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Select data courtesy of the U.S. National Library of Medicine.

© 2023 DeepDyve, Inc. All rights reserved.

Military Medicine

Subject:
Medicine (miscellaneous)
Publisher:
Association of Military Surgeons of the United States —
Oxford University Press
ISSN:
0026-4075
Scimago Journal Rank:
70

2023

Volume Advance Article
January
Volume 188
Supplement 5 (Sep)Supplement 4 (Jul)Supplement 3 (May)Supplement 2 (May)Supplement 1 (Mar)Issue 9-10 (Aug)Issue 7-8 (Jun)Issue 5-6 (Apr)Issue 3-4 (Feb)

2022

Volume Advance Article
DecemberNovemberOctoberSeptemberAugustJulyJune
Volume 2022
September
Volume 188
Supplement 3 (May)Issue 9-10 (Dec)Issue 7-8 (Dec)Issue 5-6 (Dec)Issue 3-4 (Dec)Issue 1-2 (Dec)
Volume 187
Supplement 2 (May)Issue 11-12 (Jun)Issue 9-10 (Mar)Issue 7-8 (Mar)Issue 5-6 (Mar)Issue 3-4 (Mar)Issue 1-2 (Jan)

2021

Volume Advance Article
JulyJuneMayAprilMarchFebruaryJanuary
Volume 188
Issue 7-8 (Dec)Issue 5-6 (Dec)Issue 3-4 (Nov)Issue 1-2 (Dec)
Volume 187
Supplement 1 (Dec)Special Issue_13 (Apr)Issue 11-12 (Oct)Issue 9-10 (Feb)Issue 7-8 (Oct)Issue 5-6 (Aug)Issue 3-4 (Feb)Issue 1-2 (May)
Volume 186
Supplement 3 (Oct)Supplement 2 (Sep)Supplement 1 (Jan)Issue 11-12 (Nov)Issue 9-10 (Aug)Issue 7-8 (Jul)Issue 5-6 (May)Issue 3-4 (Feb)Issue 1-2 (Jan)

2020

Volume Advance Article
DecemberNovemberJulyJuneApril
Volume 2020
June
Volume 188
Issue 5-6 (Jul)
Volume 187
Issue 5-6 (Dec)Issue 3-4 (Dec)Issue 1-2 (Dec)
Volume 186
Issue 11-12 (Dec)
Volume 185
Supplement 3 (Oct)Supplement 2 (Jun)Supplement 1 (Jan)Issue 11-12 (Dec)Issue 9-10 (Sep)Issue 7-8 (Aug)Issue 5-6 (Jun)Issue 3-4 (Mar)Issue 1-2 (Feb)

2019

Volume Advance Article
DecemberSeptemberMayAprilMarchFebruaryIssue 7-8 (Jul)
Volume 2019
September
Volume 184
Supplement 2 (Nov)Supplement 1 (Mar)Issue 11-12 (Dec)Issue 9-10 (Oct)Issue 7-8 (Jul)Issue 5-6 (May)Issue 3-4 (Mar)Issue 1-2 (Jan)

2018

Volume Advance Article
NovemberIssue 7 (Jun)
Volume 183
Supplement 3 (Nov)Supplement 2 (Sep)Supplement 1 (Mar)Issue 11-12 (Nov)Issue 9-10 (Sep)Issue 9 (Sep)Issue 7-8 (Jul)Issue 5-6 (May)Issue 3-4 (Mar)Issue 3 (Mar)Issue 1-2 (Jan)Issue 1 (Jan)

2017

Volume 182
Supplement 2 (Sep)Supplement 1 (Mar)Issue 11 (Nov)Issue 9-10 (Sep)Issue 9 (Sep)Issue 7 (Jul)Issue 5 (May)Issue 3 (Mar)Issue 1-2 (Jan)Issue 1 (Jan)

2016

Volume 181
Supplement 5 (May)Supplement 4 (Nov)Supplement 2 (Feb)Supplement 1 (Jan)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2015

Volume 180
Supplement 10 (Oct)Supplement 4 (Apr)Supplement 3 (Mar)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2014

Volume 179
Supplement 11 (Nov)Supplement 8 (Aug)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2013

Volume 178
Supplement 10 (Oct)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2012

Volume 177
Supplement 9 (Sep)Supplement 8 (Aug)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2011

Volume 176
Supplement 8 (Aug)Supplement 7 (Jul)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2010

Volume Advance Article
March
Volume 2010
February
Volume 175
Supplement 8 (Aug)Supplement 7 (Jul)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2009

Volume Advance Article
April
Volume 2009
June
Volume 174
Supplement 5 (May)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (Apr)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2008

Volume 2008
May
Volume 173
Supplement 1 (Jan)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2007

Volume 172
Supplement 2 (Nov)Supplement 1 (Nov)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2006

Volume 171
Supplement 1 (Oct)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2005

Volume 170
Supplement 4 (Apr)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 1 (Jan)

2004

Volume Advance Article
July
Volume 169
Supplement 12 (Dec)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2003

Volume 168
Supplement 1 (Sep)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2002

Volume Advance Article
NovemberJune
Volume 2002
April
Volume 167
Supplement 4 (Sep)Supplement 3 (Aug)Supplement 2 (Apr)Supplement 1 (Feb)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2001

Volume 166
Supplement 2 (Dec)Supplement 1 (Sep)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

2000

Volume 165
Supplement 3 (Nov)Supplement 2 (Jul)Supplement 1 (Apr)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1999

Volume 164
Supplement 8 (Aug)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1998

Volume 163
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1997

Volume 162
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1996

Volume 161
Supplement 1 (Aug)Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1995

Volume 160
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1994

Volume 159
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1993

Volume 158
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1992

Volume 157
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1991

Volume 156
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1990

Volume 155
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1989

Volume 154
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1988

Volume 153
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Oct)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1987

Volume 152
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1986

Volume 151
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1985

Volume 150
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1984

Volume 149
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1983

Volume 148
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1982

Volume 147
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1981

Volume 146
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1980

Volume 145
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1979

Volume 144
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1978

Volume 143
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Jul)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1977

Volume 142
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1976

Volume 141
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1975

Volume 140
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1974

Volume 139
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1973

Volume 138
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1972

Volume 137
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1971

Volume 136
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1970

Volume 135
Issue 12 (Nov)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1969

Volume 134
Issue 13 (Dec)Issue 12 (Dec)Issue 11 (Nov)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1968

Volume 133
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (Jun)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1967

Volume 132
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1966

Volume 131
Supplement 9 (Sep)Issue 12 (Dec)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 4 (Apr)Issue 2 (Feb)Issue 1 (Jan)

1965

Volume 130
Issue 11 (Nov)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1964

Volume 129
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1963

Volume 128
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)

1962

Volume 127
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 3 (Mar)Issue 2 (Feb)

1961

Volume 126
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1960

Volume 125
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1959

Volume 124
Issue 12 (Dec)Issue 11 (Nov)Issue 10 (Oct)Issue 9 (Sep)Issue 8 (Aug)Issue 7 (Jul)Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1958

Volume 123
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)
Volume 122
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1957

Volume 121
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)
Volume 120
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1956

Volume 119
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)
Volume 118
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1955

Volume 117
Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)
Volume 116
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1954

Volume 115
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)
Volume 114
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1953

Volume 113
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)
Volume 112
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1952

Volume 110
Issue 6 (Jun)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1951

Volume 109
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)
Volume 108
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1950

Volume 107
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)
Volume 106
Issue 6 (Jun)Issue 5 (May)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1949

Volume 105
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)
Volume 104
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1948

Volume 103
Issue 6 (Dec)Issue 5 (Nov)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)
Volume 102
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1947

Volume 101
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)
Volume 100
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1946

Volume 99
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)
Volume 98
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1945

Volume 97
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jun)
Volume 96
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1944

Volume 95
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)
Volume 94
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1943

Volume 93
Issue 6 (Dec)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)
Volume 92
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1942

Volume 91
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)
Volume 90
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1941

Volume 89
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)
Volume 88
Issue 6 (Jun)Issue 5 (May)Issue 4 (Apr)Issue 3 (Mar)Issue 2 (Feb)Issue 1 (Jan)

1940

Volume 87
Issue 6 (Dec)Issue 5 (Nov)Issue 4 (Oct)Issue 3 (Sep)Issue 2 (Aug)Issue 1 (Jul)

0020

Volume Advance Article
April
journal article
LitStream Collection
Scoping Review of Postvention for Mental Health Providers Following Patient Suicide

Daly, Kelly A; Segura, Anna; Heyman, Richard E; Aladia, Salomi; Slep, Amy M. Smith

2023 Military Medicine

doi: 10.1093/milmed/usac433pmid: 36661225

ABSTRACT Introduction As suicides among military personnel continue to climb, we sought to determine best practices for supporting military mental health clinicians following patient suicide loss (i.e., postvention). Materials and Methods We conducted a scoping review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Our initial search of academic databases generated 2,374 studies, of which 122 were included in our final review. We categorized postvention recommendations based on the socioecological model (i.e., recommendations at the individual provider, supervisory/managerial, organizational, and discipline levels) and analyzed them using a narrative synthesizing approach. Results Extracted recommendations (N = 358) comprised those at the provider (n = 94), supervisory/managerial (n = 90), organization (n = 105), and discipline (n = 69) levels. Conclusions The literature converges on the need for formal postvention protocols that prioritize (1) training and education and (2) emotional and instrumental support for the clinician. Based on the scoped literature, we propose a simple postvention model for military mental health clinicians and recommend a controlled trial testing of its effectiveness. Despite over two decades of U.S. DoD–sponsored prevention initiatives,1 the annual rate of suicide among military personnel continues to climb.2 In 2020, 580 service members (SMs) died by suicide (a rate of 28.7 per 100,000, compared with a civilian rate of 13.5 per 100,000) representing an increase of 41.4% from 2015.3,4 Because of this alarming increase, there are DoD-endorsed interventions for commanders, unit members, friends, and family members impacted by an SM’s suicide (i.e., postvention).5 Notably, absent from these protocols is the provision of support for the SM’s treating mental health (MH) clinician.5–7 The occupational stressors for MH treatment providers are well established (e.g., isolation and vicarious trauma). Military clinicians’ experiences are compounded by role strain. Military MH clinicians must maintain their own readiness while serving both their patients (providing the best possible care) and the U.S. government (acting in the military’s best interest), duties that often compete. Navigating this requires frequent negotiation between the ethics and practices of psychology and of military service, an inevitable setup for moral injury when something goes wrong. Having a patient die by suicide profoundly impacts MH clinicians, personally and professionally.8–10 Across studies, clinicians have reported shock, horror, sadness, distress, guilt, and shame upon learning of a patient’s death.7,11–13 Indeed, in the immediate aftermath of a suicide, providers’ reactions are often akin to those of the deceased individual’s loved ones.14 Symptoms of post-traumatic stress disorder (PTSD) and depression are not uncommon,15–18 with one-third of clinicians still experiencing severe distress 1 year later.19 Although suicide has been described in the literature as an “occupational hazard”20–22 for MH professionals, in practice it is handled as an aberration.23 As such, following suicide clinicians report (1) feelings of responsibility, failure, loneliness, isolation, and perceived stigma and (2) having their competence questioned and fearing colleagues’ assumptions of negligence.8,24–29 In addition, clinician burnout is extremely common30 and approximately one-third consider leaving the field.31 Even among the most resilient clinicians, changes in practice (e.g., increased time devoted to undue risk assessment rather than treatment; overly lengthy, litigation-minded record keeping; and over-hospitalization) are widespread and often enduring.11,19,21 In institutional settings, clinicians’ treatment decisions, via case files, are customarily subject to a thorough review following patient suicide.32–34 Although the manifest purpose of such reviews is to generate “lessons learned” and improve ongoing patient care, clinicians often experience them as unhelpful and blaming.35 In the U.S. military, clinicians undergo a particularly intense standard-of-care review process to make a wrongdoing determination.36,37 This lengthy process has been described as unduly punitive and a significant source of fear by military clinicians.6,37,38 Moreover, research suggests that in the wake of patient suicide, a substantial portion of Air Force Medical Service clinicians feel unsupported by their units, leadership, and the MH community.6,38 In contrast, a nascent line of research has demonstrated that effectively coping with a patient’s suicide can lead to post-traumatic growth and positive changes in professional practice, including the pursuit of advanced training and treatment specialization in suicidality.25,31,39 Thus, both positive and negative outcomes are possible for clinicians after the loss of a patient to suicide. CURRENT STUDY In 1968, Edwin Shneidman coined the term “postvention” to highlight preventative interventions that can be conducted with survivors following patient suicide.9 Because of the difficulty of testing clinician postvention recommendations, there have been almost no efficacy trials. Given military health systems’ size and interest in maintaining readiness in clinicians as force protection agents, military systems would be ideal settings to test whether clinician postvention works. Thus, in this scoping review, we sought to (1) systematically identify the most promising postvention targets (i.e., practices to minimize long-term negative repercussions of patient suicide and maximize the potential for post-traumatic growth) that could be tailored to military MH settings and (2) organize them within a socioecological framework40 (i.e., clinician, supervisor, organization, and discipline). Taking a parsimonious approach, we were most interested in recommendations with the potential to simultaneously mitigate multiple adverse outcomes (e.g., PTSD, depression, burnout, and leaving the field) and promote growth among military clinicians. METHOD The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews protocol can be found in Online Supplement S1. Inclusion and Exclusion Criteria Inclusion criteria were (1) publication in English or Spanish, (2) published between January 1992 and February 2022, and (3) focused on (a) the impact/effect of patient suicide on a clinician or (b) recommendations or approaches to support providers after patient suicide. We considered studies using quantitative and qualitative methodology, as well as case reports, case series, cross-sectional, prospective, and interventional studies, clinical trials, dissertations, book or book chapters, commentaries, previous systematic or literature reviews, and editorials for inclusion. Exclusion criteria were (1) focused solely on the impact/effect of patient suicide on health care workers, without explicitly identifying needs that could be addressed, and (2) postvention for family members, peers, or friends. Article Selection Process The review protocol followed the PRISMA guidelines. The search was conducted by two Ph.D.-level authors (K.A.D. and A.S.) in January and February 2022. Three teams of at least two researchers reviewed selected articles based on the protocol. The first team independently screened titles and abstracts, indicating exclusion or possible inclusion. Then, researchers from the second team independently assessed the full text of the possible inclusion articles for eligibility. If researchers from either the first or second team disagreed about inclusion, we reached an agreement through consensus by two PhD-level coauthors. Data Extraction Five study characteristics were extracted: (1) authors and year of publication; (2) publication type (i.e., quantitative, qualitative or mixed-methods study, review, conceptual paper, theses/dissertation, book chapter, and case study); (3) sample characteristics (i.e., n, military or nonmilitary, country, and type of health care provider); (4) identified needs or types of support targeting health care providers after patient’s suicide (e.g., program, suggestion/recommendation, protocols, and training); and (5) postvention recommendations’ socioecological level (i.e., individual, supervisory, organization, and discipline). Data Synthesis and Analysis Extracted data were processed via broad, thematic qualitative analysis across socioecological levels and then summarized using a narrative descriptive synthesizing approach.41 We did not consider article bias or research rigor. RESULTS As shown in the PRISMA flowchart (Fig. 1), the initial search produced 2,374 articles for abstract review, 2,183 of which were excluded after screening. After reviewing the full text of the remaining 191 articles, 122 studies were included (see Tables I and Supplementary Table S1). Almost all of the 122 articles were in English (98.4%); three-fourths were published in the last 15 years. Most were empirical (quantitative [21.3%], qualitative [15.6%], and mixed-methods [15.6%]); 21.3% were reviews, and 12.3% were conceptual. Empirical studies sampled MH clinicians (e.g., psychologists, psychiatrists, counselors, and social workers; 63.6%, n = 56, including four with military providers), medical staff (i.e., nurses and physicians; 19.3%, n = 17), and MH residents/trainees (17.0%, n = 15). FIGURE 1. Open in new tabDownload slide PRISMA flowchart diagram for the scoping review process. TABLE I. Characteristics of the Included Studies (N = 122) . % . n . Year of study publication 1992-2007 26.2 32 2008-2022 73.8 90 Type of publication Quantitative study (n rangea = 22-713) 21.3 26 Qualitative study (n range = 4-103) 15.6 19 Mixed-methods study (n range = 25-515) 15.6 19 Narrative review 15.6 19 Conceptual paper (including postvention guidelines) 12.3 15 Case studies 6.6 8 Systematic review (n range = 10-58) 5.7 7 Personal narrative 5.7 7 Other (i.e., editorial and conference report) 1.6 2 Language of the study English 98.4 120 Spanish 1.6 2 . % . n . Year of study publication 1992-2007 26.2 32 2008-2022 73.8 90 Type of publication Quantitative study (n rangea = 22-713) 21.3 26 Qualitative study (n range = 4-103) 15.6 19 Mixed-methods study (n range = 25-515) 15.6 19 Narrative review 15.6 19 Conceptual paper (including postvention guidelines) 12.3 15 Case studies 6.6 8 Systematic review (n range = 10-58) 5.7 7 Personal narrative 5.7 7 Other (i.e., editorial and conference report) 1.6 2 Language of the study English 98.4 120 Spanish 1.6 2 Note. Percentages for the type of contribution sum more than 100% because of one study being both a systematic review and a mixed-methods study. a n range shows the minimum and maximum number of health professionals who experienced a patient/client’s suicide or received the implementation of a postvention training program for quantitative, qualitative, or mixed-methods studies. For the systematic review category, n range represents the minimum and maximum number of articles included. Open in new tab TABLE I. Characteristics of the Included Studies (N = 122) . % . n . Year of study publication 1992-2007 26.2 32 2008-2022 73.8 90 Type of publication Quantitative study (n rangea = 22-713) 21.3 26 Qualitative study (n range = 4-103) 15.6 19 Mixed-methods study (n range = 25-515) 15.6 19 Narrative review 15.6 19 Conceptual paper (including postvention guidelines) 12.3 15 Case studies 6.6 8 Systematic review (n range = 10-58) 5.7 7 Personal narrative 5.7 7 Other (i.e., editorial and conference report) 1.6 2 Language of the study English 98.4 120 Spanish 1.6 2 . % . n . Year of study publication 1992-2007 26.2 32 2008-2022 73.8 90 Type of publication Quantitative study (n rangea = 22-713) 21.3 26 Qualitative study (n range = 4-103) 15.6 19 Mixed-methods study (n range = 25-515) 15.6 19 Narrative review 15.6 19 Conceptual paper (including postvention guidelines) 12.3 15 Case studies 6.6 8 Systematic review (n range = 10-58) 5.7 7 Personal narrative 5.7 7 Other (i.e., editorial and conference report) 1.6 2 Language of the study English 98.4 120 Spanish 1.6 2 Note. Percentages for the type of contribution sum more than 100% because of one study being both a systematic review and a mixed-methods study. a n range shows the minimum and maximum number of health professionals who experienced a patient/client’s suicide or received the implementation of a postvention training program for quantitative, qualitative, or mixed-methods studies. For the systematic review category, n range represents the minimum and maximum number of articles included. Open in new tab Postvention Recommendations Extracted recommendations (N = 358) were at the provider (n = 94), supervisory/managerial (n = 90), organization (n = 105), and discipline (n = 69) levels. Supplementary Table S2 and Figure 2 summarize the recommendations; Online Supplement S2 provides comprehensive descriptions. FIGURE 2. Open in new tabDownload slide Postvention socioecological model. At the individual provider level, recommendations targeted relational support (n = 69), self-care (n = 35), preparation for the possibility of a patient’s suicide (n = 35), acknowledgment of the deceased patient’s life (n = 26), and practical elements (n = 19). At the supervisory/managerial level, recommendations focused on the supervisor–supervisee dyad (n = 87) and supervisor actions on behalf of the organization (n = 27). At the organizational level, recommendations were directed at the development of a comprehensive postvention protocol (n = 101), the creation of a workplace culture of openness and non-judgment regarding patient suicide (n = 25), and the review of investigatory processes (n = 8). Finally, at the discipline level, recommendations were aimed at suicide education and postvention implementation (n = 38), future research (n = 34), and cultural shifts (n = 15). DISCUSSION The primary purpose of clinician postvention is to mitigate adverse outcomes and bolster growth among clinician survivors. The secondary purpose is the prevention of future patient suicide loss.42,43 Commensurate with the breadth and depth of personal and professional impacts of patient suicide, concrete recommendations toward these aims have been made at all levels of the socioecological model. (Although all services have basic postvention guidelines,44–47 they are not comprehensive, focusing largely on supporting those close to suicide completers other than the clinician.) Postvention recommendations include articulated steps for both pre- and post-patient suicide loss across discipline, organizational, supervisory, and individual provider levels. We summarize these here, but because of space limitations, the specific recommendations with citations are included only in Supplementary Table S2. Discipline-wide calls for increased suicide-related training and education for MH clinicians (of all professions) at all career stages are common. Across the literature, the authors impel the MH care discipline toward a cultural shift in the way patient suicide is handled. This is operationalized via recommendations to cultivate open noncritical atmospheres around patient suicide and revise case review procedures at the organization level; foster safe environments for communication and disclose one’s own experiences of patient suicide at the supervisory level; and universal preparedness for patient suicide at the provider level. Discipline-level proposals to make clinician postvention standard practice are reflected in recommendations for the development of tailored postvention protocols, with specific roles for staff, at the organizational level; the responsibilities of supervisors to clinician survivors (e.g., extra supervision and caseload accommodations) and in carrying out their organizations’ protocols (e.g., informing all staff of the patient death) at the supervisory level; and practical elements (e.g., consultation with an attorney and update patient record) at the provider level. The individualized nature of effective postvention is widely acknowledged. At the discipline level, this is evident in suggestions that future research identifies subpopulations of clinicians who may be more vulnerable to adverse outcomes and for calls to recognize providers as survivors. The concept of individualizing postvention is reflected through recommendations for (1) at the organization level: flexible work accommodations; (2) at the supervisory level: a menu of potential support recommendations (with advice for case-by-case use); and (3) at the MH professional level: self-care, engaging personal support networks, and finding meaning in the loss. Overall, the scoped literature converges to advocate that organizations develop formalized postvention protocols with pre- and post-incident components that (1) facilitate clinicians’ training and education about suicide and (2) provide individualized emotional and instrumental support for the clinician survivor. Although the postvention recommendations are sensible, the necessity for empirical testing for both positive and iatrogenic outcomes is needed before their widespread dissemination. As a cautionary parallel, the also eminently sensible Critical Incident Stress Debriefing48 was widely disseminated to help first responders cope with trauma by immediately sharing and processing their experiences in groups. However, rigorous testing documented that rather than promote coping, Critical Incident Stress Debriefing often increased adverse effects (e.g., risk for PTSD).49,50 With that caution in mind, we selected among the simplest recommendations appropriate to be adopted in a military MH context. We prioritized recommendations from the reviewed literature that we believed (1) could simultaneously improve multiple outcomes (e.g., decreasing burnout professional inefficacy and depression and increasing post-traumatic growth) among MH clinicians, (2) could be implemented with relatively little investment, and (3) readily lent themselves to empirical testing. Recommendations for Military Clinician Postvention Distilling the scoped literature’s recommendations, we propose a two-phase approach to military MH clinician postvention (see Fig. 3). Phase I (universally implemented before patient suicide) consists of (1) comprehensive suicidology education and (2) each clinician developing a personalized postvention plan (see Online Supplement S3). Phase II (implemented after patient suicide) includes individual clinicians’ postvention plan activation and engagement of the dual-support model. A heuristic model (Figure 3) that includes (1) proximal and distal outcomes of clinician suicide loss and (2) proposed moderators (i.e., hypothesized positive impacts of prevention) that could buffer the impacts of patient suicide—should be systematically tested in a randomized controlled trial of military clinician postvention. FIGURE 3. Open in new tabDownload slide Proposed model of USAF clinician Postvention. Suicidology Education (Prevention Phase) Military suicide researcher and USAF veteran Dr. Craig Bryan51 asserts that (almost) everything we think about suicide is wrong, such as the relationship between mental illness and risk and the ubiquity of warning signs. Indeed, the most rigorous computational models of suicide completion (assessed across 14 million individuals) have positive predictive values (PPV) of <0.01.52 Meta-analyses of instruments available to clinicians for risk assessment produced a pooled PPV of 5.5% for suicide; when analyses were restricted to psychological instruments alone, the pooled PPV was 3.7%.53 Even with the best available tools (including purely computational simulation), science’s ability to predict an individual patient’s suicide is close to 0.52,54 This is the humbling, little-acknowledged reality of clinical practice. Military services need to acknowledge that suicide will never be eradicated. Efforts to reduce suicide risk are necessary; however, “zero suicide” campaigns are aspirational, unfulfillable, and may backfire when they misleadingly imply that all suicide is preventable and that someone (often a clinician) should be blamed if one does occur. The illusionary expectation of predictability is only reified by the standard-of-care review process, during which clinicians are faulted for failing to foresee what research has repeatedly found to be unforeseeable. A common theme across the postvention literature is the need for universal information regarding the ubiquity of patient suicide.7,17,55,56 Conservative estimates suggest that half of psychiatrists, one-fourth of psychologists, and one-fifth of social workers will have a patient die by suicide.29,30 Thus, all military MH clinicians should receive annual comprehensive suicidology education30,57–59 comprising (1) the nature of suicide (e.g., function of access/means, impulsivity, weak correlation between mental illness and suicide, and lack of orthogonal risk factors)51,60–63; (2) the potential and limitations of treatment (e.g., poor predictive utility of existing risk assessment measures, degree of control a provider has over patient behavior, individualized nature of effective prevention measures, and evidence base for the treatments that reduce suicide in military settings)8,11,51,64,65; and (3) common clinician impacts following patient suicide (e.g., likely personal and professional reactions, litigious and punitive experiences, case review process specifics, and typical reactions from colleagues).57,66–68 Finally, Bryan51 calls for all military MH clinicians to be trained in (1) Brief Cognitive Behavioral Therapy for Suicide Prevention and (2) knowledge of means safety (voluntary limitation of access to lethal objects [e.g., firearms and medications]). In summary, military clinicians should be educated on the best available interventions and their limitations (Fig. 3). Clearly, comprehensive suicidology education is needed by the entire MH care discipline—military and civilian—and was one of the top recommendations in a nationally representative sample of MH clinicians who have experienced patient suicide.68 It would function as informed consent regarding a critical on-the-job risk and how to mitigate the risk of (but never fully prevent) both patient suicide and its fallout. Suicidology can borrow from associated areas; for example, informing individuals of probable responses to disaster trauma has been found to be among the most effective buffers against prolonged adverse effects.69 Thus, clinicians learning about the limitations of predicting and preventing suicide can help dispel their self-perceptions of, and review boards’ expectations of, omnipotence,30,70 and buffer against burnout (i.e., emotional exhaustion and professional inefficacy) and self-blame.71,72 Patient suicide has been described as the most isolating event that can happen to clinicians,73 as discussions with colleagues about patient suicide remain taboo66 and fraught with perceived admissions of guilt for negligence.74 At an organizational level, the literature’s recommendations implicitly hypothesize that grounding clinicians in the realities of science and practice can improve the handling of suicide within clinics (e.g., reducing clinician survivors’ self-stigma and colleagues’ stigma [real and perceived]), organizations’ policies, and, if implemented broadly and continually, the discipline itself. Individual Postvention Plan (Developed in Prevention Phase, Implemented in Postvention Phase) Postvention involves universal prevention efforts for clinicians before a suicide and post-suicide mitigation efforts. Thus, several authors7,13,75,76 have recommended individual postvention plans be developed before, and activated following, a patient’s suicide. Indeed, there is some evidence to suggest that clinicians who never anticipate their own reactions to patient suicide suffer more pronounced negative effects.67,77 Creation of individualized plans requires clinicians to be knowledgeable about patient suicide and its consequences and to devise how to employ their personal resources (e.g., support systems and self-care strategies).13,75,76 Paradoxically, although 97% of practicing MH clinicians rate patient suicide as their greatest fear,73 individual preparation is rare.76 Postvention plans are hypothesized as necessary to prepare providers to enact the steps needed to take care of themselves (personally and professionally) and decrease anxiety associated with having to make quick decisions following patient suicide.75 Although used rarely with clinicians themselves, the skill of mentally preparing for crisis (during which emotions overwhelm one’s ability to engage in the best course of action) is widely used in MH treatment. One example is “Cope Ahead,” (i.e., psychological rehearsal to build mastery in the face of crisis), a core skill imparted in Dialectical Behavior Therapy,78 among the treatments with the strongest evidence base for reducing suicide.79 Another example, akin to individual postvention plans, is safety plans used with victims of intimate partner violence and suicidal patients (e.g., Victim Inventory of Goals, Options, and Risks80,81). Safety planning presents an opportunity for the individual to be given psychoeducation (e.g., common triggers and typical duration of a suicidal impulse) about the phenomena (e.g., suicidality) and strategizes personalized coping responses to effectively protect against negative impacts of future crisis events.82–84 Ultimately such plans enhance individuals’ sense of self-efficacy.82 A final example comprises other types of mental preparation for a crisis. Pre-disaster psychological preparedness plans (primarily for natural disasters in at-risk areas) and stress inoculation training (a preventative intervention applied for a host of issues from combat deployment to a potentially terminal diagnosis) have been shown to mitigate against developing anxiety, depression, and PTSD following crises.85–87,88 These approaches can be leveraged as models for how clinicians could develop individualized postvention plans. The scoped studies recommend that providers’ postvention plans include resources and skills that reflect individual characteristics and work settings (e.g., personal care needs and institution or private setting).7,13,75,76 Researchers recommend clinicians reevaluate postvention plans at least annually. To help MH professionals create a postvention safety plan, we have developed a checklist derived from the scoped literature’s recommendations (see Online Supplement S3). Future research should assess how the implementation of suicidology education and the creation of individual postvention plans (Fig. 3) impact the organizational culture around suicide (e.g., frequency of conversations about suicide, openness of clinicians to explore suicide-related fears, and new resources or strategies implemented within clinics). Bifurcated-Support Model (Postvention Phase) Social support (operationalized in countless distinct ways across scoped papers) is among the most frequent clinician postvention recommendations. This is unsurprising given extensive evidence of social support’s positive effects on emotional and physical health and its buffering impact on individual post-trauma adjustment across research foci.89 In some specialized MH settings (e.g., child protective services and training sites), clinicians can implement the scoped literature’s suggestions to use their supervisors for instrumental and emotional support following patient suicide. However, most civilian and military credentialed providers practice independently and do not have formal clinical supervision. In organizational settings (as opposed to private practice), there is often a clinician who is their commander or boss. Such superior–subordinate relationships are complicated because of the role conflicts inherent between being (1) a leader and (2) a more senior clinician who might provide emotional support and post-suicide review/supervision. Thus, scoped literature recommends bifurcated support (Fig. 3), with instrumental and emotional support roles handled by different people inside and outside, respectively, the clinician survivor’s chain of command. For instrumental support, MH clinic leaders have the responsibility to motivate, influence, and direct subordinates through assignments.90 Channeling combat and operational stress control,91 clinic leaders should be physically present, model resilience, and provide instrumental support (e.g., reduce administrative requirements and provide professional coverage) to see the clinician survivor through this crisis. Leaders who model resilience and future focus during crises enhance resilience in their subordinates.92,93 Furthermore, individuals who spontaneously mention their leaders as positive influences when describing how they coped with personal crises seem to be more resilient to their negative effects.94 For emotional support, a postvention clinician support program95 could be established. Following a patient suicide, the clinicians would be matched to a clinician survivor of equal or higher rank who volunteered to serve as a post-suicide guide. The guide should be outside of the clinician survivor’s chain of command and share their own experience and recovery, inform the clinician about the review process, and help the clinician prepare for and process the myriad meetings about the case. Ideally, this individual would be granted confidentiality and privilege so that both parties could communicate honestly about their thoughts and feelings, facilitating uninhibited emotional support. Open communication about patient suicide is thought to combat clinicians’ experiences of isolation and enable them to voice their recovery needs.13,96 Bifurcated support could also contribute to a cultural shift in the way MH patient suicides are treated by military services. Combined educational and contact-based (encountering impacted individuals) initiatives have reduced common stigmas (e.g., those about tuberculosis, leprosy, and mental illness) among health care workers.97 There is some suggestion that initiatives tend to be most effective when the stigmatized individual serves a role in developing and implementing the corrective program.98 By having another clinician survivor guide the supportive intervention, we hypothesize that the newly impacted clinician will experience less isolation, self-stigma, and perceived blame. Furthermore, the visibility of the program, headed by clinician survivors, may reduce stigma among clinicians generally. Finally, the creation of this support model would give volunteer guide opportunities for “giving back,” facilitating greater meaning-making of their own loss experiences. Meaning-making was both a common goal among clinician survivors in the scoped literature30,99,100 and a strong empirical predictor of post-traumatic growth.30,101 Testing the Proposed Model of Military Clinician Postvention Figure 3 provides a testable heuristic model of postvention based on the scoped literature. We hypothesize that prevention activities (i.e., suicidology education and development of an individual postvention plan) will increase confidence in social support, clinicians’ self-efficacy expectancies,102 providers’ knowledge of suicide prediction and intervention, and leaders’ knowledge about suicide prediction and intervention. These factors are hypothesized to buffer (i.e., moderate) post-suicide negative outcomes. Following a patient suicide and implementation of the clinician survivor’s postvention plan, we hypothesize the following proximal outcomes (compared with providers at sites without a comprehensive postvention program): (1) higher self-efficacy and perceived social support and (2) lower isolation, self-blame, perceived blame from others, and intention to leave the military MH system. We also hypothesize the following distal outcomes: (1) more post-traumatic growth and (2) lower depressive symptoms, PTSD symptoms, burnout, and leaving the military MH system. Limitations This scoping review has limitations, both implicit in the reviewed literature and attributable to our procedure. Most of the literature is anecdotal and based on a retrospective report103,104; even papers detailing the implementation of postvention programs lack outcome data beyond clinicians’ feelings about the procedures.33 This is not a criticism of the scoped research but a reflection of how difficult a phenomenon postvention is to study because it is triggered by low base-rate events. The scarcity of empirical research is what drove our decision to conduct a scoping review and include all types of literature (e.g., guidelines, studies, and letters to the editor) that could be informative in this area. A clear limitation is that this review coalesces recommendations from sources varying from a clinician’s lessons learned to a formalized, implemented postvention program. Finally, we may have missed some gray literature75; because the reviewed recommendations reached saturation, the likelihood of discovering important, undiscovered novel recommendations or findings is negligible. CONCLUSION Our proposed model consolidates the themes evident across the reviewed literature, including more (1) training and education and (2) support (emotional and instrumental) in forms that would be helpful to military MH clinicians. The most important contribution to this literature, however, is the identification of a need for a controlled trial of a postvention program to empirically test what mitigates adverse outcomes and facilitates clinician recovery. ACKNOWLEDGMENTS The authors would like to thank Lt. Col. Elisha Parkhill (who instigated this review) and Lt. Col. Eric Meyer for their insightful comments. We would like to acknowledge those who made initial inclusion determinations and conducted preliminary data extraction: John Shepherd, Ana Ivic, Vini Zaninovic, Samara Trindade, Huidi Yang, Sophia Palacios, George Ryan Ghorayeb, Lizbeth Morales, Steven Chen, Nancy Benhur, Evie Jin, Rachel Oakes, Maxine Heintz, Sherry Fung, Jennie Ochshorn, Adeen Izzathullah, and Danish Khalil. SUPPLEMENTARY DATA Supplementary material is available at Military Medicine online. FUNDING This activity was funded under subcontract 29700-0005, Item 3.3.1.1 to New York University; contract provided by the U.S. Air Force Medical Readiness Agency (AFMRA) to Cherokee Insights, LLC. CONFLICT OF INTEREST STATEMENT None declared. DATA AVAILABILITY All data are incorporated into this article and its online supplementary material. All data are freely accessible. CLINICAL TRIAL REGISTRATION Not applicable. INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS) Not applicable (review paper). INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC) Not applicable. INSTITUTIONAL CLEARANCE Institutional clearance approved. INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT K.A.D., A.S., and R.E.H. determined search terms, inclusion criteria, and the framework for data organization and analysis. K.A.D., A.S., and S.A. reviewed all sources and analyzed data. K.A.D., A.S., and R.E.H. drafted the manuscript, which was reviewed, edited, and shaped by A.M.S.S., who also helped determine the initial goals of the project. All authors read and approved the final manuscript. REFERENCES 1. Van Winkle EP , Orvis KA: Annual Suicide Report . Department of Defense; 2018 . Available at https://www.dspo.mil/Portals/113/2018%20DoD%20Annual%20Suicide%20Report_FINAL_25%20SEP%2019_508c.pdf; accessed August 16, 2022 . 2. U.S. Department of Defense . Department of Defense Releases Calendar Year 2019 Annual Suicide Report . Department of Defense ; 2019 . 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Case Report: Isosulfan Blue–Related Anaphylaxis

Adams, Jacob; Goc, Jonathan; Zeien, Justin; Patel, Alpesh; Gambardella, Josephine

2023 Military Medicine

doi: 10.1093/milmed/usac419pmid: 36610991

ABSTRACT Anaphylaxis is an acute multisystem syndrome typically resulting from the sudden release of mast cell and basophil-derived mediators into the circulatory system. Isosulfan blue dye is a rare, but known, mediator of anaphylaxis with an incidence between 0.16% and 2% of cases. We report two cases of anaphylaxis attributed to the use of isosulfan blue dye in the intraoperative setting. Both of the patients we report had grade 3 anaphylactic reactions requiring vasopressors to correct significant hypotension. Both patients required overnight monitoring in the intensive care unit with the second patient also requiring continued vasopressor support. INTRODUCTION Anaphylaxis is an acute multisystem syndrome typically resulting from the sudden release of mast cell and basophil-derived mediators into the circulatory system.1,2 Anaphylaxis applies to immunoglobulin E (IgE)-dependent mechanisms, which account for 60% of perioperative anaphylaxis,3 non-IgE-dependent immunologic mechanisms, and non-immunologic mechanisms.4,5 The incidence of anaphylaxis in general anesthesia is 1:1,250 to 1:18,600.6 The most common identifiable causes of perioperative anaphylaxis are antibiotics, blood products, chlorhexidine, neuromuscular blocking agents, sugammadex, hypnotic agents, opioids, colloids, and latex.7 Clinical signs and symptoms of anaphylaxis include pruritus, shortness of breath, hypotension, bronchospasm, laryngeal edema, tachycardia or bradycardia, cyanosis/oxygen desaturation, and reduced or absent capnography tracing.8 Cardiovascular collapse is the first detected manifestation in up to 50% of cases.1,7 We present two cases of anaphylaxis attributed to the use of isosulfan blue dye in the intraoperative setting. These patients have provided written HIPAA authorization to publish these case reports. CASE REPORTS The first case involved a 17-year-old female who was scheduled for melanoma excision from her right upper extremity with a sentinel lymph node biopsy. She had no history of drug allergies, and her past medical history was only significant for melanoma and acne vulgaris. Two hours before surgery, four aliquots of 0.1 mL of 0.5 mCi technetium-99m-labeled sulfur colloid radiotracer were injected intradermally around the melanoma. One hour before surgery, she received premedication as part of a multimodal, opioid-sparing analgesic approach to reduce intraoperative and postoperative analgesic requirements along with facilitating expedited recovery after surgery. The premedication included 400 mg of gabapentin, 650 mg of oral acetaminophen, 100 mg of oral celecoxib, and 20 mg of intravenous famotidine. The preoperative course was uneventful. Induction of anesthesia entailed intravenous injection of 100 mg of lidocaine, 100 μg of fentanyl, and 200 mg of propofol. Because of copious clear secretions in the patient’s mouth, her airway was thoroughly suctioned, and 0.1 mg of glycopyrrolate was intravenously administered. A laryngeal mask airway was then placed for airway support. Three minutes after induction of anesthesia, 2 g of cefazolin was administered intravenously in addition to 6 mg of dexamethasone for postoperative nausea and vomiting prophylaxis. Nine minutes after induction of anesthesia, 2 mL of isosulfan blue dye was intradermally injected in the four quadrants around the right upper arm melanoma and massaged for 5 minutes. Sixteen minutes after injection of isosulfan blue dye, a local anesthetic mixture consisting of 10 mL of 1% lidocaine with 1:200,000 epinephrine and 10 mL of 0.25% bupivacaine with 1:200,000 epinephrine was injected subcutaneously into the right axillary area. Eighteen minutes after injection of isosulfan blue dye, the patient became hypotensive to 60/35 mm Hg with a heart rate in the low 80s. Her blood pressure did not increase after three intravenous boluses of phenylephrine for a total of 800 μg over a 10-minute period. The anesthesia provider notified the surgeon of the patient’s persistent hypotension and called for assistance from additional anesthesiologists. The anesthesia and surgical teams agreed to pause the surgery. The patient was noted to have swelling in her upper extremities, face, neck, and ears at that time. Over the next 15 minutes, the patient was treated with a 1.5-L bolus of Lactated Ringers, 1 g of intravenous calcium, 50 mg of intravenous diphenhydramine, 10 mg of intravenous dexamethasone, two units of intravenous vasopressin, and 30 μg of intravenous epinephrine. While receiving the aforementioned treatments, the patient’s heart rate increased to a maximum of 155 and plateaued in the 110s. The patient remained hypotensive to 60s-70s/30s-40s for a total of 20 minutes, but, eventually, these treatments increased the patient’s blood pressure to 150/90 with a heart rate in the low 100s. Oxygen saturation, tidal volumes, and peak airway pressures were unchanged throughout the event. After a discussion between the anesthesia provider and the surgeon, there was an agreement to resume the surgery for two reasons: (1) The surgery was close to completion with the most stimulating portions of the surgery already finished and (2) the patient was hemodynamically stable with minimal concern for recurrence of hemodynamic compromise. The anesthesia provider was prepared with intravenous epinephrine boluses and an epinephrine infusion in case of recurrence of hypotension. Upon removal of the surgical drapes at the end of the case, diffuse total body swelling was noted. Postoperatively, while in the postanesthesia care unit, the patient’s blood pressure dropped to 65/40 mm Hg, and her heart rate decreased to 50. After 10 mg of intravenous ephedrine, 25 mg of intravenous diphenhydramine, and a 1.2-L bolus of Lactated Ringers, her blood pressure and heart rate normalized to 145/70 mm Hg and 70, respectively. Laboratory investigations postoperatively were unremarkable except for an elevated tryptase level of 13 μg mL−1 (normal <11 μg mL−1); slightly elevated white blood count and glucose; and slightly lower than normal CO2, total protein, albumin, and alkaline phosphatase. The patient had an uneventful overnight stay in the intensive care unit (ICU) where the diffuse swelling resolved and she had no further hypotensive episodes. She was discharged from the hospital the following day. The second case involved a 62-year-old female who was scheduled for bilateral sentinel lymph node excision for breast cancer staging. She had no history of drug allergies, and her past medical history was significant for the aforementioned breast cancer along with osteosarcoma previously treated with chemotherapy and radiation, intermittent chemotherapy–induced neuropathic pain in her distal extremities, depression, hypothyroidism, and brachial plexitis. The preoperative course was uneventful. Induction of anesthesia entailed intravenous injection of 50 μg of fentanyl, 50 mg of lidocaine, and 150 mg of propofol. A laryngeal mask airway was then placed for airway support. Three minutes after induction of anesthesia, 2 g of cefazolin was intravenously administered to the patient. Five minutes after induction of anesthesia, 3 mL of isosulfan blue dye was injected subcutaneously into the patient’s right breast, deep into the areola. Immediately afterward, a local anesthetic mixture consisting of 10 mL of 1% lidocaine with 1:200,000 epinephrine and 10 mL of 0.25% bupivacaine with 1:200,000 epinephrine was injected subcutaneously around the surgical field. Twenty-seven minutes after induction of anesthesia, the patient became hypotensive to 57/38 mm Hg with a heart rate of 92. Her blood pressure did not increase after three intravenous boluses of phenylephrine (600 μg over an 8-minute period). Surgery was paused at this time. The patient was treated with a 600-mL bolus of Lactated Ringers, 4 mg of intravenous dexamethasone, 50 mg of intravenous diphenhydramine, six units of intravenous vasopressin, 125 mg of intravenous methylprednisolone, 300 μg of intravenous epinephrine, and an epinephrine infusion of 10 μg min−1. While receiving these treatments, the patient’s heart rate stayed in the 90s to low 100s. The patient remained hypotensive to 60s-70s/40s-50s for a total of 40 minutes. After this time, the treatments increased the patient’s blood pressure to 95/65 mm Hg with a heart rate of 90. Oxygen saturation, tidal volumes, and peak airway pressures were unchanged throughout the event. After a discussion between the anesthesia provider and surgeon, it was decided to complete the surgery for several reasons: (1) This procedure was deemed time-sensitive in light of the patient’s (presumed) advanced cancer, and rescheduling the staging procedure would delay treatment and could worsen future recovery outcomes; (2) the surgery was close to completion; and (3) despite requiring a low-dose epinephrine infusion, the anesthesia provider determined the patient was hemodynamically stable enough and they felt comfortable allowing the surgery to finish. Upon completion of the surgery, the patient was transported to the ICU with an epinephrine infusion running at 10 μg min−1 and remained hemodynamically stable. Laboratory investigations were not drawn. She remained on the epinephrine infusion in the ICU and had an uneventful overnight stay without additional hypotensive episodes. On the first postoperative day, she underwent a full cardiac workup, including a bedside echocardiogram, which did not reveal any significant abnormalities. She was discharged from the hospital later that day. Of note, this patient underwent another surgical procedure approximately 2 weeks later and received the same medications for induction of anesthesia and the same antibiotics. However, she did not receive isosulfan blue dye and did not have recurrence of anaphylaxis. DISCUSSION Numerous reports of anaphylactic reactions to isosulfan blue dye exist with the current estimated incidence between 0.16 and 2% of cases.9–11 Mortality secondary to anaphylactic reactions to isosulfan blue dye is exceedingly rare and has not been demonstrated in several studies.9–11 However, mortality estimates because of perioperative anaphylaxis range from 1.4% to 6%, with another 2% of patients surviving with anoxic cerebral injury.12 Three grades of allergic reactions to isosulfan blue dye have been described. Grade 1 reactions only involve skin symptoms such as urticaria, pruritus, hives, or a generalized rash. Grade 2 reactions include transient hypotension (defined as systolic blood pressure > 70) not requiring vasopressor support. Grade 3 reactions include hypotension (systolic blood pressure < 70) requiring vasopressor support.11 In our two reported cases, both patients had grade 3 reactions because of the significant hypotension they experienced and the need for vasopressors. Although the literature reports severe (i.e., grade 3) anaphylactic reactions to isosulfan blue dye, milder allergic reactions likely occur more frequently than the reported 0.16%-2% range.13 Regardless, routine pretreatment for patients receiving isosulfan blue dye is not currently standard practice.14 However, some studies have suggested pretreatment with steroids or antihistamines or even skin testing before the procedure, particularly for high-risk patients with allergies similar to isosulfan blue dye or a history of asthma.13 The decision to pretreat or perform skin testing before surgery is further complicated by the fact that the pathophysiology of these adverse reactions is not well defined. The release of basophil-derived mediators from mast cells that drive these adverse reactions can be IgE immune–mediated, non-IgE (IgG or IgM) immune–mediated, or due to direct activation of mast cells.15 Non-IgE-mediated and direct activation of mast cells are termed pseudo-allergic reactions and prevented by pretreatment with steroids or antihistamines.15 IgE-mediated mast cell degranulation is the mechanism behind true anaphylactic reactions,15 and currently, there are no studies demonstrating effective pretreatments in humans. It is often difficult to identify a causative agent for perioperative anaphylaxis as there is no definitive test to prove or disprove anaphylaxis. In one study, a causative agent was discovered in only 24% of patients with the most common culprit being antibiotics, particularly cefazolin.15 Skin testing has been described but is limited by the simultaneous administration of multiple different drugs in the intraoperative setting, making it difficult to determine which drug(s) to test, along with allergists often lacking familiarity with these drugs.16 Tryptase levels have also been described, but their collection after an allergic reaction is time-sensitive and the lack of a baseline value significantly decreases their sensitivity.16 Even when patients who experienced perioperative anaphylaxis undergo subsequent anesthesia, the overwhelming majority do not have another perioperative allergic reaction.15 In the first case, isosulfan blue was the presumed cause of the patient’s anaphylactic reaction because of the close temporal relationship between subcutaneous injection of isosulfan blue and onset of hemodynamic instability. However, the authors recognize the possibility of cefazolin (or another medication administered either during induction of anesthesia or at the beginning of the surgery) serving as the inciting factor for anaphylaxis, particularly because of the higher incidence of anaphylaxis associated with these other medications, especially cefazolin, and the similar close temporal relationship between their administration and onset of hemodynamic instability. In the second case, isosulfan blue was the presumed cause of the patient’s anaphylaxis for similar reasons as the first case in addition to the lack of intraoperative anaphylaxis experienced by the patient 2 weeks later during a surgery in which she received the same medications, including cefazolin, except isosulfan blue. Yet, as previously mentioned, some patients who experience perioperative anaphylaxis do not experience anaphylaxis again when exposed to the same inciting medication. The authors again recognize the possibility of cefazolin or another medication administered around the same time frame as isosulfan blue serving as the causative agent of anaphylaxis. A high index of suspicion is required to quickly identify and treat anaphylaxis while under general anesthesia as the presenting symptoms may include cardiovascular collapse, hypotension, bronchospasm, tachycardia, and laryngeal edema.12 In both of the cases reported, hypotension was the initial presenting sign with total body swelling and tachycardia also noted in the first patient. Both patients had no noticeable respiratory symptoms or signs. The differential diagnosis can be broad and include other causes of these cardiorespiratory symptoms. Cardiovascular collapse may be caused by hemorrhage, cardiogenic shock, arrhythmias, sympathectomy from neuraxial anesthesia, local anesthetic systemic toxicity, sepsis, and venous air embolism. Hypoxia, increased airway pressures, and ventilation difficulties may be caused by acute asthma exacerbation, aspiration, malignant hyperthermia, pulmonary embolism, pulmonary edema, pneumothorax, and transfusion-related acute lung injury. Early recognition of the signs of anaphylaxis in the intraoperative setting and prompt initiation of treatment are crucial to achieve better outcomes.17 The suggested initial and secondary steps for the management of anaphylaxis while under general anesthesia can be seen in Table I.18 TABLE I. Initial Management of Anaphylaxis During General Anesthesia Initial therapy Stop administration of antigen Maintain airway and administer 100% O2 Discontinue all anesthetic agents Start intravascular volume expansion (2-4 L of crystalloid/colloid with hypotension) Give epinephrine (5-10 μg intravenous bolus with hypotension, titrate as needed; 0.1-1.0 mg intravenous with cardiovascular collapse) Secondary treatment Antihistamines (0.5-1 mg kg−1 diphenhydramine) Catecholamine infusions (starting doses: epinephrine 4-8 μg min−1, norepinephrine 4-8 μg min−1, or isoproterenol 0.5-1 μg min−1 as an infusion, titrated to desired effects) Bronchodilators: inhaled albuterol, terbutaline, and/or anticholinergic agents with persistent bronchospasm) Corticosteroids (0.25-1 g hydrocortisone; alternatively, 1-2 g methylprednisolone) Sodium bicarbonate (0.5-1 mEq kg−1 with persistent hypotension or acidosis) Airway evaluation (before extubation) Refractory shock: vasopressin and additional monitoring/echocardiography Initial therapy Stop administration of antigen Maintain airway and administer 100% O2 Discontinue all anesthetic agents Start intravascular volume expansion (2-4 L of crystalloid/colloid with hypotension) Give epinephrine (5-10 μg intravenous bolus with hypotension, titrate as needed; 0.1-1.0 mg intravenous with cardiovascular collapse) Secondary treatment Antihistamines (0.5-1 mg kg−1 diphenhydramine) Catecholamine infusions (starting doses: epinephrine 4-8 μg min−1, norepinephrine 4-8 μg min−1, or isoproterenol 0.5-1 μg min−1 as an infusion, titrated to desired effects) Bronchodilators: inhaled albuterol, terbutaline, and/or anticholinergic agents with persistent bronchospasm) Corticosteroids (0.25-1 g hydrocortisone; alternatively, 1-2 g methylprednisolone) Sodium bicarbonate (0.5-1 mEq kg−1 with persistent hypotension or acidosis) Airway evaluation (before extubation) Refractory shock: vasopressin and additional monitoring/echocardiography Open in new tab TABLE I. Initial Management of Anaphylaxis During General Anesthesia Initial therapy Stop administration of antigen Maintain airway and administer 100% O2 Discontinue all anesthetic agents Start intravascular volume expansion (2-4 L of crystalloid/colloid with hypotension) Give epinephrine (5-10 μg intravenous bolus with hypotension, titrate as needed; 0.1-1.0 mg intravenous with cardiovascular collapse) Secondary treatment Antihistamines (0.5-1 mg kg−1 diphenhydramine) Catecholamine infusions (starting doses: epinephrine 4-8 μg min−1, norepinephrine 4-8 μg min−1, or isoproterenol 0.5-1 μg min−1 as an infusion, titrated to desired effects) Bronchodilators: inhaled albuterol, terbutaline, and/or anticholinergic agents with persistent bronchospasm) Corticosteroids (0.25-1 g hydrocortisone; alternatively, 1-2 g methylprednisolone) Sodium bicarbonate (0.5-1 mEq kg−1 with persistent hypotension or acidosis) Airway evaluation (before extubation) Refractory shock: vasopressin and additional monitoring/echocardiography Initial therapy Stop administration of antigen Maintain airway and administer 100% O2 Discontinue all anesthetic agents Start intravascular volume expansion (2-4 L of crystalloid/colloid with hypotension) Give epinephrine (5-10 μg intravenous bolus with hypotension, titrate as needed; 0.1-1.0 mg intravenous with cardiovascular collapse) Secondary treatment Antihistamines (0.5-1 mg kg−1 diphenhydramine) Catecholamine infusions (starting doses: epinephrine 4-8 μg min−1, norepinephrine 4-8 μg min−1, or isoproterenol 0.5-1 μg min−1 as an infusion, titrated to desired effects) Bronchodilators: inhaled albuterol, terbutaline, and/or anticholinergic agents with persistent bronchospasm) Corticosteroids (0.25-1 g hydrocortisone; alternatively, 1-2 g methylprednisolone) Sodium bicarbonate (0.5-1 mEq kg−1 with persistent hypotension or acidosis) Airway evaluation (before extubation) Refractory shock: vasopressin and additional monitoring/echocardiography Open in new tab In both cases, although anaphylaxis was not the clear diagnosis initially, the hypotension was treated promptly and aggressively. Once the patient is stable, a discussion with the surgeon is recommended to determine if it is necessary to continue with the procedure and postoperative disposition. The decision to continue the procedure is typically determined by weighing the severity of the anaphylactic reaction and the patient’s condition against the urgency of the procedure.3,19 The surgeries in both reported cases were paused after discussion with the surgeon but allowed to proceed once hemodynamic stability was achieved. Disposition typically includes close monitoring for 24-48 hours, depending on the severity of the reaction and the patient’s recovery course.3 In our cases, the first patient was admitted to the ICU overnight because of concern for recurrence of hypotension as evidenced in the postanesthesia care unit. The second patient was admitted to the ICU because of the need for continued vasopressor support. Ultimately, both patients experienced good outcomes as a result of the decisive actions of the anesthesia providers and the effective communication among the perioperative teams. ACKNOWLEDGMENTS Not applicable. FUNDING The authors received no funding for this work. CONFLICT OF INTEREST STATEMENT The authors have no conflicts of interest to disclose. DATA AVAILABILITY Not applicable. CLINICAL TRIAL REGISTRATION Not applicable. INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS) Not applicable. INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC) Not applicable. INSTITUTIONAL CLEARANCE Not applicable. INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT J.Go. and J.Z. gathered resources and background information and drafted the case report. J.A. reviewed, edited formatting, and added table. J.Ga. and A.P. were a part of original case and provided oversight and formatting guidance. All authors read and approved the final manuscript. REFERENCES 1. Sampson HA , Munoz-Furlong A, Bock SA, et al. : Symposium on the definition and management of anaphylaxis: summary report . J Allergy Clin Immunol 2005 ; 115 ( 3 ): 584 – 91 .doi: 10.1016/j.jaci.2005.01.009 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Lieberman P : Mechanisms of anaphylaxis beyond classically mediated antigen- and IgE-induced events . Ann Allergy Asthma Immunol 2017 ; 118 ( 3 ): 246 – 8 .doi: 10.1016/j.anai.2017.01.009 . Google Scholar Crossref Search ADS PubMed WorldCat 3. Mertes PM , Malinovsky JM, Jouffroy L, et al. : Reducing the risk of anaphylaxis during anesthesia: 2011 updated guidelines for clinical practice . J Investig Allergol Clin Immunol 2011 ; 21 ( 6 ): 442 – 53 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 4. Genovese A , Stellato C, Marsella CV, et al. : Role of mast cells, basophils and their mediators in adverse reactions to general anesthetics and radiocontrast media . Int Arch Allergy Immunol 1996 ; 110 ( 1 ): 13 – 22 .doi: 10.1159/000237305 . Google Scholar Crossref Search ADS PubMed WorldCat 5. Veien M , Szlam F, Holden JT, et al. : Mechanisms of nonimmunological histamine and tryptase release from human cutaneous mast cells . Anesthesiology 2000 ; 92 ( 4 ): 1074 – 81 .doi: 10.1097/00000542-200004000-00026 . Google Scholar Crossref Search ADS PubMed WorldCat 6. Mertes PM , Volcheck GW, Garvey LH, et al. : Epidemiology of perioperative anaphylaxis . Presse Med 2016 ; 45 ( 9 ): 758 – 67 .doi: 10.1016/j.lpm.2016.02.024 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Mertes PM , Laxenaire MC, Alla F, et al. : Anaphylactic and anaphylactoid reactions occurring during anesthesia in France in 1999-2000 . Anesthesiology 2003 ; 99 ( 3 ): 536 – 45 .doi: 10.1097/00000542-200309000-00007 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Harper NJN , Cook TM, Garcez T, et al. : Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6) . Br J Anaesth 2018 ; 121 ( 1 ): 159 – 71 .doi: 10.1016/j.bja.2018.04.014 . Google Scholar Crossref Search ADS PubMed WorldCat 9. Perenyei M , Barber ZE, Gibson J, et al. : Anaphylactic reaction rates to blue dyes used for sentinel lymph node mapping: systematic review and meta-analysis . Ann Surg 2021 ; 273 ( 6 ): 1087 – 93 .doi: 10.1097/SLA.0000000000004061 . Google Scholar Crossref Search ADS PubMed WorldCat 10. Cimmino VM , Brown AC, Szocik JF, et al. : Allergic reactions to isosulfan blue during sentinel node biopsy—a common event . Surgery 2001 ; 130 ( 3 ): 439 – 42 .doi: 10.1067/msy.2001.116407 . Google Scholar Crossref Search ADS PubMed WorldCat 11. Montgomery LL , Thorne AC, Van Zee KJ, et al. : Isosulfan blue dye reactions during sentinel lymph node mapping for breast cancer . Anesth Analg 2002 ; 95 ( 2 ): 385 – 8 .doi: 10.1213/00000539-200208000-00026 . Google Scholar Crossref Search ADS PubMed WorldCat 12. Gibbs NM , Sadleir PH, Clarke RC, et al. : Survival from perioperative anaphylaxis in Western Australia 2000-2009 . Br J Anaesth 2013 ; 111 ( 4 ): 589 – 93 .doi: 10.1093/bja/aet117 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Sajan A , Griepp DW, Hakmi H, et al. : Isosulfan blue and anaphylaxis . Ochsner J 2021 ; 21 ( 4 ): 419 – 24 .doi: 10.31486/toj.20.0162 . Google Scholar Crossref Search ADS PubMed WorldCat 14. Raut CP , Daley MD, Hunt KK, et al. : Anaphylactoid reactions to isosulfan blue dye during breast cancer lymphatic mapping in patients given preoperative prophylaxis . J Clin Oncol 2004 ; 22 ( 3 ): 567 – 8 .doi: 10.1200/JCO.2004.99.276 . Google Scholar Crossref Search ADS PubMed WorldCat 15. Banerji A , Bhattacharya G, Huebner E, et al. : Perioperative allergic reactions: allergy assessment and subsequent anesthesia . J Allergy Clin Immunol Pract 2021 ; 9 ( 5 ): 1980 – 91 .doi: 10.1016/j.jaip.2020.11.025 . Google Scholar Crossref Search ADS PubMed WorldCat 16. Garvey LH , Ebo DG: Perioperative hypersensitivity reactions: time for collaboration . J Allergy Clin Immunol Pract 2021 ; 9 ( 5 ): 1992 – 3 .doi: 10.1016/j.jaip.2021.02.025 . Google Scholar Crossref Search ADS PubMed WorldCat 17. Lieberman P , Nicklas RA, Oppenheimer J, et al. : The diagnosis and management of anaphylaxis practice parameter: 2010 update . J Allergy Clin Immunol Pract 2010 ; 126 ( 3 ): 477 – 80. doi: 10.1016/j.jaci.2010.06.022 . Google Scholar Crossref Search ADS WorldCat 18. Levy JH : The allergic response. In: Barash PG, Cullen BF, Stoelting RK et al. , eds. Clinical Anesthesia . 8th ed. Wolters Kluwer ; 2017 : 212 – 3 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 19. Sadleir PHM , Clarke RC, Bozic B, et al. : Consequences of proceeding with surgery after resuscitation from intra-operative anaphylaxis . Anaesthesia 2018 ; 73 ( 1 ): 32 – 9 .doi: 10.1111/anae.14106 . Google Scholar Crossref Search ADS PubMed WorldCat Author notes The views expressed in this material are those of the authors and do not reflect the official policy or position of the U.S. Government, the DoD, the Department of the Army, or the Department of the Navy. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US. This work is written by (a) US Government employee(s) and is in the public domain in the US.
journal article
Open Access Collection
A Review of Verbal and Written Patient Handoffs Applicable to the U.S. Military’s Expeditionary Care System

Kunce, Nicholas E; Lyon, Arthur; Carlton, Duncan; Jeyarajah, Theepica; Strayhorn, Catherine M; Lopreiato, Joseph; Wilson, Ramey

2023 Military Medicine

doi: 10.1093/milmed/usac418pmid: 36617244

ABSTRACT Introduction Long considered a danger point in patient care, handoffs and patient care transitions contribute to medical errors and adverse events. Without standardization of patient handoffs, communication breakdowns arise and critical patient information is lost. Minimal training and informal learning have led to a lack of understanding the process involved in this vital aspect of patient care. In 2017, the U.S. Army commissioned a report to study the process of patient handoffs and identify training gaps. Our report summarizes that process and makes recommendations for implementation. Materials and Methods Scoping literature review of 139 articles published between 1999 and 2017 using PubMed, CINAHL, Cochrane, and Medline databases. Verbal tools for handoffs were evaluated against 12 criteria including patient ID, history, current situation, contingency planning, ability to ask questions, ownership, and read back. Written tools were evaluated against a matrix of 126 casualty/treatment attributes. Results Among verbal communication protocols, the highest scoring handoff mnemonics were HAND ME AN ISOBAR, IPASS the BATON, and I-SBARQ. Among written handoff tools, the highest scoring documents were the Special Operations Forces (SOF) Mechanism, Injuries, Signs, and Treatment (MIST) Casualty Treatment Card and the Department of Defense (DD) Form 1380 Tactical Combat Casualty Care (TCCC) Card. Four critical process elements for patient handoffs and transfers were identified: (1) interactive communications, (2) limited interruptions, (3) a process for verification, and (4) an opportunity to review any relevant historical data. Conclusions The findings in this review highlight the need for standardized tools and techniques for patient handoffs in the U.S. Military’s expeditionary care system. Future research is needed to trial verbal and nonverbal handoffs under field conditions to gather observational data to assess effectiveness. The results of our gap analyses may provide researchers insight for determining which handoffs to study. If standardized handoffs are utilized, training programs should incorporate the four critical elements into their curricula. INTRODUCTION Patient handoffs, or handovers, are the primary communication tool for ensuring patient safety during transitions of care. Patient handoffs are usually composed of either a written document or a verbal presentation of the critical aspects necessary for continued care of the patient. Although effective communication during transitions of care has been considered critical, multiple publications and disciplines over the years have noted the threat posed by poor communication during transitions of care.1–3 Additionally, despite its importance, training the process for handing off patients is often not conducted, partially covered, or required once as a completed event and is not properly assessed.4 In the U.S. Military healthcare system, patient handoffs occur both inside and outside of conflict and sometimes require transnational patient movement to definitive care. These movements are conducted within the multiservice Joint Trauma and En Route Care systems, a complex network of joint service medical evacuation and En Route Care platforms designed to move critically ill patients around the world from the point of injury to definitive care sites.5 Although globally integrated, these multiservice platforms are implemented from independent and culturally distinct service healthcare systems with their own traditions and methodology. This complex movement of patients with varying implementation of patient handoffs may contribute to medical errors and be a threat to patient safety. The purpose of this report attempts to answer the question: What is known from the literature regarding communication during patient handovers? Moreover, this report attempts to review and explore the salient findings of a scoping review of the literature regarding patient handoffs applied to both civilian and military healthcare systems, review gap analyses of verbal and nonverbal patient handoff methods, and provide recommendations for change within the Joint En Route Care system to strengthen patient handoffs from the point of injury to definitive cares sites. METHODS A scoping review of the literature was performed by employing PubMed, Google Scholar, CINAHL, Cochrane, and Medline using a keyword search, which included terms such as “roles of care,” “patient handoffs/transfers,” “MEDEVAC,” “En Route Care,” “mnemonics,” and “checklists,” among others. The aim was to review the literature and collect information related to Joint En Route Care, patient handoffs, patient transfers, and existing communication tools that are used to facilitate patient movement along the care continuum while simultaneously maintaining the progression of care. The inclusion criteria for the selected citations were based on six topics that represent aspects of Joint En Route Care and performance in theater. The topics included communication elements/protocols, definitions of “En Route Care,” critical elements, continuity/continuum of care, educational requirements, and technologies to support En Route Care. Articles not meeting the inclusion criteria were eliminated. In support of the scoping review, citation tracking was employed to empirically validate selected citations. This approach identifies the most influential articles for a certain topic by tracking the number of times it has been cited by peers in their own published work. The citation tracking statistics were presumed to illustrate the chosen citations’ importance, standardization, and peer acceptance in the field, offering substantive validity evidence for the literature. Among three tracking databases examined (Google Scholar from Google, Scopus from Elsevier, and Web of Science from Thompson Scientific), Google Scholar was selected to conduct the citation tracking for its comprehensiveness between 1999 and 2017. Also, to control for extreme variation in the frequency distribution of the number of citations, a 5% trimmed mean was obtained, excluding the 5% most cited and 5% least cited articles and publications. This eliminated outliers among the citations to provide a more general representation of the citations. Within the literature search, structured verbal and nonverbal patient handoff procedures were identified. Among the verbal patient handoffs, the most cited verbal handoff tools were selected for further evaluation (see List S1). For the nonverbal patient handoffs, only those focusing on communication between role 1 and role 2 military medical facilities within the En Route Care system were selected because of the sheer number of different domains identified (see List S3). A gap analysis was then performed for both the verbal and nonverbal handoff procedures. For verbal handoffs, the gap analysis consisted of comparing a previously published 12-domain checklist (see List S2) identifying the most vital pieces of information to be included in a patient handoff developed by Nasarwanji et al.6 with the elements described for that particular handoff. Considerations were also drawn from other previously published analyses focusing on handoff mnemonics (Riesenberg et al.,7 Rosenbluth,8 and Starmer et al.9 For nonverbal handoffs, the gap analysis consisted of comparing informational attributes (i.e., patient care information) of each nonverbal handoff against the traceability matrix designed and built by the research effort. Each nonverbal handoff was analyzed to establish informational attributes and determine the degree of thoroughness each provided with regard to the documentation of patient condition and treatment. This matrix was a seven-category system comprising 126 patient casualty/treatment attributes that provided the foundation for the gap analysis and determined the ability of each nonverbal handoff to document pertinent information as compared to the DD Form 1380 TCCC Card, currently the preferred record of trauma care identified by the Defense Health Agency Procedural Instruction, Number 6040.01.10 During the analysis of the nonverbal handoffs, seven main categories of informational attributes were identified and thought to encompass all of the topics included in each handoff—these included identification, mechanism of injury, injuries, symptoms, treatment, fluids, and medications. Included in these seven main categories were 126 subcategories of casualty and treatment attributes (see List S4). Each of the nonverbal handoffs were compared against this seven-category system comprising 126 patient casualty/treatment attributes. A screening criterion for both gap analyses was utilized, so further analysis could be performed on the handoffs once they were compared against their standard—this screening criterion was if each handoff met at least 50% of the categories found in the standard they were compared to. RESULTS In total, 279 citations were identified during the scoping literature review. Subsequently, 157 citations published between 1999 and 2017 were selected as applicable to the project effort using the inclusion criteria. The breakdown of citations per topic is as follows: communication elements/protocols (82), definitions of “En Route Care” (45), critical elements (20), continuity/continuum of care (8), educational requirements (4), and technologies to support En Route Care (4). Some citations were included in multiple topic foci if they were identified as including the respective topic information. Using citation tracking, 139 citations were selected for final inclusion. A summary of this screening process is illustrated in Figure 1. FIGURE 1. Open in new tabDownload slide Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews diagram for Joint En Route Care, patient handoffs, patient transfers, and existing communication tools. *Screening if the article pertained to Joint En Route Care training and performance in theater, with specific focus on the definitions of En Route care—including patient handoffs and transfers, continuity/continuum of care, critical elements and educational requirements, and communication tools and protocols.ꞱScreening with empirical valuation of the validity for the literature by citation tracking—to appreciate the large variation of citation frequency of the articles/publications, a 5% trimmed mean was calculated, excluding the 5% most cited and 5% least cited articles/publications to give a more average representation of the literature.∆From citation tracking, 94 of the 139 citations (67.6%) were found listed in Google Scholar and were cited a total of 6,736 times, with an average of about 72 per citation and a median of about 27. Regarding the structured verbal patient handoffs, 25 of the most frequently cited verbal handoff tools in the form of mnemonics were identified. Only 3 of the previously 25 verbal handoff mnemonics met at least 50% of the criteria in the 12-domain checklist following the gap analysis (see Supplementary Tables S1 and S2). These mnemonics included HAND ME AN ISOBAR, which met 83% of the criteria; I PASS THE BATON, which met 67% of the criteria; and I-SBARQ, which met 50% of the criteria. For the structured nonverbal patient handoffs, six casualty care checklists that pertained to handoffs between role 1 and role 2 transfers were identified. Using the same eligibility requirement of meeting at least 50% screening criteria for the gap analysis, only two nonverbal handoff checklists met criteria (see Supplementary Tables S3 and S4). The DD Form 1380 TCCC card met 66% of the 126 attributes and the SOF MIST Casualty Treatment Card met 65% of the attributes. The summary of the results can be seen in Figure 2. FIGURE 2. Open in new tabDownload slide Summary illustration of the gap analyses performed for both the selected verbal mnemonics and nonverbal checklists. This process includes the identification, screening, eligibility, and final inclusion of verbal mnemonics and nonverbal checklists selected for further consideration. Information regarding communication tools/protocols and critical elements was also extrapolated from the literature review. Specifically, in 2012, the Committee on Patient Safety and Quality Improvement (Opinion No. 517)11 discussed the importance of effective communication during patient handoffs. The Committee recommended for the implementation of a standardized approach to handoff communication that includes the following: interactive communications, limited interruptions, a process for verification, and an opportunity to review any relevant historical data.11 DISCUSSION During our review of the current patient handoff literature, we extrapolated several notable claims. These include information on what should be included in a patient handoff, that the U.S. Military has demonstrated lack of medical documentation in the role 1 setting, and suggestions that verbal and nonverbal handoffs together provide for a more optimal patient transfer of care. Moreover, the literature review resulted in the extrapolation of various verbal and nonverbal handoffs that were subsequently compared using gap analyses. Several themes emerged in the scoping literature review regarding Joint En Route Care, patient handoffs, patient transfers, and existing communication tools. Here, we discuss the most salient themes as represented by these authors’ suggestions and findings. Arora et al. in 2006 suggested that the objective of a patient handoff is to give accurate information including the following: the patient’s care, treatment and services, current condition, and any recent or anticipated changes.12 In the 2012, the Air Medical Physician Association suggested that patient handoffs should include topics like patient information, problems, pertinent past history, and plan and precautions/potential pitfalls.13 Stahl et al. in 2009 showed that a structured checklist significantly reduces patient errors because of lost information and communication lapses between trauma Intensive Care Unit team members during handoffs.14 Therien et al. in 2011 showed that in the U.S. Military, there is a marked lack of data in medical documentation from the point of injury and En Route Care phases of combat casualty care and the granularity of the available data is low—the authors of this comparative analysis of patient medical records in the Joint Theater Trauma Registry database also suggested that this study clearly showed deficiencies in role 1 medical documentation in the U.S. Military.15 This study also noted that research efforts at point of injury and role 1 have faced challenges because of the lack of documentation compliance, which have been shown to have a direct effect on the provision of En Route Care as a whole. Finally, Arora et al. in 2009 suggested that verbal handoffs accompanied by written documentation in a structured format or technology solution improve satisfaction of handoff quality, improve provider identification, and improve retention of information.16 One of the most important themes inferred from this literature review is the potential threat to patient safety because of a lack of implementing universal patient handoffs. Multiple studies and organizations discuss the danger of handovers and the efficacy of establishing standard turnover procedures in reducing errors in patient care.9,12,17–19 Moreover, implementation of a structured handoff protocol, in addition to effective teamwork and communication, can positively impact practice and patient safety.20 As previously discussed, IPASS the BATON, HAND ME AN ISOBAR, and I-SBARQ were the highest scoring mnemonics of the 25 evaluated through the 12-point criterion. Although I PASS THE BATON and HAND ME AN ISOBAR offer more details in their composition, many of the elements included in these (i.e., allocate staff, nominate participants, and elect a leader) may be superfluous in a military setting, especially in extreme situations where safety and time are reduced or lacking. Favoring the I-SBARQ mnemonic, in 2014, flight nurses in the aeromedical evacuation teams of the En Route Care System started using I-SBAR for handoffs.21 The I-SABRQ mnemonic is compelling because its variations (I-SBAR, SBAR, SBARR, and SBAR-T) suggest flexibility that may allow for local standardization of information and permit variation across multiple care settings. In its simplest form, SBAR, it still combines both objective (situation and background) and subjective (assessment and recommendations) components that allow for customization and implementation, while still adhering to a relatively standardized format. When approaching written documents, the DD-1380 clearly outperformed all competitors with the exception of the SOF MIST Card, which it barely edged out, both sharing many similarities. With its simplicity, high score seen in the gap analysis, and proven battlefield record over the last decade in various forms, the DD-1380 appears to continue to serve as a useful point of injury written documentation tool for both conventional and SOF formations. Although some of the identified issues such as integration of the en route patient records have been addressed, the U.S. Military continues to practice a series of formal, informal, or absent patient turnover standard operating procedures depending on location, institution, department, discipline, and service affiliation. Although this wide variation provides ample options to review for solutions, it also reveals the size of the problem faced. It also must be considered that end users will often have only months rather than years of training and on-the-job experience found in the civilian sector to master these skills. Therefore, methods must be both effective and simple given the large entry-level competency of the population. Given the discussed findings of this review, we recommend that the U.S. Military establish formal verbal and nonverbal standards for patient handoffs and incorporate them into every service member’s tactical combat casualty care curriculum. These standards should incorporate the four critical elements as outlined in the recommendations from the 2012 Committee on Patient Safety and Quality Improvement11: (1) interactive communications, (2) limited interruptions, (3) a process for verification, and (4) an opportunity to review relevant historical data. Future studies should focus on assessing the effectiveness of both verbal and nonverbal handoff tools—this paper attempts to identify gaps in handoff tools but lacks the observational data that could be assessed upon testing these tools under field conditions. Future studies should also focus on implementation and analysis of a standard training curriculum for handoffs to determine what method is most effective to train and validate handoff procedures. One of the limitations in the methodology of our gap analyses was that it was performed collaboratively by the research team, which may have inadvertently introduced some bias—future studies should consider independent review when evaluating the different tools. Another limitation in our scoping review was the employment of a trimmed mean to control for extreme variation in the frequency distribution of the number of citations in the selected articles and publications that ultimately underwent further review. Since the 5% most cited articles and publications were excluded from out review, future studies may find utility in reviewing the more frequently cited literature. CONCLUSION The findings from this scoping review and gap analyses highlight the enduring need for standardized tools and techniques for patient handoffs in the U.S.Military’s expeditionary care system. Although this report offers insight into possible options for standardized patient handoff formats in the expeditionary care system, future research is needed to determine their effectiveness and the best methodology for incorporating them into medical and individual service member education. Efforts currently at the Uniformed Services University are exploring various instructional methods on teaching formal handoffs during the tactical combat casualty care curriculum. Ideally, data collected from these investigations will guide U.S. Military wide curriculum changes that increase the accuracy and effectiveness of written and verbal handoffs from the point injury to reception state-side. We conclude from our analysis that the most salient points in patient handovers are Lack of an accepted universal format for patient handoffs may present a real threat to patient safety both on and off the battlefield. There are vetted models suitable for this purpose currently available for implementation. Instruction in these procedures and techniques needs to be integrated into a longitudinal training program for personnel to ensure competency across the U.S. Military. ACKNOWLEDGMENTS None declared. SUPPLEMENTARY MATERIAL Supplementary Material is available at Military Medicine online. FUNDING Joint Program Committees-6 Medical Research and Material Command, Award No. HU0001-16-2-0025. CONFLICT OF INTEREST STATEMENT None declared. CLINICAL TRIAL REGISTRATION None declared. INSTITUTIONAL REVIEW BOARD (HUMAN SUBJECTS) Not applicable. INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC) Not applicable. INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT C.M.S. was the Principal Investigator of the report commissioned by the U.S. Army in 2017 who performed the scoping review and gap analyses. N.E.K., A.L., D.C., T.J., C.M.S., J.L., and R.W. reviewed the report and edited the manuscript. All authors read and approved the final manuscript. DATA AVAILABILITY The data that support the findings of this study are available on request from the corresponding author. All data are freely accessible. INSTITUTIONAL CLEARANCE Institutional clearances approved. REFERENCES 1. Hohenhaus S , Powell S, Hohenhaus JT: Enhancing patient safety during hand-offs: standardized communication and teamwork using the ‘SBAR’ method . AJN Am J Nurs Sci 2006 ; 106 ( 8 ): 72A – 72B .doi: 10.1097/00000446-200608000-00028 . Google Scholar Crossref Search ADS WorldCat 2. Horwitz LI , Meredith T, Schuur JD, Shah NR, Kulkarni RG, Jenq GY: Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care . Ann Emerg Med 2009 ; 53 ( 6 ): 701 – 710. e704 .doi: 10.1016/j.annemergmed.2008.05.007 . Google Scholar Crossref Search ADS PubMed WorldCat 3. Wood K , Crouch R, Rowland E, Pope C: Clinical handovers between prehospital and hospital staff: literature review . Emerg Med J 2015 ; 32 ( 7 ): 578 – 9 .doi: 10.1136/emermed-2013-203165 . Google Scholar Crossref Search ADS WorldCat 4. Dracup K , Morris PE: Passing the torch: the challenge of handoffs . Am J Crit Care 2008 ; 17 ( 2 ): 95 – 7 .doi: 10.4037/ajcc2008.17.2.95 . Google Scholar Crossref Search ADS PubMed WorldCat 5. Defense Health Agency : En Route Care. 1st ed. . 2020 : 1 – 23 . Available at https://jts.amedd.army.mil/assets/docs/education/ewsc/En_Route_Care_EWSC_1.0.pdf; accessed January 4, 2022 . 6. Nasarwanji MF , Badir A, Gurses AP: Standardizing handoff communication . J Nurs Care Qual 2016 ; 31 ( 3 ): 238 – 44 .doi: 10.1097/NCQ.0000000000000174 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Riesenberg LA , Leitzsch J, Little BW: Systematic review of handoff mnemonics literature . Am J Med Qual 2009 ; 24 ( 3 ): 196 – 204 .doi: 10.1177/1062860609332512 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Rosenbluth G : Standardizing the handoff process: better handoffs, safer care. (PowerPoint Slides) . University of California San Francisco Medical Center and Benioff Children’s Hospital . 2012 . 9. Starmer AJ , Spector ND, Srivastava R, et al. : Changes in medical errors after implementation of a handoff program . N Engl J Med 2014 ; 371 ( 19 ): 1803 – 12 .doi: 10.1056/NEJMsa1405556 . Google Scholar Crossref Search ADS PubMed WorldCat 10. DHA-PI, Policy 6040.01 . Implementation Guidance for the Utilization of DD Form 1380, Tactical Combat Casualty Care (TCCC) Card , June 2014 . 2017 . 11. American College of Obstetricians and Gynecologists : Communication strategies for patient handoffs: Committee Opinion No. 517 . Obstet Gynecol 2012 ; 119 : 408 – 11 .doi: 10.1097/AOG.0b013e318249ff4f . Crossref Search ADS PubMed WorldCat 12. Arora V , Johnson J: A model for building a standardized hand-off protocol . Jt Comm J Qual Patient Saf 2006 ; 32 ( 11 ): 646 – 55 .doi: 10.1016/S1553-7250(06)32084-3 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Safe Handoff of Care in Air/Ground Medical Transport : Position Statement of the Air Medical Physician Association AMPA Board of Trustees, January 9, 2012 . Air Med J 2012 ; 31 ( 2 ): 77doi: 10.1016/J.AMJ.2012.01.004 . OpenURL Placeholder Text WorldCat Crossref 14. Stahl K , Palileo A, Schulman CI, et al. : Enhancing patient safety in the trauma/surgical intensive care unit . J Trauma 2009 ; 67 ( 3 ): 430 – 5 .doi: 10.1097/TA.0b013e3181acbe75 . Google Scholar Crossref Search ADS PubMed WorldCat 15. Therien SP , Nesbitt ME, Duran-Stanton AM, Gerhardt RT: Prehospital medical documentation in the Joint Theater Trauma Registry: a retrospective study . J Trauma Acute Care Surg 2011 ; 71 ( 1 ): S103 – 8 .doi: 10.1097/TA.0b013e3182218fd7 . Google Scholar Crossref Search ADS WorldCat 16. Arora VM , Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S: Hospitalist handoffs: a systematic review and task force recommendations . J Hosp Med 2009 ; 4 ( 7 ): 433 – 40 .doi: 10.1002/jhm.573 . Google Scholar Crossref Search ADS PubMed WorldCat 17. Starmer AJ , O’Toole JK, Rosenbluth G, et al. : Development, implementation, and dissemination of the I-PASS handoff curriculum: a multisite educational intervention to improve patient handoffs . Acad Med 2014 ; 89 ( 6 ): 876 – 84 .doi: 10.1097/ACM.0000000000000264 . Google Scholar Crossref Search ADS PubMed WorldCat 18. Department of Defense Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality : Guide to action: TeamSTEPPS – Team Strategies and Tools to Enhance Performance and Patient Safety – “Creating a safety net for your organization” . In. Agency for Healthcare Research and Quality . Vol 06-0020-42011. 19. Steinemann S , Bhatt A, Suares G, et al. : Trauma team discord and the role of briefing . J Trauma Acute Care Surg 2016 ; 81 ( 1 ): 184 – 9 .doi: 10.1097/TA.0000000000001024 . Google Scholar Crossref Search ADS PubMed WorldCat 20. Leonard M , Graham S, Bonacum D: The human factor: the critical importance of effective teamwork and communication in providing safe care . BMJ Qual Saf 2004 ; 13 ( suppl 1 ): i85 – i90 .doi: 10.1136/qshc.2004.010033 . Google Scholar Crossref Search ADS WorldCat 21. Potter CE : Administration of the en route patient staging system . Air Force Instruction 44165 . United States Government. US Air Force ; 2014 . Author notes Digital poster displayed for Military Health System Research Symposium 2021. This project was sponsored by the Uniformed Services University of the Health Sciences (USU); however, the information or content and conclusions do not necessarily represent the official position or policy of, nor should any official endorsement be inferred on the part of, USU, the Henry M. Jackson Foundation for the Advancement of Military Medicine, the Department of Defense, or the U.S. Government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US. This work is written by (a) US Government employee(s) and is in the public domain in the US.
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Influenza Vaccine Effectiveness and Test-Negative Study Design Within the Department of Defense

Sayers, David R; Iskander, John K

2023 Military Medicine

doi: 10.1093/milmed/usac436pmid: 36637409

ABSTRACT Test-negative observational studies are routinely used to assess vaccine effectiveness. This test method consistently shows lower annual vaccine effectiveness in the highly vaccinated U.S. military compared to the general population. Incorporating other test designs and broader impact measures may better estimate influenza vaccine benefits in highly vaccinated groups. A test-negative design is a type of observational case–control study that has been routinely used to calculate vaccine effectiveness (VE) against seasonal influenza and has also been used frequently to estimate VE against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although influenza vaccinations are required annually for service members in the Department of Defense (DoD), VE calculations from test-negative studies typically demonstrate lower VE compared to national data. Multiple reasons may contribute to lower annual VE in service members, but it is important to consider the limitations of a test-negative study design in a highly vaccinated population and whether other study designs that take into account both vaccinated and unvaccinated person-time (e.g., ones that use incident rate ratios) would more accurately reflect the protection afforded from influenza vaccination. The methodology for a test-negative observational case–control study involves having all participants defined by a specific syndrome (e.g., acute respiratory illness), and a diagnostic test is used to determine cases and controls. Table I shows how individuals within a study are captured, and VE is estimated by comparing the odds of vaccination between cases and controls (calculation of VE = (1 − odds ratio) × 100 or VE = 1 − (AD/BC)) × 100).1 VE can refer to different outcomes depending on the study goals (e.g., protection against infection, medically attended infection, severe disease, and death). Advantages of this study design lead to its frequent use. First, controls and cases are identified at the same time, which simplifies the methods. Additionally, the study population (both cases and controls) has similar health care use patterns, reducing confounding from health care–seeking behavior.2 Thus, historically test-negative designs are commonly used to monitor in-season effectiveness of influenza vaccines against circulating strains. TABLE I. Calculation of Unadjusted Vaccine Effectiveness Using a Test-Negative Design Vaccination status . Patients who sought medical care . Positive influenza test Negative influenza test Vaccinated A B Not vaccinated C D Vaccination status . Patients who sought medical care . Positive influenza test Negative influenza test Vaccinated A B Not vaccinated C D Open in new tab TABLE I. Calculation of Unadjusted Vaccine Effectiveness Using a Test-Negative Design Vaccination status . Patients who sought medical care . Positive influenza test Negative influenza test Vaccinated A B Not vaccinated C D Vaccination status . Patients who sought medical care . Positive influenza test Negative influenza test Vaccinated A B Not vaccinated C D Open in new tab Within the DoD, test-negative designs are also routinely used to assess influenza VE. Interestingly, VE for service members is consistently calculated to be lower than the U.S. population (Table II). Often, only mid-season VE for service members is published. Meanwhile, DoD beneficiary VE rates are similar to U.S. population data. Multiple factors may influence this. Recurrent vaccination has been shown in some studies to diminish the antibody response to influenza and possibly reduce VE. Second, service members vaccinated early in the fall season for reasons of convenience or necessity (e.g., impending deployment) experience waning of immunity.3 Ultimately, the study design may require a refinement if it repeatedly produces lower VE in a population when compared to other populations with lower vaccination rates. TABLE II. Annual Influenza Vaccine Effectiveness Estimates . DoD service members (AFHSD data)12,14–16,18 . DoD beneficiaries (AFHSD, USAFSAM, NHRC data)12–19 . U.S. population (CDC data)20 . 2016–2017 3%a (−25% to 25%) USAFSAM: 42%a (24%–55%); 48% (37%–56%) NHRC: 45%a (5%–68%) 40% (32%—46%) 2017–2018 19%a (3%–33%) 18% (4%–30%) AFHSD: 51%a (41%–59%); 49% (42%–55%) NHRC: 55%a (17%–75%); 63% (50%–73%) 38% (31%–43%) 2018–2019 13%a (−11% to 32%) USAFSAM: 47%a (35%–57%); 30% (22%–38%) NHRC: 58%a (38%–72%) 29% (21%–35%) 2019–2020 Influenza A: 12%a (−10% to 30%) Influenza B: 31%a (20%–40%) AFHSD: 54%a (46%–60%) 46% (40%–52%) 39% (32%–44%) . DoD service members (AFHSD data)12,14–16,18 . DoD beneficiaries (AFHSD, USAFSAM, NHRC data)12–19 . U.S. population (CDC data)20 . 2016–2017 3%a (−25% to 25%) USAFSAM: 42%a (24%–55%); 48% (37%–56%) NHRC: 45%a (5%–68%) 40% (32%—46%) 2017–2018 19%a (3%–33%) 18% (4%–30%) AFHSD: 51%a (41%–59%); 49% (42%–55%) NHRC: 55%a (17%–75%); 63% (50%–73%) 38% (31%–43%) 2018–2019 13%a (−11% to 32%) USAFSAM: 47%a (35%–57%); 30% (22%–38%) NHRC: 58%a (38%–72%) 29% (21%–35%) 2019–2020 Influenza A: 12%a (−10% to 30%) Influenza B: 31%a (20%–40%) AFHSD: 54%a (46%–60%) 46% (40%–52%) 39% (32%–44%) a Mid-season influenza vaccine effectiveness estimates. Abbreviations: AFHSD: Armed Forces Health Surveillance Division; CDC: Centers for Disease Control and Prevention; NHRC: Naval Health Research Center; USAFSAM: United States Air Force School of Aerospace Medicine. Open in new tab TABLE II. Annual Influenza Vaccine Effectiveness Estimates . DoD service members (AFHSD data)12,14–16,18 . DoD beneficiaries (AFHSD, USAFSAM, NHRC data)12–19 . U.S. population (CDC data)20 . 2016–2017 3%a (−25% to 25%) USAFSAM: 42%a (24%–55%); 48% (37%–56%) NHRC: 45%a (5%–68%) 40% (32%—46%) 2017–2018 19%a (3%–33%) 18% (4%–30%) AFHSD: 51%a (41%–59%); 49% (42%–55%) NHRC: 55%a (17%–75%); 63% (50%–73%) 38% (31%–43%) 2018–2019 13%a (−11% to 32%) USAFSAM: 47%a (35%–57%); 30% (22%–38%) NHRC: 58%a (38%–72%) 29% (21%–35%) 2019–2020 Influenza A: 12%a (−10% to 30%) Influenza B: 31%a (20%–40%) AFHSD: 54%a (46%–60%) 46% (40%–52%) 39% (32%–44%) . DoD service members (AFHSD data)12,14–16,18 . DoD beneficiaries (AFHSD, USAFSAM, NHRC data)12–19 . U.S. population (CDC data)20 . 2016–2017 3%a (−25% to 25%) USAFSAM: 42%a (24%–55%); 48% (37%–56%) NHRC: 45%a (5%–68%) 40% (32%—46%) 2017–2018 19%a (3%–33%) 18% (4%–30%) AFHSD: 51%a (41%–59%); 49% (42%–55%) NHRC: 55%a (17%–75%); 63% (50%–73%) 38% (31%–43%) 2018–2019 13%a (−11% to 32%) USAFSAM: 47%a (35%–57%); 30% (22%–38%) NHRC: 58%a (38%–72%) 29% (21%–35%) 2019–2020 Influenza A: 12%a (−10% to 30%) Influenza B: 31%a (20%–40%) AFHSD: 54%a (46%–60%) 46% (40%–52%) 39% (32%–44%) a Mid-season influenza vaccine effectiveness estimates. Abbreviations: AFHSD: Armed Forces Health Surveillance Division; CDC: Centers for Disease Control and Prevention; NHRC: Naval Health Research Center; USAFSAM: United States Air Force School of Aerospace Medicine. Open in new tab The degree of impact of these variables on VE is not well defined but critical for vaccine policy decisions. Influenza vaccines have been used by the DoD for years. It was first utilized across the military during World War II, and since the early 1950s, annual influenza vaccine requirements for service members have been in place.4 Each year, the DoD’s goal is to reach >90% influenza vaccination rates by January 15.5 Studying VE in a highly vaccinated population adversely affects the statistical power of the analysis, given the limited number of unvaccinated cases and controls. In other words, a larger number of cases are needed to detect a vaccine effect. Thus, comparing test-negative study designs to other methods could lead to a better understanding of the best way to estimate VE in a highly (and repeatedly) vaccinated military population. Some observational studies done with different study designs calculated higher VE against seasonal influenza.6,7 These study designs that used person-time or incidence rate ratios may better quantify benefits from vaccination when limited unvaccinated cases and controls exist. Additionally, controlling for frequency and timing of influenza vaccination would help quantify the impact of different variables, and studies conducted in diverse settings (i.e., recruitment sites) could quantify benefits unique for military operations. All observational studies have limitations. There are numerous potential reasons for “bias toward the null” or lower VE seen in observational studies involving influenza and other respiratory virus vaccines. It is well established that “real-world” investigations yield lower efficacy compared to clinical trials. For vaccines against influenza (and SARS-CoV-2) whose primary benefits are reduction in disease severity rather than the production of sterilizing immunity, using infection as a sole endpoint will both yield lower VE and underestimate vaccine impact.8 Better quantifying protection from disease severity and availability to work and train is critical for the military and may provide valuable information to civilian workforces. Methodological issues involving influenza VE in the primary military population of healthy adults aged 18 to 39 have been relatively understudied. This is understandable since the largest burden of serious illness occurs in persons aged 50 years and over, and as U.S. influenza vaccine recommendations have expanded to encompass all persons aged 6 months and up, increased attention has been paid to the burden of disease among pediatric age groups. However, a better understanding of the persistently lower VE seen in military populations could enhance delivery, acceptance, and overall disease prevention benefits of the U.S. military influenza vaccine program as well as encourage vaccination among young working age adults in the civilian sector, who are immunized at much lower rates compared to their military counterparts.9 There is also a need to use additional measures of vaccine impact beyond crude VE to quantify disease prevention. This is especially true if VE is based only on less severe outcomes or only on test-negative design studies. The concept of vaccine impact, as defined by the World Health Organization, includes vaccine efficacy and effectiveness but also indirect benefits of vaccination.10 For vaccines such as influenza and SARS-CoV-2, which do not necessarily conform to standard herd immunity thresholds and principles, a full description of such benefits may require supplemental data collection and analysis. Since increased rates of severe respiratory disease have been demonstrated with recruits and other military trainees compared to civilian adults,11 focusing on accession and deployment sites as well as on effects during peaks of influenza transmission (e.g., measuring absenteeism and presenteeism) is an important area of study. Although test-negative studies are commonly used to assess influenza VE, this methodology has consistently demonstrated lower annual VE in service members. Comparing study designs with this highly vaccinated population may more accurately estimate vaccine protection. Accounting for other variables (i.e., repeat vaccinations and timing of immunizations) and considering other ways to quantify vaccine impact are other imperative areas needed to help guide influenza vaccine recommendations and policy and might have implications for future recommendations for SARS-CoV-2 vaccines. ACKNOWLEDGMENTS None declared. FUNDING None declared. CONFLICT OF INTEREST STATEMENT None declared. DATA AVAILABILITY No original data. All data are from other published studies. CLINICAL TRIAL REGISTRATION Not applicable. INSTITUTIONAL REVIEW BOARD Not applicable. INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE Not applicable. INSTITUTIONAL CLEARANCE Institutional clearance approved. REFERENCES 1. Dean NE , Hogan JW, Schnitzer ME: COVID-19 vaccine effectiveness and the test-negative design . N Engl J Med 2021 ; 385 ( 15 ): 1431 – 3 .doi: 10.1056/NEJMe2113151 . 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Available at https://health.mil/Reference-Center/Policies/2020/08/21/DHA-PI-6025-34; accessed September 9, 2022 . 6. Strickler JK , Hawksworth AW, Myers C, Irvine M, Ryan MA, Russell KL: Influenza vaccine effectiveness among US military basic trainees, 2005–06 season . Emerg Infect Dis 2007 ; 13 ( 4 ): 617 – 9 .doi: 10.3201/eid1304.061308 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Wang Z , Tobler S, Roayaei J, Eick A: Live attenuated or inactivated influenza vaccines and medical encounters for respiratory illnesses among US military personnel . JAMA 2009 ; 301 ( 9 ): 945 – 53 .doi: 10.1001/jama.2009.265 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Chua H , Feng S, Lewnard JA, et al. : The use of test-negative controls to monitor vaccine effectiveness: a systematic review of methodology . Epidemiology 2020 ; 31 ( 1 ): 43 – 64 .doi: 10.1097/EDE.0000000000001116 . Google Scholar Crossref Search ADS PubMed WorldCat 9. 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Shoubaki LA : Department of Defense Global, Laboratory-based Influenza Surveillance Program’s influenza vaccine effectiveness estimates and surveillance trends for 2016–2017 influenza season . Med Surveillance Mon Rep 2018 ; 25 ( 1 ): 8 – 9 . Google Scholar OpenURL Placeholder Text WorldCat 14. Shoubaki L , et al. : Department of Defense Midseason Vaccine Effectiveness Estimates for the 2017–2018 Influenza Season . Naval Health Research Center, San Diego, CA, United States , 2018 . 15. Coleman R , et al. : Department of Defense End-of-Season Influenza Vaccine Effectiveness Estimates for the 2017–2018 Season . Naval Health Research Center, San Diego, CA, United States , 2018 . 16. Lynch LC , et al. : Department of Defense midseason estimates of vaccine effectiveness for the 2018–2019 influenza season . Med Surveillance Mon Rep 2019 ; 26 ( 7 ): 24 – 7 . Google Scholar OpenURL Placeholder Text WorldCat 17. Kersellius GD , et al. : Respiratory pathogen surveillance trends and influenza vaccine effectiveness estimates for the 2018–2019 season among Department of Defense beneficiaries . MSMR 2020 ; 27 ( 1 ): 17 – 23 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 18. Thervil JW , et al. : Department of Defense mid-season vaccine effectiveness estimates for the 2019–2020 influenza season . MSMR 2021 ; 28 ( 6 ): 16 – 9 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 19. Wenping H , et al. : Influenza surveillance trends and influenza vaccine effectiveness among Department of Defense beneficiaries during the 2019–2020 influenza season . MSMR 2021 ; 28 ( 3 ): 2 – 8 . Google Scholar OpenURL Placeholder Text WorldCat 20. Available at https://www.cdc.gov/flu/vaccines-work/effectiveness-studies.htm, last reviewed Aug 2; accessed September 25, 2022 . Author notes The views expressed are those of the authors and do not reflect the official views of the United States Air Force, the United States Coast Guard, nor the Department of Defense. © The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/pages/standard-publication-reuse-rights)
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