Surgical Critical Care Initiative (SC2i) Biobank and Databank Growing
Over the course of four short years, the Uniformed Services University of the Health Sciences’ (USU) Surgical Critical Care Initiative (SC2i) has banked approximately 50,000 samples that include, but are not limited to, blood, serum, tissue, affluent, PBMCs, cerebral spinal fluid, and bacteria. Samples are maintained in a biobank which is a large collection of biological or medical data and tissue samples, collected for research purposes. Specimens are collected on a time and event-driven basis across the Center’s three clinical sites, all of which are operating under Good Clinical Laboratory Practices (GCLP). These rigorous standards ensure the reliability and integrity of data generated by the SC2i molecular core laboratories.
Clinical and biomarker datasets are then aligned and transferred to the SC2i’s secure Central Data Repository on Amazon Web Service GovCloud. Drawing from a growing bank comprising over 33 million data elements, the SC2i is aggressively pursuing the development of nine clinical decision support tools, three of which have been released internally and are now moving towards integration into the Military Health System Genesis, the Department of Defense’s new Electronic Health Record (EHR).
Building on the work of Capt. Eric Elster, professor and chair of USU Walter Reed Surgery, and others during Operations Enduring Freedom and Iraqi Freedom, the SC2i was established in 2013 to develop biomarker-driven CDSTs for the critically ill, with the goal of improving clinical outcomes and reducing costs.
“The USU SC2i is uniquely positioned to leverage large medical data sets and advanced machine learning techniques to deliver precision medicine for critically ill service members and their families”, said Elster.
The SC2i has thus far enrolled 1,500 military and civilian patients across seven (7) studies to power the development of CDSTs associated with a high risk of morbidity or mortality (e.g. venous thromboembolism, pneumonia, acute kidney injury).
Fig 1. Focused on improving clinical outcomes for injured service members, the USU Center follows a product-driven approach that begins and ends at the patient bedside.
Surgical Critical Care Initiative (SC2i) has deployed a Mobile Application to Predict the Need for a Massive Transfusion
A systematic approach to treating traumatically injured patients requires effective decision-making around the activation of an institution’s massive transfusion protocol (MTP). In most civilian centers, the implementation of this type of protocol is a significant commitment of what are relatively scarce resources, both in terms of personnel and material resources. Bedside clinicians are generally faced with this critical decision equipped with little more than some basic data points, and their own experience and clinical judgement. Previously published scoring systems are of little use at the bedside as they are either overly simplistic (and therefore not sufficiently accurate) or are too complicated for ease of use.
As a result, the Surgical Critical Care Initiative (SC2i) at the Uniformed Services University of the Health Sciences (USU) has created a statistically powerful and accurate mobile application that can assist a clinician in this life-saving decision. The mobile app allows for the accurate prediction of massive transfusion based on a sophisticated statistical model created using admission variables readily available to the clinician at the bedside. The MTP app has been validated on a cohort of 363 patients and was recently turned into a Fast Healthcare Interoperability Resources-enabled clinical decision support tool to allow for seamless insertion into today’s Electronic Health Records (EHRs). The SC2i is currently working to deploy the mobile app in both military and civilian environments to further validate its clinical utility.
“The MTP mobile app developed by the USU SC2i will ensure the right patients receive damage control resuscitation, leading to improvements in clinical outcomes and resource utilization”, says Capt. Eric Elster, professor and chair of the Department of Surgery at USU and the Walter Reed National Military Medical Center.
Fig 1. (left) The Massive Transfusion Protocol mobile application uses simple clinical variables like heart rate, and blood pressure to support decision making. (Right) A clinical provider uses the MTP mobile app to determine whether or not a trauma patient just admitted to the emergency room requires a massive blood transfusion.
Surgical Critical Care Initiative (SC2i) Center Supports Undergraduate and Graduate Medical Education
The Uniformed Services University of the Health Sciences (USU) Surgical Critical Care Initiative (SC2i) offers a robust medical training and education pipeline that supports surgical residents, medical students, and students from military academies. Located in Bethesda, Md., this center is one of the premier combat casualty care research programs of the Department of Defense and is ideally positioned to support the development of aspiring military surgeons and critical care providers.
Medical students who join the SC2i under the Capstone Initiative have the option to follow two tracks. Under the supervision of a senior scientist, those inclined to work in a laboratory environment will tackle a discovery science project tied to wound healing. Students will participate in the generation of hypotheses, processing of specimens – to include molecular assays— and interpretation of results. The second track focuses on data analytics (i.e. bioinformatics and biostatistics). Here, the students will work under the supervision of the Bioinformatics Core Services team lead, sequentially supporting the curation of complex datasets and the development of predictive algorithms for clinical conditions associated with a high degree of morbidity or mortality, like venous thromboembolism, pneumonia, bacteremia, acute kidney injury, acute respiratory distress syndrome, among others. For both tracks, and depending on the length of the internship – a minimum of four weeks is expected – the students will be expected to produce an abstract that will hopefully lead to either a talk or a poster presentation.
Marine Corps Capt. (Dr.) Michael Baird is one such success story, supporting the development of a Clinical Decision Support Tool that will predict Acute Respiratory Distress Syndrome and subsequently presenting his work at the Society of Military Orthopedic Surgeons. Baird, now in his transitional intern year, will be returning to Bethesda this summer to begin his orthopedic surgery residency.
“The opportunity for students like Michael to work with a team of world-experts and be immersed in cutting-edge research at an early stage of their education can have a profound influence on their future career choices. Many not only choose to train in the surgical specialties represented in the SC2i program, but also develop an enthusiasm to pursue a more demanding and exciting academic career track“, says Dr. Martin Ottolini, USU Capstone director.
Fig 1. In support of its medical education and training mission, the SC2i embeds military and civilian medical students and surgical residents within the center to support the development of aspiring military surgeons and critical care providers. Both actively participate in the research as well as the development of knowledge products like. posters, talks or manuscripts.
Surgical Critical Care Initiative (SC2i) Can Accurately Predict Invasive Fungal Infection (IFI) in our Combat Wounded
During the recent military conflict in Afghanistan, invasive fungal infections (IFI) emerged as a complication with surprising incidence (7%) and high morbidity and mortality (8%) among severely injured military personnel.
"Invasive fungal infections are devastating and proven to have high rates of other complications such as secondary bacterial infections, wound failure, sepsis and death in our wounded warriors. IFI can also require proximal revision of amputations up to the hip or pelvis to save our service members lives. The ability to accurately predict who is most at risk and initiate early, or even prophylactic, local and systemic anti-fungal therapies for those patients is crucial in turning the tide against this aggressive process. Our CDST give us the ability to do just that", says Lt. Col. (P) Benjamin Kyle Potter, chief of Orthopedic Surgery at Walter Reed National Military Medical Center (WRNMMC) and deputy director of the Surgical Critical Care Initiative (SC2i) at the Uniformed Services University of the Health Sciences.
In collaboration with the Infectious Disease Clinical Research Program and Trauma Infectious Disease Outcomes Study, the SC2i developed the IFI clinical decision support tool (CDST) to drive early therapeutic interventions near the point of injury and at definitive treatment centers.
Used retrospectively on a cohort of 22 combat-wounded patients enrolled at WRNMMC in 2017, the IFI CDST has so far performed flawlessly, with 100% true positive and true negative rates. The SC2i is now moving towards deploying the tool into the Military Health System Genesis, the Department of Defense’s new electronic health record.
Fig 1. (left) The IFI CDST uses standard clinical variables to predict the presence of an invasive fungal infection in a trauma patient. (right) The CDST, accessible to all military providers via a web interface, can instantly generate a probability to drive prophylactic interventions.