must be capable of assessing trainees proficiency with the handoff protocols and tools based on patient outcome and handoff training objectives. Validation of the prototype will be through testing to demonstrate improved performance, team communication, training engagement, and simulated patient outcomes. A detailed test plan will be developed in order to demonstrate that the deliverable meets the intent of the simulation training framework. A Phase III commercialization plan will be developed during Phase II that addresses transition to industry and/or relevant users. If required, a protocol for the protection of human subjects for this effort will be developed in Phase I for use in Phase II. 

PHASE III: The team will be expected to support the DHA in transitioning the technology to the designated service(s) for use. During Phase III, the team will support the DHA and the selected service(s) in the system integration and qualification testing for the software technology developed in Phase II. This will be accomplished through integration and test events in order to transition the technology into the selected system(s), training center(s), and/or school house(s). Integration of this system will require testing to demonstrate improved performance team communication, training engagement, and improved simulated patient outcomes. Private Sector Commercial Potential: The efforts of the research in a simulation framework for handoff training and performance will have direct application to high-risk organizations that involve training personnel to operate in complex domains. These domains include civilian healthcare, nuclear energy, commercial air transportation, and the space industry. 


1: Department of Defense Patient Safety Program and Agency for Healthcare Research and Quality. 2006. TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety: Pocket Guide (AHRQ Pub. No. 06-0020-2). Rockville, Maryland.

2: Riesenberg, L. A. (2012). Shift-to-shift handoff research: Where do we go from here? Journal of Graduate Medical Education, 4(1), 4-8.

3: Apker, J., Mallak, L. A., Applegate, E. B., Gibson, S. C., Ham, J. J., Johnson, N. A., & Street, R. L. (2010). Exploring emergency physician“hospitalist handoff interactions: development of the handoff communication assessment. Annals of emergency medicine, 55(2), 161-170.

4: Gakhar, B., & Spencer, A.L. (2010). Using direct observation, formal evaluation, and an interactive curriculum to improve the sign-out practices of internal medicine interns. Academic Medicine, 85(7), 1182-1188.


KEYWORDS: Medical Handoff Training, Healthcare Simulation Training, Medical And Paramedical Training, Medical Technology, Patient Safety, Team Communication 

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