[Senate Hearing 109-]
[From the U.S. Government Publishing Office]
DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2006
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TUESDAY, MAY 10, 2005
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 10:07 a.m., in room SD-192, Dirksen
Senate Office Building, Hon. Ted Stevens (chairman) presiding.
Present: Senators Stevens, Inouye, and Mikulski.
DEPARTMENT OF DEFENSE
Medical Programs
STATEMENT OF LIEUTENANT GENERAL KEVIN C. KILEY, M.D.,
SURGEON GENERAL, DEPARTMENT OF THE ARMY
OPENING STATEMENT OF SENATOR TED STEVENS
Senator Stevens. My apologies, gentlemen. Too many
telephones and e-mails. It is one of those things.
We do welcome you to our hearing today to review the
Department of Defense (DOD) medical programs. We have two
panels scheduled. First, we will hear from the Surgeons
General, followed by the Chiefs of the Nursing Corps. Joining
us today from the Army, we have Surgeon General Kevin Kiley and
Admiral Donald Arthur from the Navy. We welcome you both in
your first hearing before us and look forward to working with
you closely. We welcome back General Peach Taylor from the Air
Force.
The President's fiscal year 2006 request for the defense
health program is $19.8 billion, an 8.9 percent increase over
fiscal year 2005. The request provides for health care for over
8.9 million beneficiaries and the operation of 70 inpatient
facilities and 1,085 clinics.
Despite the increase for this year's funding, the
subcommittee remains concerned that the funding may not be
sufficient to meet all of the requirements. We recognize that
the continuing conflict in Iraq and the global war on
terrorism, along with rising costs of prescription drugs and
related medical services, will continue to strain your
financial resources requested in this budget. And they will
place a demand on our medical service providers, both those
deployed in combat and those manning the posts here at home.
Senator Inouye and I are familiar with the value of
military medicine, and we are interested in hearing from you
regarding continuing operations.
Let me yield to my good friend from Hawaii.
STATEMENT OF SENATOR DANIEL K. INOUYE
Senator Inouye. Thank you very much, Mr. Chairman. I want
to join you in welcoming our witnesses this morning as we
review the state of the Department's medical programs. General
Taylor, we welcome you back to our subcommittee.
It is our hope that this hearing will spotlight the
numerous medical advances achieved by the men and women of the
medical corps and also accelerate improvement and progress
where it might be needed. The chairman and I, since World War
II, have followed the advances in personnel protection and
combat casualty care which have changed the fate of thousands
of our military men and women.
The improvements in battlefield protection and combat care
have given our military the lowest level of combat deaths in
history. While there is still regrettable loss of life in Iraq
and Afghanistan, the fact that we are saving hundreds of lives,
which could not have been saved in past military operations, is
proof that these advances are paying off. Several factors
contribute to this change, and we have read your testimony and
you have outlined several of them, including medical training
and facilities operated by the services.
The training our medical personnel can receive cannot be
equated with the private sector. One cannot deny that there are
major differences in the medical requirements of our men and
women serving in the military to the care required in your
average civilian hospital. The personnel training and
facilities of our medical system are all part of the elaborate
network that feed off each other. Today these pieces are all
connected and are continuing to make historic advances.
However, it appears that this system could be on a brink of
destruction.
We have been told that there is a chance that the Uniformed
Services University of Health Sciences and Walter Reed Medical
Center are potential targets for the base realignment and
closure (BRAC). I hope not, because I believe this would be a
tragic mistake. Our military medical facilities are essential
to winning the global war on terrorism, and as you may know,
the Senate included language in the supplemental conference
report directing that funding available to the Department of
Defense should not be used to close any military medical
facility which is conducting critical medical research or
medical training or caring for wounded soldiers. It is our hope
that this message is received by the Department loud and clear
before the BRAC list is compiled.
As a footnote to all of this, the chairman and I have,
throughout the years, visited with our troops, and in each
visit, we find that the major concern of all of them has been
health care. Is my wife being cared for? Are the pediatricians
working on my child? And I think we should keep in mind that
there are many men and women who enlist because of the
availability of health care.
It is no secret that we are having problems at this time in
recruiting and retaining, and if we take this benefit away,
then I think we will have real problems. So we look forward to
discussing this and many other issues that are crucial to the
military medical system.
Once again, I would like to thank the chairman for
continuing to hold hearings on these issues that are important
to our military and their families. I thank you very much, Mr.
Chairman.
Senator Stevens. Yes, sir.
General Kiley, do you want to go first? We cannot figure
out who should be first. Please, we would be glad to have your
testimony.
General Kiley. Sir, I would be happy to.
Chairman Stevens, Senator Inouye, and distinguished members
of the subcommittee, I am Lieutenant General Kevin Kiley, and I
am honored to serve as the 41st Surgeon General of the United
States Army.
Our medical department, our Army Medical Department
(AMEDD), is at war in support of our Army, defending our great
Nation in the global war on terrorism. Since September 2001,
the Army has been involved in the most prolonged period of
combat operations since Vietnam. One key indicator of the
success of our medical training, doctrine, and leadership is
our casualty survivability. During Vietnam, approximately 24
percent of all battle casualties died. As recently as Operation
Desert Shield/Desert Storm, 22 percent of our battle casualties
did not survive their wounds. In Operation Iraqi Freedom, less
than 10 percent of these soldiers, marines, sailors, and airmen
have died of their wounds.
This improved survivability is due to superior training of
our combat medics, leveraging technology to provide
resuscitative surgical care far forward on the battlefield, the
superb efforts of the Air Force's critical care aeromedical
evacuation teams, and the advanced research and state-of-the-
art care available at our major medical centers such as
Landstuhl, Walter Reed, Brooke, and Madigan, as well as other
sister services.
This phenomenal improvement in survivability is also due to
great teamwork on the part of the three services, the United
States (U.S.) medical industry, and the Members of Congress who
have supported numerous advancements in combat casualty care.
On behalf of the Army, I would like to thank you for your
tremendous support over the years and tell you how much I look
forward to working with this subcommittee to improve even
further our ability to sustain the health of the Army family,
whether it be in combat or at camps, posts, and stations around
the world in support of the global war on terrorism.
I would like to take a few minutes to explain how the
entire Army Medical Department integrates its multiple
functions to project and sustain a healthy and medically
protected Army. We are most certainly an AMEDD at war. Since
the spring of 2003, the Army has sustained a deployed
population averaging 125,000 soldiers in Southwest Asia, while
maintaining our global commitments around the world. We have
mobilized more than 349,000 Reserve component soldiers.
The demands placed on the Army Medical Department to
support this effort across the entire spectrum of operations is
significant. To support the deployed force, more than 36,000
Army medics, physicians, nurses, dentists, allied health care
professionals, health care administrators, and our enlisted
personnel have deployed into Southwest Asia. Nearly 20,000 of
these personnel are active duty component, and this total
represents approximately half of the Army's active medical end
strength not involved in long-term training, our residencies
and internships. Many of these soldiers are deploying for the
second time in 4 years. On the battlefield, they have provided
care to more than 21,000 injured or ill soldiers who were
evacuated from theater to Landstuhl Regional Medical Center and
then hospitals in the United States, often within 1 or 2 days
of injury, and have also cared for more than 16,000 Iraqi
nationals, coalition soldiers, and U.S. civilians. Fifty-one
AMEDD personnel have made the ultimate sacrifice in Iraq and
Afghanistan.
In theater, our Active and Reserve component medical units
deliver a standard of care comparable to what soldiers and
their families receive at our installations here in the United
States. Technological advancements and improved aeromedical
evacuation allow us to reduce our initial medical footprint in
theater to 6 percent of the deployed force, down from 14
percent in Operations Desert Shield and Storm. Innovative
medical health care providers have introduced techniques
normally found in major medical centers to our deployed combat
support hospitals. As an example, Lieutenant Colonel Trip
Buckenmaier pioneered the use of advanced regional anesthesia
and pain management while deployed with the 31st Combat Support
Hospital with tremendous success. This technique allows
complicated surgical procedures to be performed on a conscious
soldier using spinal anesthesia and nerve blocks. It holds
great promise to improve patient recovery and minimize
postoperative complications common with general anesthesia,
certainly as well as making those soldiers much more
comfortable.
Back in the United States, our Army Medical Command
supports the deployment of active component and mobilization
and deployment of Reserve component units. Our medical
treatment facilities conduct pre- and post-deployment medical
screening to ensure soldiers are medically ready to deploy and
to withstand the rigors of the modern battlefield. Nearly
23,000 mobilized Reserve component soldiers have developed an
illness or an injury during their mobilization that required
the Army to place them in a medical holdover status.
Approximately two-thirds of these soldiers are returned to the
Army in a deployable status in an average time of approximately
93 days from entering medical holdover.
All of our major medical centers are engaged in providing
the best possible treatment and rehabilitation to combat
casualties. You are familiar with the tremendous care provided
at Walter Reed Army Medical Center, but just as noteworthy is
the care provided to wounded soldiers at William Beaumont,
Womack, Madigan, Darnall, Eisenhower, and Tripler Army Medical
Center, as well as some of our relatively smaller facilities at
Forts Carson, Stewart, Riley, and Drum, among others.
We recently expanded our medical amputee program to include
a second amputee center at Brooke Army Medical Center in San
Antonio, Texas. This center, collocated with the Institute for
Surgical Research and the Army Burn Unit, will allow us to
build upon the innovative care delivered at Walter Reed and to
export advances in the treatment and rehabilitation of amputees
and extremity injuries to not only military facilities but the
rest of the medical community.
During this period of unprecedented operational tempo, we
have maintained and improved the quality of care we deliver to
soldiers, their families, and our retirees. Despite less than
100 percent backfill for deployed health care providers, we
have maintained workload levels in our direct health care
facilities. It is true that private sector workload is
increasing, but not because we are doing less work at our
facilities. As we have had to prioritize workload to support
casualty care and deployment medical screening, family member
and retiree care has, in some cases, shifted to the private
sector. Additionally, families of mobilized Reserve component
soldiers now have TRICARE available to them as their health
insurance in many areas where military facilities do not exist
or do not have the capacity to absorb the additional enrollees.
We have also completed a successful transition to the next
generation of TRICARE contracts. The reduction in the number of
regions, a national enrollment database, and increased
flexibility on the part of market managers, our military
treatment facility (MTF) commanders, will greatly enhance our
ability to support ongoing mobilization and deployments, Army
transformation, and upcoming base realignment and closure
decisions.
In closing, I want to emphasize that the defense health
program is a critical element of Army readiness. Healthy
soldiers capable of withstanding the rigors of modern combat,
who know their families have access to quality, affordable
health care, and who are confident when they retire they will
have access to that same quality health care, is an incredibly
powerful weapons system. Every dollar invested in the defense
health program does much more than just provide health
insurance to the Department's beneficiaries. Each dollar is an
investment in military readiness. In Operation Iraqi Freedom
(OIF) and Operation Enduring Freedom (OEF), that investment has
paid enormous dividends, and in my visits to Iraq, I can
document that personally.
PREPARED STATEMENT
Again, I would like to thank you for your past and future
support and, sirs, I look forward to answering your questions.
Thank you.
Senator Stevens. Thank you very much, General.
[The statement follows:]
Prepared Statement of Lieutenant General Kevin C. Kiley
Mr. Chairman and distinguished members of the Committee, thank you
for your support of the Army Medical Department (AMEDD) which is
providing world class care to Soldiers in Operations Enduring and Iraqi
Freedom (OEF/OIF). Without your support we would not have had the
resources to develop and refine multiple health care initiatives
designed to enhance and improve medical care for Soldiers and their
families before, during and after deployments. The AMEDD is at war and
is spread around the world with an unprecedented operational tempo. I
returned from my first visit to Iraq in mid-March and am extremely
proud of the remarkable professionalism and compassionate performance
of the entire AMEDD team in combat, preparing units for deployment and
return, and maintaining the health of Soldiers, retirees, and their
families at home.
In Iraq and Afghanistan, the United States and our allies continue
to struggle with forces opposed to freedom. Soldiers know that from the
91W combat medic riding alongside them in convoy, to the aid station
and combat support hospital, and throughout the evacuation chain to
Landstuhl Regional Medical Center and on to home-station hospitals in
the States, they will receive rapid, compassionate care from the
world's best military medical force.
Our medical force in Iraq and Afghanistan has saved hundreds of
lives--Soldiers, civilians and even those who fight against us--due to
remarkable battlefield techniques, patient transportation and
aeromedical evacuation, and state-of-the-art equipment and personnel.
Battlefield health care for OEF and OIF has been enhanced by placing
state-of-the-art surgical and medical care far forward on the
battlefield providing life saving care within minutes after injury.
This far forward care is integrated with a responsive and specialized
aeromedical evacuation that quickly moves patients to facilities for
follow-on care. Improved disease prevention and environmental
surveillance has reduced the rate of non-combat disease to the lowest
level of any U.S. conflict. In OIF, more than 91 percent of all
casualties survive their wounds, the highest survivability rate of any
US conflict.
We owe this improvement to several advancements. Improvements in
tactics and protective equipment allow Soldiers to survive previously
lethal injuries. The best trained combat medics and far forward
resuscitative care, have also contributed to survivability. Our combat
support hospitals in Iraq and Afghanistan support a full range of
medical specialties, including many subspecialties like cardio-thoracic
and neurosurgery. Technology now allows the Military Health System to
deliver the same care available at Brooke Army Medical Center or Walter
Reed in Mosul, Baghdad, or Kandahar. Today's Soldiers deserve better
than essential life-saving care while deployed, they deserve the same
superb quality care available to them and their families here in the
United States. I am proud to say that we are doing just that today on
the battlefields of Southwest Asia.
I would like to highlight several ongoing successes. Since January
2002, the U.S. Army Trauma Training Center, in association with the
Ryder Trauma Center, University of Miami/Jackson Memorial Hospital,
Miami, FL, has trained 32 Forward Surgical Teams and Combat Support
Hospital surgical elements deploying in support of the Global War on
Terrorism--more than 650 Active and Reserve Components (RC) healthcare
providers. The training program has evolved to provide bonafide total
team training to physicians, nurses, and medics, all focused on care of
the acutely injured patient. This unique multidisciplinary pre-
deployment clinical training has displaced deployment ``on-the-job''
clinical training as the appropriate training method to ensure safe,
effective combat casualty resuscitative surgery and care--it is
clinical teamwork that makes a tremendously positive difference in care
of the wounded. The Center is recognized as the Department of Defense
(DOD) Center of Excellence for Combat Casualty Care Team Training and
received the 2005 DOD Patient Safety Award for Team Training.
Uncontrolled bleeding is a major cause of death in combat. About 50
percent of those who die on the battlefield bleed to death in minutes,
before they can be evacuated to an aid station. Tourniquets, new blood-
clotting bandages and injectable clot-stimulating medications are
saving lives on the battlefield.
All Soldiers are taught to stop bleeding as a Common Task,
including applying a pressure dressing and a tourniquet, if needed.
Currently all Soldiers have the means of using a tourniquet. The new
Soldier Improved First Aid Kit (IFAK) includes a next-generation
tourniquet. This tourniquet allows a trained, isolated Soldier to stop
bleeding in an arm or leg. Between March 2003 and March 2005, U.S. Army
Medical Materiel Center-Southwest Asia issued 58,163 tourniquets (four
types) to CENTCOM-deployed units. Since April 1, 2004, a total of
193,897 tourniquets have been issued to Army units deploying to
theater. This includes 112,697 of two tourniquets proven 100 percent
effective in control of severe bleeding (Combat Application Tourniquet
or CAT and SOFTT). Beginning April 1, 2005 all new Soldiers will
receive specific instruction on the CAT during Basic Combat Training.
By the end of June 2005, deployed Soldiers without an approved
tourniquet will all have received the CAT through the U.S. Army
Medical Materiel Center-Southwest Asia, which placed an order for
172,000 CATs and 56,000 SOFTTs in mid-March 2005. The vendors expect
to fill the complete order of 228,000 by the end of June or earlier. In
fact, by the end of April more than 121,000 of these tourniquets have
been shipped to Qatar for distribution throughout the CENTCOM theater
of operations. Soldiers deploying for the next rotation of OIF/OEF will
either be issued the CAT as an individual item or the IFAK (which
contains the CAT) through the Rapid Fielding Initiative (RFI)
sponsored by Program Executive Office: Soldier.
The U.S. Army Medical Research and Materiel Command continues to
study a variety of agents which help control moderate to severe
bleeding including a bandage made of chitosan (HemCon), a
biodegradable carbohydrate found in the shells of shrimp, lobsters and
other animals. Chitosan bonds with blood cells, forming a clot.
Chitosan was shown to be effective in stopping or reducing bleeding in
more than 90 percent of combat cases, without known complications. The
Food and Drug Administration (FDA) cleared this bandage for use in
November 2002. Army combat medics are using this bandage in Iraq and
Afghanistan today.
War is stressful for Soldiers and their families. The AMEDD has
taken several steps to help minimize stresses associated with frequent,
prolonged deployments. There are a wide array of mental health assets
in Theater. These include Combat Stress Control teams and other mental
health personnel assigned to combat units and hospitals. We have
conducted three formal Mental Health Assessments, two in Iraq and one
in Afghanistan. The reports of the most recent Assessments are pending
DOD review and release.
Soldiers receive post-deployment briefings as they return home
focusing on the challenges of reintegration with families and
employers. Soldiers are cautioned that their families have changed and
grown, and that they may have a different role. They are also warned
about possible symptoms of deployment-related stress, such as
irritability, bad dreams, and emotional detachment.
The post-deployment health assessment includes several mental
health questions. The document is reviewed by a licensed healthcare
provider. If Soldiers answer positively to the mental health questions,
the provider may direct further evaluation and/or treatment.
The Assistant Secretary of Defense (Health Affairs) recently
announced a DOD policy to require all Service Members to receive a
second post-deployment mental health assessment 90 to 120 days after
redeployment. Soldiers may be hesitant to admit or are unsure they are
experiencing mental health issues when they first return. They are more
likely to develop or recognize problems and report them three to six
months later, after the ``honeymoon'' period has worn off. We are
working diligently to identify and assist Active, Reserve, and National
Guard Soldiers who experience post-deployment difficulties. There is
more work to be done in this area and we continue to refine and improve
our ability to identify and provide early and effective treatment to
Soldiers who are experiencing post deployment mental health issues.
A Joint Theater Trauma Registry (JTTR) is now becoming a reality,
modeled after the civilian standard established by Public Law 101-590,
Trauma Care Systems Planning and Development Act. The JTTR pulls
together the medical records of wounded (and deceased) Soldiers cared
for in battlefield hospitals, and includes both their pre-hospital care
and subsequent care in CONUS. When complete, the JTTR will present the
most comprehensive picture of war wounds ever assembled. This medical
database is invaluable for real-time situational awareness and medical
research. By combining the JTTR with other personnel and operational
databases, we anticipate its increased value will lead to improvements
in Soldier Personal Protective Equipment (e.g. body armor), vehicle
design, and small unit tactics.
We remain committed to providing high quality, expert medical care
to all Soldiers who become ill or injured in the line of duty. There is
only one standard of medical care for all Soldiers regardless of
Active, Reserve, or National Guard status. That is why we created the
Medical Holdover (MHO) program. In an effort to report MHO patient data
up and down the chain, we created a Medical Holdover module in our
Medical Operational Data System (MODS), a proven system with robust
capabilities for patient tracking and Soldier health reporting. Once we
were convinced that the data was timely and accurate, we began to
integrate data from other systems, eliminating so-called
``stovepipes''. We started with Medical Evaluation Board (MEB) tracking
data, and now have three more patient tracking and administrative
systems feeding into MODS. Those measures were so successful that every
Army major command involved in MHO operations now uses MODS as the sole
source for information on MHO Soldiers. To further enhance MODS'
capabilities, we expect to have pay and finance, and personnel data
integrated over the next 90 days.
Management and expeditious disposition of MHO Soldiers must balance
a great number of factors. First, healing takes time. If all combat
operations ceased today, we would still have MHO patients to care for
one and one half years from now. Another factor is the simple fact that
no one knows Soldier health care better than the AMEDD. We know best
how to treat Soldiers, when Soldiers are fit to return to duty, and
when they have to undergo a Medical Evaluation Board. For the RC
Soldier, however, an Army MTF may be hundreds of miles away from home
and typically, what a Soldier wants most when he or she returns from a
deployment is to go home.
In an effort to allow RC MHO Soldiers to receive care close to
their homes, the Army developed the Community Based Health Care
Initiative (CBHCI). CBHCI provides top quality health care for ill and
injured RC Soldiers. It increases the Army's medical treatment, command
and control, and billeting capacities. Thus, the CBHCI allows the Army
to reunite Soldiers with their families. The principal instruments of
the CBHCI are the Community Based Health Care Organizations (CBHCOs).
These are units staffed primarily by mobilized National Guard Soldiers.
Their mission is to provide case management for, and ensure command and
control of healing RC Soldiers. The CBHCOs acquire health care from
Army, Navy, and Air Force facilities; the VA; and the TRICARE network.
They represent the Army's commitment to take care of our Soldiers and
their families with speed and compassion.
Accession of Health Care Professionals into our Active force is
becoming a more significant challenge. We are starting to see a
downturn in our Health Professions Scholarship applicants for both the
Medical and Dental Corps. Since student scholarship programs are the
bedrock of Army Medical Department accessions, I have directed my staff
to closely monitor this trend. We rely on these scholarship programs
because direct recruitment of fully qualified physicians, dentists and
nurses is difficult due to the extremely competitive civilian market
for these skill sets.
Likewise I am concerned about the retention of health care
professionals. Their successful retention is a combination of
reasonable compensation, adequate administrative and support staffs,
appropriate physical facilities, equity of deployments and family
quality of life. Changes in Special Pay ceilings have allowed us to
increase the rates we now offer physicians that sign a four year
contract. We also have increased the dollar amount that we pay our
Certified Registered Nurse Anesthetists to improve their retention
rates. We will continue to evaluate and adjust rates to improve our
retention efforts. At the same time, we have developed and implemented
programs to affect the non-monetary issues positively effecting
retention. We have implemented policies that ensure equity of
deployments by maximizing our deployment pool, providing adequate
notification of impending deployment, and providing a predictable
period of family separation. All of these assist us in the retention of
our active component medical force.
The Commander, U.S. Army Recruiting Command and I are working
diligently toward the establishment and implementation of new and
enhanced initiatives to reverse these emerging trends. Some of these
include increasing the recruitment of Physician Assistants; the
development of a program to allow serving officers to obtain a Bachelor
of Science in Nursing and the direct involvement of my senior medical
and dental consultants in the recruitment effort to continue to tell
the story of the practice of Army Medicine. Of equal concern to me are
the recruitment challenges facing the Army Reserve and National Guard.
I fully support all of the actions being taken by the Chief of the Army
Reserve (CAR), LTG Helmly, and the Director, National Guard Bureau, LTG
Schultz) as they deal with the unique issues surrounding Army Reserve
recruitment efforts in the current operational environment.
As with Recruitment, my staff and I continue to work hand in hand
with the CAR and the Director of the Army National Guard to determine
programs necessary for adequate retention. RC Soldiers have continually
answered the call to service and it is critical that we develop the
appropriate programs to ensure that their expertise and experience are
not lost. Considering that over 50 percent of the total Army medical
force is in the Reserve Components, issues surrounding the financial
and family impact of extended and recurring deployments must be
addressed and resolved if we are to retain a viable medical force for
future operations.
Several related Army and DOD initiatives are creating temporary and
permanent population changes on our Army installations. They include:
support of GWOT pre- and post-deployment health; Modularity--now known
as Army Modular Force (AMF); Training Base Expansion; the Integrated
Global Basing and Presence Strategy and Base Realignment and Closing
(BRAC) 2005. These major population shifts create a tremendous
challenge for Army Medicine as we try to adjust to meet local and
regional medical markets.
As we rebalance the military Health System in the affected markets,
our continued focus is to provide quality health care that is
responsive to commanders and readily accessible to soldiers and
families. We are working very closely with commanders, installations,
arriving units, family support groups and the local communities
surrounding our installations to ensure that access and quality of
healthcare remain high. We are leveraging all available AMEDD, DOD and
VA health care capacity in each locale. We are working closely with our
TRICARE Regional Offices and Managed Care Support Contractors on
market-by-market business case analyses to strike the right balance
between Direct Care and Purchased Care capacity.
It should be noted that these are solutions pending release of BRAC
2005, after which the AMEDD will develop permanent plans for
rebalancing health service support across installations and regions.
During fiscal years 2005 and 2006, at many installations, even our
temporary expansions may lag the arrival of Soldiers and family
members. In the interim, we are extending clinic hours, hiring
additional staff, and temporarily increasing referrals to TRICARE
network providers to insure continuity of care.
The AMEDD is actively engaged in the DOD Patient Safety Program,
which is a system-wide effort to reduce medical errors combined with
non-attributional reporting and multi-disciplinary analysis of events.
The goal is the trending of incidents, identification of lessons
learned and the implementation of best practices that can be propagated
system-wide by the Patient Safety Center. The AMEDD is making
significant strides in creating a culture of patient safety where staff
is comfortable reporting patient safety events in an environment free
of intimidation. We are improving error reporting by increasing
leadership awareness at all levels through multiple approaches
including collaborative training efforts with the DOD Patient Safety
Program.
Communication is the number one causal factor in almost all patient
safety events. The AMEDD Patient Safety Program has made major
advancements in team training in targeted high-risk environments such
as emergency departments, labor and delivery units, and intensive care
units. DOD's Pharmacy Data Transaction Service (PDTS), implemented in
2001, established a centralized, automated drug data repository
integrating all DOD patients' medication data from medical treatment
facility pharmacies, the 54,000 TRICARE retail network pharmacies and
the TRICARE Mail Order Pharmacy. As a direct result of this system's
ability to screen all patients' medications against the complete
medication profile, PDTS has prevented over 60,000 clinically
significant drug-drug interactions, which would have otherwise resulted
in patient harm. In 2004, a multi-year strategic Army Pharmacy
automation initiative was implemented and focused on preventing
medication errors and improving medication-use safety through the
integration of automation technology at all Army pharmacies worldwide.
This initiative will reduce and prevent medication errors that often
lead to increased utilization of more costly healthcare.
The AMEDD continues to work with DOD to improved medical care for
RC Soldiers and their family members. RC Soldiers and their families
now receive TRICARE coverage not only while on active duty but also
before and after. This can lessen the worries of deployed personnel
about their family members' health and also serve as an incentive for
experienced Soldiers to remain in the Reserve after their deployment.
When a RC Soldier is called to active duty for more than 30 days in
support of a contingency operation, they and their family members have
full TRICARE coverage up to 90 days before the start of active duty.
The coverage is the same as that provided for family members of any
active duty Soldier, including options for TRICARE Prime and TRICARE
Prime Remote and eligibility for family dental coverage. To ensure
continuity of care, these Reservists and family members continue to
receive TRICARE coverage for 180 days after leaving active duty under
the Transitional Assistance Management Program (TAMP). After TAMP,
Soldiers may choose to continue TRICARE coverage for their families for
up to 18 months under the Continued Health Care Benefits Program
(CHCBP) or to enroll in the new TRICARE Reserve Select (TRS) program,
scheduled to be implemented on April 26, 2005. Under TRS, Soldiers
agreeing to serve in the Selected Reserve may receive one year of
purchased TRICARE Standard coverage for their families for each
consecutive 90 days spent on active duty in support of a contingency
operation.
From June to November 2004, TRICARE transitioned from eleven
contract regions and seven contracts to three CONUS regions. The new
generation of contracts is performance-based and designed to maximize
the efficient use of military treatment facilities while flexibly using
civilian healthcare resources when appropriate. Portability of benefits
between regions is improved and several functions, such as pharmacy and
the administration of TRICARE for Life have been consolidated into
nation-wide contracts. As part of the transition to the new contracts,
measures are being taken to improve coordination between military
facilities and civilian network providers and to make access to care
more patient-centered. TRICARE Online (TOL) offers patients better
information about their choice of appointments and allows them to make
appointments after normal duty hours, while reducing the rate of ``no-
shows.'' Over 50,000 appointments were made through TOL in 2004, and
the program is being expanded to include more facilities. A commercial-
off-the-shelf web-based electronic fax service is providing efficient
transmission of referrals from military treatment facilities to network
providers. After a successful pilot at 30 facilities, a contract has
been awarded to provide this service Army-wide. The Enterprise-Wide
Referral and Authorization process is a high-priority effort to use
net-centric technology and improved business processes to streamline
and standardize the referral and authorization of care to network
providers. The goals of the three-phase plan are to increase patient
satisfaction, make the referral process more efficient, and to optimize
allocation of military and civilian healthcare resources. The current
short-term phase is standardizing several critical processes while
emphasizing improved handling of urgent referrals.
The Army continues to improve the quality of healthcare for
Soldiers and families stationed overseas. The Vicenza Birthing Center
initiative was driven by cultural differences between child birth
procedures in local Italian hospitals and U.S. expectations for
obstetrical and gynecological care. These differences have had an
adverse impact on family member morale and Soldier readiness for a
number of years. In multiple venues, U.S. Soldiers and family members
of the Vicenza community have, with one voice, asked for a safe,
reliable and accessible U.S. standard of healthcare, particularly in
regard to obstetrical services. With the deployment of the 173rd
Airborne Brigade, this concern is even more acute and being championed
by the U.S. Army Europe Commander. In response to this need, the AMEDD
developed an interim solution by establishing a temporary birthing
center at the Vicenza Army Health Clinic. This birthing center will
accommodate the needs of the vast majority of normal pregnancies and
births. We will continue to depend on our Italian host nation hospitals
for emergency obstetrical care. In these cases, care is comparable to
U.S. standards. The birthing center is currently under construction and
will be operational by 8 June 2005.
On December 13, 2002, the Military Vaccine Agency (an executive
agency of the Army Surgeon General) began implementation of DOD's
Smallpox Vaccination Program in support of the national smallpox
preparedness plan announced by the President. The Smallpox Vaccination
Program is using the existing FDA-licensed smallpox vaccine consistent
with its label. The program is tailored to the unique requirement of
the Armed Forces. Like civilian communities, DOD ensures preparedness
by immunizing personnel based on their occupational responsibilities.
These include smallpox response teams and hospital and clinic workers,
as well as designated forces having critical mission capabilities. Like
other vaccinations, this will be mandated for designated personnel
unless they are medically exempt. The last year includes both major
advances and major setbacks in the Military Immunization Program. Since
December 2002, the DOD has vaccinated more than 770,000 personnel
(Army: more than 410,000 personnel [military + civilian]) against
smallpox, representing the largest cohort of smallpox-protected people
on Earth. These vaccinations have been conducted with great care to
exempt people with personal medical conditions that bar smallpox
vaccination. Review by military and civilian experts shows that adverse
events after smallpox vaccination have been at or below historical
rates expected among smallpox vaccines. In early 2003, DOD and Army
clinicians and scientists identified an elevated risk of heart
inflammation (myo-pericarditis) in male smallpox vaccines in their 20s.
Our follow-up of these cases shows them to have a rapid and high degree
of recovery. With clinical teams focused at Brooke and Walter Reed Army
Medical Centers, we continue to follow these patients and provide them
state-of-the-art care, to learn more about the condition.
The Department lost an important countermeasure against anthrax
weapons in October 2004, when a U.S. District Court judge enjoined
operation of the Anthrax Vaccination Immunization Program (AVIP) for
inoculation using Anthrax Vaccine Adsorbed (AVA) to prevent inhalation
anthrax. Anthrax spores continue to be the#1 threat among bioweapons.
Until the injunction, the DOD had administered 5.2 million doses of AVA
to 1.3 million people (Army: more than 1.9 million doses to over
500,000 people), as well as assisting with 20 human safety studies
described in 34 publications in medical journals. In April 2005, the
Court agreed to allow the DOD to restart the AVIP under a U.S. Food and
Drug Administration Emergency Use Authorization and the Army is
preparing to administer AVA to individuals between 18 and 65 years of
age who are deemed by DOD to be at heightened risk of exposure due to
attack with anthrax. The terms of the Emergency Use Authorization allow
Soldiers to refuse receiving the AVA without penalty after reviewing
educational information on AVA. I expect we will restart the program
under the Emergency Use Authorization by mid-May 2005 for Soldiers
serving in, or deploying to, Southwest Asia and Korea.
Army scientists continue their work in research and development of
new vaccines, including adenovirus vaccines, malaria vaccine, and
plague vaccine. These vaccines are needed to protect against microbes
that threaten Soldiers in basic training, in tropical locations, or as
bioweapons, respectively. Adenovirus vaccine research involves tablets
to protect against a militarily relevant respiratory germ. Malaria is
one of the leading infectious causes of death around the world. The
Walter Reed Army Institute of Research's malaria research program is a
world leader in this field. Plague vaccine research is centered at the
US Army Medical Research Institute of Infectious Diseases, another
world-class asset of the U.S. Army.
During all this unprecedented activity and keen competition for
limited resources, the courage, competence and compassion of the
AMEDD's people amaze me. Despite the long hours, separation from
family, danger, and hardship required to fight the Global War on
Terrorism, they remain firmly committed and motivated to provide the
best possible support for American Soldiers, their families, and all
others who are entrusted to their care. Nothing saddens us more than to
lose a Soldier. With your continued support, the AMEDD will continue to
do everything possible to prevent these terrible losses whether from
battle wounds or non-battle illnesses and injuries. We will always
remember our core mission: to preserve Soldiers' lives and health
anywhere, anytime, in war and in peace. We will never forget the
Soldier.
______
Biographical Sketch of Lieutenant General Kevin C. Kiley
Lieutenant General Kevin C. Kiley, M.D., is a 1972 graduate of the
University of Scranton, with a bachelor's degree in biology. He
received his medical degree from Georgetown University School of
Medicine in 1976. He served a surgical internship and then an
obstetrics and gynecology residency at William Beaumont Army Medical
Center, El Paso, Texas, graduating in 1980.
His first tour was with the 121st Evacuation Hospital in Seoul,
South Korea, where he was the chief of OB/GYN services from 1980 to
1982. He returned to the residency training program at William Beaumont
Army Medical Center and served as Chief, Family Planning and Counseling
Service. He then served as Assistant, Chief of the Department of OB/GYN
until February 1985.
He was assigned as the Division Surgeon of the 10th Mountain
Division, a new light infantry division in Fort Drum, New York. In July
1985, he assumed command of the newly activated 10th Medical Battalion,
10th Mountain Division. He served concurrently in both assignments
until May 1988. He returned to William Beaumont Army Medical Center,
where he first served as the Assistant Chief, then Chairman of the
Department of OB/GYN.
In November 1990, he assumed command of the 15th Evacuation
Hospital at Fort Polk, Louisiana, and in January 1991, he deployed the
hospital to Saudi Arabia in support of Operations Desert Shield and
Desert Storm. Upon his return, he was assigned as the Deputy Commander
for Clinical Services at Womack Army Medical Center, Fort Bragg, North
Carolina, from November 1991 to November 1993.
He is a 1994 graduate of the U.S. Army War College, Carlisle
Barracks, Pennsylvania. He assumed command of the Landstuhl (Germany)
Regional Medical Center and what is now the U.S. Army Europe Regional
Medical Command at Landstuhl, Germany, June 30, 1994. He also served
concurrently as the Command Surgeon, U.S. Army Europe and 7th Army from
September 1995 to May 1998.
In April 1998 he assumed the duties as; Assistant Surgeon General
for Force Projection; Deputy Chief of Staff for Operations, Health
Policy and Services, U.S. Army Medical Command; and Chief, Medical
Corps. On June 5, 2000 he assumed duties as Commander of the U.S. Army
Medical Department Center and School and Fort Sam Houston and continued
as Chief of the Medical Corps. He served as the commander of Walter
Reed Army Medical Center and North Atlantic Regional Medical Command
and Lead Agent for Region I from June 2002 to June 2004.
Lieutenant General Kiley assumed the duties of Acting Commander,
U.S. Army Medical Command on 8 July 2004. After receiving Senate
confirmation of his nomination, he was sworn in as the 41st Army
Surgeon General and assumed the duties as Commanding General, U.S. Army
Medical Command on October 4, 2004. He was promoted to the grade of
Lieutenant General on October 12, 2004.
He is a board-certified OB/GYN and a fellow of the American College
of Obstetricians and Gynecologists.
Among his awards and decorations are the Distinguished Service
Medal, Defense Superior Service Medal, Legion of Merit (three Oak Leaf
Clusters), Bronze Star Medal, Defense Meritorious Service Medal,
Meritorious Service Medal (two Oak Leaf Clusters), Army Commendation
Medal, The Army Superior Unit Award (one Oak Leaf Cluster), the ``A''
professional designator, the Order of Military Medical Merit, and the
Expert Field Medical Badge.
Senator Stevens. Senator Mikulski, I was not looking in
your direction. Did you have an opening statement?
Senator Mikulski. I will do that when I get to my
questions.
Senator Stevens. Thank you. I apologize for not recognizing
you.
Admiral Arthur.
STATEMENT OF VICE ADMIRAL DONALD C. ARTHUR, MEDICAL
CORPS, SURGEON GENERAL, UNITED STATES NAVY
Admiral Arthur. Yes. Good morning, Chairman Stevens,
Senator Inouye, Senator Mikulski. Thank you very much for
having us here this morning.
I am not going to read my statement. You have read that and
I appreciate that.
Senator Stevens. All of your statements will be printed in
the record as if read.
Admiral Arthur. Yes, sir. I would like to make some general
comments and to reiterate some of what is in here, but not all
of it.
First, I would like to highlight that we have a series of
priorities in Navy medicine, and the first will always be our
readiness. We break readiness down into a number of different
factors.
The first and foremost is to make sure that our sailors and
marines and whatever soldiers, airmen, and coast guardsmen we
take care of are ready for their duties and are a healthy
population, as well as their families so that they have the
confidence that they can go and deploy and we will take care of
their families.
Our second readiness priority is to be ready ourselves to
deploy in whatever manner we are asked to. I was in Iraq in
December and January. I noticed we had so many significant
improvements in how we do business in the combat arena over
Desert Storm where I served with the marines. We had, for
example, digitized radiography. We had computers all over. We
had a lot of advanced systems. The thing that was the most
critical to the care of wounded soldiers and marines over there
was the training that the corpsmen and medics got. The corpsmen
and medics were there and delivered the care right at the time
of wounding. The training of the surgical teams, the rapid
medevac, and the incredibly great service at Landstuhl on the
way back to the United States. I think you can be very, very
proud of the care that your wounded soldiers, marines, sailors,
airmen, coast guardsmen are getting over there. As Senator
Inouye said, it is the best in history with the lowest disease
non-battle injury rate and the greatest survivability in the
history of combat.
A third priority for our readiness is homeland security,
and this is an area of great concern for me because I think
that in some sectors of our Government, we have not yet fully
prepared for an attack on our homeland. We have a program with
the Bethesda Military Medical Center compound, as well as the
National Institutes of Health (NIH) compound right next door,
and the Suburban Hospital Trauma Center, to form a mega-center
which could respond to casualties in the National Capital area,
and you should be seeing more about that very soon.
Our second priority is to continue to deliver the quality
health care for which we have become well known. We have the
advantage of being a health care system as opposed to much of
the rest of America where I believe we have a disease care
industry. We get paid not by how many procedures and how many
immunizations we give, but we get paid by our line and the
number of soldiers, sailors, airmen, and marines we have on
duty, and that is our metric for success.
The Chief of Naval Operations (CNO) interviewed me 1 year
ago for this job that I am currently honored to hold, and he
asked me could our casualties be seen and treated at civilian
hospitals, and I said, well, sure they could. They can be very
well treated at Johns Hopkins or at Mayo Clinic. But those
hospitals would not understand two things that are critical to
our treatment of our casualties.
Number one, that the soldiers, sailors, airmen, and
marines' injuries are not just to that person, they are to his
or her entire family. These are family injuries.
The second thing that civilian hospitals will not
understand about our casualties is that even lying at Bethesda
or Walter Reed, these marines and soldiers are still in combat.
They still remember the stresses that they incurred in combat
and we care for them in a way that civilian hospitals could not
do just because we have the background and we have shared that
combat experience with them.
We have another advantage in our delivery of quality health
services in our collaboration with the Veterans Administration
(VA). Yesterday Secretary Nicholson opened up the joint DOD-VA
clinic at Pensacola, Florida. We have joint clinics which we
are building in Great Lakes and Charleston, South Carolina that
I think will be of great benefit to both veteran populations.
Our third priority is to help shape the force of the
future, not to meet the needs of yesterday but meet tomorrow's
needs, which will include not just the traditional combat
casualty care, but also homeland security, stability
operations, and the global war on terror requirements. This may
require that we shape our forces differently, that we have some
different capabilities than we thought we would need if only
our missions were combat casualty care, and I refer to the
recent mission of Mercy in Banda Aceh taking care of tsunami
and disaster relief victims over there. They needed surgeons.
They needed the combat casualty care type of specialties, but
they also needed pediatricians, OB-GYN specialists, preventive
medicine specialists, and all of those specialties that are not
necessarily planned for combat casualty care.
We are focusing on Active and Reserve integration; that is,
that we more fully incorporate our Reserve component in our
active duty warfighting plans. We now have six Active duty
fleet hospitals, for example, and two Reserve fleet hospitals.
We would like to have just eight fleet hospitals that combine
Active and Reserve components to be more fully integrated.
One other integration effort that I think would be of great
benefit is to better integrate the three service medical
departments in how we train, equip, recruit, supply, and how we
deploy so that we can be as fully interoperable in the combat
arena as we can be.
And last, I would like to thank you very much for your
support and the encouragement that you have given us in finding
the best casualty care management for the veterans that are now
over there in OIF and OEF.
I apologize. I will have to leave before my colleague, Rear
Admiral Lescavage, testifies. I have to fly out of town, but we
are very proud of the accomplishments of our Navy Nurse Corps
as a member of our team.
PREPARED STATEMENT
Senator Inouye, you mentioned that you were proud of the
accomplishments of our Medical Corps. I would say one of the
great benefits of our Medical Department is that we are not
just a medical corps or a nurse corps of a medical service
corps or dental corps or a hospital corps. We are a
combination. We are the team. It is that teamwork, that
synergistic effort of all of our corps together, that really
makes us strong. You do not find that in civilian institutions,
and that is what I think makes our military medical departments
great.
Thank you very much.
Senator Stevens. Thank you, Admiral.
[The statement follows:]
Prepared Statement of Vice Admiral Donald C. Arthur
Chairman Stevens, Ranking Member Inouye, distinguished members of
the subcommittee, I welcome the opportunity to share with you how Navy
Medicine is taking care of our nation's Sailors, Marines, and their
families.
As our nation continues to fight the Global War on Terror, Navy
Medicine will continue to meet the health care needs of our
beneficiaries, active duty, military retirees, and eligible family
members. These efforts reflect our unrelenting commitment to our
primary mission--Force Health Protection. The components of Force
Health Protection are: (1) preparing a healthy and fit force; (2)
deploying medical personnel to protect our warriors in the battlefield;
(3) restoring health on the battlefield; (4) providing care to our
retired warriors through TRICARE for Life; and (5) providing world-
class health care for all beneficiaries.
Priorities
To meet the needs of those entrusted to our care, Navy Medicine
established five priorities to meet our unique dual mission. That dual
mission is first, to support and protect our operational forces while
working in concert with the Chief of Naval Operations' and Commandant's
vision for the Navy-Marine Corps team, and second, to provide health
care to their family members and retirees.
Readiness
Readiness is our number one priority. To be ready, Navy Medicine
must be responsive, agile and aligned with operational forces. We need
to have the right people with the right capabilities ready to deploy in
support of the Navy-Marine Corps team.
In current operations, Navy Medicine has made significant
advancements in the health care provided by First Responders and
improved surgical access during the critical ``golden hour.'' In
addition to improving health care after traumatic battlefield injuries,
Navy Medicine is also curbing infectious disease outbreaks, decreasing
occupational injuries, and providing preventive medicine and mental
health care services.
An outstanding example of Navy Medicine's more capable, flexible
and responsive force is the creation of the Expeditionary Medical
Facility (EMF). These facilities, with similar capabilities as Fleet
Hospitals, are lighter and more mobile and can be set up within 48
hours. EMFs may be used independently or in combination with the
theater's joint health system for evacuation, medical logistics,
medical reporting, and other functions, ensuring better
interoperability with the Army and the Air Force. The flexibility of
EMFs continues to evolve to meet operational requirements and provide
robust medical care for major conflicts, low-intensity combat,
operations other than war, and disaster/humanitarian relief operations.
We are also expanding the role of Navy Medicine on the battlefield
with the 1,000 Sailors either deployed overseas or preparing to deploy
with Maritime Force Protection Command units. These Sailors receive a
half-day in training from doctors and hospital corpsmen in how to use
special medical kits. These ``Point of Injury'' kits contain items like
an easy to use tourniquet, a specialized compression bandage, QuikClot
(a product designed to stop bleeding), antibiotic and pain medications.
These kits are designed for self-care or buddy care in the minutes
before a corpsman arrives on the scene.
The Global War on Terror has challenged us to broaden our view of
medical readiness. Our Military Treatment Facilities (MTF) are prepared
to respond to any contingency, to provide expert health care to
casualties returning from theater, and be ready to support the Nation's
needs in collaboration with the National Disaster Medical System.
Additionally, Navy Medicine launched three major initiatives to meet
the needs of disaster preparedness focused on staff, supplies and
systems.
Using the Strategic National Stockpile as a model, we are planning
for additional equipment to enhance the capabilities of local MTFs. We
developed a successful multi-service online medical and emergency
management educational tool, as well as an Emergency Management Program
Readiness Course that has become the DOD Medical training standard. The
Disaster Preparedness, Vulnerability Analysis Program (DVATEX) was
developed to evaluate military, federal, and local community
responsiveness. This program goes beyond assessing MTF threat
vulnerability and capability assessment; it also provides training in
medical and operational management.
Collaboration with other organizations, including other federal and
civilian agencies, is essential for effective and efficient disaster
response. A local example of this type of collaboration is taking place
at the National Naval Medical Center in Bethesda, Maryland. Because of
its proximity to the National Capital Region, the National Naval
Medical Center established a disaster preparedness and response
coalition with the National Institutes of Health and Suburban Hospital
Healthcare System in Bethesda. Recently, they conducted a joint
disaster drill involving Montgomery County and municipal emergency
response organizations and other members of the local area hospital
network.
Delivering a more fit and healthy force, mitigating the risk of
injury or illness, and providing more effective resuscitation of
battlefield casualties will enhance Navy Medicine's readiness and
ability to prosecute the Global War on Terror. Medical research and
development is a critical enabler of this effort. Our research
investments allow us to transform into a defensive weapon system that
will promote health and fitness, protect people from injury and
disease, and effectively reduce, manage and rehabilitate casualties. In
addition, these research investments and capabilities help Navy
Medicine respond to the current and future needs of the Fleet and Fleet
Marine Force.
Navy scientists conduct basic, clinical, and field research
directly related to military requirements and operational needs.
Current studies focus on the efficacy trials for blood substitutes to
treat combat casualties; new treatment modalities for musculoskeletal
injuries and acute acoustic barotrauma; and solutions for the emerging
threats of combat stress, among others. Our medical research laboratory
facilities equal those at modern academic and industrial institutions.
Beyond this capacity, a number of these laboratories have unique test
equipment and specialized software for pursuing research on current and
projected biomedical problems. Research is further supported in other
Navy laboratories as well as in partnership with the Army and Air
Force, and other Federal agencies.
Research in non-government laboratories is promoted through an
active collaborative research and technology transfer program that
develops cooperative research and development agreements with
universities and private industry to ensure that research products from
our laboratories benefit the entire country. Navy-supported medical
research efforts have influenced the civilian practice of medicine,
assisted the Ministries of Health in developing nations, and provided
technology for other Federal initiatives.
Our overseas research facilities are national assets serving the
strategic interests of the regional Combatant Commander and the local
Ambassador. They bring unique surveillance capabilities and advanced
laboratory capabilities to areas where infectious diseases are a
significant threat to our personnel. These capabilities were recently
leveraged in the tsunami relief effort in Banda Aceh. In addition to
supporting the mission of Force Health Protection, the overseas labs
are strategic partners in promoting Theater Security Cooperation.
Lastly, they are developing a new alliance with the Centers for Disease
and Control to further that agency's efforts in mitigating the risk
that emerging infectious diseases pose to the health of our citizens
and our economy.
Quality, Economical Health Services
Navy Medicine's second priority is providing quality, cost-
effective health services. While focusing on quality health care, Navy
Medicine has recognized the need to provide the best possible health
care within our resource constraints. Through careful business
planning, Navy Medicine aligned MTF operations to focus on the
preservation of health, and the prevention of disease and injury.
Recently, the Naval Health Clinic in Pearl Harbor instituted a new
Individual Health Readiness (IHR) program. The goal of this program is
to ensure each Pearl Harbor Sailor is healthy and mission-ready. It was
established to build and improve total Navy Regional Hawaii health
readiness in response to a growing number of shore and sea Sailors
deploying. The IHR program ensures each Sailor has an up-to-date health
assessment to determine deployment limiting conditions, dental
readiness, immunization status, lab studies and individual medical
equipment needs to ensure the command's level of health readiness--both
dental and medical--is 95 percent or better.
An enterprise focused on quality must understand what products or
services have value to its customers and the metrics used to measure
the delivery of quality health care. In meeting quality standards, Navy
Medicine must take into consideration regulatory compliance
requirements, the working environment, as well as evaluating the
patients' experience.
The many facets of quality control provide us with constant
opportunity to evaluate health care delivery. For example, creating a
fit force translates into improved Medical Readiness for our warriors,
while ensuring a highly trained and ready Medical team to provide
compassionate quality care for the wounded, injured, or sick. In
addition, Navy Medicine has designated a Combat Operational Stress
Consultant to serve as the Navy and Marine Corps subject matter expert
on combat and operational stress. This consultant will allow Navy
Medicine increased oversight and further development of prevention and
mental health care efforts for our military personnel.
We established a family-centered care program to enhance patient
safety, health, cost efficiency and patient and staff satisfaction. We
are currently working with the TRICARE Management Activity and the
other services to ensure that the program is widely available. In
addition, we have coordinated our efforts with other related entities
within Navy Medicine, such as the Perinatal Advisory Board, to optimize
our efforts.
Increased cooperation and collaboration with our federal health
care partners is essential in providing quality care. As an extension
of our ability to care for our patients, Navy Medicine's partnership
with Veterans Affairs medical facilities continues to grow and develop
into a mutually beneficial partnership. Although not directly related
to the Military Health System, it is imperative that Navy Medicine
strengthens its relationship with the Department of Veterans Affairs.
This begins with the seamless transfer of care for injured service
members to the VA and includes sharing resources to optimize our
efforts and avoid duplicating services.
The care for Sailors and Marines who transfer to and receive care
from a VA facility while convalescing is coordinated through the VA
Seamless Transition Coordinator. This full time VA staff member is co-
located at National Naval Medical Center and interacts with OEF/OIF
Points of Contact at each VA Medical Center. The Seamless Transition
Program was created by former Veterans' Affairs Secretary Principi
specifically to address the logistical and administrative barriers for
active duty service members transitioning from military to VA-centered
care.
Although recently-wounded Sailors and Marines differ from the VA's
traditional rehabilitation patient in age and extent or complexity of
injury, Navy Medicine and the VA must adapt to meet their needs. In the
past, patients were admitted to the VA's rehabilitation service with
multiple clinical services addressing individual requirements. To
enhance continuity, clinical outcomes, and improved family support,
National Naval Medical Center physicians now remain as the Case
Managers throughout the transition process. Currently, weekly
teleconferences to review Bethesda transfer patients are conducted with
primary transfer sites, such as the VA Medical Center in Tampa,
Florida. In addition to site visits and teleconferences, Navy Medicine
will continue to coordinate with other facilities, forge relationships,
share best practices, and enhance delivery to all of our patients. This
level of interaction and cooperation will need to continue at every
level to ensure the care of our wounded warriors is never compromised.
With regard to the sharing of resources, the level of sharing
between DOD and VA health care activities has improved. Navy Medicine
supports Commanding Officers who pursue sharing and collaboration with
VA facilities in their communities. In fact, Navy Medicine currently
manages 28 medical agreements and 45 dental agreements through the
Military Medical Support Office (an office that coordinates health care
for active duty members who are stationed in remote areas without local
Military Medical Treatment Facilities).
Some of these agreements represent efforts to consolidate support
functions for the medical facilities. However, other more comprehensive
examples of resource-sharing efforts between the agencies include: the
Navy Blood Program at Naval Hospital Great Lakes which uses the North
Chicago Veterans Affairs Medical Center spaces to manufacture blood
products in exchange for blood products, precluding the need for Navy
to build a new blood center at Naval Hospital Great Lakes; and the DOD/
VA Federal Pharmacy Executive Steering Committee (FPESC) which was
charted to oversee joint agency contracts involving high dollar and
high volume pharmaceuticals designed to increase uniformity and improve
the clinical and economic outcomes of drug therapy in both systems.
Navy Medicine is also partnering or planning to partner with the VA
in five hospital/ambulatory care center construction projects. Naval
Hospital Pensacola is working with the VA on a joint-venture outpatient
medical care facility; Naval Hospital Charleston has a future VA
construction start for a Consolidated Medical Clinic (CMC) aboard Naval
Weapons Station Charleston, SC; Naval Hospital Great Lakes is
considering Joint Ambulatory Care Clinic adjacent to the North Chicago
Veterans Affairs Medical Center's main facility; Naval Hospital Guam is
considering a project where the VA would accept an adjacent site to
construct a small freestanding community-based outpatient clinic from
Navy; and Naval Hospital Beaufort is also considering a future project
with the VA.
Guided by Navy Medicine leadership, last year each MTF developed a
comprehensive business plan focused on meeting operational readiness
requirements while improving population health. These plans emphasize
such areas as improved contingency planning, pharmacy management,
clinical productivity, implementation of evidence-based medicine,
advanced access, and seamless referral management for beneficiaries.
Navy Medicine is currently in the process of creating a system that
will allow MTF commanders to monitor their performance in these areas
so they can better balance measures of operational readiness, customer
satisfaction, internal efficiency and human capital development.
Beginning in the early 1990's, Navy Dentistry began consolidating
its command suites from 34 commands to 15. The cost savings included
the elimination of redundant officer, enlisted and civilian support
personnel formerly involved in the administration of the separate
command infrastructure. In 2004, Navy Dentistry again consolidated 15
commands into three. The primary objective of the most recent dental
consolidation was to integrate Dental Commands with the larger MTF
command suite in the shared geographical area to eliminate more than 90
duplicate administrative functions--all of this was accomplished
without adverse impact on the dental health care delivered and in a
manner that is transparent to the customers. The remaining three
commands are the Dental Battalions supporting the Fleet Marine Force.
As Navy Medicine strives to obtain long-term value through disease
prevention and increased quality of life, each MTF business plan
includes a preventive health initiative with the goal of exceeding
national measures of breast health promotion, long-term asthma
management and control of diabetes. Our leadership developed guidelines
for these Navy-wide efforts and created tools to monitor performance in
these areas. Next year, we plan to expand our efforts to address
obesity, lack of exercise and tobacco use; with the goal of reducing
the risk of long-term disabling illnesses.
Finally, another critical component of providing quality care
requires that Navy Medicine be an active participant in the
implementation of the new TRICARE contracts. Although the TRICARE
benefit structure remains the same, there have been changes in program
administration that are intended to make health care delivery more
customer-focused and support better coordination between MTFs and
civilian provider networks. Organizational changes implemented to
support the new business environment include the disestablishment of
Lead Agents and the establishment of three TRICARE Regional Offices
(TRO) aligned with the regional contracts in the United States--North,
South, West. Each of the Services was responsible for providing a Flag/
General Officer or Senior Executive Service civilian dedicated for a
TRO Director position: Army-North, Air Force-South, Navy-West. The Navy
has named RADM Nancy Lescavage as the second TRO Director. RADM
Lescavage is relieving retiring RADM James Johnson in June 2005.
Shaping Tomorrow's Force
The Navy and Marine Corps are reshaping the fighting force by
defining future requirements, including the medical requirements of the
warfighters. As a result, Navy Medicine's third priority--Shaping
Tomorrow's Force--focuses on recruiting, training, and retaining the
most capable uniformed members to match manpower to force structure to
combat capability. This is an important piece of the Department of the
Navy's more comprehensive Human Capital Strategy.
Navy Medicine is quickly transforming in concert with the Navy and
Marine Corps to provide medical support to the fighting forces as they
adapt to the changing nature of global warfare, including emerging
missions such as: humanitarian operations, regional maritime security,
providing care for detainees, and homeland defense--all of which place
additional requirements on shaping the force of the future. Our
uniformed personnel will participate in increasingly complex joint
environments and move efficiently between forward deployed settings and
fixed facilities ashore. We must be proficient and productive at the
right cost.
A recent example of the Navy Medicine's flexibility in engaging in
a humanitarian mission would be the rapid response to the earthquake
and tsunamis that struck the Indian Ocean. Within days, U.S.S. Abraham
Lincoln and U.S.S. Bonhomme Richard were en route to assist those in
need. U.S. helicopters from Lincoln and from Bonhomme Richard
Expeditionary Strike Group, afloat in the Indian Ocean, proved
invaluable in delivering relief supplies to remote areas. After the
carrier strike group left, one of the Navy's hospital ships, U.S.N.S.
Mercy, took over the mission and deployed with a robust medical
capability and the support services appropriate for disaster relief.
The ship offered shipboard health services and sea-based support to a
variety of military and civilian support agencies, including U.S. non-
government organizations, involved in the relief effort. In addition,
Sailors from the Navy Environmental Preventive Medicine Unit out of
Pearl Harbor worked on improving sanitation and holding down mosquito
populations, while ship's nurses went ashore and conducted classes on
patient care.
Currently, Navy Medicine is deployed afloat and ashore in five
geographic regions, providing preventive medicine, combat medical
support, health maintenance, medical intelligence and operational
planning. This operational tempo, along with the nature of casualties
from Operations Enduring and Iraqi Freedom, has created new demands for
medical personnel in terms of numbers and types of specialties needed.
As a result, Navy Medicine analyzed the uniformed and civilian
communities of medical and dental providers to ensure it is meeting
operational requirements as efficiently as possible.
In order to meet the transformation requirements, the uniformed and
civilian personnel composition of some Navy medical specialties will
change in the near future. For example, over 1,700 non-readiness
related military positions are being converted into civilian positions
in 2005. We want to ensure operational requirements are fulfilled by
uniformed personnel-while identifying those functions that can be
performed by civilian or contractor personnel. Our intent is not to
eliminate positions, but rather to reduce the number of active duty
personnel performing non-readiness functions.
A key component of Shaping Tomorrow's Force is the quality and
innovative delivery of education and training provided to medical
personnel. Streamlining our education and training assets has served us
well as Navy Medicine embraces new technologies and methods of
learning. These new technologies will have a profound impact upon
quality of training and in saving money and time. By maximizing the use
of remote-learning capabilities, Navy Medicine ensures that medical
personnel have access to the right training at the right time. Also, we
continue to study the value of advanced simulation training for our
health care providers. By introducing simulated patients into the
training curriculum, medical personnel are able to practice skills in
an environment that will prepare them for real world situations.
One Navy Medicine: Active and Reserve
Navy Medicine is one team. It is comprised of tremendously capable
individuals--Active Duty, Reserve and Civilian. We must seamlessly
integrate the talents and strengths of our entire workforce to
accomplish our dual mission--Force Health Protection and quality health
care to our beneficiaries.
One of our goals is to better utilize the expertise of our Reserve
force by increasing integration with the active duty component. We no
longer have separate Active and Reserve fleet hospitals, but one fleet
hospital system where Reservists work side-by-side with active duty
personnel. The establishment of these Operational Health Support Units
(OHSU) has created increased cooperation and collaboration between both
components. In addition, consolidation of dental units into the OHSUs
has been done to mirror changes implemented by Navy Medicine's active
component.
Reservists comprise 20 percent of Navy Medicine's manpower
resources and their seamless integration with our active duty force is
a major priority in achieving our ``One Navy Medicine'' concept. Since
the beginning of Operation Iraqi Freedom, more than 3,700 Reservists
have been activated to be forward deployed or to meet the needs of MTFs
whose active duty personnel were deployed. In addition, the Navy's
Expeditionary Medical Facility Dallas deployed earlier this year to
Kuwait with 382 people, 366 of which were Reservists.
Through an innovative Medical Reserve Utilization Program (MEDRUP),
Navy Medicine's headquarters assumes operational control of medical
Reservists called to active duty. They are selected using an
information system that manages more than 6,000 Navy medical Reservists
and matches personnel to requirements based on qualifications,
availability and criteria. This system has proven indispensable in
employing Reservists in support of the Global War on Terror.
Finally, with regard to the Reserve Component, Navy Medicine
provides physical and dental services to the Navy's Reserve Force
(71,500) and Marine Corps Reserve (37,734) personnel in support of
individual medical readiness--a critical component prior to
mobilization.
Delivery of Joint Defense Health Services
Navy Medicine's final priority addresses how we jointly operate
with the Army and Air Force. Ideally, all U.S. medical personnel on the
battlefield--regardless of service affiliation--should have the same
training, use the same communications system and operate the same
equipment because we are all there for the same reason--to protect our
fighting forces. It should not matter whether the casualty is a
Soldier, a Sailor, an Airman or a Marine. The individual should receive
the same care, and service medical personnel should be similarly
trained to provide this same level of care. Along with the Army and the
Air Force, Navy Medicine is actively pursuing the concept of
standardized operating procedures to ensure consistency of health care
and interoperability of our medical forces through a Unified Medical
Command. As a Unified Medical Command, the mission of our separate
medical departments could implement reductions to the internal costs of
executing our missions while providing a framework of interoperability
among the services.
Mr. Chairman, Navy Medicine has risen to the challenge of providing
a comprehensive range of services to manage the physical and mental
health challenges of our brave Sailors and Marines, and their families,
who have given so much in the service of our nation. We have
opportunities for continued excellence and improvement, both in the
business of preserving health and in the mission of supporting our
deployed forces, while at the same time protecting our citizens
throughout the United States.
I thank you for your tremendous support to Navy Medicine and look
forward to our continued shared mission of providing the finest health
services in the world to America's heroes and their families--those who
currently serve, those who have served, and the family members who
support them.
Senator Stevens. General Taylor.
STATEMENT OF LIEUTENANT GENERAL GEORGE PEACH TAYLOR,
JR., M.D., AIR FORCE SURGEON GENERAL,
DEPARTMENT OF THE AIR FORCE
General Taylor. Mr. Chairman, Senator Inouye, Senator
Mikulski, and other members of the subcommittee, it is a
privilege and pleasure to be here today. I look forward to
working with you on our common goals to ensure a sustained high
quality of life for our military members and their families. We
appreciate your interest and support in providing for America's
heroes.
I am proud to say that the men and women of the Air Force
Medical Service have done an exceptional job throughout
Operations Nobel Eagle, Enduring Freedom, and Iraqi Freedom in
providing the expeditious, state-of-the-art health care for
Active duty and Reserve component personnel of all the
services. We attribute our success to our continued focus on
four health effects: providing care to casualties, ensuring a
fit and healthy force, preventing disease and injury, and
enhancing human performance.
EXPEDITIONARY MEDICAL SUPPORT
Our light, lean, and mobile expeditionary medical support
(EMEDS), is the linchpin of our ground mission. Our EMEDS
modularity has supported our field commanders by ensuring the
right level of medical care is provided to our warriors
wherever they are. As important, the speed with which we can
deploy EMEDS is unprecedented, making EMEDS the choice for
special forces and quick reaction forces in the United States,
as well as abroad.
As part of a joint team, we now have more than 600 medics
in 10 deployed locations, including running the large theater
hospital in Balad, Iraq, and two smaller hospitals in Kirkuk
and at the Baghdad International Airport. Just as in the
States, these serve as regional medical facilities for all the
services.
Our approximately 400 aeromedical evacuation personnel, the
majority of them Guard and Reserve, are doing incredible work,
accomplishing more than 55,000 patient movements since the
beginning of Operation Iraqi Freedom.
In addition, partnering with our critical care air
transport teams, our aeromedical evacuation system has made it
possible to move seriously injured patients with astonishing
speed, as short as 36 hours from the battleground to stateside
medical care, unheard of even a decade ago.
DEPLOYMENT HEALTH SURVEILLANCE PROGRAM
Caring for our troops also means ensuring that they are
healthy and fit before they deploy, while they are deployed,
and when they return home. We work very, very hard on our
deployment health surveillance program. The payoff has been
that we had the lowest disease non-battle injury rates of all
time. That care extends beyond the area of operations. Since
the first of January 2003, we have accomplished 100,000 post-
deployment assessments for Air Force Active duty and Reserve
component personnel with 9.5 percent requiring follow-up for
deployment related medical or dental health concerns. We are
meticulously tracking every airman to ensure that he or she
receives all the health care needed, including mental health
help, which I would like to describe in some detail.
We deploy two types of mental health teams to support our
deployed airmen, a rapid response team and an augmentation
team. We currently have 49 mental health personnel deployed for
current operations, 31 of whom are supporting Army or joint
service requirements. Behavioral indicators during OEF and OIF
are encouraging. In our review of data from fiscal years 2000
and 2004, child abuse rates remained virtually unchanged, and
spouse abuse rates and alcohol-related incident rates actually
declined over the past 5 years. To date, there have been no Air
Force suicides in Iraq or Afghanistan during OEF or OIF.
However, we are increasingly supporting Army and Marine
operations. We need to be prepared for our Air Force troops to
have greater exposure to traumatic stress. Initiatives to
reassess the mental health status of our personnel, 90 to 180
days post-deployment, will allow us to better monitor and
address mental health needs as they emerge.
FIT TO FIGHT PROGRAM
Another critical way we are protecting the health of Air
Force members is with a revitalized physical fitness program
that will improve their safety and performance in the
expeditionary environment and help them survive significant
injury and illness. Our fitness centers have seen an
approximate 30 percent jump in use. I am proud to be part of
General Jumper's strong push, fit to fight, an initiative that
has focused on both the individual and commander
responsibilities for health and well-being.
EPIDEMIC OUTBREAK SURVEILLANCE PROJECT
Our prevention efforts also include cutting edge research
and development, such as the epidemic outbreak surveillance
project (EOS), an Air Force initiative that combines existing
and emerging biodefense technologies that will eventually be
deployed worldwide for near real-time total visibility of
biological threats to our troops. Through gene shift
technology, EOS will offer us the power of knowing when and who
a disease is stalking. This is the incredible medicine of the
future that will change how we do business forever, and we are
doing it now in the Air Force.
COMPOSITE OCCUPATIONAL HEALTH AND OPERATIONAL RISK TRACKING SYSTEM
Another of our exciting initiatives, created with your
help, is the composite occupational health and operational risk
tracking system known as COHORT, a program that links Air Force
information systems such as personnel and operational medical
systems to surveillance activities, allowing us to track the
occupational health of our personnel throughout their careers
and beyond.
We are also particularly grateful to this subcommittee for
support of our crucial laser eye protectant initiative which
will help us study, prevent, detect, and treat laser eye
damage.
We continue to partner with civilian institutions for
training in critical care, such as our Center for Sustainment
of Trauma and Readiness Skills (C-STARS) platform at Baltimore
Shock Trauma, as well as groundbreaking research in
telemedicine and other areas.
TRICARE
Perhaps not as high-tech, but certainly one of the greatest
tools we have to ensure the health of our troops is TRICARE.
The TRICARE strategy is vitally important to us, even more so
in wartime. It supplants direct care for the Active duty
member, provides peace of mind that family members are taken
care of, and ensures health care access for our Guard and
Reserve members in all our communities. Peacetime health care
through TRICARE cannot be separated from our primary wartime
mission. We have one mission: to care for our troops and their
families.
PREPARED STATEMENT
There remain great challenges in our military health care
system. These include sustaining a world-class environment of
practice for our men and women practicing medicine and
dentistry in military facilities around the globe. I am eager
to work with the Congress as we mold and improve your military
health care system, a system that has no peer, no rival, one
that is true to those who work in it every day and one that is
deserving of the sacrifice and dedication of men and women in
uniform.
Thank you, Mr. Chairman and members of the subcommittee.
[The statement follows:]
Prepared Statement of Lieutenant General George Peach Taylor, Jr.
Mr. Chairman, Senator Inouye, and members of the committee; it is a
pleasure to be here today to share with you stories of the Air Force
Medical Service's success both on the battle front and the home front.
Air Force medics continue to prove their mettle, providing first
class healthcare to more than 1.2 million patients. Additionally, we
continue to have medics far from home, supporting air and land
operations from the Philippines to Kyrgyzstan to Iraq.
The Air Force Medical Service, or AFMS, and medics from our sister
services have undertaken the most significant changes in military
medicine since the beginning of TRICARE. In the last few years, we have
fielded the largest increase in benefits since the creation of Medicare
and CHAMPUS in the mid-1960s.
At the same time, we are medics at war. We have been engaged in
battle for nearly 4 years. Not since Vietnam has our operations tempo
been as elevated. Not since then has combat been as continuous. The
Global War on Terror is the most significant engagement of this
generation . . . and I am immensely proud of the medical and dental
care we provide anywhere, anytime.
Some have the opinion that wartime and peacetime care are two
separate and distinct missions. I disagree strongly. We have one
mission: to care for our troops, which includes their families. The
home-station and deployment sides of that mission are inextricably
linked. We are able to achieve the necessary balance because of our
ability to focus on what we call our four health effects, the four most
important services medics contribute to the fight. The four health
effects are:
(1) Ensuring a fit and healthy force
(2) Preventing illness and injury
(3) Providing care to casualties, and
(4) Enhancing human performance
These four effects are what medics must bring to the fight,
everyday, from Whiteman Air Force Base in Missouri, to Balad Air Base
in Iraq.
ENSURING A FIT AND HEALTHY FORCE
Air Force Fitness Program
The Air Force's most important weapon system is the Airman. We
invest heavily in our people to ensure they are mentally and physically
capable of doing their job. They need to be; we ask them to launch
satellites, fix aircraft, perform surgery, pilot multi-million dollar
aircraft, and thousands of other tasks used to support and execute
battle. Commanders need their Airmen to perform these tasks in harsh
environments, under extreme stress, often under fire. If any of them is
unfit or too ill to accomplish their roles, the mission suffers.
The Roman General Renatus wrote that ``little can be expected from
men who must struggle with both the enemy and disease.''
In other words, if we aren't fit, we can't fight.
Two years ago, General Jumper, our Chief of Staff, unveiled the Air
Force's new program to improve fitness. The Fit to Fight initiative
puts greater emphasis on physical fitness training to enhance not only
the ability of Airmen to work in the challenging expeditionary
environment, but also the ability to sustain significant injury and
illness far from home and be able to survive field care and long-
distance aeromedical evacuation. Fit to Fight is working. Across the
Air Force, fitness center managers report that usage of their
facilities is up 30 percent. The results: before the program started
only 69 percent of Airmen passed their fitness test. Now, even with
more stringent requirements, we have an 80 percent pass rate.
Additionally, a secure web site gives commanders up-to-the-minute
reports on the status of their active duty, Guard, and Reserve troops'
fitness levels. Now leaders know instantly what percentage of their
troops are fit to fight.
True fitness is measured by more than strength and stamina--it
involves a whole person concept that includes physical, dental, and
mental health. Our Deployment Health Surveillance program gives us
visibility over each of these important health factors.
We can never forget that we ask our fighting men and women to do so
in harsh environments, far from home, far from sophisticated health
care facilities. A healthy, fit warrior is much better able than a
less-fit person to sustain a significant illness or injury and be
stabilized for long distance travel.
Deployment Health Surveillance program
Our fitness and Deployment Health Surveillance programs complement
each other. The first provides healthy troops to the fight, the second
maintains and monitors their health. We are very proud of our
Deployment Health Surveillance program that has resulted in our lowest
Disease Non-Battle Injury Rates (DNBI) of all time, about 4 percent
across the Department of Defense. The Air Force Medical Service
conducts a variety of activities that ensure comprehensive health
surveillance for our Total Force Airmen pre-, during, and post-
deployment, and indeed, throughout their entire careers.
Annual Preventive Health Assessments ensure each Airman receives
required clinical preventive services and meets individual medical
readiness requirements. This data is conducted globally and recorded in
an AFMS-wide database--therefore, the health of each Airman, whether
active duty, Guard or Reserve, can be tracked throughout his or her
service and in any location. This is an invaluable medical readiness
tool for commanders.
Pre-deployment medical assessments are performed on every Airman
who deploys for 30 or more days to overseas locations without a fixed
medical facility. While deployed, the member is protected by preventive
medicine teams who identify, assess, control and counter the full
spectrum of existing health threats and hazards, greatly enhancing our
ability to prevent illness and injury.
These Preventive Aerospace Medicine teams, or PAM teams, are our
unsung heroes. They are small units--usually only three or four
people--including an aerospace medicine physician, bioenvironmental
engineer, public health officer and an independent duty medical
technician. Theirs are among the very first boots on the ground
whenever we build a base in theater. Before the fence is raised and the
perimeter secured, these medics are securing the area against
biological and chemical threats. PAM teams sample and ensure the safety
of water, food, and housing. They eliminate dangers from disease-
carrying ticks, fleas, and rodents. Ultimately, they can claim much of
the credit for the extremely low Disease Non-Battle Injury Rate.
As our troops redeploy, post-deployment assessments are conducted
for the majority of Airmen in-theater, just before they return home.
Commanders ensure that all redeploying Airmen complete post-deployment
medical processing immediately upon return from deployment, prior to
release for downtime, leave, or demobilization.
During this process, each returning individual has a face-to-face
health assessment with a health care provider. The assessment includes
discussion of any health concerns raised in the post-deployment
questionnaire, mental health or psychosocial issues, special
medications taken during the deployment, and concerns about possible
environmental or occupational exposures. The health concerns are
addressed using the appropriate DOD/VA assessment tool such as the
Post-Deployment Health Clinical Practice Guideline.
Since the first of January 2003, we have accomplished 100,000 post-
deployment assessments for Air Force members, including almost 27,000
from our Air Reserve Component, or ARC, personnel. Of these
assessments, we identified approximately 6,500--or 9 percent--active
duty and about 3,000--or 11 percent--ARC personnel that required a
follow-up referral. This equates to only 9.5 percent of our returning
personnel that require follow-up due to deployment-related medical or
dental health concerns.
To better ensure early identification and treatment of emerging
deployment-related health concerns, we are currently working on an
extension of our post-deployment health assessment program to include a
re-assessment of general health with a specific emphasis on mental
health. It will be administered within six months of post-deployment
using a standard re-assessment process. The re-assessment will be
completed before the end of 180 days to afford Air Reserve Component
members the option of treatment using their TRICARE health benefit.
I am pleased to report that a recent Government Accountability
Office audit on Deployment Health Surveillance concluded that our
program had made important improvements and that from 94 percent and 99
percent of our Airmen were receiving their pre- and post-deployment
assessments.
To address the mental health needs of deployed Airmen, the Air
Force deploys two types of mental health teams: a rapid response team
and an augmentation team. Mental health rapid response teams consist of
one psychologist, one social worker and one mental health technician.
Our mental health augmentation teams are staffed with one psychiatrist,
three psychiatric nurses and two mental health technicians. Deployed
mental health teams use combat stress control principles to provide
consultation to leaders and prevention and intervention to deployed
Airmen. The Air Force currently has 49 mental health personnel deployed
for current operations, 31 of whom are supporting Army or joint service
requirements. We currently use psychiatric nurses at our aero-medical
staging facilities to better address emerging psychological issues for
Airmen being medically evacuated out of the combat theater.
The Air Force is also in the process of standardizing existing
redeployment and reintegration programs, which help Airmen and family
members readjust following deployments. These programs involve
collaborative arrangements among the medical, chaplain and family
support communities. Airmen and their families can also take advantage
of The Air Force Readiness Edge, a comprehensive guide to deployment-
related programs and services, as well as Air Force OneSource, a
contractor-run program that provides personal consultation via the web,
telephone or in-person contacts. AF OneSource is available 24 hours a
day, and can be accessed from any location.
After deployments, psychological care is primarily delivered
through our Life Skills Support Centers, which deliver care for alcohol
issues, family violence issues and general mental health concerns.
Staffing of more than 1,200 professionals includes a mix of active
duty, civilian and contract personnel who serve as psychiatrists,
psychologists, social workers, psychiatric nurses and mental health
technicians. We currently offer ready access to mental health care in
both deployed and home-station locations.
The Air Force also looked at several behavioral indicators from
fiscal year 2000 to fiscal year 2004 to examine trends before and after
initiation of OEF and OIF. Child abuse rates were virtually unchanged
throughout the Air Force over the 5-year span, and spouse-abuse rates
and alcohol-related incident rates actually declined somewhat over the
past 5 years. To date, there have been no Air Force suicides in Iraq or
Afghanistan during OEF and OIF. Since the onset of OEF (Oct. 7, 2001),
there have been 125 suicides in the Air Force. Only four suicides
involved personnel who had been previously deployed to Iraq or
Afghanistan, representing a rate (4.2 per 100,000) much lower than the
Air Force historical average over the last 8 years (9.7 per 100,000).
The Air Force Chief of Staff has placed increased emphasis on adherence
to existing Air Force suicide prevention policies in recent months, and
the current very low rates so far for this fiscal year (7.1 per 100,000
as of March 2, 2005) are encouraging.
Our reviews indicate that deployed Airmen have faced less exposure
to traumatic stress than their Army and Marine counterparts, and
therefore have experienced less psychological impact during current
operations. We must be prepared, however, for this to change. More
recently, Air Force personnel have been called upon to support convoy
operations. Additionally, future operations may place additional
demands upon our Airmen, and we must be ready to respond. Initiatives
to re-assess the mental health status of our personnel 90-180 days
post-deployment will allow us to better monitor and address mental
health needs as they emerge.
PREVENTING CASUALTIES
Today's Global War on Terrorism will be with us for years to come.
Terrorism confronts us with the prospect of chemical, biological, and
radiological attacks. Of those, the most disconcerting to me are the
biological weapons. Nightmare scenarios involving biologicals include
rapidly spreading illnesses, ones so vicious that if we cannot detect
and treat the afflicted quickly, there would be an exponential
onslaught of casualties.
Just as General Jumper talks about the need for our combatants to
find, fix, track, target, engage and assess anything on the planet that
poses a threat to our people--and to do so in near real time--so must
medics have the capability to find biological threats, and to track,
target, engage and defeat such dangers; whether they are naturally
occurring--like Severe Acute Respiratory Syndrome, or ARS--or manmade,
like weaponized smallpox.
The rapidly advancing fields of biogenetics may provide the
technology that allows us to identify and defeat these threats. Many
consider the coupling of gene chip technology with advanced informatics
and alerting systems as the most critical new health surveillance
technology to explore--and we are doing it now in the Air Force.
Silent Guardian
This evolving technology was tested recently in a Deployment Health
Surveillance exercise in Washington, DC. The test started shortly
before the inauguration and ended with the close of the State of the
Union Address. The exercise, codenamed Silent Guardian, involved the
military medical facilities that ring the National Capital Region. We
placed teams in each of these facilities to collect samples from
patients who had fever and flu-like illnesses. The samples were then
transported to a central lab equipped with small, advanced biological
identification unit--the ``gene chip'' I mentioned--capable of testing
for, and recognizing, scores of common or dangerous bacteria and
viruses. And when I say small, I mean that the gene-reading chip at the
center of this system is smaller than a fingernail.
To run this many tests using the technology we normally use today
would require a large laboratory, two to five weeks, numerous staff,
and thousands of swabs and cultures dishes. But this new analyzer is
closer in technology to the hand-held medical tricorder used by Dr.
McCoy in Star Trek than it is to the swab-culture-wait-grow method
currently used.
We knew the test results within 24 hours, not the days or weeks
required in the past. All results were entered into a web-based program
that tracks outbreak patterns on a map. Additionally, we had mechanisms
in place to automatically alert medics and officials of potential
epidemics or biological attacks.
Epidemic Outbreak Surveillance
The systems used in Silent Guardian are a small part of the
Epidemic Outbreak Surveillance project, or EOS, an Air Force initiative
that combines existing and emerging biodefense technologies by using a
``system of systems'' approach in a rigorous real-world testbed. This
project is currently in the Advanced Concept Technology Demonstration
phase, but we hope to eventually deploy this technology to military
bases worldwide for near real-time, total visibility of biological
threats to our troops. These threats are not just those of biological
warfare, but I want this team to focus on threats to our troops from
naturally occurring disease outbreaks, from adenovirus to influenza.
Imagine the power of knowing when and who a disease was stalking!
When fielded, EOS will integrate advanced diagnostic platforms,
bio-informatic analysis tools, information technology, advanced
epidemiology methods, and environmental monitoring. Alone, none of
these provide a defense against a biological attack, either natural or
manmade. Woven together, they create a biodefense system that permits
medics to rapidly identify threats, focus treatment, contain outbreaks,
and greatly decrease casualties.
Another exciting advancement we expect to start transitioning this
year is our technical ability to create an unlimited number of COHORTs
of each Airman, which will provide occupational and medical
surveillance from the time he or she joins the Air Force until
retirement or separation, regardless of where the Airman serves or what
job he or she performs. We will finally be able to tie together medical
conditions, exposure data, duty locations, control groups, and
demographic databases to globally provide individual and force
protection and intervention, reducing disease and disability. These
tools will be working in near real time, and eventually will be
automated to work continuously in the background to always be searching
for key sentinel events.
Diabetes is another enemy that takes lives, and it too can be
defeated. We have been collaborating with the University of
Pennsylvania Medical Center to create Centers of Excellence for
diabetes care. Diabetes can affect anyone--in or out of uniform--so
this effort promises to improve the lives of all beneficiaries.
Together, we are seeking ways to prevent and detect the onset of
diabetes while providing proven, focused prevention and treatment
programs to rural communities, minority populations, the elderly and
other populations prone to this disease.
RESTORE HEALTH
High Survivability Rate
We have enjoyed significant success in the third health effect we
bring to the fight--that of restoring the health of our sick or injured
warriors. Innovations in both technology and doctrine are dramatically
improving survival rates of our troops on the battlefield.
During the American Revolution, a soldier had only a 50/50 chance
of living if injured on the battlefield. From the Civil War through
World War II, about 70 percent of the injured survived their injuries.
Aeromedical evacuation in Vietnam is partly responsible for increasing
the survival rate to nearly 75 percent. During Operation IRAQI FREEDOM
(OIF), 90 percent of those injured in combat survived their wounds. We
attribute this success to the combination of our rapidly deployable
modular Expeditionary Medical units, excellent joint operations, and
our transformed aeromedical operations.
EMEDS
The Expeditionary Medical Support concept, or EMEDS, has proven
itself invaluable in OIF. EMEDS is a collection of small, modular
medical units that have predominantly replaced our large, lumbering
theater hospitals. Big things come in small packages, and there are at
least three big benefits to these small EMEDS:
First, by breaking up our large deployable medical facilities, we
can spread our resources geographically to locations around the globe
where they are needed the most; an efficient use of our assets.
Secondly, EMEDS units are easier to insert far forward and
integrate with other services, so our medics are closer to the action
and closer to the wounded who need our lifesaving skills. For example,
our Aeromedical Evacuation Liaison Teams and aeromedical staging
facilities were loaded into humvees and provided direct combat service
support to the Army V Corp and 1st Marine Expeditionary Forces convoys
as they fought their way along the Tigris and Euphrates from northern
Kuwait to Baghdad in 2003.
Finally, these units are small, light, and lean. How small? The
people and equipment comprising the entire Air Force medical support in
OIF have taken up less than one percent of the cargo space of all
assets headed to the war. EMEDS' small footprint allows us to pick them
up and put them down anywhere quickly. We get to the fight faster. For
example, in OIF, we opened 24 bases in 12 countries in a matter of
months, each with a substantial EMEDS presence. That formidable
presence served not only Air Force troops, but also ground forces
throughout the region. To further ensure quality care, we deployed
over-pressurized tents that are capable of keeping biological and
chemical weapons from seeping into our medical facilities.
EMEDS' modularity allows its components to be mixed and matched
effortlessly with other EMEDS units or even another Service's assets to
create the package of medical care required. Whether it's a small
clinic or a large 250-bed hospital that does everything short of organ
transplants, the right level of medical care is prescribed and provided
to our warriors.
The speed with which these EMEDS deploy is phenomenal. One of our
first EMEDS units in theater was a 25-bed hospital based at the Air
Force Academy in Colorado. The time elapsed from the moment EMEDS
members got their telephone call notifying them of deployment, gathered
and transported all 100 medics and their equipment, pitched their tents
in Oman, and saw their first patient, was just 72 hours. Because of
this capability, we are the medics of choice for Special Forces and for
quick-reaction forces in the United States and abroad.
Less than one month after the September 11th, 2001, attacks, a
medical team supporting Special Operations saved the life of the first
soldier severely injured while supporting Operation ENDURING FREEDOM.
Exactly 3 years later, on September 11th, 2004, Air Force medics
accomplished the miraculous save of a horribly wounded Airman in
Baghdad. I will share this story later in my statement. But in between
and since these two remarkable medical events, there have been volumes
of compelling stories reflecting the awesome capabilities of the Air
Force Medical Service and our joint Air Force-Army-Navy medical team as
we care for our troops.
Caring for Iraqis
Not all of our patients are American military members. Throughout
this conflict, we have treated Iraqi civilians, our Iraqi allies, and
even the enemy. After Saddam was toppled, we moved hospitals into
places like Tallil, Baghdad International Airport, and Kirkuk, where we
continue to treat all those caught in harm's way, whether friend or
foe.
To emphasize that point, I have two very compelling stories
concerning the care we provide Iraqi nationals. The first involves a
horribly wounded detainee believed to have received his wounds while
engaged in combat against our troops. He was going to be transferred to
an Iraqi hospital, but begged to remain with American doctors until his
wounds were resolved. His words to our Air Force surgeon were, ``If I
go, I will surely die. I trust only you.''
This trust and faith in Americans plays a role in my next story,
too. Air National Guard medics from the EMEDS at Kirkuk treated a group
of badly injured Iraqis brought into camp by American soldiers. While
the camp was under mortar fire, our medics worked to save the men. By
morning, all were stabilized. They were transported to another medical
facility the following day. Captain Julie Carpenter, a nurse, rode with
one of the men, and because he was still in pain, she tried to provide
some comfort. She would look in his eyes or hold his hand because, as
she said, ``I wanted him to feel he wasn't alone; I imagine it was
scary for him.''
She thought little of the incident until days later she learned
that the thankful families of these injured Iraqis approached American
troops and provided information that led our troops to the location and
the capture of Saddam Hussein.
Expeditionary health care is a military tool that not only saves
lives; it can turn confrontation into cooperation, revealing compassion
to be the long arm of diplomacy.
Expeditionary Health Technology
Restoring health in the expeditionary environment requires that our
dedicated medical professionals are equipped with cutting-edge
technology. For example, we are seeking techniques to convert common
tap or surface water into safe intravenous (IV) solutions in the field.
We are also developing the ability to generate medical oxygen in the
field rather than shipping oxygen in its heavy containers into the
field.
Telehealth is another fascinating technology that enhances the
capabilities of our medics. It allows a provider in Iraq to send
diagnostic images such as X-rays through the Internet back to
specialists located anywhere in the world, Wilford Hall Medical Center,
for instance, for a near real-time consult. This insures that each
Soldier, Sailor, Airman or Marine in the field has access to one of our
outstanding specialists almost anytime and anywhere.
Aeromedical Evacuation
Restoring health also means bringing casualties back from the front
as quickly as possible to sophisticated medical care. The Air Force
Medical Service makes its unique contribution to the Total Force and
joint environment through our aeromedical mission and the professionals
who perform it. The job of Aeromedical Evacuation crewmembers is not
easy. They must perform the same life-saving activities their peers
accomplish in hospitals, but in the belly of an aircraft at over 20,000
feet. The conditions are sometimes challenging as crew members work
under the noise of the engines or when flying through turbulence--but
there is no place else they would rather be. TSgt Pamela A. Evanosky of
the 315th Aeromedical Evacuation Squadron out of Charleston AFB said,
``AE is exhausting duty. But I love it. I know everyday that I make a
difference. This is the most honorable and rewarding work I could
possibly ever do.''
It truly is rewarding, and I am very proud to report, that Sergeant
Evanosky and her fellow AE crewmembers have accomplished over 55,000
patient movements since the beginning of OIF, and they have never lost
a patient.
Critical Care Air Transport Teams
Occasionally, our AE crews transport a patient who is so ill or
injured that they require constant and intensive care. When that
happens, our AE medical capability is supplemented by Critical Care Air
Transport Teams, or CCATTs. These are like medical SWAT teams that fly
anywhere on a moment's notice to retrieve the most seriously injured
troops. Team members carry special gear that can turn almost any
airframe into a flying intensive care unit (or ICU) within minutes. An
in-theater EMEDS commander told me that CCATTs are a good news/bad news
entity. He said, ``The bad news is, if you see the CCATT team jumping
on a plane, you know someone out there is hurt bad. The good news is,
if you see CCATT jumping on a plane, you know that someone will soon be
in the miraculous hands of some of the best trained medics in
existence.''
No discussion of aeromedical evacuation is complete without
recognizing the critical contribution of the Reserve Component. About
88 percent of AF Aeromedical Evacuation capability is with the Guard
and Reserve. I am deeply proud of and awed by their dedication and
self-sacrifice in delivering sick and often critically injured troops
from the battlefront into the care of their families and our medics at
the home front.
The Miracle of Modern Expeditionary Medicine
The seamless health care we provide with our Sister Services from
battlefield to home station can be illustrated by the miraculous, life-
saving story of Senior Airman Brian Kolfage.
Airman Kolfage suffered horrendous wounds when an enemy mortar
landed near him. These mortars have a kill radius of 150 feet. Kolfage
was about 10 feet away. The blast threw him half the length of a
football field. It shredded both legs and his right arm. Normally, no
one could survive such an injury, but an Air Force medic who was close
by when the blast occurred was able to respond immediately.
The field surgeons had Airman Kolfage on the operating table in
five minutes and were able to stabilize him. Aeromedical Evacuation
crews and CCATT teams transported him halfway around the world to
Walter Reed Army Medical Center.
Senior Airman Kolfage was airlifted from the site of injury over
6,000 miles away to a hospital just 6 miles from where we now sit. And
this all happened in a time span of just 36 hours. That is something
that could not have happened in previous conflicts.
Airman Kolfage lost both legs and his right hand. But he has
definitely not lost his spirit. He arrived at Walter Reed flat on his
back, but vows to walk out of there. I believe him. He takes vows
seriously. As a matter of fact, he just exchanged them with his
girlfriend--now wife--whom he recently married at Walter Reed.
This is a miracle of modern technology, seamless joint medical
operations, and the resiliency of youth. In any other war, this young
man would have lost his life; now he has it all before him.
Every day the Air Force Medical Service sees thousands of patients.
We try to make a difference with each individual; in Airman Kolfage's
case, we know for sure we made the ultimate difference.
ENHANCE HUMAN PERFORMANCE
The fourth health effect we contribute to warfighting is the
enhancement of human performance. Helping Airmen perform to the best of
their abilities means we must have people who are highly trained,
competent, and equipped with advanced technology that can both help
them do their jobs and protect them while doing so. We are seeking to
enhance human performance for our troops through cutting-edge research
and development that will improve the safety and performance of our
troops in the expeditionary Air Force.
For example, we continue to pursue methods of enhancing our
member's eyesight. Obviously, good vision has always been important to
our troops, particularly pilots whose eyes may be their navigators. But
detecting and protecting our troops' eyesight is especially critical
now that Directed Energy Weapons, or Lasers, are widely available and
capable of inflicting great injury to the eye.
A laser pointed into an eye can temporarily or even permanently
damage an Airman's vision, so we seek special lenses for eyewear and
helmet shields that can block harmful laser rays. Detecting laser eye
injuries can be difficult; treating such injuries is currently next to
impossible. Consequently, we are fielding retinal surveillance units in
high-threat areas to accomplish eye exams, always looking for evidence
of laser damage. We are searching for valid therapies to treat these
types of newly recognized injury patterns. No such therapy currently
exists.
Finally, we'll push the envelope on ocular technologies by trying
to create vision devices that will allow our Airmen to see to the
theoretical limit of the human eye, which some say is 20-over-8. If
successful, this will provide our pilots and warriors the ability to
see twice as far as an adversary.
The Changing AFMS Construct
The AFMS faces the challenge of delivering these four health
effects in times of significant change in the two constructs in which
we operate; that of medicine and of military operations planning--how
we fight wars.
Changes in Health Care
Health care has changed radically in the past 15 years. In my
tenure as a physician, advances in pharmaceuticals, diagnostics--like
the CAT scan and MRI-fiber optic techniques such as laparoscopy,
arthroscopy, and the use of stints for blocked arteries, and anesthesia
breakthroughs have radically altered our military treatment facilities.
In the private sector, small, full-service hospitals have gone the way
of the eight-track tape, replaced by more efficient medical complexes
that focus on outpatient care and ambulatory surgery.
The same pressures that prompted civilian health care facilities to
move to outpatient surgery have influenced transitions in the Air Force
delivery of health care as well. Historically, we structured ourselves
to have hospitals at most bases. We now have substantially transitioned
our facilities to the point where fewer than 30 percent of our bases
have hospitals. In fact, if you look today, we have fewer hospital beds
in the entire Air Force, 740, than existed at the Air Force's Wilford
Hall Medical Center in 1990, which had 855.
Another important way the military has adapted to the changing
health care construct is to operate much more closely with sister
service and civilian hospitals to provide comprehensive patient care.
For instance, the Landstuhl Army Medical Center in Germany--the first
stop for many of our wounded returning from Afghanistan and Iraq--has a
contingency of almost 300 permanent-party Airmen working side-by-side
with their nearly 900 Army counterparts.
We enjoy a similar sharing opportunity with the University of
Colorado at Denver. Most of nearby Buckley Air Force Base's patient
care assets are now located at the University's Fitzsimmons medical
campus. Our close working relationship with the university hospital and
its president, Dennis Brimhall, are responsible for the efficient and
innovative use of medical resources and quality care for our
beneficiaries.
Strong relationships with civilian agencies--like that of our
Center for Sustainment of Trauma And Readiness Skills, or C-STARS
program--have benefited both our peacetime TRICARE and wartime AEF
missions. The Air Force has three of these centers, one each in the
Cincinnati University Hospital Trauma Center in Ohio, Saint Louis
University Hospital in Missouri, and the R. Adams Cowley Shock Trauma
Center in Baltimore. Military medics work in tandem with their civilian
counterparts there to care for seriously ill or traumatically injured
patients, patients seldom seen in military MTFs. These programs prepare
our providers for deployment by exposing them to the wounds they will
treat in combat. In the future, we will be looking for new ways to
partner with these civilian institutions, such as in education and
research and development.
Changes in War-Fighting
The second construct change is that of the Air Force mission
itself. When I entered the Air Force in the late 1970s, we planned,
trained, and equipped our medics on the basis of the threats faced in
two major operational plans of short duration. That construct is no
longer valid, as can clearly be seen with the Global War on Terrorism.
The Air Force created its Air Expeditionary Force structure, in
part, in response to this new construct. The AFMS needed to restructure
itself, too, so that it could face multiple commitments overseas of
both short and long duration. Our nation requires that medics field
combat support capabilities that are very capable, rapidly deployable,
and sustainable over long periods. This has driven three additional
changes to our medical system. Our people must be trained, current, and
extractable to support the warfighter. Medics must be placed at
locations where they can maintain the skills they need for their combat
medicine mission. It is also vital that these locations must allow the
medics to deploy easily without significantly interrupting the care
they provide the base or TRICARE beneficiaries, especially at those
locations with sustained medical education training programs.
This is exactly the challenge that the Air Force Chief of Staff
Gen. John P. Jumper issued to me in creating expeditionary medics:
medics who are focused on developing the skills for the field and eager
to deploy for four of every 20 months.
We are assigning medics at large facilities into groups of five so
that one team can be deployed at any one time while the other four
remain to work and train at home stations. We are also reviewing the
ratio of active-to-reserve medics and asking ourselves important
questions: What mix of the active duty to reserve component will ensure
the best balance between the ability to deploy quickly and the
capability to surge forces when necessary?
Finally, we are actively reviewing the total size of the AFMS to
make sure that over the next few decades we can successfully fulfill
our wartime mission while still providing the peacetime benefit to our
members, retirees, and their families.
TRICARE
The next generation of TRICARE contracts is now completely
deployed. The transition was smoother than that experienced in the last
contract transition in the 1990s. Service contracts are now in place to
fully support the benefit enhancements to our active and reserve forces
that were temporary in 2004, but made permanent by the fiscal year 2005
National Defense Authorization Act. Although we experienced some
challenges with referral management, both the government and our
contractors are working to find solutions and we have seen improvement
over the past several months. We will continue to work this issue
aggressively as access both in the direct care system as well as the
network continues to be closely monitored.
The TRICARE benefit is generous, and many retirees who have the
choice between our care and that offered by their civilian insurers are
opting for the military's medical system. In spite of the increase in
benefits and the ever-growing population to whom it is delivered, the
TRICARE system continues to receive satisfaction ratings superior to
that of civilian health care systems.
Working with the Department of Veterans Affairs
Our concern about the care of our beneficiaries continues even
after they have left the DOD system; therefore, the DOD/VA Resource
Sharing Program continues to be a high priority for the Air Force
Medical Service. The new Health Executive Council is making promising
steps toward removing barriers that impede our collaborative efforts.
We constantly explore new areas in which we can work to jointly benefit
our patients and are currently finding these opportunities in
information technology, deployment health medicine, pharmacy, and
contingency response planning and patient safety programs. We are
particularly proud of progress toward improving transitional services
and the delivery of the benefit to our separating service members.
These combined, cooperative efforts are a win-win-win for United
States, the VA, and most importantly, our beneficiaries. Of course, I
remain very proud of our numerous joint VA-Air Force operations, from
Anchorage to Las Vegas, from Albuquerque to Travis Air Force Base
California, we continue to team well with the VA.
Recruiting and Retention
The AFMS continues to face significant challenges in the
recruitment and retention of physicians, dentists, and nurses; the
people whom we depend upon to provide care to our beneficiaries. The
special pays, loan repayment programs, and bonuses to our active and
reserve component medics do help, and I thank you for supporting such
programs. Nearly 85 percent of nurses entering the Air Force say they
joined in large part because of these incentives.
We also recognize the importance of maintaining a modern and
effective infrastructure in our military treatment facilities, from
clinics to medical centers. The atmosphere in which our medics work is
as important as any other retention factor. We have wonderful patients,
patriotic and willing to sacrifice. They deserve not only the most
brilliant medical and dental minds, but first class equipment and
facilities. Every day, I strive to make that happen.
Conclusion
The Air Force Medical Service is proud to be part of a joint
medical team that provides seamless care to America's heroes, no matter
what Service they are from. We can boast of a full-spectrum, effects-
based health care system. Our focus on a fit and healthy force coupled
with human performance enhancement strategies and technologies,
promotes maximum capability for our Total Force warriors. Our health
surveillance programs keep them and their units healthy day to day,
ready to take on the next challenge. When one of our warriors is ill or
injured, we respond rapidly through a seamless system from initial
field response, to stabilization care at our expeditionary surgical
units and theater hospital, to in-the-air critical care in the
aeromedical evacuation system, and ultimately home to a military or VA
medical treatment facility. Across service lines, at every step, we are
confident that our Soldiers, Sailors, Airmen and Marines--active duty,
Guard and Reserve--are receiving the high level of medical care they
deserve, from foxhole to home station.
As we work to improve upon this solid foundation, the men and women
of the Air Force Medical Service, at home or deployed, remain committed
to caring for our troops. We appreciate your support as we build to the
next level of medical capability.
Thank you.
Senator Stevens. Thank you very much, gentlemen.
We have had enormous response as a volunteer military in
terms of those people who have been coming in, particularly the
younger people. What success have you had in terms of
increasing enlistment of medical professionals and retaining
them after they come in? For instance, are our bonuses and
other initiatives giving you good enough tools to assure a
sufficient number of reenlistments? No one is really talking
about this so far as I can see. But it has got to be different
now than it was back in the days of the draft. How are you
doing in terms of recruitment and retention? General Kiley.
MEDICAL PROFESSIONALS RECRUITING AND RETENTION
General Kiley. Sir, thank you for the question. I think
there are two parts to it. Our enlisted combat medic recruiting
and retention appears to be going pretty well. As you know, our
combat medics are emergency medical technician-basic (EMT-B)
certified, and that seems to have been a draw for many young
men and women to get the opportunity to get that certification.
The area we are concerned with, which I think you are also
asking about, is the area of our professional officer corps,
recruiting and retaining them, both physicians and nurses. We
are still short, in terms of our authorizations, against what
we have on hand for both corps. Specifically, we project this
year to be close to 200 nurses short in terms of our total end
strength.
Senator Stevens. What about doctors, physicians?
General Kiley. Sir, we are probably close to that same
number short in physicians. The dynamics are slightly different
for the two corps. I think Colonel Bruno will tell you that
there is a nationwide shortage of nurses and nursing starts in
terms of young men and women who would like to go into nursing
as a profession, a lot more that would like to than can get
into school. That is one problem.
We have not offered, until recently, the same level of
scholarship opportunities that we are offering now, and we are
starting to get some interest in scholarships in nursing school
and also in ROTC.
We have had some difficulty in retaining nurses. This is
for the same reasons as we have with physicians. This is hard
duty and deployment for 1 year. It is relatively new, even
though we have been in the global war on terrorism since 9/11.
For some, the potential for repetitive deployments has been a
little bit of an issue.
I am encouraged. We are taking some steps recently to
increase bonuses and to look at other opportunities to get
nurses on board.
For physicians, recently the Congress increased the
ceilings on retention bonuses for physicians. We have not fully
funded those inside the services to the maximum for all
physicians. There has been an effort between the three services
to balance the amount of bonuses per specialty, focusing on
combat-relevant specialists. I think the personnel tempo
(PERSTEMPO), the deployment tempo, the long deployments have
also been a challenge for some of our physicians also. About
half of the physicians in our Army that are not in training as
interns and residents have had at least one deployment, and
many are on the second deployment. We have got some of our
general surgeons that are on a third deployment now between the
Bosnia and Kosovo, Afghanistan, and now Iraq operations.
I think it is a little too early to tell in terms of long-
term retention for physicians what the personnel tempo of the
physicians in terms of deployments and redeployments will be on
retention. I am still encouraged. I just talked to a young
physician the other day who took great pride in the fact that
he spent 1 year with combat troops in Iraq and is now back in a
training position, training the next generation of physicians.
We have increased the bonuses and we continue to work that.
We are also working to get clearer data which, believe it
or not, tells us each physician, as they arrive at a point
where they can actually make the decision do I get out or do I
sign up for another bonus. We do not actually know the numbers.
We have got a fair number of continuation data, how many
doctors continue to stay on, and those numbers look relatively
good. But I am authorized to 43-47 I believe, and I am at about
41-50, plus or minus. The cycle changes. Over the summer we
lose and gain, and then in the fall we lose and gain again.
So I am concerned. I think we have been at our global war
on terrorism and this deployment challenge for physicians and
nurses long enough that those that have had bonuses that they
are letting run out are now at the point where they are
starting to let them run out.
Our certified nurse anesthetists. We increased the bonuses
for certified nurse anesthetist recognizing that we had a real
retention problem. And the preliminary indications are that
they have responded to those increased bonuses and that we have
signed up a fairly large number of our critical nurse
anesthetists.
So it is a mixed picture right now. We are watching it
pretty carefully. We have got a whole host of new plans and
programs working with our recruiting command getting physicians
and nurses engaged in going to facilities and talking to
doctors and medical students as a way to bring them on board.
So I think we do not have the final answer yet, but I remain
concerned about that.
Senator Stevens. You mentioned homeland security. Are you
prepared to take on the problems of homeland security through
your Reserve and Guard? Do you have enough medical people in
those areas?
General Kiley. Well, that also is an area of concern. As
you know, we have a policy now, a 90-day boots on the ground,
for physicians and dentists, so that they can preserve their
private practices. I do think it is a challenge for the
Reserves. The nature of health care in the private sector is
such that physicians cannot afford in their practices to leave
for 6 months or 1 year, and so they are very reluctant to sign
up.
We do watch the numbers very closely, and depending on the
nature of the mission, we may be stretched very thin using
medical reserves to support significant homeland defense
operations. I do not have any more specific answer to that
question. I know it is a concern for us.
Senator Stevens. Do you have any comment on those
questions, Admiral?
RECRUITMENT AND RETENTION
Admiral Arthur. Yes, sir. Thank you. I think that was a
very good, comprehensive answer, and I echo many of those
sentiments. I would like to add just a couple of other things.
I think there is a tremendous value to having an all-
volunteer service. I have talked with many veterans whose sons
have died in combat, and one of the things they tell me is they
are very proud of their son, that he--and in some cases a she,
but not for us in the Navy--volunteered to go there, wanted to
serve his country, and that he felt that he died in an
honorable way. I do not think that that same sentiment is
echoed for people who are conscripted to service.
One of the great things, I think, about our medical system
is the camaraderie that we have with other health care
professionals who share the same core values that we have, the
great training that we give, but the greatest benefit that I
have seen is that we never ask any of our patients how sick
they can afford to be. We give the right care every single
time. I think it is those things that keep people in the Navy,
the Army, the Air Force medical systems because it is a job
satisfaction not only their professional lives, but they feel
that they are not just not successful, but significant in their
contributions to their Nation. So I think the voluntary service
is of great value.
Like the Army, we have difficulty in retaining those
specialties who tend to have more deployments than others: the
surgeons, the nurse anesthetists, the perioperative nurses, the
combat medic equivalents in the Navy. But I think so far we are
doing pretty well because people want to serve, and that is the
volunteer aspect.
I have gone over there in December and January and talked
to thousands of our medical department folks out there. They
all would like to be home, but when their time and their duty
is done. They know what they are doing over there is important.
Thank you.
Senator Stevens. General Taylor.
General Taylor. Sir, just a couple of points. From the
Active duty side, we continue to be challenged in the Dental
Corps and the Nurse Corps with sustaining the right number of
folks. I believe we have most of the tools to shape the force
properly and build the force properly. It is just putting these
things in effect takes time. A lot of the cycling, particularly
for the nurses, is in relation to the outside communities'
shortage of nurses and the capability of nurses. So we are in
competition for many of these and it makes it more difficult. I
am sure that General Brannon will come in behind and talk about
some of the efforts in pay, ROTC, and other activities that we
are trying to do to recruit and retain nurses.
I have to say one of the things that we have worked real
hard on is placing our medics in an air expeditionary force
structure so that they go out 120 days every 20 months. It is a
system that can sustain itself. It is very enthralling to talk
to medics, either in Iraq or Afghanistan or upon return, and
how excited they are being able to participate in the
activities and supporting the armed forces forward. This
experience of deploying forward for most of our medics is a
very important part of their life and their contribution to the
service.
From the Medical Corps perspective, we tend to be
challenged in certain specialty types. We are working to adjust
that specialty mix, but by and large, you know that most of the
Medical Corps we get are through two very wonderful programs.
The Uniformed Services University and our Health Services
Professional Scholarship program continue to provide
outstanding physicians for each of us in the services.
From the Reserve component perspective, the Air National
Guard is taking up the challenge of homeland security. Their
greatest challenge, as they reform the Air National Guard to
create military medical capabilities aligned along the FEMA
regions, is getting the equipment, getting the training, and
then getting the staff aboard to move into creating the
capabilities to provide rapid medical response to a homeland
security event. So I am working very hard with the Guard to try
and help them restructure their medics in a way that provides
not only capability for the Federal forces, as we deploy out,
but provide a wonderful asset for the States and the Governors
to use in case of a homeland security strike.
Senator Stevens. We were disturbed when we heard that the
Uniformed Services University of Health Sciences (USUHS) might
be closed and equally disturbed when we heard that Walter Reed
might be closed. We are monitoring both of those rumors.
But one thing that disturbs me is the feeling that there
just are not enough physicians, doctors, professionals who are
willing to volunteer and stay in the service. Many of those in
your profession have received substantial Federal assistance in
their education. We used to have a requirement if the person
got such assistance, a certain amount of time had to be
dedicated to service in the military. That has been eliminated
from our laws. What would you think about reinstating it? Is it
still there? I do not think it is still there. Well, I will ask
the staff.
My information from home is we used to have a provision
that said that they had to spend some time in places where
there were not enough physicians in the civilian community, and
that was one of the commitments that they made if they got
their financial assistance during their medical education. But
I do not think we still have the requirement of military
service for those who have the assistance.
General Taylor. Sir, as far as I understand it, in the
Health Professions Scholarship program (HPSP), you owe 1 year
for every year of training, and for those who go to the
Uniformed Services University, they owe 7 years after their
training.
Senator Stevens. But is that military service?
General Taylor. Military service.
Senator Stevens. All right. We will get a report on that.
Thank you.
Senator Inouye.
Senator Inouye. If I may follow up on that, is it not true
that of the 3,600 graduates of USUHS, the retention rate is
extraordinary? For example, the medium length of unobligated
retention for physician specialists, not including USUHS grads,
I believe is 2.9 years, but for USUHS grads, the unobligated
service retention is about 9 years. Is that not correct?
General Taylor. Senator, I do not think we know the
specific numbers there. It is true it is universally understood
that those who attend USUHS, because of their long commitment,
stay longer in the service. You must complete USUHS, complete
your medical residency training, and then the clock starts
ticking on your 7 years of service. Certainly that is longer
than the HPSP where they only owe 4 years. So it is true that
they will stay longer.
Senator Inouye. I am told that beyond the unobligated,
there are 9 years for USUHS grads, medium rate.
And further, we have been advised that if we compare USUHS
to the four major physician accession centers, USUHS is cost
effective. It sounds astounding, but I suppose it is correct.
Does Walter Reed still maintain 40 medical specialty
programs?
General Kiley. To the best of my knowledge, yes, Senator,
they do.
Senator Inouye. Because I have been told that that is one
of the major attractions for physicians in the military.
TRAINING PROGRAMS
General Kiley. Yes, sir. What Walter Reed really is is the
linchpin for Army medicine. There are very robust training
programs across the entire spectrum, many of which are combined
with training programs at the National Naval Medical Center.
Many students in medical school that get an opportunity to
rotate at Walter Reed really get excited about being in Army
medicine and having an opportunity to serve at Walter Reed.
Some of our best, not all, physicians in the military will
actively seek to be assigned at Walter Reed because of its
prestige, not only its location in Washington, DC, but the
prestige of the research that goes on, the robustness and the
size of the training programs that allow them to do research to
train the next generation of physicians and certainly nurse and
also enlisted personnel, all of whom train at Walter Reed.
It is a very big, complex organization. It delivers very
sophisticated tertiary level, university, academic level health
care. And as you know, it is also our major receiving facility
in the continental United States for combat casualties that are
coming back where we apply those skills.
So it has a recruiting and retention capability. It is
recognized worldwide as are the prestigious Navy and Air Force
facilities. So it is not without significance as it relates to
not only that, but longevity, the same discussion you just had
with continuation rates of physicians. Certainly many of the
USUHS grads get an opportunity to rotate as medical students,
like my daughter, and see that as a career potential for them.
So there are significant second and third order effects to this
facility, yes, sir.
Senator Inouye. Admiral Arthur, during the ancient war, the
one that the chairman and I were involved in--there was much
talk about what we called section 8, mental cases. In this war
we see pictures of amputees and blinded veterans and such, but
very seldom hear about so-called section 8. What is their
status? Do we have a lot?
COMBAT STRESS
Admiral Arthur. Section 8 is the psychiatric. Okay. I think
that is an Army term.
We are, I think, just seeing the results of combat stress
in our veterans. I think we have not truly had a major combat
that our Nation's armed forces have been associated with since
Vietnam. I think Desert Storm, Bosnia, Grenada, Panama--we have
been in conflict, but not in such a sustained way.
Having been in combat, I feel that 100 percent of the
people who experience combat are in some way affected, some a
little, some a lot more. I think we as the services need to be
very sensitive to picking up the combat stress not because the
children are affected or the spouses are affected or the jobs
are affected, but because we are sensitive enough in our post-
deployment screening tools to see the effect and to treat it at
its lowest level, by that I mean in garrison rather than
sending someone to a hospital, if they go to a hospital to do
the treatment as a outpatient rather than an inpatient and to
return people to function.
I think one of the best things that all three services have
done is to enlist their retirees and other people in the
communities so that we do not lose track of anyone who does not
just return to garrison, but actually gets out of the service
or goes back to Reserve duty and may not have the support that
an Active duty member has. I think we are all very, very
concerned about what I would call combat stress to ensure that
we properly honor the services of the veterans and understand
it.
As I said in my opening statement, I think this is in the
purview of the military. We know what combat stress is about
because we have been there and we understand it. I think the
more we can do that keeps our veterans from having to go to
civilian centers where they are not as well prepared the better
we will be, and that includes our Veterans Administration
hospitals as we partner with them to treat veterans.
Senator Inouye. Do you believe that we are adequately
demonstrating this concern and sensitivity?
Admiral Arthur. I believe that we adequately have attention
being drawn to it. I think renewed collaboration that DOD has
with the Veterans Administration in treating combat stress is
refreshing. We have a lot of programs and I am encouraged by
the amount of effort and attention that we are bringing to bear
on this, all three services, right now.
Senator Inouye. Thank you.
General Taylor, we have just received a report that the Air
Force is short in a large array of medical and dental fields.
For example, the Air Force is now short in dentistry,
anesthesiology, gastroenterology, rheumatology, pulmonary,
cardiology, oncology, hematology, internal medicine, and it
goes on and on. Is that a correct picture?
General Taylor. Sir, we are short in certain areas. We are
shorter in other areas than in some other ones. The way we have
tried to adjust for that, of course, is to work on the pay and
compensation for those specialties that are in the career
field. We have been working actively with the recruiting
services to recruit people, and then we have continued to work
hard to mold new accessions into those specialty areas.
Some of the ways that we have adjusted to that is to try
and ensure that we place our military specialists in those
locations where they can best maintain their skills.
Concentrating internists in hospitals and moving them from the
smaller clinics and into the hospitals has been one way to
adjust for that. That would allow those small clinics then to
contract for internal medicine referrals locally rather than to
put a military internist in a small clinic forward.
So most of these are trying to adjust to the correct size
while we continue to press for new entries into the career
field and that the pay and incentives remain intact. The other
part of this is to try and ensure that people in those areas of
expertise are practicing the full spectrum of their health care
in our larger facilities.
Senator Inouye. Are you noting success in your programs?
General Taylor. Sir, I believe we are seeing success in
that program. It is going to take time, as was mentioned by my
colleagues here, to see how those incentives work. We
appreciate what Congress has given us in terms of pay and
retention and scholarship programs to recruit and retain these
people, and we believe we have the adequate tools to do the
work.
Senator Inouye. Well, as one Member of the Congress, I
would like to thank all of you for your service. Thank you very
much.
Thank you, Mr. Chairman.
Senator Stevens. Senator.
Senator Mikulski. Thank you very much, Mr. Chairman, and to
our Surgeons General.
First of all, as the Senator from Maryland, we are very
familiar with military medicine in our State and so honored to
have Naval Bethesda in our State. Walter Reed, though next
door, we view as part of--we do not want to say part of our
State, but certainly close to that. The hospital ship Comfort
is based in Baltimore, and of course, we have USUHS, the
uniformed services medical school, and up Route 270, of course,
is Fort Detrick, though not literally under your command,
certainly is coming up with the research that is so important
in what you are doing. So we feel very strong about it.
We too are really proud of what you are doing in
battlefield medicine, acute care, and also the primary care
that you provide to families. So we are on your side, and even
my own primary care physician gave me an article from the
Journal of American Medical Association (JAMA), the American
medical journal, talking about the stunning results in what you
have been able to do in battlefield medicine. It is beyond all
expectation and all hope. I know gratitude will come to you the
rest of your life in this.
I am worried about the shortages that you are talking about
with the physicians, and I too have been troubled about the
rumored closing of both USUHS and Walter Reed.
In terms of USUHS, I would like to be able to ask you,
General Kiley, a couple of questions. First of all, is it true,
picking up on Senators Stevens and Inouye, that the USUHS
graduate serves a longer time than someone who has come through
a conventional medical school, and could you share with us how
committed they stay? All medicine is 24/7, but military
medicine is 36/7. You work a 36-hour day.
General Kiley. Senator, that is a great question. Thank
you.
PROGRAMS FOR ASSESSING PHYSICIANS
I think as General Taylor referenced, there are two general
programs for assessing physicians, and the Uniformed Services
University has the students go through an Active duty status
with pay allowances and privileges. In exchange for those 4
years as a medical student, the young doctors graduate and are
commissioned as Medical Corps captains. And then they have a 7-
year obligation. The internship year right after medical school
or, in many cases now, just the residency, internal medicine
being 3, general surgery being 5 years, OB-GYN being 4 years,
as an example--those 3, 4, or 5 years do not count in working
off the obligation.
Senator Mikulski. So they do not count toward the 7 years.
General Kiley. That is correct. But they do count toward
retirement. So these young physicians get through their
training, and then they have a 7-year commitment. The intent,
as I understand it, was pretty clear. I hear this routinely
from my daughter, who is a USUHS graduate and finishing her
second year of medicine residency, that they will get out to
10, 11, 12, 13 years before they reach that first unobligated
decision point. Many of them--and I cannot give you a number,
but clearly early on and so some of the more senior
physicians--many had prior service. So they already had some
commitment into retirement.
Senator Mikulski. But the bottom line is do they serve
longer? Do you know that?
General Kiley. Our best estimate is yes, Senator, they seem
to because the HPSPers--the larger group, by the way, at least
for the Army--we get 60 doctors every year from the Uniformed
Services. We get between 250 to----
Senator Mikulski. Well, I am not saying it is not a
substitute for----
General Kiley. No, ma'am. I understand.
Senator Mikulski. So, in other words, USUHS--the Naval
Academy does not do all of the officer corps for the Navy.
General Kiley. But if you are a West Point graduate with a
5-year obligation from West Point and you are a USUHS graduate
with a 7-year obligation, those two are additive. So you are
close to retirement before you can even decide----
Senator Mikulski. Yes, but you might not be coming from
West Point.
General Kiley. That is correct.
Senator Mikulski. You might be coming a different route.
General Kiley. But the HPSPers--those only owe 4 years.
They only owe 4 if they do a full 4-year scholarship.
Senator Mikulski. So the HPSP is the scholarship program.
Is that correct?
General Kiley. Yes, ma'am.
Senator Mikulski. Now, in terms of the scholarship program,
as I understand it, last year you had less than one applicant
per slot, while USUHS had 10 initial applicants for every slot
getting into USUHS. Are you aware of that?
General Kiley. I do not believe that the number was less
than one applicant per slot. I believe it was about 1.1 to 1.2
applicants per slot, which is down from what it used to be.
Senator Mikulski. Yes, but that is not a lot.
General Kiley. No, ma'am, it is not.
Senator Mikulski. That is not a lot. And when you think
that there are 10 people lining up to get into one slot in
USUHS and we are talking about closing it, but it is barely one
on one for the DOD HSP program, then I think we need to
evaluate the scholarship program and find out why. But it is
also a lesson saying let us not close USUHS.
Now, we understand the military doctors are a military
doctor rather than a doctor who is currently in the military.
But as I understand it, first of all, you have got about
1,000 vacant physician positions, and not only are you
competing with those at Hopkins or Mercy, like in our own
State, Suburban, which you just referenced, Admiral, but you
are also competing with the VA. The VA can pay more than the
military. Am I correct?
General Kiley. I believe they can, yes, ma'am, at least in
some specialties.
SCHOLARSHIP PROGRAM
Senator Mikulski. Well, see, I think these are the issues
that we need to look at, and they would not be necessarily the
scope of this hearing. But I think we do need to look at the
scholarship program.
Senator Stevens. Would you say that again, Senator?
Senator Mikulski. Well, today the Department of VA, as I
understand it from my old work on the VA Subcommittee before we
were reorganized, sir, can pay its civilian physicians more
than DOD can under title 38. Therefore, not only are you
competing with academic centers of excellence and community-
based medicine, but you are also competing even against the VA
in many of the same geographic areas where people are serving.
Again, I come back to military medicine being a 36/7 calling.
So we do not want to short change the VA exactly because
this seamless transition that you are developing and we are so
enthusiastic about, but at the same time, if you are trying to
get a surgeon, these specialties, but even in the primary care
area, this would seem to be a challenge. And also VA is
offering scholarships in nursing, scholarships in medicine and
so on. So I think we need to look at this and how you are going
to be competitive.
My advice is that we should not close USUHS because USUHS
might bring not only medical skill but a military culture as
compared to simply training a doctor to be in the military. I
think the military doctor has an influence on the doctor in the
military to grasp this very unique culture that you are the
leaders of.
Do you see where I am? So I think we need to look at that.
I would also think that we should look at perhaps debt
reduction. When someone has completed their medical school,
their debt in many instances is over $100,000. It is
breathtaking for some. Then they think, I want a different life
here and they are ready to think about this perhaps, but we
should think about forgiving their debt as they entered the
military. We already know then they have gotten through medical
school. So it is not a crap shoot to know if they are going to
make it. So I think we need some new thinking. Have you thought
about this?
Senator Stevens. That is a good idea. We ought to all think
about that, Senator. That is a very good idea.
Senator Mikulski. Yes. And then when they come in,
essentially we swap debt for duty.
General Kiley. Yes, ma'am.
General Taylor. Yes, ma'am. We do have certain tools that
fit that category. The question is whether we are effectively
using them or do we have the wide range of authority to fully
execute those. We do have some debt relief tools. We do have
some recruiting tools, and I think it is a very good question
as to whether we are effectively using them or we are limited
in size and scope because of finances or congressional caps. I
think it is worthy for us to look at it.
General Kiley. I think you hit on it, $100,000 in debt. If
you are coming out of Georgetown or George Washington (GW), you
may be closer to $200,000 in debt based on the estimates of the
cost. These young physicians then look at an Army salary with
this debt on them, and it is very hard. Every year we have a
couple physicians that come on Active duty, having incurred an
obligation in ROTC in undergraduate, who have those kind of
debts. They can sometimes struggle.
We do have some programs that recognize some of that debt
reduction, but the programs are not nearly robust enough to
address some of the issues you have had.
The second piece about the VA receiving more. One of the
things the VA physicians, as I understand it, have as part of
their retirement package is that these bonuses that they are
given as physicians in the VA are all calculated into their
retirement pay. They are not calculated into the military
retirement pay.
Senator Mikulski. Well, I think we need to then look at how
the VA is doing it and perhaps some lessons learned.
But the point of debt forgiveness is that perhaps when
someone has completed their internship, they have got all this
debt, this could be another recruitment time, or even when they
have completed their residency. Some young people do not now
want the hassle, the malpractice issues and the health
maintenance organization (HMO), the insurance stuff, and the
idea of being in the military would be very attractive to them.
I know my time is up, but I am very keen on this
recruitment and retention.
Senator Stevens. I want to ask the three witnesses here if
they will confer and give us a suggestion on how to flesh out
the Mikulski plan. We have several provisions in Federal law
that it is really payment rather than forgiveness because those
loans are not made by the Federal Government primarily. I think
they are mostly reinsured by the Federal Government. But I do
think that you ought to give us a plan that would allow the
services to entice young doctors and professionals to come into
the services with an addition to their salary to repay those
loans.
MEDICAL PROFESSIONALS LOAN REPAYMENT
We do that here in the Senate to a certain extent. I do not
know if you know that. It is not very much. We give the
authority to a Senator to add to the salary an incentive
payment for retention of employees who do have these debts. I
have seen them come to my office with more than $100,000 and
the lawyers coming in with almost $200,000.
So I think this is probably one of the things that is a
deterrent to enter Government service, and particularly
military medical service. You ought to give us a plan. We will
flesh it out and see if we cannot get the money for it this
year.
Senator Mikulski. Very good.
Senator Stevens. We will call it the Mikulski plan.
Senator Mikulski. Okay.
Senator Stevens. Well, Sonny Montgomery had his plan. You
have got yours.
Senator Mikulski. Sounds good to me.
[The information follows:]
Medical Professionals Loan Repayment
The Health Professions Loan Repayment Program (HPLRP) has
been a very important accession and retention tool to the Air
Force Medical Service in certain areas. During the four year
history of the current program, it has helped sustain the Nurse
Corps Accession program, accounting for nearly half of the
Nurse Corps accessions. It has also helped the Air Force Dental
Corps to slightly improve the retention of general dentists
(non-residency trained). Although HPLRP has been successful in
some of our accession and retention endeavors, there is a low
rate of HPLRP takers among physicians and residency-trained
dentists.
Physicians, dentists, and certain Biomedical Sciences Corps
specialists tend to have larger debt burdens than other health
professionals and, due to salary differences, have a greater
potential for quickly paying off these loans working in the
civilian sector versus the military. Physician and dental
officer average debt load is $100,000-$120,000 with some even
approaching $350,000. Health professionals have cited high
student debt load as a major factor in their decision to
separate from the Air Force.
A few recommendations to improve the effectiveness of the
health professions loan repayment program are: (1) make HPLRP
tax free, perhaps mirroring the Indian Health Service Loan
Repayment Program; (2) allow HPLRP service obligation to run
concurrent with any other service obligation; (3) receive HPLRP
appropriation to provide adequate quotas to improve the current
program; and (4) establish an adequate accession bonus for
physicians and dentists to augment the HPLRP as a more
attractive accession tool. These improvements would help the
military services attract and retain fully qualified health
professionals especially in those extremely hard to recruit
specialties.
Senator Stevens. Thank you very much, gentlemen. We
appreciate very much your service and your testimony here
today. We look forward to hearing from you further about this
idea, and I think it is a good one to pursue.
We will now turn to the Nurse Corps. Thank you again for
coming.
We are now going to hear from the nursing corps. This
subcommittee's view is that the nursing corps are vital to the
success of our military medical system. We thank you for your
leadership and look forward to your comments and telling us
your challenges. From the Army, we will hear from Colonel
Barbara Bruno, who is the Deputy Chief of the Army Nurse Corps.
We welcome you here, Colonel. We will also hear from Admiral
Nancy Lescavage, Director of the Navy Nurse Corps, and Major
General Barbara Brannon, Assistant Surgeon General for Nursing
Services for the Air Force.
Your patron saint is my friend here from Hawaii, so I will
yield to him.
Senator Inouye. Welcome. Is this not Nurses Week?
General Brannon. This is indeed.
Colonel Bruno. It is.
Senator Inouye. I think it is most appropriate that you are
here, and I want to congratulate all of you and thank you for
the service you are rendering to our country. It is very
essential. We would rather listen to you than listen to me. So,
Mr. Chairman.
Senator Stevens. Senator Mikulski, comments?
Senator Mikulski. I believe that the issues of recruitment
and retention are actually severe in nursing because of the
issues in the larger community. But again, for everybody who is
at Naval Bethesda and we have seen you on the hospital ship
Comfort, we are so appreciative of what you do, and want more
of you.
Senator Stevens. Colonel Bruno.
STATEMENT OF COLONEL BARBARA J. BRUNO, AN, DEPUTY
CHIEF, ARMY NURSE CORPS, UNITED STATES ARMY
Colonel Bruno. Thank you very much. Good morning, Chairman
Stevens, Senator Inouye, and Senator Mikulski. Thank you for
your unwavering support to provide the best nursing care
possible to American soldiers, their families, and eligible
beneficiaries.
I am Colonel Barbara Bruno, Deputy Chief of the Army Nurse
Corps. It is a real honor and a privilege to speak to you this
morning on behalf of Major General Gale Pollock, the Chief of
the Army Nurse Corps. She is hosting an historic military
medical conference in Hanoi, Vietnam today. She sends her
regards and wishes she could be here.
I am going to highlight specific achievements and concerns
that relate to the ability of the Army Nurse Corps to serve a
Nation at war. As of March 2005, 765 nurses have deployed to 17
countries, in addition to Operation Enduring Freedom in
Afghanistan and Iraqi Freedom.
Caring for critically injured soldiers can be incredibly
stressful to the deployed staff and to the staff within our
medical treatment facilities. Nursing research conducted at
Walter Reed showed that nurses' feelings and emotions, while
caring for returning injured soldiers, mirrored their deployed
nursing counterparts. Yet they experience them in different and
more long-lasting ways. Whereas deployed nurses have short and
intense exposures to patients with severe and devastating
trauma, nurses in our fixed facilities have prolonged and much
more personal experience. They experienced high levels of
empathy with the injured and their families. This empathy is
common amongst all health care providers and is described as
compassion fatigue. Soldiers involved in health care receive
awareness training and educational material regarding
compassion fatigue.
The shortage of nurses in the civilian sector does have a
direct impact on the entire Federal nursing force. We continue
to leverage available incentives and seek additional creative
avenues to recruit nurses. To remain viable in a very tight
labor market, we have to be competitive.
One extremely successful recruiting tool we have used in
the Army is the Army Medical Department enlisted commissioning
program. This is a 2-year education completion program for
enlisted soldiers who have acquired the appropriate
prerequisites. The Reserve component has expressed interest in
a similar program.
Another successful initiative directed at civilian Federal
nurses is the direct hire authority. With this program, the
time delay between finding a candidate and acceptance of a job
offer has been significantly reduced. We are optimistic that
the National Security Personnel System will alleviate the
obstacles to hiring civilian nurses.
While recruiting is an obvious challenge, retention is of
greater concern and a much less conspicuous one in nature. As
the incentive gap with the civilian sector widens, it will be
increasingly difficult to retain qualified nurses in military
service, and for the Army this loss is twofold. We lose a
superb soldier and a highly trained, experienced nurse.
Successful retention of nurses is a combination of
financial compensation, deployment equitability, and military
benefit preservation. With the support of General Kiley, as he
mentioned earlier, we have been very successful in the
incentive specialty pay program for nurse anesthetists. The
preliminary numbers reveal that 72 percent of the eligible
nurse anesthetists have signed a multiyear contract since the
increase in incentive pay. This information suggests a positive
correlation between the increased pay and retention and
provides us with good research for future retention strategies
of other specialties.
Our commitment to nursing research remains strong. Walter
Reed Army Medical Center has partnered with Mount Aloysius
College in Pennsylvania as part of a congressionally funded
nursing telehealth applications initiative. This relationship
provides a quality learning experience to nursing students in a
rural environment. While students and faculty remained at Mount
Aloysius, two Army nurses took care of various patients in the
medical intensive care unit (ICU) at Walter Reed, bringing that
clinical setting to rural Pennsylvania. Our commitment to
addressing the nursing education insufficiencies exemplifies
Army Nurse Corps leadership, innovation, and new approaches to
solve problems.
Nursing research is invaluable to excellent, evidence-based
nursing practice. We thank you for your dedicated funding and
continued support of the TriService nursing research program.
PREPARED STATEMENT
The Army Nurse Corps continues to move forward with
initiatives to improve the best nursing organization in the
world. Our research is changing nursing practice globally, and
Army nurses are highly valued throughout the world. With the
continued support of Congress, Army Nurse Corps compassion and
leadership will ensure that we are able to take care of our
military men and women and that they receive the finest health
care anytime anywhere.
I thank you for this opportunity to speak to you today.
[The statement follows:]
Prepared Statement of Colonel Barbara J. Bruno, AN
Mr. Chairman and distinguished members of the committee, thank you
for your unwavering support to provide the best nursing care possible
to American Soldiers, their families and eligible beneficiaries. In
today's unprecedented environment of global, joint and collaborative
military medical operations, we continue to see success in the Global
War on Terrorism, and have made numerous improvements in nursing care
delivery at home, abroad and on the battlefield.
I am Colonel Barbara Bruno, Deputy Chief, Army Nurse Corps (ANC).
It is an honor and privilege to speak to you today on behalf of Major
General Gale Pollock, the 22nd Chief of the Army Nurse Corps. MG
Pollock is hosting an historic military medical conference in Hanoi,
Vietnam.
Military forces engage in security cooperation activities to
establish important military interactions, building trust and
confidence between the United States and its multinational partners.
The visible and purposeful presence of U.S. Military capabilities is an
integral part of an active global strategy to ensure security and
stability. The Asia Pacific Military Medicine Conference (APMMC) is one
of the critical tools used to accomplish this.
The APMMC is the premier medical conference in the Pacific Command
(PACOM) area of responsibility. This conference provides a forum for
U.S. Military health care providers and leaders to collaborate with
Allied and friendly countries in the Asia-Pacific region. Topics of
military medical significance such as interoperability, medical
readiness, illnesses, battle injuries, medical technological
advancements, force health protection, and disaster/consequence
management are the primary foci of the APMMC.
As the U.S. Army, Pacific Surgeon, MG Pollock will conduct
bilateral discussions with senior delegates from over thirty countries
attending the APMMC. These bilateral discussions provide a forum to
plan future medical events with regional partners, and enhance
influence and access to these nations in order to combat terrorism,
transform alliances, and build coalitions for the future. This year's
APMMC is in Hanoi, Vietnam. This is particularly significant as it is
the first time the U.S. Military has ever co-hosted a conference of
this magnitude with the country of Vietnam.
The ANC is actively engaged in strategic planning to allow us to
achieve the greatest benefit, both human and monetary. During this
congressional hearing I will take the opportunity to highlight specific
achievements and concerns that relate to the ability of the ANC to
serve a Nation at war.
Army Nurses possess the expert clinical skills, compassion, and
leadership acumen requisite to execute the most challenging missions in
austere environments. As of March 2005, 419 Active Component (AC) and
151 Reserve Component (RC) nurses were currently deployed to 17
different countries including Operation Enduring Freedom/Operation
Iraqi Freedom (OEF/OIF). An additional 95 Army Nurses have supported
other medical training missions as subject matter experts, trainers, or
medical augmentees. Since our last testimony, our deployments total
over 74,045 person-days.
The 31st Combat Support Hospital (CSH) from Ft. Bliss, TX and the
67th CSH from Wuerzburg, Germany transitioned at the end of the 2004
calendar year with the 86th CSH from Ft. Campbell, KY and the 228th CSH
(a combined AC/RC unit) from San Antonio, TX. The 115th Field Hospital
from Ft. Polk, LA, is also in Iraq as medical support for Abu Ghraib
Prison. The RC continues to take the lead in the medical support
mission in Afghanistan with the 325th Field Hospital from Los Angeles,
CA being replaced by the 249th Field Hospital from Independence, MO. In
addition to the CSHs, 45 nurses deployed on eight Forward Surgical
Teams (FST) in support of OEF/OIF and two RC CSHs deployed to Germany
as backfill.
Army Nurses are serving critical roles in direct support of the War
on Terrorism at all ranks and skill levels. At the company grade level,
nurses are instrumental in the leadership and direct supervisory
training that combat medics receive during their Advanced Individual
Training at Fort Sam Houston, Texas. This training provides combat
medics with the critical knowledge they need to care for battlefield
casualties. Often, the diverse clinical experience of the nurse is the
only conduit between training and the trauma of war for these young
medics. In addition, 44 Army Nurses are embedded with Divisions and
Brigade Combat Teams providing direct nursing care to Soldiers in the
field while also providing advanced training to combat medics prior to
and during deployment.
The value of the Advanced Practice Nurse (APN) has never been as
evident as it is in today's Army. Their expanded roles in the health
care delivery system make them a highly prized commodity. APNs in
varying specialties utilize their expertise to ensure patients
transition smoothly from point of entry through the healthcare system
based on each patient's individual needs.
The positive impact Army APNs are having on patient outcomes has
created a tremendous demand for their services in various healthcare
settings. Trauma Registry Coordinators, Nurse Practitioners, Nurse
Anesthetists, Psychiatric Clinical Nurse Specialists, and senior-level
Case Managers are just a few of the roles in which these highly
educated nurses are serving.
In late 2004, six Army APNs deployed to Iraq to serve as Trauma
Registry Coordinators. These Army Nurses have been an integral
component of the Army Medical Department's (AMEDD) Theater Trauma
System. This demonstration project adopted the American College of
Surgeons Committee on Trauma's model for civilian trauma care into the
current theater of operation. The Theater Trauma System initiative has
multiple components: pre-hospital care coordination, utilization of
clinical practice guidelines for trauma management and patient
movement, trauma research and integration of clinical information
systems for care delivery, and command and control. The overarching
goal has been to ensure ``the right patient, to the right provider, at
the right location and right time.''
A cornerstone of the Theater Trauma System is the Joint Theater
Trauma Registry (JTTR). The JTTR application is used to capture data
from non-integrated clinical and administrative systems within the
AMEDD, our sister Services and the Department of Defense. The Trauma
Registry Coordinators ensure that critical clinical data is collected
in theater and incorporated into the JTTR to provide a comprehensive
picture of trauma patients from point of injury through rehabilitation.
To date, the JTTR contains more than 7,000 records of battle and non-
battle injuries of United States, Allied and enemy combatants. Our
support of this initiative remains steadfast, for as the Theater Trauma
System matures, JTTR data will be used to improve the overall quality
of care provided to our injured Soldiers.
An unprecedented move for Family Nurse Practitioners (FNP)--
substituting for Physician Assistants at Echelon II medical companies--
begins during the next rotation of OIF. These FNPs will provide primary
care in field environments and initiate treatment for wounded soldiers.
Our RC Army Nurses continue to demonstrate excellence in health
care management. In addition to deploying nurses to theater, numerous
others are serving in a backfill capacity in our Medical Treatment
Facilities (MTF). Most noteworthy are the APNs serving as senior-level
Case Managers at the Regional Medical Commands. These nurses are
credited with the development of medical holdover case management and a
patient tracking tool. They supervise 158 Army Reserve and National
Guard nurses serving as Case Managers in MTFs and Community Based
Healthcare Organizations located close to Soldiers' homes.
These RC nurses functioning as Case Managers assist their physician
colleagues to aggressively manage highly complex wartime patients to
achieve positive outcomes for the 21,500 Soldiers who have required
medical care following mobilization. Of the 16,453 Soldiers processed
since the establishment of the medical holdover management program,
10,868 Soldiers have returned to their units. This success, a direct
result of compassionate care and attention to detail, clearly
demonstrates the need for nurses in the ambulatory healthcare setting.
Combat is demanding and taxing. Estimates are that between 3
percent and 4 percent of the general adult population in the United
States suffers from Post Traumatic Stress Disorder (PTSD) (Narrow, Rae,
Robins & Regier, 2002). Among Gulf War veterans, estimates are that
between 2 percent and 10 percent suffer from PTSD (Iowa Persian Gulf
Study Group, 1997; Kang, Natelson, Mahan, Lee & Murphy, 2003). In a
systematic review of 20 studies that compared the prevalence of
psychiatric disorders in Gulf War veterans to a comparison group of
veterans previously deployed for other conflicts not including current
operations, Gulf War veterans were three times more likely to develop
PTSD (Stimpson, Thomas, Weightman, Dunstan & Lewis, 2003). More
recently, in a cross-sectional study of 3,671 Soldiers and Marines
surveyed 3 to 4 months after returning from deployments to Afghanistan
or Iraq, between 6 percent and 13 percent of the participants suffered
from PTSD (Hoge et al., 2004). The prevalence of PTSD increased
linearly with the number of firefights Soldiers experienced and being
wounded.
The Department of Defense and the Department of Veterans Affairs
are taking a proactive approach to monitoring and treating PTSD. One of
the 26 clinical practice guidelines jointly developed by the Army, Air
Force, Navy, and Veterans Affairs addresses the management of Post-
Traumatic Stress. An Army nurse leads the clinical practice guideline
effort at the Army Medical Command (MEDCOM) disseminating these
evidence-based practice recommendations across the AMEDD.
Caring for critically injured soldiers can be incredibly stressful
for the deployed staff and the staff within our fixed MTFs. Nursing
research conducted at Walter Reed Army Medical Center showed that
nurses' feelings and emotions while caring for returning injured
soldiers mirrored their deployed nursing counterparts, yet they
experienced them in different and more long-lasting ways. Whereas
deployed nurses have short and intense exposures to patients with
severe and devastating trauma, nurses in our fixed facilities have
prolonged and much more personal exposure. They experienced high levels
of empathy with the injured and their families. This empathy is common
among all health care providers and is described as ``compassion
fatigue.'' Soldiers involved in healthcare receive awareness training
and educational material regarding compassion fatigue.
The shortage of nurses in the civilian sector continues to have a
direct impact on the federal nursing force, both military and
government service requirements. The AC accession mission for Army
Nurses has not been met since 1998 while the RC has not met mission
since 2002. At the end of fiscal year 2004, the AC ANC was 203 officers
below its budgeted end strength of 3,415 and missed its goal of
accessing 385 new officers by 48. The RC ANC also missed its accession
goal of 507 new officers by 141.
A recent study commissioned by the United States Army Accession
Command, determined that specific offers and messages can improve the
accession rate and help to relieve our shortages. The sample population
included registered nurses, graduate nurses, and nursing students.
Reducing minimum service obligations, adjusting deployment length,
ensuring assignment preferences, and increasing financial incentives
have the most potential impact on nurse accession. As a result of these
findings, the Chiefs of Nursing for U.S. Army Cadet Command (USACC) and
U.S. Army Recruiting Command (USAREC) have developed several
initiatives aimed at increasing overall nurse recruitment.
The first initiative from USACC is the Centralized Nurse
Scholarship program. It was implemented to focus additional Reserve
Officer Training Corps (ROTC) battalions on the nurse mission. They
accomplished the initiative by increasing the number of schools
actively recruiting nursing cadets from 47 to approximately 200 and
using the nurse mission as a quantifier of success. They also
consolidated Nursing Scholarships at USACC Headquarters, centralizing
funds, and providing responsive access to scholarship resources
wherever qualified nurse applicants are located. The new program also
allows students to choose how their scholarship dollars are used. This
benefits those students who may have received additional academic
scholarships that are specified for tuition only. In addition, the
tuition cap and book stipend were increased by $3,000 and $300 per year
respectively.
The second initiative from USACC is an expanded ROTC Nurse Educator
Tour and Nurse Summer Training Program (NSTP). Showcasing ROTC's
Leadership Development and Assessment Course (LDAC) and NSTP are
significant recruiting tools available to Army Nursing. During the
summer of 2004, 150 nurse educators were invited to attend the LDAC at
Ft. Lewis, WA, in an effort to display the versatility of our nursing
cadets in both the field training and clinical environments. The nurse
educators who participated in this program witnessed nursing students
during leadership training at the LDAC and then received a tour of
Madigan Army Medical Center where they observed nursing students in the
clinical setting during NSTP. Nurse educators participating in the tour
left with a new-found dedication to Army ROTC and a better appreciation
for the ANC as a whole. As a result of their positive experiences, many
of these educators now require students returning from LDAC and NSTP to
provide a presentation about the experience to their classmates,
inviting more queries about the ANC as a career option. Most schools
are now encouraging qualified students to consider Army ROTC and many
are giving academic credit for NSTP completion. The success of this
program has already made a significant impact in nursing student
recruitment at these universities.
In light of this success, USACC has experienced a greatly improved
collegial relationship with all universities in attendance. In an
effort to improve recruiting efforts while promoting the positive image
of Army Nursing, focus has shifted this year to universities who have
been less than supportive in the recent past. One hundred
representatives from these universities have been invited to attend
this years Nurse Educator Tour. This type of networking and partnering
will increase a positive view of Army Nursing in the civilian
community.
While USAREC recruiting initiatives are similar in nature to those
of USACC, their targeted population is larger and more diverse. They
are solely responsible for recruitment of RC nurses and all other
nurses and nursing students not eligible for ROTC.
The Health Professional Loan Repayment Program (HPLRP) was
instituted in fiscal year 2003 and targeted new accessions to provide
nurses with an educational loan repayment benefit up to $29,000. Prior
to HPLRP implementation, USAREC was limited to a sign-on bonus as their
only financial incentive tool. To date, 345 AC nurses have benefited
from this program.
The Army Nurse Candidate Program (ANCP) targets nursing students
prior to graduation who are not eligible for ROTC but are still fully
qualified as a direct accession nurse. It provides a $1,000 monthly
stipend and a $10,000 bonus paid in two increments. The ANCP provides
USAREC the ability to recruit nursing students as early as their
sophomore year. This program will give us the leverage to offer
accession incentives to students much earlier in their education
program which is essential when competing with the civilian market.
The Army Enlisted Commissioning Program (AECP), used by AC enlisted
Soldiers, is an extremely successful recruiting tool. The program
provides a 2-year education completion program for enlisted Soldiers
who have acquired the appropriate prerequisites. Currently 75 Soldiers
are funded annually to obtain their Bachelor of Science Degree in
Nursing.
The last AC recruiting initiative we want to highlight is the
accession bonus. Money is programmed through fiscal year 2008 to
implement this plan. The current accession bonus is $15,000. The
proposed increase is $5,000 per year through fiscal year 2008. With
these targeted increases, USAREC believes we will become comparable to
the standard sign on bonus of our civilian competition.
Reserve Component accessions are a concern. Although their overall
strength remains good, accession percentages have declined in the past
2 years.
While recruiting is an obvious challenge, retention is of greater
concern, and much less conspicuous in nature. Unlike recruitment, the
inability to retain a mid-level officer comes at a much higher expense.
For the military, the loss is two-fold--a superb Soldier and a highly
trained and experienced nurse.
Nurses have continually answered the call to service and it is
critical that we develop appropriate retention strategies to ensure an
adequate force structure exists to support our fighting forces. Their
successful retention is a combination of financial compensation,
deployment equitability, and military benefit preservation.
The critically low density area of concentration that is most
severely affected by attrition is the Certified Registered Nurse
Anesthetist (CRNA). CRNA actual end strength has fallen to 70 percent.
With the support of Lieutenant General Kiley, The Army Surgeon General,
Health Affairs and the Army, the ANC was successful in implementing a
major restructuring of the Incentive Specialty Pay (ISP) program for
CRNAs that addressed two issues important to this population. First, it
provided the first increase in ISP in nearly 10 years to officers
fulfilling their initial Active Duty Service Obligation (ADSO). This
change was central to our retention strategy as disparity in pay for
this population was identified as a major source of dissatisfaction.
Additionally, the revised ISP structure provided the option to receive
significantly higher annual ISP payments in exchange for incrementally
longer service obligations, one to 4 years, after completing their
initial ADSO.
Preliminary numbers reveal that of the 116 CRNAs eligible to sign
for multi-year contracts, 84 (72 percent) have done so. The information
suggests a positive correlation and retention of other nursing
specialties may require ISP programs. Our next specialty concerns are
the operating room, intensive care unit (ICU), and emergency room (ER)
nurses who are in high demand both in the Army and the civilian
healthcare market.
Financial compensation is also a retention initiative for our
government service employees. Several civilian personnel initiatives
are focused on alleviating government nursing shortages. Nursing has
benefited from Direct Hire Authority (DHA). The time delay between
finding a candidate and acceptance of a job offer was reduced from over
100 days to an average of 19 days under DHA.
Madigan Army Medical Center is participating in the first iteration
of the National Security Personnel System (NSPS). This system
recognizes the need to modernize the personnel system for the
Department of Defense. The NSPS must significantly improve the
personnel system for healthcare occupations.
One initiative that demonstrates promise is the Army Civilian
Training Education Development System (ACTEDS). This program is an Army
Requirements-based system that ensures development of civilians through
a blending of progressive and sequential work assignments, formal
training, and self-development for individuals as they progress from
entry level to key positions. ACTEDS provides an orderly, systematic
approach to technical, professional, and leadership training and
development similar to the military system. It provides civilian
employees base documents specific for career development within their
chosen profession. Several ACTEDS plans are now available to government
civilian nurses.
Another retention strategy currently implemented focuses on
intrinsic rewards. The role of the Nursing Consultants to the Surgeon
General is expanding to include input into the personnel deployment
system and involvement with the officer distribution process for all
critical wartime specialties. This strategy coupled with implemented
policies to ensure equitable utilization of our deployment pool will
assist us in the retention of highly educated professional nurses.
Limiting the unknown for nurses by providing adequate notification of
impending deployment and providing a predictable period of family
separation should improve retention.
Walter Reed Army Medical Center has partnered with Mount Aloysius
College in Cresson, Pennsylvania as part of a phased 4-year Nursing
Telehealth Applications Initiative. This relationship, which provides a
quality learning experience to improve the academic preparation of
nurses, will assist to alleviate the critical nursing shortage.
The purpose of this study was to determine if the concept of a
``Virtual Clinical Practicum TM'' was a viable venue for nursing
students to gain clinical skills in the absence of physically visiting
clinical sites. Nursing students attending Mount Aloysius College, a
rural community, have no opportunity to experience an ICU environment.
Using Telehealth Technology, nursing students observed and learned
about the nursing care of complicated adult medical patients and
experienced an ICU clinical experience remotely. While students and
faculty remained at Mount Aloysius, the nurse experts, two ANC
Officers, took care of various patients in the Medical ICU at Walter
Reed.
The professionalism and clinical expertise of the ANC officers was
enthusiastically embraced by both the students and faculty. There are
follow-on studies planned with this technology. Our commitment to
address nursing education insufficiencies exemplifies ANC leadership,
innovation, and new approaches to solve current problems.
Nursing research, like the Nursing Telehealth Applications
Initiative, is invaluable to excellent, evidence-based nursing
practice. We thank you for your dedicated funding and continued support
of the TriService Nursing Research Program. Army nurses along with
their Federal and civilian colleagues are dedicated to the
dissemination of knowledge and improvement of professional nursing
practice.
Army Nurses are conducting and participating in a number of studies
specific to the care of deployed troops. Nurses at Walter Reed Army
Medical Center are collaborating with their Air Force colleagues to
assess aeromedical evacuation needs of war injured service members. At
Brooke Army Medical Center, Army and Air Force Nurses are determining
best methods to teach nurses how to care for chemical casualties and
how to facilitate long term skills retention.
Nurse researchers at several locations are investigating deployment
experiences of AMEDD personnel to seek information on improving quality
of care for wounded service members and the emotional health of nursing
personnel. Compassion fatigue of nurses who are working at our fixed
facilities is another area of ongoing inquiry.
Nurses at Madigan Army Medical Center are enhancing Combat Medic
skill sustainment using simulated battlefield conditions and SimMan,
life-sized, computer-linked robots. This study will validate and
standardize Combat Medic evaluation scenarios and template evaluator
competencies.
Madigan Army Medical Center is also studying the impact of head
nurse leadership on retention of junior ANC Officers. This research
will provide information about essential leadership competencies and
performance expectations from ANC Officers.
Nurses at Walter Reed Army Medical Center, Madigan Army Medical
Center, and the Army Medical Department Center and School are
coordinating the multi-site Military Nursing Outcomes Database (MilNOD)
study being conducted at six Army, three Air Force, and four Navy
facilities. This study is investigating the relationship of staffing to
various nurse and patient outcomes. The study team continues to
collaborate with the California Nursing Outcomes Coalition and the
Veteran's Administration Outcomes Database Project (VANOD), building
upon each other's collective experience in this unique work. The
research team and collaborators, including the American Nurses'
Association's National Database for Nursing Quality Improvement
(NDNQI), created the National Nursing Quality Database Consortium and
held an invitational methodology conference this past fall. The purpose
of the conference was to learn from and work with researchers from
other disciplines, who are at the cutting edge of new methods to
analyze these types of data. The National Nursing Quality Database
Consortium is hosting its first national conference this spring to
share the knowledge gained from this collaboration with other
colleagues in the nursing field.
Recognizing the benefit of nursing research departments staffed
with Doctorally prepared nurse researchers conducting militarily
relevant nursing research, I am pleased to announce we have opened a
research department at Tripler Army Medical Center, the fourth in the
Army Medical Department. These nurses are working with the Hawaii
Nursing Taskforce and Queen's Medical Center on a grant submission to
study the Effect of Magnet Environments on Patient and Nursing
Outcomes. Other research initiatives include evidence-based practice
projects to develop standards of practice for pressure ulcer prevention
and preparing children for surgery. Additionally, working with Pearl
Harbor Naval Base and Hickam Air Force Base clinic nurses, military
nurse researchers at Tripler will utilize research findings to
standardize and implement the most appropriate nursing interventions
and document measurable nursing outcomes for specific inpatient and
outpatient military beneficiaries.
Anesthesia students are very involved in research activities
studying pain and re-warming techniques following surgery, and the
effects of different anesthetic medication and adjunct therapies on
patient outcomes. New technologies, such as piezoelectric technology,
are also being studied. This technology allows a Soldiers' vital signs
to be continuously monitored while being transferred from the field to
a definitive care setting.
In addition to our research activities, the ANC is dedicated to
Soldier training and professional military education. Preparing our
Soldiers to provide relevant, competent and professional care in any
environment requires a robust training program. The ANC is constantly
adapting our training programs to prepare Soldiers for their primary
occupational specialty and go-to-war skills.
The Department of Nursing Science (DNS) at the Army Medical
Department Center and School (AMEDDC&S) is using research and lessons
learned from our deployed colleagues to improve training. Among the
many initiatives over the last year, trauma and burn care was
incorporated into the ANC Officer Basic Course. Combat stress education
was added to the Army Nurse Captains Career Course. Ethical treatment
of all patients is highlighted in all of our courses. In addition,
components of Warrior Ethos Training and simulation experiences are
being incorporated into the program to better prepare Soldiers for
combat survival. The U.S. Army School of Aviation Medicine is piloting
a Joint Enroute Care Course to prepare ICU and ER Nurses and improve
care for patients evacuated from the battlefield via rotary wing
aircraft.
The ANC extends our appreciation and recognizes the faculty
leadership of the Uniformed Services University of the Health Sciences
(USUHS) for their academic achievements and initiatives. The Graduate
School of Nursing has been instrumental in providing highly trained,
FNPs, CRNAs, and Doctorally prepared nurses. Graduates from these
programs continue to enjoy a higher than average national pass rate on
certification exams. We look forward to the May graduation of their
first Peri-operative Clinical Nurse Specialist Course and the addition
of a Military Contingency Medicine course.
The ANC continues to move forward with initiatives to improve the
best nursing organization in the world. Our research is changing
nursing practice globally and the officers of the ANC are highly valued
throughout the world. With the continued support of Congress, the
clinical excellence, compassion, and leadership strengths of Army
Nurses will ensure our military men and women receive the world's
finest healthcare anywhere, anytime.
Senator Stevens. Admiral Lescavage.
STATEMENT OF REAR ADMIRAL NANCY J. LESCAVAGE, NAVY
NURSE CORPS, UNITED STATES NAVY
Admiral Lescavage. Good morning, Chairman Stevens, Senator
Inouye, Senator Mikulski. I am Rear Admiral Nancy Lescavage,
the 20th Director of the Navy Nurse Corps and Commander of the
Naval Medical Education and Training Command in Bethesda,
Maryland. It is indeed an honor and privilege to speak before
you about our outstanding 5,000 Active and Reserve Navy nurses
who continue to provide preeminent health care in all
operational, humanitarian, and conventional settings. I want
you to know our military and civilian nurses continue to
proudly demonstrate professional excellence in promoting,
protecting, and restoring the health of all entrusted to our
care anytime and anywhere.
I would like to address five specific areas.
Number one, as our Surgeon General addressed, is readiness.
In this area, Navy medicine's first priority, Navy nurses
remarkably deliver superb medical care throughout the
battlefield continuum. We have recorded over 125,000 mission
days in operational and training exercises. Navy nurses have
deployed this past year throughout the world to Kuwait, Iraq,
Djibouti, Afghanistan, Bahrain, the Philippines, Thailand, and
Guantanamo Bay. As you know, humanitarian efforts have been
provided to tsunami and Haitian relief countries, as well as in
our homeland in Pensacola after Hurricane Ivan.
Some examples of our readiness training are the following.
Through the Navy trauma training course with LA County/
University of Southern California Medical Center in Los
Angeles, our Navy nurse instructors provide participants real-
life exposure while integrating with the hospital's trauma
staff to provide specialized care. Our nurses who are training
there are part of a team of physicians and corpsmen who soon
will go in harm's way. The newly established Navy EnRoute Care
Corps has trained 22 Navy nurses at Camp Lejeune, North
Carolina prior to their deployment to Iraq. This course
includes a training pipeline involving the Air Force critical
care air transport course, Navy trauma training course, and
helicopter egress and water survival training. We also continue
to contract with civilian trauma centers in close proximity to
our medical treatment facilities for additional training and
real-life experiences in trauma.
To optimize the readiness capability of our sailors and
marines, we have placed nurse practitioners on board our
aircraft carriers Nimitz, Kennedy, and Enterprise. In addition
to rendering traditional episodic care on those carriers, our
nurse practitioners promote wellness through post-deployment
health assessments, tobacco cessation, and medical exams. A
nurse practitioner with two other health care team members was
recently deployed to the Nimitz to assist 6,000 of our sailors,
who were just coming back from the Middle East, which resulted
in the most efficient completion of the post-deployment health
assessment evolution known to any vessel.
The second area I want to address is quality health
services. In sync with Navy medicine's second priority of
delivering quality and cost-effective health care, our Navy
nurses span the continuum of care from promoting wellness to
maintaining the patient's optimal performance. Innovative
examples include the mental health nurse outreach program with
the Marine Corps School of Infantry at Camp Lejeune, the
Partnership for In-Garrison Health and Readiness in Camp
Pendleton, and the Nurse Managed Welcome Center at Pearl
Harbor. Through a comprehensive referral network with the VA
transition program, our nurse case managers are right in there
assessing rehab specialists in collaboration with other
specialties for our returning casualties to get the best care
possible.
Other initiatives include the Nurse Run Medevac Transport
Team at Bethesda and our specialized wound care clinics
throughout our medical treatment facilities (MTF).
In an age of cost containment, our nurses are savvy in
business planning and continuously evaluate best health care
business practices. Nurses in the ambulatory care setting have
implemented clinical business rules and performance goals to
guide their daily practice. Disease management programs for
asthma, diabetes, breast cancer, and cardiac care have improved
the patient screening rates. They have recaptured network costs
and they have maximized provider productivity and guaranteed
exceptional continuity of care, which is what it is all about.
To enhance our quality of care, a sample of research topics
includes clinical knowledge development from care of the
wounded during Operation Iraqi Freedom, retention of recalled
Nurse Corps Reservists, the effects of oxidative stress on
pulmonary injury in our Navy divers, and factors associated
with post partum fatigue in our Active duty women in the
military. Several of these studies are funded by the TriService
Nursing Research Program, which fosters military nursing
excellence and promotes collaboration between not only military
nurse researchers but with academia as well.
In support of One Navy Medicine concept, which Admiral
Arthur spoke to, the integration of our Active, Reserve, and
civilian nurses renders a more efficient, effective, and fully
mission-ready nursing force. With the deployment of over 400 of
our Active duty Navy nurses, along with the mobilization of our
reserve Navy nurses to support our military treatment
facilities, there has been neither a reduction of inpatient bed
capacity nor an increase of disengagements to the network.
Together, as an example, we have also optimized joint
training opportunities such as the chem-bio-radiological
Defense training program between Navy Health Care New England,
the Rhode Island National Guard and the marines at their local
Reserve center. In addition, while our Active duty nurses
attend the EnRoute Care course, our Reserve nurse officers
participated in a pilot program of the Joint EnRoute Care
course in the U.S. Army School of Aviation at Fort Rucker.
Never have opportunities been greater for all of our corps
to be in executive positions. To meet the mission in all care
environments through Navy medicine's fourth priority of shaping
our force, it is critical we specifically shape Navy nursing
with the right number of nurses with the right education and
training in the right assignments at the right time. Our Active
duty component is presently 96 percent manned, with 2,979 of
our almost 3,100 positions filled. However, for the first time
in over 10 years, we only attained 68 percent of our fiscal
year 2004 Active duty recruitment goal, acquiring 63 out of 92
nurses.
Of note, though, we recently increased our nurse accession
bonus to $15,000 to be competitive with the other services. In
addition, since the inception of the Nurse Candidate Program,
this is the first year we were able to essentially double the
accession bonus from $5,000 to $10,000 and their monthly
stipends doubled as well from $500 to $1,000.
Regarding our Reserve recruiting goal, we may experience
challenges in attaining specific specialties. Of particular
note, the hospital corpsmen professional development option was
initiated last year for Reserves as part of a 3-year pilot
program. In this scenario, our Reservists are provided drill
credits while attending a bachelor of science in nursing
curriculum. This upward mobility program will serve as an
accession source for junior Nurse Corps officers.
We also, in five of our military treatment facilities, are
doing a pilot program where nurses are paid similar to VA
nurses for on-call, holiday, weekend, and shift differential,
and that is registered nurses (RNs) and in the future our
licensed practical nurses (LPNs).
Promoting retention, we have several initiatives to retain
our talented professional nursing force. Our graduate education
scholarship program is our number one retention tool. We give
about 90 of those scholarships every year. We carefully
identify our graduate education programs and we are trying to
take the specialties that are most used in wartime and train to
them. We strongly support our nurses to attend USUHS.
Another significant first-time accomplishment. We were able
to increase the certified registered nurse anesthetist
incentive special pay to a multiyear contract this year. As
part of a 1-year pilot program, we also have initiated special
pays similar to the VA hospitals, as stated. After 1 year, we
will evaluate these programs to see what that does for our
retention and increasing salaries.
To maximize our joint medical capabilities, as our final
priority, we collaborate and integrate with the other services,
as well as with local, State, and Federal agencies. As nurses
function in significant roles in homeland security within Navy
medicine, we also participate in joint programs for chemical
and biological defense, and in many of our treatment
facilities, nurses are at the forefront for emergency
preparedness.
In conclusion, the Navy Nurse Corps has been consistently
dynamic in this ever-changing world. Our Navy nurses are using
the latest technology, as you well know. We are conducting
cutting-edge research and creating health policies across
military medicine to advance our practice and improve all of
our delivery systems.
It has been an honor to serve as the 20th Director of the
Navy Nurse Corps. I am very proud of our distinguished corps
and of our great history. The Nurse Corps this Friday on May 13
turns 97 years old. As I move on to a new assignment as
Director of TRICARE Regional Office West in San Diego, I remain
committed to the Navy Nurse Corps, our great Navy, and the
Marine Corps team, and the Department of Defense. Like many of
our Navy nurses and my professional colleagues who function in
pivotal executive roles, I will continue to support our efforts
to impact legislation, health care policy, and medical delivery
systems. I hand the Navy Nurse Corps over to the very capable
leadership of my successor, Rear Admiral (Select) Christine
Bruzek-Kohler.
My greatest gift every day lies in working with the fine
officers and civilians who support our military and in
collaborating with my splendid colleagues, not only in the
armed forces, but across academia and in our Federal and
international governments. I want you to know we give our best
always to the heroes, past and present, who keep this country
free and our best to their families who support them so well.
Thank you. As always, we appreciate your great support.
Senator Stevens. Thank you, Admiral.
Admiral Lescavage. You are welcome, Senator.
[The statement follows:]Lescavage.txt
Prepared Statement of Rear Admiral Nancy J. Lescavage
Good morning, Chairman Stevens, Senator Inouye and distinguished
members of the Committee. I am Rear Admiral Nancy Lescavage, the 20th
Director of the Navy Nurse Corps and Commander of the Naval Medical
Education and Training Command. It is indeed an honor and privilege to
speak before you about our outstanding 5,000 Active and Reserve Navy
Nurses who continue to provide preeminent health care in all
operational, humanitarian and conventional settings.
As key members of the Navy Medicine team, our military and civilian
nurses proudly demonstrate operational readiness and personal
excellence in promoting, protecting and restoring the health of all
entrusted to our care anytime, anywhere. Aligned with our Surgeon
General's five priorities, we continuously monitor our capabilities and
embrace innovations to meet challenges head-on during these rapidly
changing times. I will address each priority and illustrate how Navy
Nursing meets our unique dual mission in the support and protection of
our operational forces, while at the same time providing health care to
family members and retirees.
READINESS
In the area of readiness, Navy Medicine's first priority, Navy
Nurses continue to readily adapt and remarkably deliver superb medical
care throughout the battlefield continuum in support of our operational
and humanitarian mission via Surgical Companies, Surgical Teams, Shock
Trauma Platoons, the Forward Resuscitative System, Fleet Hospitals,
Expeditionary Medical Facilities, on Navy and Hospital Ships, and our
Military Treatment Facilities at home and abroad. In addition to the
services provided by our nurses assigned to operational billets, we
have recorded more than 125,000 mission days in operational and
training exercises. Operational platform and intensive trauma training
formulate the framework for our nurses to capably provide immediate and
emergent interventions and perform safely in any situation or austere
environment.
In meeting our mission requirements, we continuously shape our
Force Structure with emphasis on critical care, emergency, trauma,
perioperative, medical-surgical, anesthesia and mental health nursing
specialties. Navy Nurses have deployed this past year throughout the
world to Kuwait, Iraq, Djibouti, Afghanistan, Bahrain, the Philippines,
Thailand and Guantanamo Bay, Cuba. Humanitarian efforts have been
provided to Tsunami and Haitian relief countries, as well as Pensacola
after Hurricane Ivan. Together with our Canadian and British active and
reserve colleagues, we have also been involved in several large
combined joint task force exercises. To achieve all of this and more,
our mobilized Reserve Nurses have spectacularly integrated with our
military and civilian staff and have dedicated themselves to providing
exceptional care to our service members and beneficiaries on the
homefront.
To enhance our mission-ready capabilities, joint training
opportunities have been maximized with our military and civilian
medical communities which involves hands-on skills training, the use of
innovative state-of-the-art equipment, and the proliferation of web-
based programs for multi-system trauma casualties. Through the Navy
Trauma Training Course (NTTC) with the LA County/University of Southern
California Medical Center in Los Angeles, Navy Nurse instructors
provide participants ``real life'' exposure while integrating with the
hospital's trauma staff to provide specialized care. Our 46 nurses who
rotated through the program this past year have stated that they were
better prepared to treat our trauma casualties. The newly established
Navy EnRoute Care Course recently trained 22 Navy Nurses at Camp
Lejeune, North Carolina, prior to deploying them to Iraq. This course
includes a training pipeline involving the Air Force Critical Care Air
Transport Course, Navy Trauma Training Course, and Helicopter Egress/
Water Survival training. This highly specialized care is essential to
our Forward Resuscitative Surgery System in order to transport and
provide required medical care to patients who are at risk of sudden,
life threatening changes prior to their transport to a higher echelon
level of care. Through the Tri-service Combat Casualty Course, our
nurses train in simulated combat conditions. For specific nursing
specialty needs, the Services have supported each other. One fine
example is the coordination of intensive care unit training with
Landstuhl Medical Center for our nurses in Naples, Italy. We also
continue to contract with civilian trauma centers in close proximity to
our Military Treatment Facilities for didactic training and ``hands-
on'' care. In addition, our Nurse Internship Programs at several of our
teaching facilities continue to facilitate the transition of our new
nurses into the Navy.
To optimize the readiness capability of our Sailors and Marines, we
have placed nurse practitioners onboard the aircraft carriers NIMITZ,
KENNEDY, and ENTERPRISE. In addition to rendering traditional episodic
care, they promote wellness through post-deployment health assessments,
tobacco cessation, and medical exams. Additionally, the nurse
practitioners conduct medical training (e.g. Basic Life Support and
Deckplate Health Promotion Courses). They also update medical supplies,
equipment and practice guidelines while underway. A nurse practitioner
with two other health care team members was deployed to the aircraft
carrier NIMITZ to assist 6,000 sailors returning from Iraq, resulting
in the most efficient completion of the Post Deployment Health
Assessment Evolution of any vessel as hallmarked by the Commander of
the Naval Air Force, United States Pacific Fleet.
QUALITY HEALTH SERVICES
In sync with Navy Medicine's second priority of delivering quality
and cost-effective health care, our Navy Nurses span the continuum of
care from promoting wellness to maintaining the optimal performance of
the entire patient.
Innovative health services programs and joint partnerships across
our military treatment facilities help us to maintain a readiness focus
for our patient population. Examples include the Mental Health Nurse
Outreach Program with the Marine Corps School of Infantry at Camp
Lejeune; the Partnership for In-Garrison Health and Readiness in Camp
Pendleton; and the Nurse-Managed Welcome Center at Pearl Harbor,
Hawaii. Nurses in the Case Management Department at the National Naval
Medical Center have programs supporting the continuum of care for our
returning casualties. Through a comprehensive referral network with the
Veteran Affairs' Transition Program, our nurses can access
collaboratively-developed clinical practice models such as traumatic
brain injury and post traumatic stress guidelines. They additionally
utilize rehabilitation specialists and are now able to identify the
best available health care while the patient is on convalescent leave
or is between rehabilitation stays. There are many other military
member initiatives, such as the Nurse Run Medevac Transport Team at
Bethesda, Maryland that cares for returning casualties. We have
specialized Wound Care Clinics throughout our military treatment
facilities and we, now more than ever, utilize our mental health
nurses.
The Nurse Call Center at Jacksonville, Florida is the benchmark for
other military treatment facilities and provides 24/7 triage and advice
coverage, emergency room follow-up calls, and a direct link to the
patient's primary care manager or specialist. Disease Management
Programs for asthma, diabetes, breast cancer, and cardiac care have
improved screening rates; recaptured network costs; maximized provider
productivity; and guarantee exceptional continuity of care at Patuxent
River, San Diego, and Cherry Point. Other innovative programs include
the Health Lifestyle Choice Program for children and teens at San Diego
and the Post Partum Clinics in Bremerton, Pensacola, Guam, Twenty-Nine
Palms, and Yokosuka. In concert with the Armed Forces Center for Child
Protection, the Shaken Baby Syndrome Prevention Program is now being
piloted at six of our hospitals with additional emphasis on parent
training.
In an age of cost containment while promoting high quality of
patient care, it is essential that nurses are trained in business
planning and continuously evaluate best health care business practices.
For example, one of our nurses developed a survey to evaluate disease
(asthma and diabetes) and condition management measures as part of a
Navy-wide ``Disease and Condition Management Report Card'' which is
comprised of clinical and financial metrics. At Bethesda, nurses in the
ambulatory care setting have implemented clinic business rules and
performance goals to guide daily practice. At Naval Hospital
Jacksonville and the Naval Medical Center Portsmouth, nurses have
collaboratively developed an electronic patient tracking system which
integrates the Emergency Department with Ancillary Services. Through
the use of information technology, patient status and movement within
the facility are closely monitored; clinical data is more expeditiously
recalled; and personnel resources can be adjusted for well-justified
reasons.
Research priorities are focused on workforce retention, clinical
practice, deployment experiences, outcomes management, and the gaining
of specific competencies. A sample of research topics includes:
clinical knowledge development from care of the wounded during
Operation Iraqi Freedom; the perinatal depression screening program;
retention of recalled Navy Nurse Corps Reservists; the effects of
oxidative stress on pulmonary injury in Navy divers; retention criteria
for military health system nurses; and factors associated with post
partum fatigue in Active Duty military women. Several of these studies
are funded by the TriService Nursing Research Program, which fosters
military nursing excellence and promotes collaboration between not only
military nurse researchers but with academia as well.
Our nursing research has been disseminated through countless
professional forums worldwide, such as at distinguished conferences
sponsored by the National Nursing Honor Society Sigma Theta Tau, the
Association of Military Surgeons of the United States (AMSUS), TRICARE,
Royal College of Nursing of the United Kingdom, and the Micronesian
Medical Symposium. Numerous publications by Navy Nurses can be found in
prestigious professional journals, such as the Journal of Trauma,
Critical Care Nurse, Journal of the American Association of Nurse
Anesthetists, Military Medicine, Geriatric Nursing and many more. In
addition, many of our nurses have received esteemed awards at
University Annual Research Day presentations, as well as at the Phyllis
J. Verhonick Army Research Conference which acknowledged a joint
service study called, ``A TriService Integrated Approach to Evidence
Based Practice.''
ONE NAVY MEDICINE
In support of the One Navy Medicine concept as a third priority,
the integration of active, reserve and civilian nurses renders a more
effective, efficient and fully mission-ready nursing force both at home
and abroad. With the deployment of over 400 Active Duty Navy Nurses
along with the mobilization of Reserve Nurses to support our Military
Treatment Facilities, there has been neither a reduction of inpatient
bed capacity nor an increase of network disengagements.
Together, we have also optimized joint training opportunities, such
as the Chemical, Biological and Radiological Defense (CTR-D) Program
training between the New England Naval Health Care Ambulatory Clinics,
the Rhode Island Air National Guard, and the Marines at their local
Reserve Center. Expert instructors deliver both classroom and
confidence chamber training, including exercises involving the use of
gas masks and chemical suits. While our Active Duty Nurses attend the
Navy EnRoute Care Course, our Reserve Nurse Corps Officers recently
participated in a pilot program of the Joint Medical EnRoute Care
Course at the U.S Army School of Aviation Medicine at Fort Rucker,
Alabama. This program combines medical skills and rotary wing training
to create a cadre of joint service, multidisciplinary team members to
provide an advance level of care during transport.
SHAPING TOMORROW'S FORCE
To meet the mission in all care environments through Navy
Medicine's fourth priority of shaping tomorrow's force, it is critical
that we continuously focus on our human capital strategy. Our goal here
is to specifically shape Navy Nursing with the right number of nurses
with the right training in the right assignments at the right time, and
become the premier employer of choice for active, reserve and civilian
nurses. We accomplish this through several interdependent processes.
With nurse executive leadership, we have identified specific nursing
specialties for each deployable assignment to meet operational
requirements. Personnel with the right clinical expertise are assigned
to deployable platforms. When not deployed, these nurses serve in our
Military Treatment Facilities to meet our peacetime mission. We
carefully identify graduate education programs that best meet our
specific requirements, such as our wartime specialties in critical
care, emergency, trauma, perioperative, anesthesia, medical-surgical
and mental health. Finally, while closely monitoring the national
nursing shortage, we continue to pursue available authorities to
recruit and retain our exceptionally talented nurses.
Our Active Duty component is presently 96 percent manned with 2,979
of our 3,094 positions filled. As a result, our recruitment efforts are
focused on maintaining adequate staffing to continue to meet our
mission, particularly in our critical wartime specialties. Our pipeline
scholarship programs help contain our annual recruiting goals. However,
for the first time in over 10 years, we only attained 68 percent of our
fiscal year 2004 Active Duty recruitment goal, acquiring 63 out of 92
nurses. We recently met with success in increasing our Nurse Accession
Bonus to $15,000; we continue to maintain our presence at national
nursing conferences and tap Navy Nurses at all levels to market our
career opportunities to their professional associations. Since the
inception of the Nurse Candidate Program, this is the first year we
have essentially doubled the Accession Bonus from $5,000 to $10,000 and
the monthly stipend from $500 to $1,000.
Regarding our reserve recruiting goal, we may experience challenges
in attaining our specific specialty in some areas. Of particular note,
the Hospital Corpsman/Dental Technician Professional Development Option
was initiated last year for the Reserves as part of a 3-year pilot
program. Reservists are being provided drill credits while attending a
Bachelor of Science in Nursing curriculum. This upward mobility program
will serve as an accession source for junior Nurse Corps Officers.
Promoting retention, we have several initiatives to retain our
talented professional nursing force. As mentioned earlier, our graduate
education scholarship program is a primary motivator for recruitment
and our number one retention tool. Within our education plan, we
strongly support nurses who choose to attend the Graduate School of
Nursing at the Uniformed Services University of Health Sciences. At
present we have sixteen students in the Nurse Anesthesia, Family Nurse
Practitioner, Perioperative Clinical Nurse Specialist, and Doctoral
Programs with an additional eleven students slated to begin in the
coming academic year. As we continue to collaborate and identify our
mission requirements, the faculty leadership has refined their
curricula to meet our needs. Two classic examples include the
development of the Military Contingency Medicine/Bushmaster Program to
optimize mission readiness and the focus of research efforts towards
relevant military nursing topics.
Another significant first-time accomplishment to assist in our
retention efforts, we were able to increase the Certified Registered
Nurse Anesthetist Incentive Special Pay or ISP to a multi-year contract
program. For all Nurses, we continue to focus on quality of
professional life by granting appropriate scopes of practice and giving
them challenging leadership positions.
To recruit civil service nurses, we continue to use Special Hire
Authority to expeditiously hire nurses into the federal system. We
sometimes can supplement these new hires with recruitment, retention
and/or relocation bonuses depending on staffing requirements and
available funds. As part of a 1-year pilot program, we have initiated
Special Pays for registered nurses at five of our Military Treatment
Facilities for such things as on-call, weekend, holiday, and shift
differential with increased compensations. We will soon pilot the
program for Licensed Vocational Nurses at the same sites. After 1 year,
we will evaluate the effectiveness of these programs in retaining these
clinical experts.
JOINT MEDICAL CAPABILITIES
In continuously shaping our human capital work force of nurses, we
are better able to collaborate and integrate with the other Services,
as well as local, state and federal agencies to maximize our joint
medical capabilities within our final priority of working jointly.
Nurses now function in significant roles in Homeland Security within
Navy Medicine by developing policy, plans and a concept of operations
and then managing programs that focus on the security of our customers
and our bases. The challenges of today have created a need to evolve
the nursing role into a greater perspective that crosses the joint
service and interagency world at all levels. As one example, a Navy
Nurse is one of two medical representatives working with the Joint
Program Executive Office for Chemical and Biological Defense to assess
and analyze installations to identify appropriate levels of CBRN
(chemical, biological, radiological, nuclear) equipment distribution
and support for 59 Navy installations. Nurses at Bethesda, Maryland
have been at the forefront with the first collaborative emergency
preparedness exercise involving military, federal and civilian health
care facilities in the National Capitol Region. In addition, in many of
our Military Treatment Facilities, nurses are assigned disaster
preparedness and homeland security responsibilities. Noted for our
clinical expertise, operational experiences and solid leadership
qualities, I can assure you that our Navy Nurses are collaborating at
all levels.
CONCLUSION
The Navy Nurse Corps has been consistently dynamic in this ever-
changing world, remaining versatile as visionary leaders, innovative
change agents and clinical experts in all settings. Our Navy Nurses are
at the forefront using the latest technology in the operational setting
and in our Military Treatment Facilities; conducting cutting edge
research; performing as independent practitioners; and creating health
care policies across Military Medicine to advance nursing practice and
to improve delivery systems.
I appreciate the opportunity to share the accomplishments and
issues that face Navy Nursing. It has been an honor to serve as the
20th Director of the Navy Nurse Corps. I am very proud of our
distinguished Corps and of our great history. As I move on to a new
assignment as Director of TRICARE Region West in San Diego, I remain
committed to the Navy Nurse Corps, our great Navy and Marine Corps
Team, and the Department of Defense. Like many of our other Navy Nurses
and my professional colleagues who function in pivotal executive roles,
I will continue to support our efforts to impact legislation, health
care policy and medical delivery systems. I hand the Navy Nurse Corps
over to the very capable leadership of my successor, Rear Admiral
(Select) Christine Bruzek-Kohler.
My greatest gift everyday lies in working with these fine Officers
and Civilians and in collaborating with my splendid colleagues across
the services, across academia and in our federal and international
governments. I want you to know we give our best always to those heroes
and families who keep this country free. There is no greater honor than
to serve. Thank you.
Senator Stevens. General Brannon.
STATEMENT OF MAJOR GENERAL BARBARA C. BRANNON,
ASSISTANT AIR FORCE SURGEON GENERAL FOR
NURSING SERVICES, DEPARTMENT OF THE AIR
FORCE
General Brannon. Chairman Stevens, Senator Inouye, and
Senator Mikulski, I am delighted to once again represent your
Air Force nursing team. This year marks my sixth report to you,
and it is amazing how quickly the years pass by.
Our Air Force Medical Service has persevered in providing
outstanding health care in a very dangerous world. Air Force
nurses and aerospace medical technicians are trained, equipped,
and ready to deploy anywhere anytime at our Nation's call. It
has been an honor to care for so many heroes.
In support of Operations Enduring Freedom and Iraqi
Freedom, 2,160 Air Force nurses and technicians deployed this
past year. Our aeromedical evacuation (AE) system has proven to
be the critical link in the chain of care from battlefield to
home station.
In 2004, Air Force nursing AE crews completed 2,866
missions supporting 28,689 patient movement requests around the
world. Critical care air transport teams (CCATT) were used in
486 of the AE operations.
CRITICAL CARE AIR TRANSPORTATION TEAMS
The synergy of combining our AE crews with these critical
care air transportation teams has enabled us to transport more
critically ill patients than ever before. Additionally,
advances in technology and in pain management have greatly
enhanced patient comfort and patient safety.
SPECIALTY PROVIDERS
The success of deployed medical care depends on having
specialty providers available when needed. Certified registered
nurse anesthetists fulfilled 100 percent of their deployment
taskings, plus 47 percent of the anesthesiologist taskings.
They have ably met all mission requirements and patient care
needs.
Lieutenant Colonel Bonnie Mack and Major Virginia Johnson
deployed to Tallil Air Base in Iraq as the only anesthesia
providers for 20,000 United States and coalition forces. On one
occasion Colonel Mack and Major Greg Lowe provided 24 hours of
anesthesia for six Italian soldiers who were severely wounded
in a terrorist bombing. These men survived only because expert
anesthesia and emergency surgery was close at hand.
Air Force mental health nurses have also played an
important role in caring for our wounded and for our health
care teams. Sixteen mental health nurses were deployed to the
Ramstein Air Base contingency air staging facility to support
patients from all services. They provide early intervention to
ameliorate long-term emotional effects and in some cases even
facilitate return to duty in theater. We recently incorporated
mental health nurse practitioners into our provider teams, and
they can also substitute for psychiatrists and psychologists in
the deployed setting.
332ND EXPEDITIONARY MEDICAL GROUP
Our largest group of Air Force medical ``boots on the
ground'' is at the 332nd Expeditionary Medical Group at Balad,
which transitioned from Army to Air Force staffing last
September. Its multinational team currently includes 148 Active
duty Air Force nursing personnel, and they have many stories to
tell. They provided lifesaving surgery for a 65-year-old Iraqi
woman who triggered an explosive device as she answered her
front door. Her daughter was a translator for the U.S. forces.
They cared for the wife of an Iraqi policeman and her two
children, all badly burned, when a grenade was thrown into
their home. Since September, this team has supported 10 mass
casualties, 3,800 patient visits, and 1,550 surgeries.
Air Force nurses are outstanding commanders in both the
expeditionary environment and at home station. This past year,
3 nurses have deployed as commanders of expeditionary medical
units, and at home there are 16 nurses commanding Air Force
medical groups, 45 nurses command squadrons and 1, Colonel
Laura Alvarado, is serving as a Vice Wing Commander.
The nurse shortage does continue to pose an enormous
challenge and we need to maintain robust recruiting to sustain
our Nurse Corps. This year we have brought 110 new nurses on to
Active duty, which is slightly more than at this same point
last year.
NURSE RETENTION
Retention, of course, is the other key dimension of force
sustainment, and while monetary incentives play the key role in
recruiting, quality of life issues become important as career
decisions are being made. We continue to enjoy excellent
retention in the Air Force and we ended fiscal year 2004 close
to our authorized end strength.
In 2004, the services were directed to identify non-wartime
essential positions for conversion to civilian jobs. Initially
we targeted almost 400 nursing positions for conversion over
the next 3 years, primarily in our outpatient areas. This
allows us to concentrate our Active duty nursing personnel in
areas that will sustain their wartime skills. As force shaping
continues, we will identify additional positions, but recognize
that the nursing shortage may present hiring challenges.
TRISERVICE NURSING RESEARCH PROGRAM
The TriService Nursing Research program continues to
support major contributions to the science of nursing. This
year 25 Air Force nurses are engaged in studies covering topics
from expeditionary clinical practice to retention. For example,
Reserve nurse Colonel Candace Ross is the principal
investigator for a study on the impact of deployment on
military nurse retention. Her findings should provide a road
map for more effective retention strategies.
The Graduate School of Nursing at the Uniformed Services
University is very responsive to developing programs to meet
our military nursing requirements. The school graduates its
first class of perioperative clinical nurse specialists in May
and the inaugural Ph.D. class will complete its very successful
second year. Our certified registered nurse anesthetists
(CRNAs) program at USUHS continues to graduate top-notch
providers who score well above the national average on their
certification exam. In 2004, 9 out of the 13 graduates earned a
perfect score on the examination. This program is also unique
in that it provides hands-on experience in field anesthesia.
PREPARED STATEMENT
Mr. Chairman and distinguished members of the subcommittee,
it has certainly been a tremendous honor to serve our Nation
and to lead the more than 19,000 men and women of our Active,
Guard, and Reserve total Air Force nursing force. I have
increasingly treasured your support and your advocacy during
this very challenging time for nursing and for our Nation.
Thank you for inviting me once again to tell our Air Force
nursing story. No one comes close.
[The statement follows:]
Prepared Statement of Major General Barbara C. Brannon
Mr. Chairman and distinguished members of the committee, it is an
honor and great privilege to again represent your Air Force nursing
team. This year marks my sixth report to you and I am amazed how
quickly the years pass by. It has been an honor to support and care for
so many heroes--military men and women ready to sacrifice their lives
for the cause of freedom, national security and a safer world.
Our Air Force Medical Service has persevered in providing
outstanding healthcare in a very dangerous world. Terrorist
organizations continue to challenge our peace and security and natural
disasters have taken a huge toll in death and devastation. Air Force
Nurses and Aerospace Medical Technicians are trained, equipped and
ready to respond anytime, anywhere at our nation's call.
EXPEDITIONARY NURSING
In support of Operations ENDURING FREEDOM and IRAQI FREEDOM, 2,160
nurses, and technicians deployed this past year as members of 10
Expeditionary Medical Support Units, two Contingency Aeromedical
Staging Facilities (CASF), and five Aeromedical Evacuation (AE)
locations. Three nurses commanded expeditionary medical facilities and
provided outstanding leadership. Today, Air Force nursing personnel are
serving in a large theater hospital in Balad, smaller hospitals at
Kirkuk and Baghdad International Airport, and in other deployed
locations.
The 332nd Expeditionary Medical Group at Balad is currently home to
70 nurses, 6 licensed practical nurses and 99 medical technicians. This
multi-national group includes 148 nursing personnel from the Air Force
active duty team. During this current rotation, they have already
supported 3,800 patient visits with 1,600 hospital admissions and 1,550
surgeries. Some patients with massive trauma require surgical teams
that include up to seven different surgical specialties simultaneously.
They have responded to at least 10 mass casualty surges and have many
stories to tell. They provided lifesaving surgery and cared for a 65-
year-old Iraqi woman who triggered an explosive device when she
answered her front door. Her daughter was a translator for U.S. Forces.
They cared for a young mother, her two-year old child, and her two-
month old baby, all badly burned when a grenade was thrown into their
home. Her husband is an Iraqi policeman. The team in Balad is our
largest group of Air Force medical ``boots on the ground,'' providing
life-saving surgery, intensive care and preparation for aeromedical
evacuation.
I have had the opportunity to watch our tremendous Air Force
nursing team in action as they provide world-class healthcare to
wounded soldiers, sailors, marines and airmen. Military medics are
saving the lives of people with injuries that would have been fatal in
other wars. During World War I, 8.1 percent of the wounded died of
their wounds. Today, lifesaving medical capability is closer to the
battlefield than ever before, and in Iraq only 1.4 percent of the
wounded have died.
Aeromedical Evacuation has proven to be the critical link in the
chain of care from the battlefield to home station. The availability of
aircraft for patient movement is fundamental to the Aeromedical
Evacuation system. Patient support pallets and additional C-17 litter
stanchions have increased the number of airframes that can be used for
aeromedical evacuation.
In 2004, our Air Force nursing AE crews have flown 2,866 missions
supporting 28,689 patient movement requests around the world. The
majority of our AE missions are crewed by members of the Air National
Guard and Air Force Reserve; it is a seamless, total nursing force
capability.
The synergy of combining aeromedical evacuation crews with critical
care air transport teams (CCATT), additional high-technology equipment,
advances in pain management and more extensive crew training has
enabled us to transport more critically-ill patients than ever before.
In 2004, CCATT teams were used in 486 patient movement operations. For
example, Major Gregory Smith from Wright-Patterson Air Force Base was
deployed as the nurse on a three-person CCATT. The team cared for nine
casualties who required intensive care and were wounded during the
Battle for Fallujah. Six of these patients had lifesaving surgery
within six hours of injury and were evacuated from the field hospital
within 48 hours of injury. Eight of the nine patients required
mechanical ventilation during the flight. CCATT capability makes early
air transport possible, reducing the requirement for in-theater beds
and delivering injured troops to definitive care within hours rather
than days.
There are many, many examples of the tremendous capability and
endurance of the AE crews. In one instance, Major Marianne Korn, a
reserve flight nurse from the 452nd Aeromedical Evacuation Squadron,
March Air Force Reserve Base, and her AE crew transported 82 patients
from Ramstein Air Base to Andrews Air Force Base in response to
Operation PHANTOM FURY. Overall, during this time the squadron surged
to support a 35 percent mission increase and transported more than
1,400 patients between the CENTCOM, EUCOM and NORTHCOM theaters.
Another integral part of the aeromedical evacuation system is the
Aeromedical Staging Facility (ASF) that serves as both an inpatient
nursing unit and passenger terminal for patients in transit. They are
staffed primarily by nursing personnel from the reserve, guard and
active component of the Air Force. The level of activity is tied
closely to the intensity of the conflict. ASF nurse Lieutenant Karen
Johnson and her team cared for 296 patients from 13 separate missions
within a three-day period following fierce fighting in Operation
PHANTOM FURY.
About that same time, Colonel Art Nilsen, Chief Nurse of the Air
Force Squadron at Landstuhl Regional Medical Center, wrote to me and
highlighted the tremendous accomplishments of the Army and Air Force
team working together in that hospital. He invited me to visit and, in
early December, barely three weeks later, I landed at Ramstein Air Base
in Germany. My first stop was the 435th CASF at Ramstein, celebrating
its first anniversary. Major Todd Miller, Chief Nurse, shared the
amazing successes of the CASF over the past year. Deployed personnel
have staffed the CASF on a rotational basis; a total of 391 nursing
personnel from 55 Air National Guard, Air Force Reserve and active duty
units. The team cares for every patient that transits Ramstein, a total
of more than 22,000 in 2004. In the CASF, an empty bed is a welcome
sight and means another patient is a step closer to home.
It was already dark when I went out to the aircraft with the CASF
team. I had a chance to talk with each patient as they were transferred
from the aircraft to the waiting ambulance bus. It had been a long and
uncomfortable flight, but it was obvious that they had been well cared
for and were anxious to continue their journey home. Many talked about
the wonderful medical care they had received and gave special praise to
the Air Force team at the theater hospital at Balad Air Base and to the
AE crews.
I met many of these young men again when I visited Landstuhl
Regional Medical Center. My visit was shortly after the battles in
Fallujah, and the hospital and AE system were at surge capacity, as
busy as in the early months of war. I will never forget the wounded
marines and soldiers at Landstuhl. I was humbled by their acts of
courage, their unwavering loyalty and sense of duty to their buddies.
The nursing team on the units looked tired but energized. Everyone was
working long hours and extra days. But when word came that an aircraft
was arriving from Iraq, they came in to help--on days off and even
after finishing a long shift. Many said they thought this would be the
sentinel experience of their lives and careers. Those who had worked in
large civilian trauma centers said they had never before cared for
patients with injuries as severe.
Two days later, I was headed home on a C-17 with eighteen litter
patients, another twenty who were ambulatory and an AE crew from the
315th Reserve Squadron at Charleston, SC and the 94th Reserve Squadron
at Dobbins, GA. The medical crew director was Major Joyce Rosenstrom, a
reserve nurse with the 315th. There was also a critically wounded
marine on board who was accompanied by an active duty CCATT from the
medical center at Keesler Air Force Base, MS., led by pulmonologist,
Col Bradley Rust. The other team members were critical care nurse, Capt
Erskine Cook and cardio-pulmonary technician SrA Laarni San-Agustin.
The ten-hour flight was relatively uneventful with the medics working
non-stop to ensure each patient received great care with particular
attention to pain management. At the Andrews Air Force Base flight
line, medical personnel from the Air Force hospital, Walter Reed Army
Medical Center and Bethesda Naval Medical Center transferred patients
to waiting ambulance buses. The patients' journey from the battlefield
back to the United States was complete.
The success of deployed medical care depends on having specialty
providers available when needed. Anesthesiologists are key members of
surgical teams, but significant shortages on active duty have left gaps
on deployment packages. Certified Registered Nurse Anesthetists (CRNAs)
have filled deployment requirements for anesthesia providers forty-
seven percent of the time and have ably met all mission and patient
care requirements.
Lieutenant Colonel Bonnie Mack and Major Virginia Johnson are CRNAs
deployed to Tallil Air Base in Iraq as the only anesthesia providers
for over 20,000 U.S. and coalition forces, and civilian contract
personnel. During their deployment, a terrorist bomb ignited an Italian
police compound just 10 kilometers from their facility. Colonel Mack
and Major Greg Lowe provided anesthesia during the surgeries of six
severely wounded Italian soldiers, working continuously for almost 24
hours. These men survived because emergency surgical intervention and
anesthesia were there to support them.
During her deployment, Colonel Mack also served on a Critical Care
Expedient Recovery Team assembled at Tallil to provide medical care on
combat search and rescue missions when a para-rescue team is not
available. Their role is to provide care during transport of recovered
crew members to a medical facility. A mission can take the team into
dangerous territory, but she willingly volunteered. In her words ``it
is a great honor to be involved in the safe return of even one
airman.'' Her team flew training missions and launched in response to a
bombing in Karbala, but fortunately did not have to respond to a downed
airman.
Major Delia Zorrilla, a perioperative nurse, was awarded the Bronze
Star in recognition of her tremendous service while deployed to Manas
Air Base, Kyrgyzstan in support of Operation MOUNTAIN STORM. She served
as the Chief Nurse of the facility and established a resupply system
that ensured critical surgical supplies were available 24/7.
Our mental health nurses have played an important role in caring
for patients during Operation IRAQI FREEDOM and Operation ENDURING
FREEDOM. Sixteen mental health nurses deployed to Ramstein Air Base to
support Army troops returning from Iraq. They first interact with
patients in the CASF and screen for Post-Traumatic Stress Disorder.
They also provide patient education and strategies for coping with
emotional distress and life-altering injury. Having this capability far
forward enables early intervention and can ameliorate long-term
emotional effects and, in some cases, even facilitate return to duty in
theater.
In the last sixteen months we have recognized the importance of
mental health nurse practitioners and inserted the capability into
deployment packages. They can also substitute for psychiatrists and
psychologists in the deployed setting. We currently have five working
in our facilities and five more will begin their practitioner programs
this summer.
In addition to providing service in Operation IRAQI FREEDOM, Air
Force Nursing supports humanitarian relief around the world. Lieutenant
Colonel Diana Atwell from Beale Air Force Base, CA led a team of 14 Air
Force and 30 Salvadorian military and Ministry of Health medics in a
humanitarian mission to San Salvador. The team planned and set up
healthcare at five sites in impoverished districts within the city.
They provided primary care, internal medicine, pediatric, optometry and
dental services to more than 8,000 patients. Patients lined up for
hours and more than 11,000 patient care services were provided, double
what the team had anticipated. General Carlos Soto Hernandez, military
Chief of Staff, visited one of the sites and praised them for their
dedication and commitment.
In another humanitarian effort, Major Tina Cueller, a reservist and
Professor at the University of Texas, launched an initiative to assist
Iraqi nurses. During her annual tour at Ramstein AB, Maj Cueller
learned that over the years, looting in Iraq had stripped nursing
schools of all textbooks. When she returned to the University of Texas,
she arranged a book drive, collecting over 3,000 nursing textbooks.
They were delivered through the aerovac system from Lackland AFB,
Texas, to Ramstein Air Base Germany, to their final destination, Kuwait
City. Major Cheryl Allen, an Army nurse, received the books in Kuwait
and forwarded them to Baghdad where Colonel Linda McHale, deployed to
work with the Iraqi Ministry of Health, coordinated their distribution.
Humanitarian relief is not confined to far-away places, and the Air
Force has been called to lend a hand in support of Homeland Medical
Operations. Capt Ron Leczner from the 81st Aeromedical Staging Facility
(ASF) at Kessler, MS coordinated the transfer of 47 local nursing home
patients after the governor of Mississippi declared a mandatory
evacuation of the Gulf Coast in anticipation of Hurricane Ivan. A
skeleton crew at the ASF, including medical technician students, moved
41 non-ambulatory and six ambulatory geriatric patients to Keesler
Medical Center during 69 mile per hour winds. The nursing home
residents were returned to their facilities by ASF staff and local
ambulances within 12 hours after the hurricane passed.
Skills Sustainment
Lessons learned from the field and after-action reports have led us
to reevaluate clinical currency and sustainment training for our
nursing personnel. Our Readiness Skills Verification Program has been
refined and is web-based with embedded links to specific training
materials. Units are encouraged ``to think outside the box'' and
establish training agreements as needed with Army, Navy, VA or civilian
institutions to keep their members clinically current.
Air Force nurse and medical readiness officer Major Lisa Corso from
the 704th Medical Squadron at Kirtland, NM, found new ways to improve
the readiness skills of her reserve unit. For their annual field
training and mass casualty exercise, Major Corso invited the local Army
reserve unit to participate. Both groups were part of the planning
process and the Army medics had a wealth of first-hand experience from
members previously deployed. They provided expert instruction on skills
that were identified for refresher training. The exercise was a huge
success, and both units look forward to more joint training exercises
in the future.
Recruiting and Retention
The nurse shortage continues to pose an enormous challenge
nationally and internationally. This year, the Bureau of Labor
Statistics projected registered nursing would have the largest job
growth of any occupation through the year 2012, and it is now estimated
that job openings will exceed the available nurse pool by 800,000
positions. The crisis is complicated by an increasing shortage of
masters and doctoral-prepared nursing faculty across the country.
Although the number of enrollments in entry-level baccalaureate
programs rose 10.6 percent last year, the National League for Nursing
reported that more than 36,000 qualified students were turned away due
to limitations in faculty, clinical sites, and classrooms. Employer
competition for nurses will continue to be fierce, and nurses have many
options to consider.
A robust recruiting program is essential to sustain the Nurse
Corps; our fiscal year 2005 recruiting goal is 357 nurses. As of March
22, 2005, we have brought 110 new nurses onto active duty, 31 percent
of our goal and more than at the same point last year. The Air Force
continues to fund targeted incentive programs to help us attract top
quality nurses. We have increased our new accession bonuses from
$10,000 to $15,000 for a four-year commitment and our highly successful
loan repayment program was again available this year. Last year we
awarded 134 loan repayments, and this year funds were available for 26.
Both of these programs have been very successful in attracting novice
nurses but not as successful in attracting experienced nurses,
particularly in critical deployment specialties. To further support
recruiting, we have increased nursing Air Force ROTC quotas for the
last two years and filled 100 percent of our quotas. We added
additional ROTC scholarships for fiscal year 2005, increasing our quota
from 35 in fiscal year 2004 to 2041.
We continue to advertise our great quality of life, career
opportunities and strong position on the healthcare team. I also take
advantage of any occasion to highlight the tremendous personal and
professional opportunities in Air Force Nursing. I encourage nurses to
visit their alma mater and nursing schools near their base. Our slogan,
``we are all recruiters'' continues to reverberate, and active duty
nurses enthusiastically tell our story and encourage others to ``cross
into the blue''. We have also expanded media coverage of Air Force
Nursing activities and accomplishments to attract interest in the
civilian nurse community. The cover of the December 2004 Journal of
Emergency Nursing featured Air Force nurse Major Patricia Bradshaw and
Technical Sergeant Patricia Riordan, respiratory therapist. They
deployed to the 379th Expeditionary Aeromedical Evacuation Squadron and
were shown caring for a wounded IRAQI FREEDOM soldier. The article
showcased the unique role of critical care nurses in the aeromedical
evacuation environment. Nursing Spectrum magazine honored Lieutenant
Colonel Cassandra Salvatore as the Greater Philadelphia/Tri-State Nurse
of the Year and Capt Cherron Galluzzo, Florida Nurse of the Year for
2004 and Air Force Company Grade Nurse of the Year.
Retention is the other key dimension of force sustainment. While
monetary incentives play a key role in recruiting, quality of life
issues become very important considerations when making career
decisions. We continue to enjoy excellent retention in Air Force nurses
and ended fiscal year 2004 close to our authorized end strength of
3,760.
We conducted a survey in 2004 to identify positive and negative
influences on nurse corps retention. The top two factors influencing
nurses to remain in the Air Force were a sense of duty and professional
military satisfaction. Our nurses clearly enjoy the unique opportunity
to serve our country and to care for our troops. Local leadership and
inadequate staffing were the two primary detractors identified. We are
clarifying their concerns and are providing better leadership
development programs. We are also putting senior, experienced nurses
back at the bedside to guide and mentor our junior nurses and support
their professional development and satisfaction.
It has been three years since we initiated our Top Down Grade
Review to correct our imbalance of novice and expert nurses. We have
identified a number of company grade authorizations for conversion to
field grade based on requirements and continue to pursue adjustments of
authorizations among other career fields. We also identified the
significant positive impact civilianizing a larger percentage of
company grade positions would have on grade structure and career
progression. Serendipitously, the services were directed by the Office
of the Secretary of Defense to identify military positions not wartime
essential that could be converted to civilian jobs. In our initial
evaluation we identified 305 Nurse Corps and 75 enlisted Aerospace
Medical/Surgical Technician billets to convert to civilian
authorizations over the next three years. These changes will primarily
be in the outpatient setting, concentrating our military personnel in
our more robust patient care areas to maintain clinical currency in
wartime skills. We will continue to identify nurse positions which do
not provide expeditionary capability or support our wartime training
platforms for civilian conversion.
Research
Air Force nurse researchers continue to excel at expanding the
science of military nursing practice thanks to the strong support from
the TriService Nursing Research Program (TSNRP). This year, Air Force
nurses are again leading the way in advancing our understanding of the
effects of wartime deployment on today's military force. Twenty-five
Air Force nurses are currently engaged in research covering priorities
from clinical practice and training to recruitment and retention
issues.
Colonel Penny Pierce is an Air Force Reserve Individual
Mobilization Augmentee assigned to the Uniformed Services University of
the Health Sciences (USUHS) Graduate School of Nursing (GSN). She is
conducting research to determine the effects of deployment experiences
and stressors on women's physical and mental health, and their
likelihood to remain in military service. Colonel Pierce received the
2004 Federal Nursing Services Award at the 110th Annual Meeting of the
Association of Military Surgeons of the United States for her
pioneering research on factors that influence the health of military
women.
Colonel Candace Ross, a reserve nurse at Keesler Air Force Base in
Biloxi, Mississippi is heading up a TSNRP-funded study on the Impact of
Deployment on Nursing Retention. The study is designed to identify
factors associated with retention of nursing personnel in the military
service in hopes of identifying actionable areas for retention efforts.
Colonel Laura Talbot, an Air Force reservist with the 440th Medical
Operations Squadron at General Mitchell Air Reserve Station in
Milwaukee, Wisconsin, and nursing faculty member at USUHS, is
conducting research to test two different approaches to prosthetic
rehabilitation for soldiers with below-the-knee amputations. This
research is vital because 2.4 percent of all wounded-in-action during
Operation IRAQI FREEDOM and ENDURING FREEDOM have suffered traumatic
amputations. This is almost double the 1.4 percent during the Korean
Conflict. Her research may promote accelerated rehabilitation for
amputees and facilitate return to active duty for those who are able.
Education
The Graduate School of Nursing at the Uniformed Services University
(USUHS) supports military clinical practice and research during war,
peace, disaster, and other contingencies. The PeriOperative Clinical
Nurse Specialist program will graduate its first class of six in May
2005. The students are conducting research to identifying
organizational characteristics that promote or impede medication errors
across the surgical continuum of care. Fewer medication errors will
save lives and shorten hospital stays. They will be presenting their
work at the National Patient Safety Foundation Conference later this
spring.
The graduates of the Nurse Anesthesia Program in 2004 once again
scored significantly higher than the national average on their
certification examination. Nine of the 13 CRNA graduates scored the
maximum score of 600 and three scored 595 or higher, well above the
national average of 551.5.
In addition, the Air Force is currently funding two full-time
students and another Air Force nurse is enrolled part time in the USUHS
PhD program.
Nursing Force Development
The USAF Nurse Transition Program (NTP) marked its 27th year in
2004. The NTP is an 11-week, 440-hour course designed to facilitate the
transition of novice registered nurses to clinically competent Nurse
Corps officers. The program provides clinical nursing experience under
the supervision of nurse preceptors and training in officership and
leadership. There were several key changes this year, among them the
addition of our first overseas NTP training site at the 3rd Medical
Group, Elmendorf Air Force Base, Alaska. Last November, under the
guidance of NTP Coordinator, Major Deidre Zabokrtsky, we successfully
graduated our inaugural class of four nurses from the program.
Our nurses provide outstanding leadership in the expeditionary
environment, in military treatment facilities, and in positions not
traditionally held by Nurse Corps officers. We currently have 16 nurses
commanding Medical Treatment Facilities and 45 nurse Squadron
Commanders. Col Laura Alvarado is the first nurse to serve as a Vice
Wing Commander, and is at the 311th Human Systems Wing, Brooks City
Base, TX. Maj Kari Howie is a CRNA and the first nurse to serve as the
Deputy Chief of Clinical Services for a major command headquarters.
This year, for the first time in history, two active duty nurses
are serving concurrently as general officers in the Air Force.
Brigadier General Melissa Rank joins me, and was promoted to her
current grade on January 1, 2005.
Colonel John Murray was the first military nurse to be appointed
full professor at the Uniformed Services University of the Health
Sciences. Colonel Murray was also selected by the Assistant Secretary
of Defense for Health Affairs to serve on the National Advisory Council
for Nursing Research.
Mister Chairman and distinguished members of the Committee, it has
been my tremendous honor to serve our nation and to lead the more than
19,000 men and women of our active, guard and reserve total Air Force
Nursing team for the last five years. I have increasingly treasured
your support and advocacy during this challenging time for nursing and
for our Air Force. Thank you for inviting me to tell our story once
again. No one comes close!
Senator Stevens. Well, thank each of you very much. It is
delightful to have you back with us again this year.
I only have one question, and I am going to usurp Senator
Mikulski's role. You have heard her suggestion. Would that
suggestion have any role in the nursing corps, Colonel?
Colonel Bruno. Yes, sir, I think it certainly would. We
currently have a program in place to loan repay, but it is a
short-term, funded-this-year program to loan repay up to
$30,000 for Nurse Corps officers, one time. It has been a
useful tool in our recruiting. It was implemented at a time
when we also increased the accessions bonus for those nurses.
So they could come on to active duty and get a longer
obligation if they took the accessions bonus and the loan
repayment. So it has been useful, and we think that a continued
use of that would be great.
Senator Stevens. Admiral.
RECRUITMENT AND RETENTION
Admiral Lescavage. I believe it is a great idea. As I
observe recruiting and retention in the Navy Nurse Corps and
all across military medicine, as the Surgeons General stated,
it is not necessarily about monetary resources. We stay in for
certainly greater reasons. However, monetary resources help and
I believe that we need to be equitable.
And as I watch recruiting, I can tell you it is difficult
to be at a recruiting booth where either our sister services or
other Federal entities or in the civilian arena are all
offering different options. We all have different programs, and
perhaps it is time that we all get aligned and we are on the
same song sheet.
The idea that Senator Mikulski had is a very good one. As I
stated, we are doing a pilot program in five of our military
treatment facilities for the civilian nurses and trying to
retain them. But as mentioned, you go to the VA, and there are
different options down that road too. So we are looking for
anything out there, any ideas. So thank you.
Senator Stevens. General.
General Brannon. I would like to make two points. First of
all, our loan repayments have been the most successful tool to
bring new graduates into our Nurse Corps.
Senator Stevens. How much can you repay the debt?
General Brannon. This year we were repaying $29,000. Last
year it was $28,000, a one-time thing. We gave 134 loan
repayments. This year we had 26 to offer, and they went very
quickly. The $15,000 accession bonus is helpful, but the loan
repayment is more popular. People come out with a tremendous
amount of debt from nursing school.
The one point I would like to make, however, as our
accession bonus and loan repayment is successful, we do have
problems attracting experienced nurses in some of the critical
specialties. Both of these incentives tend to bring people who
are brand new out of school. So we do spend time molding and
shaping them.
Senator Stevens. Thank you very much.
Senator Inouye.
Senator Inouye. If I may, I would like to follow up on that
without getting into Senator Mikulski's territory.
According to the Department of Labor Statistics of the
United States, by the year 2012, there will be a demand for
over 1 million new and replacement nurses, and it appears that
we will not be able to meet that demand. So obviously it is not
just in the services but throughout this Nation. I do not know
what the solution is, but it is a very critical one and
something has to be done, otherwise we will have great problems
not in just recruiting nurses but in recruiting military
personnel.
I would like to ask a couple of questions. Most Americans
look upon nurses as being female, but I know that in the
military there are a lot of men. What proportion of the Nurse
Corps in the Army is male?
MALES IN NURSE CORPS
Colonel Bruno. About 34 percent.
Senator Stevens. And in the Navy?
Admiral Lescavage. One-third.
General Brannon. We are about the same, sir, about 32 to 33
percent.
Senator Stevens. Do you make a special effort to recruit
men or it is the same?
General Brannon. It really is the same in the Air Force,
sir.
Admiral Lescavage. They seem more than interested in
joining the military services. Many, I notice, do go on to be
nurse anesthetists or critical care nurses and operating room
nurses.
General Brannon. You know, I do notice that probably a
larger percentage of the men do have prior service, and I think
they see nursing as a wonderful career opportunity, they get
their education, and then they join the Nurse Corps.
Senator Inouye. General Brannon, what is this air
expeditionary force concept that you employ in your recruiting?
General Brannon. You mean as far as----
Senator Inouye. Deployment.
General Brannon. In deployment. Well, really the Air
Force's air expeditionary forces consist of essential teams
that are on call to deploy and manage our medical facilities in
the case of medical and to provide patient care for a period of
time. We have five teams that are in what are called the Air
Expeditionary Force (AEF) window. So we have one team that is
deployed at any time.
We use that combined with our expeditionary medical system
which is our very capable, small facilities, up to the size of
a theater hospital that we deploy far forward in kind of a hub
and spoke arrangement. So we have teams of people that come
into these areas, take over for the crew that is ready to
rotate back home, and provide that in-theater care. So it is a
great system.
I think now we have all developed the mind set that as
medics, we are expeditionary. Deployment is no longer something
that you might be called to do. It is a part of your service
and you can anticipate and look forward to your opportunity to
serve. It has created a lot of enthusiasm, I think, for that
military aspect of service.
VA NURSES
Senator Inouye. Admiral Lescavage, in your presentation I
got the impression that VA nurses are paid better than Navy
nurses. Is that correct?
Admiral Lescavage. Yes, sir, and the VA doctors in many
cases.
Senator Inouye. I thought it was the other way around.
Admiral Lescavage. Well, if you add our retirement, perhaps
that may change the numbers a bit, but as you know, not
everyone stays to retirement.
Senator Inouye. At this moment, the pay of VA nurses is
higher than military nurses?
Admiral Lescavage. It depends on the grade level, but many
times, yes.
Senator Inouye. Is that the situation in the Army?
Colonel Bruno. Yes, sir, it certainly is. We can use
special pay rates that equal what the VA is if the VA is in the
area, but they are difficult to implement. You have to do
studies, but we do utilize them effectively.
Senator Inouye. Is that the situation in the Air Force?
General Brannon. Well, sir, I do not think there is a
significant discrepancy in our Active force and the VA nurses.
What becomes of great concern is the VA nurses and our civilian
Air Force nursing force. As we look to increase our number of
civilian nurses, the competition with the VA will be
significant. So we are seeking to establish pay rates that are
comparable with VA nursing pay.
DEPLOYMENT POLICY
Senator Inouye. Is the deployment policy among the services
the same or do they differ in every service?
Colonel Bruno. I think they are different, sir. In the
Army, if you deploy, you deploy for 1 year, and you are
stabilized for as long as possible afterwards, but the
deployment is 1 year.
Senator Inouye. What about the Navy?
Admiral Lescavage. We are about 6 months, depending on the
mission.
General Brannon. We have 16 months at home and then a 4-
month deployment, then 16 months at home, 4-month deployment,
for the most part.
Senator Inouye. What would happen if the Army adopted the
Air Force plan?
Colonel Bruno. Well, I think it might be helpful with our
retention of some nurses. We have an exit poll that we conduct
when nurses leave, and one of the issues that has come forward
in the last 2 years has been the length of deployment. It is
very difficult to be away from home for that length of time.
Senator Inouye. What about the Navy?
Admiral Lescavage. Well, I think our people are pretty
happy with the 3 to 6 months. We support the marines, as you
know, and we are sending mostly operating room nurses, critical
care, and nurse anesthetists. So up to 6 months seems to do the
trick.
Senator Inouye. Have your problems increased now that
sailors are doing ground duty in Iraq?
Admiral Lescavage. I'm sorry.
Senator Inouye. The sailors are now doing infantry work in
Iraq.
Admiral Lescavage. Yes, sir.
Senator Inouye. Has that complicated your problems in Iraq?
Admiral Lescavage. No, sir. We are there to support the
sailors and the marines and any others.
Senator Inouye. Thank you, Mr. Chairman.
Senator Stevens. Thank you.
Senator Mikulski.
Senator Mikulski. Thank you very much, Mr. Chairman.
We are very much on your side. In addition to being on this
excellent subcommittee, I have a civilian life both on the
Labor/HHS Committee, and working with Senator Sue Collins, we
have been working on the civilian nursing shortage. So we know
that you are in a war for talent with community-based hospitals
and academic centers of excellence where the nurses themselves
are being trained. As you know as nurses, you tend to stay
where you get your training. It is just part of the culture. So
we understand that. And then VA is competing with them, and now
we have got all this competition. So we understand the
challenges that you face.
One of my first questions is the retention issue and what
does it take to be able to retain. Now, Senator Inouye raised
the issue of the OPTEMPO which you are facing, and I think we
would encourage an evaluation of that. Also, how we could be
supportive in that evaluation as you have to go up with your
brass. So you are not functioning by yourself here as
independent agents.
Second, I was fascinated, General Brannon, where on page 16
of your testimony you said two things affected them. It was not
only money and OPTEMPO, but it was local leadership and
inadequate staffing. What does local leadership mean? Is that
the general over the base? Is this the nurse on the floor that
the young nurse reports to?
General Brannon. Well, that is a very good question and one
I have asked myself. We need to go back and survey that.
Anecdotally when I talk to some of the junior nurses, we tend
to have a pretty junior staff, and we have very junior folks
often working together. I think they lack that closer contact
with the more seasoned, experienced nurses who provide the
professional development, the support, and really the nurturing
that every nurse needs. We are looking at changing our system a
bit to put some of the more senior experienced nurses back into
direct patient care so they can be the mentors and leaders to
our promising young officers.
INADEQUATE STAFFING
Senator Mikulski. Also, what about the inadequate staffing?
It seems like one goes against the other.
General Brannon. Sure, and I think inadequate staffing
derives from--our staffing ratios are pretty good, and I know
you are familiar with that, knowing what is going on in nursing
around the Nation, but when you have people who are deployed
off the units or out of the facility, everybody picks up a
little bit additional duty.
Senator Mikulski. So there is a lot of stress.
General Brannon. There is a lot of stress.
Senator Mikulski. So your nurses, male and female, are
saying, number one, there is the pay issue.
Second, there is the deployment, but when you are in the
military, you know you are going to be deployed, but there are
different deployment schedules within the services. The
question is should we have a uniform deployment policy. I do
not know that. I would look to you and your wise heads.
And then the other, though, is the staffing. There is the
staffing in battlefield conditions, or in your riveting story
about traveling from Iraq all the way back to Andrews, this was
a very poignant story that you tell in your testimony.
But the question is what about the use of other kinds of
nurses. At the hospitals, does everyone have to be a bachelors
degree nurse to be with you? Can you use community college
nurses? Can you look at medical corpsmen who have a background
and perhaps use that medical background, a military background,
but get an associate of arts of degree in nursing and move them
quicker into the field? Because if they are enlisted, they tend
to be older and, quite frankly, cannot take time off while they
are in school.
EDUCATIONAL LEVEL
General Brannon. Well, frankly, Senator Mikulski, I think
one of the things that makes our military nursing force so
strong is our educational level. As you know, we are across the
services an all-baccalaureate force on Active duty, with about
one-third having masters degrees.
It is very difficult to present evidence that says that
makes a difference. However, this past year in the Journal of
the American Medical Association there was a great study by
Professor Linda Aiken in Pennsylvania actually showing that in
surgical patients, the higher percentage of the baccalaureate
prepared nurses, the fewer complications and the lower the
incidence of morbidity and mortality. So I think we are
beginning to see some substantive evidence that education does
make a difference----
Senator Mikulski. I am in no way minimizing the bachelor of
science (B.S.) or whatever, but we are facing a crisis here.
And what we are looking at is, in some ways, subsets of who
does what where. I think I am confused between your use of the
terms ``military nurses'' and ``civilian nurses.'' Do you have
civilian nurses?
General Brannon. We do, indeed, and they are not all
baccalaureate.
Senator Mikulski. What do they do?
General Brannon. They provide nursing care in many of our
areas, and, as I mentioned, primarily in some of the areas
where there are critical specialties where experience makes a
big difference.
Senator Mikulski. I am going to jump in. I know our time is
short, but I do not think we understand it. I am new to this
subcommittee. It is a spectacular subcommittee with astounding
leadership, and on the 60th anniversary of the Victory in
Europe (VE) Day, we know we want to salute these guys here, one
who will forever remember the battle of Monte Cassino.
But what we are seeing is different pay, and even among all
of you, different deployment schedules. Then the use of nurses,
both the military nurses and the civilian nurses. I wonder if
you could submit to me and to the subcommittee kind of a chart
on some of these issues as we look at it and then maybe perhaps
a comparison to VA and other Federal counterparts so we can
work with you on what we need to do to help you and also then
to sort out where other talent could be used in the military
but not at this highly unsophisticated level.
[The information follows:]
Pay Scale Comparisons
The chart below compares the civilian pay grades assigned
to inpatient registered nurses at a representative sample of
our medical treatment facilities (MTFs). The MTFs queried all
Bachelor of Science in Nursing requirements for their civilian
nursing staff. Contract employees may hold an Associate Degree
in Nursing if it is written into the contract. Eglin AFB and
Wilford Hall Medical Center pay the standard General Schedule
(GS) rate while other locations are authorized locality pay.
The civilian pay rates were obtained from Salary.com and are
current as of June 1, 2005.
The grade for our nursing positions is predetermined;
however, the VA does not advertise positions in the same
manner. Each successful applicant is reviewed by a Nursing
Professional Standards Board to determine grade and salary
based on the individual's education and experience. Once the
grade is determined, the pay scale for that particular locality
is used. As a result, the VA rates could not be included.
----------------------------------------------------------------------------------------------------------------
Civilian--Local
Location Facility GS Level/Pay Pay
----------------------------------------------------------------------------------------------------------------
Anchorage, AK.................. Elmendorf AFB...................... GS 9 ($50,476)........... $67,757
Dayton, OH..................... Wright-Patterson AFB............... GS 11 ($54,389).......... $57,299
Pensacola, FL.................. Eglin AFB.......................... GS 11 ($57,000).......... $51,694
San Antonio, TX................ Wilford Hall Medical Center........ GS 11 ($53,841).......... $53,306
San Francisco, CA.............. David Grant Medical Center......... GS 9 ($49,841)........... $66,352
................................... GS 10 ($54,886).......... ...............
Washington DC.................. Malcolm Grow Medical Center........ GS 11 ($55,652).......... $59,941
----------------------------------------------------------------------------------------------------------------
Senator Mikulski. I just say to my colleagues and to
everyone listening, starting on page 4 is Major General
Brannon's story about these thousands of flights that you have
made and how they made a difference. So let us just kind of
work together, but we have got a very big job.
Good luck to you, Admiral. So you are going to be running
TRICARE.
Admiral Lescavage. Yes, ma'am.
Senator Mikulski. Well, that is called jumping out of the
fat and into the fire.
Thank you.
ADDITIONAL COMMITTEE QUESTIONS
Senator Stevens. Thank you very much, Senator.
I thank you very much for your testimony. Senator Mikulski
is right. We all remember your services very well from our days
in World War II. It is a few days after the 60th anniversary.
So none of you were there, but we thank you anyway for being
part of the group that helped us so much. We look forward to
working with you in trying to find additional ways to give
incentives for your recruitment. Thank you very much.
Colonel Bruno. Thank you, sir.
Admiral Lescavage. Thank you, sir.
General Brannon. Thank you, sir.
[The following questions were not asked at the hearing, but
were submitted to the Department for response subsequent to the
hearing:]
Questions Submitted to Lieutenant General Kevin C. Kiley
Questions Submitted by Senator Ted Stevens
SUPPORTING TRANSFORMATION
Question. Would each of you please describe some of the new
technologies and tactics that have proven most effective in caring for
our front line troops?
Answer. The adoption of new trauma doctrine, called Tactical Combat
Casualty Care (TC\3\), has incorporated additional emphasis on care far
forward, be it self aid, buddy aid, or medic aid. With an emphasis on
early intervention, this doctrinal change has had a significant effect
in reducing deaths and limiting subsequent necessary treatment and
rehabilitation. This doctrine is empowered through the use of new
products, such as tourniquets, hemostatic bandages, and the newly
reconfigured first aid kit.
Another doctrinal change over the past several years has been the
speedy removal of patients through evacuation chains to definitive care
within our medical centers and hospital in Europe and the United
States. There are definitive benefits to the patient who can begin
treatment routines sooner, but it also reduces the medical footprint in
theater and thereby medical Soldiers at risk. This doctrinal change
could not have occurred without a broader scope of evacuation support
medical devices, such as Codman neurological monitors, Chillbuster
patient warmers, Belmont fluid warmers, or KCI wound vacuums.
Question. What tools and equipment are still required to improve
the care provided to combat casualties?
Answer. A recent study of all available resuscitative fluids and
volume expanders was concluded, and the study found the use of hextend
as the most efficacious in clinical outcomes. This product is being
worked into our Rapid Equipping Force Initiative for quick fielding to
the theater for full scale adoption.
The use of recombinant factor VII as a clotting agent for surgical
patients as well as internal bleeding from blunt trauma could have an
incredible effect. This product, which is approved in Europe, is in a
Phase III clinical trial for a trauma indication and if successful, it
will be rushed to full scale use. Because it does not have FDA
approval, it is only used in an off-label, compassionate manner which
limits its potential value.
Oxygen remains a consistent treatment component of combat casualty
care, and many actions are being taken to reduce the need for cylinders
in theater. Today, oxygen is the largest logistical burden for the
medics. In an adaptation of industrial oxygen generators, used for
welding and manufacturing processes, new medical generators are being
developed in smaller scale and greater oxygen content. This downsizing
has gotten to the point that wards and operating room tables can be
supported through these ambient air oxygen generators. Continued
development is ongoing to reduce them to individual patient sizes that
will support evacuation patients.
______
Question Submitted by Senator Pete V. Domenici
ACCESS TO MENTAL HEALTH SERVICES
Question. I understand from your statements that you are diligently
pursuing incidences of mental health issues such as depression, anxiety
and post-traumatic stress disorder. I commend you for that. It is my
understanding that to date the Department of Defense has done a good
job reaching out to soldiers upon their return.
My concern is for mental health services for rural Guard and Air
Guard members in particular. Those Guardsmen in places like Springer,
New Mexico are far from metropolitan areas and do not have access
following demobilization to military mental treatment facilities with
mental health services.
I understand that this rural demographic is a small portion of your
total population, but do you share my concerns about mental health
access for rural Guard and Reserve members and if so can you give me
your thoughts on how we might best address this issue?
Answer. Providing mental health services for rural Guard and Air
Guard members is a recognized challenge. Reserve component Soldiers,
who have been activated, are entitled to all of the behavioral health
services offered to active duty personnel. After demobilization,
reserve component Soldiers are entitled to the TRICARE benefit for six
months. Veterans who have served in OEF/OIF are entitled to care at the
Veterans' Administration for two years. However, rural Reserve
component soldiers may not live near military or VA providers. The
Military One Source program was developed in October 2003 for Soldiers
and Army civilians redeploying from combat. It includes a 24-hour,
seven-days-a-week toll-free phone information and referral telephone
service and a website with links to information and assistance.
Initially developed by the Army for both active and reserve component
Soldiers and family members worldwide, it has now been adopted by the
Department of Defense for all service members, families, and civilian
employees. In January 2005, the Department of Defense announced a Post-
Deployment Health Reassessment to screen all Soldiers 90 to 180 days
after deployment. One of the reasons for this additional screening is
that many Soldiers will not recognize or report mental health symptoms
at the time they return home, but may later. These reassessments are
scheduled to begin on September 1, 2005.
______
Questions Submitted by Senator Richard C. Shelby
ANTHRAX VACCINATIONS
Question. Pursuant to the order of a federal district court, the
anthrax vaccination program has been suspended. However, this past
December Secretary Wolfowitz requested an emergency authorization to
resume use of the anthrax vaccine. Considering all the documented
health risks, does the panel feel it is in the best interest of the
military to resume vaccinating our troops? And why?
Answer. Anthrax spores can kill or incapacitate American troops if
used against us as a weapon. It is clearly in the best interests of our
troops to use the only round-the-clock protection available against
this lethal threat. The sudden deaths from inhalation anthrax among
U.S. Postal Workers and other Americans during the fall 2001 anthrax
attacks on Senator Daschle and Senator Leahy and other targets
demonstrate how easy it is for people to breath in anthrax spores
without realizing they have been exposed. In April 2002, the National
Academy of Sciences released a Congressionally commissioned report that
reviewed all available scientific evidence and heard from people
concerned about anthrax vaccine. The National Academy of Sciences then
concluded that the anthrax vaccine licensed by the Food and Drug
Administration protects against all forms of anthrax and is as safe as
other vaccines.
COMBAT STRESS CONTROL TEAMS
Question. General Kiley, in your testimony you state there are a
wide array of mental health assets in theater including Combat Stress
Control teams and other personnel assigned to units and hospitals. Can
you provide some numbers and tell us how many teams and personnel make
up this program? Are there any current plans to increase your numbers
of mental health assets in theater?
Answer. Since the beginning of Operation Iraqi Freedom, combat
stress units and other mental health assets have been deployed into
theater. Personnel include psychiatrists, psychologists, social
workers, psychiatric nurses, occupational therapists and enlisted
technicians. As well as the combat stress control teams, there are
mental health assets organic to the division and combat surgical
hospitals. They work in close conjunction with the chaplains. The
combat stress teams work closely with leaders and Soldiers to help them
cope with both the stresses of combat and the challenges of being away
from families for long periods of time. Their role is to provide
education, preventive services, and restoration and treatment services.
Typical educational activities include combat and operational stress
control and suicide prevention classes, and preparation for reunion
with their families. Clinical work includes individual and group
evaluation and treatment. There are 10 combat stress control teams in
theater, with a total of 224 mental health personnel. This number is
appropriate for the number of U.S. forces deployed in the CENTCOM
Theater. To add more to the theater would not add significant benefit
and would detract from the staff available in CONUS and OCONUS
providing care to other Soldiers and their families.
RECRUITING AND RETENTION
Question. In your testimony, General Kiley, you note that you are
concerned about the retention of health care professionals and that you
are working with the Commander of Army Recruiting to reverse the
current trends. How far from your desired retention and recruiting rate
are you currently? What steps are you taking to address the situation?
Answer. The Global War on Terrorism and Army transformation make
recruitment and retention of Army Medical Department personnel
challenging. Transformation has provided a new set of requirements
which, given the long training tail for medical personnel, cannot be
immediately met through recruitment and student programs. The only way
to meet this need, in the near term, is to retain individuals to fill
these positions. At the same time, members of the Army Medical
Department have some of the most ``exportable'' skills in the Army and
some skills, like the Nurse, are in short supply and high demand in the
civilian market place. The lure of lucrative employment coupled with no
deployments is having its effect on retention. A comparison of three
year average continuation rates for 1999 to 2001 (pre 9/11) against
2002 to 2004 shows significant changes. At the 7th year of service,
Nurses are down from 87 percent to 84 percent and at the 5th year, 93
percent to 90 percent; Physician Assistants have demonstrated a
remarkable drop in the 12th, 13th and 14th year of service (92 percent
to 76 percent, 85 percent to 77 percent and 88 percent to 72 percent
respectively).
Direct accessions of medical personnel have also proved to be
challenging. The chart below shows current fiscal year 2005 recruitment
for both Active and Reserve component medical personnel.
----------------------------------------------------------------------------------------------------------------
Active Duty Percent Army Reserve Percent National Guard Percent
----------------------------------------------------------------------------------------------------------------
Medical Corps................ 18 of 40......... 45 64 of 201........ 32 12 of 104....... 12
Dental Corps................. 10 of 30......... 33 7 of 48.......... 15 0 of 32......... .......
Nurse Corps.................. 75 of 170........ 40 225 of 485....... 46 13 of 55........ 24
----------------------------------------------------------------------------------------------------------------
The backbone of medical recruiting is our student programs
(scholarships and stipends). Recruitment for these student programs is
more difficult than expected. The Army has requested additional Health
Professions Scholarship Program allocations. We believe that these
additional scholarships are needed and as individual influencers learn
that more scholarships are available, they will be filled by quality
individuals who will shape the medical department of the future.
Increases in Incentive Special Pays, Accession Bonuses, Loan
Repayment Programs and other incentive pays are all tools which can be
utilized by the recruiters and Commanders to influence recruitment and
retention decisions. In February 2005, the Army increased Incentive
Special Pays for Certified Registered Nurse Anesthetists retroactive to
January 1, 2005. As of June 2005, 88 percent of the eligible Nurse
Anesthetists elected to sign a new Incentive Special Pay contract.
Twenty-two percent of these nurses opted for 1-year contracts and 78
percent opted for multi-year contracts.
The Surgeon General approved the utilization of Active Duty Health
Professions Loan Repayment as an accession tool to assist U.S. Army
Recruiting Command (USAREC) in meeting their recruitment mission for
Physician's Assistants in fiscal year 2006. This will be the first year
that USAREC has been tasked to directly recruit Physician's Assistants.
Anecdotal evidence suggests that the ability to offer recent graduates
from civilian Physician's Assistants programs the opportunity to have
the Army assist in the repayment of their educational loans will make a
difference in their propensity to serve. This is a new program for this
group; however it has proven to be very successful with Pharmacy
officers and Registered Nurses in the past.
Finally, USAREC signed a contract with Merritt Hawkins in June 2005
for a 6-month trial period to recruit Army Reserve Physicians. Merritt
Hawkins is the top-ranked civilian Healthcare Professional recruiting
firm in the country. The trial period is to run from July to December
2005.
ANTHRAX VACCINATIONS
Question. During the height of the Iraq invasion, concern, and more
specifically controversy, surrounded vaccinating our armed forces for
anthrax. This debate has not died down. The FDA has reported that there
are over 50 side effects to the anthrax vaccination, and this is taking
into account that former FDA Director David Kessler has stated that
only 10 percent of reactions ever get reported. In 1998 the former
Secretary of the Army Luis Caldera acknowledged the anthrax vaccine was
linked to ``unusually hazardous risks.'' There have been documented
cases of DOD continuing shots after major reactions, which violates
vaccine instruction and documented cases of DOD administering shots
from expired lots. Further, Senate Report 103-97 stated that the
vaccine has still not been eliminated as a cause of the Gulf War
Syndrome. In the past 5 years, thousands of cases of adverse reactions,
causing serious health problems, have been linked to the anthrax
vaccine. Several soldiers have even died from the shots. In light of
the inherent risks in the program, I would appreciate hearing the
panels' views as to why are we still mandating that our servicemembers
receive these shots?
Answer. Anthrax spores can kill or incapacitate American troops if
used against us as a weapon. It is clearly in the best interests of our
troops to use the only round-the-clock protection available against
this lethal threat. The sudden deaths from inhalation anthrax among
U.S. Postal Workers and other Americans during the fall 2001 anthrax
attacks on Senator Daschle and Senator Leahy and other targets
demonstrate how easy it is for people to breath in anthrax spores
without realizing they have been exposed.
In April 2002, the National Academy of Sciences (NAS) released a
Congressionally commissioned report that reviewed all available
scientific evidence and heard from people concerned about anthrax
vaccine. The National Academy of Sciences then concluded that the
anthrax vaccine licensed by the Food and Drug Administration protects
against all forms of anthrax and is as safe as other vaccines.
While some individuals have expressed concern about anthrax
vaccine, a detailed analysis of 34 peer-reviewed medical journal
articles shows that people vaccinated or unvaccinated against anthrax
have the same health experiences. It is well recognized that minor
temporary side effects are underreported (which is the point Dr.
Kessler was making); however, serious adverse events are reported,
especially in a well-monitored integrated health system, such as the
Military Health System.
With reference to adverse events, Defense policy requires anyone
who presents to medical personnel with a significant adverse health
condition after receiving any vaccination (e.g., anthrax, smallpox,
typhoid) to be evaluated by a physician to provide all necessary care
for that event. The physician must determine whether further doses of
that vaccine should be given, delayed, or a medical exemption--either
temporary or permanent--be granted. Military medical personnel are
trained how to manage perceived or actual adverse events after
vaccination with any vaccine.
As of July 2005, anthrax vaccinations are voluntary, under an
Emergency Use Authorization issued by the Food and Drug Administration.
As for links between anthrax vaccinations and illnesses among Gulf
War veterans, two publications by the civilian Anthrax Vaccine Expert
Committee concluded that multi-symptom syndromes among some veterans of
the Persian Gulf War were not reported more often among anthrax
vaccines than expected by chance. As explained in these articles, the
vast majority of adverse-event reports involve temporary symptoms that
resolve on their own. While one death has been classified as
``possibly'' related to a set of vaccinations, these civilian
physicians did not attribute other reported deaths to anthrax
vaccination.
Secretary Caldera's actions are quoted out of context. His finding
related to the risks to the manufacturing enterprise (the only
manufacturer licensed by the Food and Drug Administration to produce
anthrax vaccine) if the manufacturer was subjected to multiple
lawsuits. He was not referring to the risks of the vaccine itself. In a
Congressionally commissioned report, the National Academy of Sciences
concluded in April 2002 that anthrax vaccine is as safe as other
vaccines.
______
Questions Submitted by Senator Daniel K. Inouye
SUICIDE PREVENTION
Question. What is the process for assuring our troops and their
leadership are well trained in suicide prevention and intervention
protocols as they relate to both the peacetime and wartime missions?
Answer. Suicide prevention is a Commander's program. The proponent
for the program to include training is Army G-1. In general, Army units
typically have an annual requirement to conduct suicide prevention
training. This is usually conducted by installation Chaplains or
Behavioral Health personnel. Many units and installations sponsor
Applied Suicide Intervention Training (ASIST) that provides specific
intervention skills to noncommissioned officer leadership and selected
Soldiers. Formal investigations are done after every active duty
suicide focusing on lessons learned and prevention. Additional training
is also provided to support agency staff, including Chaplains and
healthcare providers, on how to identify signs of suicide and how to
effectively screen and intervene with service members who are having
suicidal thoughts. Leaders, both officer and non-commissioned officers,
receive training on how to take care of their troops in the area of
suicide.
HEALTH ASSESSMENTS
Question. How does the AMEDD determine if soldiers are both
psychologically and physically healthy enough to be deployed? What
improvements should be made in the current pre-deployment evaluation?
Answer. The Pre-Deployment Health Assessments (DD 2795) falls
within the overall framework of Force Health Protection, which provides
comprehensive health surveillance. All Soldiers identified as having
psychological and/or physical health related concerns are screened by
medical personnel for further evaluation. Medical personnel make
recommendations to Commanders concerning whether or not Soldiers are
healthy enough for deployment. Identifying Soldiers who are at risk for
physical injury before deployment is an area for improvement in pre-
deployment evaluation. In addition, an annual preventive health
assessment has been developed and will be fielded in the coming year.
This annual requirement specifically includes assessment of domains
relevant to medical readiness, both physical and psychological. The
implementation of this annual assessment will help to maintain the
health of our troops across the deployment cycle, not just immediately
before.
______
Questions Submitted by Senator Patrick J. Leahy
Question. You have been working for four years with congressional
support to develop a robust, mobile hospital solution to replace the
Deployable Medical Systems you've had in place for nearly thirty years
now. With the research and development phase of this work now near its
end, is it not time to move this effort to the next stage and develop a
procurement program for these hard-shelled, mobile hospital units?
Answer. The research and development phase has not been completed
for hard wall shelters. In fact, the Army only recently received just
one set of first prototype shelters with the most recent being provide
in the spring of this year. Though the shelters exhibit promise, there
are some shortcomings from our initial review and have yet to gather
the most meaningful data, operational user tests. At this moment, there
are two competing designs at work with an expected down select in the
late fiscal year 2006, early fiscal year 2007 timeframe. We anticipate
that the Army will find separate technologies within each prototype
system that has value and will compete a requirement that builds upon
combined characteristics. At present, the further developmental and
procurement quantities have been programmed as requirements into our
budget, but higher priority requirements preclude its funding at this
point in time.
COMPOSITE HEALTH CARE SYSTEM
Question. I have followed the evolution of CHCS II and Tricare
Online with interest, and it strikes me that there is a confluence of
maturing technologies that can be leveraged to empower the patient to
improve health care quality while reducing health care costs. If
Department of Defense servicemembers and beneficiaries are given the
ability to securely enter data about themselves and their medical
problems into CHCS II via Tricare Online, it will solve a huge problem
facing the military health system, namely how to get standardized
clinical information into the medical record without using expensive
and scarce medical personnel. Physicians would get better information
about their patients, and patients would get immediate guidance from
the tools mounted on Tricare Online to help them with their problems. I
know there are knowledge tools in CHCS II, but I would like each of you
to comment on any plans your service has to offer them to beneficiaries
on Tricare Online. What are your thoughts about using Tricare Online to
help populate subjective clinical information into CHCS II?
Answer. The Health Assessment Review Tool (HART) and Personal
Health Record (PHR) are two such tools that are projected for a TOL
interface with CHCS II. A web-enabled HART is by far the most effective
and efficient method of making HART available to all populations
(TRICARE Standard, TRICARE Prime, Reserve/National Guard, civilian
employees of DOD activities). The successful implementation of this
web-enabled functionality is a positive step toward empowering the
patient to participate in his or her own heath care.
The E-Health Personal Health Record (PHR), accessible via TOL,
addresses the Military Health System's (MHS) need for a secure portal
for beneficiaries to access their electronic medical record. The MHS is
working with commercial organizations and the Veterans Health
Administration to define optimal business processes and to develop
industry leading functional and technical requirements. This structured
response capability is scheduled for deployment in fiscal year 2008,
capabilities will allow the patient to review or enter allergies, past
medical history and to review test results and other information that
must be either posted or verified by the medical staff. This will help
to ensure that the information was received by the patient and prevent
unnecessary visits to check lab results that were normal.
______
Questions Submitted by Senator Barbara A. Mikulski
POST TRAUMATIC STRESS DISORDER
Question. The New York Times recently reported that an Army study
shows that about one in six soldiers in Iraq report symptoms of major
depression, serious anxiety or post-traumatic stress disorder, a
proportion that some experts believe could eventually climb to one in
three, the rate ultimately found in Vietnam veterans. (NY Times, Dec.
16, 2004). (Reference for the above Army study is: New England Journal
of Medicine, Vol. 351, No. 1, pg. 13).
According to the Times and the Army report, ``through the end of
September, the Army had evacuated 885 troops from Iraq for psychiatric
reasons, including some who had threatened or tried suicide. But those
are only the most extreme cases. Often, the symptoms of post-traumatic
stress disorder do not emerge until months after discharge''. (NY
Times, Dec. 16, 2004).
The Times also referenced a report by the GAO that found similarly
alarming results: ``A September report by the Government Accountability
Office found that officials at six of seven Veterans Affairs medical
facilities surveyed said they `may not be able to meet' increased
demand for treatment of post-traumatic stress disorder.'' (NY Times,
Dec. 16, 2004).
However, despite this well-documented crisis, I am concerned that
we are not doing enough to combat PTSD.
In light of these very serious concerns, what is the Department of
Defense doing to address well-documented examples of PTSD in our men
and women returning from the battlefields of Iraq, Afghanistan and
elsewhere?
Answer. The Department of the Army complies with a series of
Department of Defense policies which govern the Pre- and Post-
Deployment Health Assessment process. A February 2002 Joint Staff
Policy details the procedures for Deployment Health Surveillance and
Readiness. The Pre- and Post-Deployment Health Assessments (DD 2795 and
DD 2796) are designed to provide comprehensive health surveillance for
service members affected by deployments. The overarching goal of the
Army is to provide countermeasures against potential health and
environmental hazards to include Post Traumatic Stress Disorder (PTSD)
for optimal protection to our troops. Early detection and management of
all deployment-related health concerns, including PTSD, can reduce
long-term negative health consequences and improve the quality of life
for those with deployment concerns. All Soldier's identified with PTSD
and/or other mental health symptoms are referred to mental health
providers for further evaluation and follow-up. The Post-Deployment
Health Assessment provides ongoing identification and management of
later emerging deployment health concerns. Copies of all Pre- and Post-
Deployment forms are kept in a central database at the U.S. Army
Medical Surveillance Activity.
This system of identification and treatment is being further
enhanced through implementation of a Post-Deployment Health
Reassessment to be conducted at the 3-6 month period after service
members return from an operational deployment. This program will
provide an opportunity for identification and treatment of health
concerns, including mental health concerns, that emerge over time. In
addition, DOD and VA have also collaborated in the development and
dissemination of an evidence-based clinical practice guideline for
identification and treatment of acute stress and PTSD in both primary
care and specialty mental health care settings.The guideline supports
the Post Deployment Health Evaluation and Management Clinical Practice
Guideline that was fielded for mandatory implementation in every
military primary care clinic in 2003. Because PTSD is not the only
mental health concern resulting from deployment and because PTSD is
often related to physical health symptoms, additional guidelines have
been developed and disseminated throughout the military health system
to include a DOD/VA Clinical Practice Guideline for Major Depression,
Substance Use Disorder, and Ill-defined conditions and concerns.
Question. Are clinical trials being conducted in conjunction with
our nation's pharmaceutical industry?
Answer. The Army Medical Department is not currently conducting
clinical trials in conjunction with the pharmaceutical industry.
Question. Is the Department aware that there exists a not-for-
profit organization in Maryland that is committed to pulling together
all developing new technologies for the treatment of PTSD?
Answer. The Army is aware that the Department of Defense, in
collaboration with the Department of Veteran's Affairs, has contracted
with the Samueli Institute for Information Biology (SIIB) to conduct
the program entitled Integrative Healing Practices for Veterans (VET
HEAL). SIIB is a non-profit, non-affiliated medical research
organization, based in Maryland, supporting the scientific
investigation of healing processes with Information Biology and its
application in health and disease.
Question. What is the Department doing to identify these and other
innovative approaches to the treatment of PTSD?
Answer. The Army Medical Department, in conjunction with the
Department of Defense and the members of the National Center for PTSD
partnered to develop The Iraq War Clinician Guide, which is now in its
second edition (June 2004). This guide was developed specifically for
clinicians and addresses the unique needs of veterans of the Iraq war.
Topics include information about the management of PTSD in the primary
care setting, caring for veterans who have been sexually assaulted, and
the unique psychological needs of the amputee patient. Similarly, the
Veterans Health Administration and the military services developed the
VA/DOD clinical practice guideline for the management of post-traumatic
stress. In addition, the Department of Defense has partnered with the
Department of Veterans Affairs to conduct two randomized clinical
trials, including one focused on effective treatment for military women
and one focused on prevention and education for early intervention
through a technology enhanced program called DESTRESS. These studies
aid us in ensuring our treatments are the most effective they can be
and they are provided at the appropriate time. DOD and VA have also
collaborated in the development and dissemination of an evidence-based
clinical practice guideline for identification and treatment of acute
stress and PTSD in both primary care and specialty mental health care
settings.The guideline supports the Post Deployment Health Evaluation
and Management Clinical Practice Guideline that was fielded for
mandatory implementation in every military primary care clinic in 2003.
______
Questions Submitted to Vice Admiral Donald C. Arthur
Questions Submitted by Senator Ted Stevens
SUPPORTING TRANSFORMATION
Question. Would each of you please describe some of the new
technologies and tactics that have proven most effective in caring for
our front line troops?
Answer. The Navy is involved in the following projects and programs
to care for our front line troops:
--The introduction of Body Armor, the Forward Resuscitative Surgical
System, and reduced evacuation times has had a substantial
impact in reducing members killed in action (KIA) compared to
prior conflicts.
--The introduction of Quikclot for controlling hemorrhage.
--Fielding of a Patient Tracking Device in OIF and OEF, the Tactical
Medical Coordination System (TacMedCS).
--Combat Trauma Registry (CTR). This registry has made a major
contribution to understanding of casualties. Data summarized
from the CTR forms have been used in theater to provide medical
situation updates. The CTR is being used for ongoing studies
and analyses which include: head, neck and face injury study,
extremity injury study, and shunt efficacy study.
--Field Oxygen Concentration Units, reducing need for cylinders.
--EnRoute Care System--the supplies, equipment and personnel
available to use any mobility platform to transport critically
injured casualties.
--Improved Medical Diagnostic Capabilities in Field of Operations:
Digital Radiography.
--Individual First Aid Kit (IFAK), (including tourniquets and
advanced compression dressings for self and buddy aid).
--Improved First Responder Aid Bag.
--OSCAR (Operational Stress Control and Relief) to Reduce Combat
Stress.
--New Seats Installed in the Small Special Operations Boats (should
reduce injuries to operating personnel through greater shock
absorption).
--Use of a Centralized Computer System to Collect Heat Stress Data on
Ships (should reduce the incidence of heat injury and reduce
work load. Also has land-based applications).
--Improved Methods of Rapidly Gathering and Assessing Lessons Learned
Data from ongoing experiences linkage to off-the-shelf
solutions/ideas for providing care to front line troops.
The Marine Corps has introduced new technologies and tactics to
improve first responder care, resuscitative surgery, and patient
evacuation with enroute care.
--First responder care. Marines from I MEF and II MEF have received
Combat Lifesaver Training to enhance their ability to provide
self-aid and buddy aid. These Marines also received a new
Individual First Aid Kit (IFAK) to improve their ability to
stop life-threatening bleeding. The new IFAK includes a
hemostatic agent (QuikClot), a new tourniquet, and improved
battle dressings.
--Resuscitative Surgery. The Marine Corps has successfully used the
Forward Resuscitative Surgery System (FRSS) to provide life-
saving surgery far forward on the battlefield. The FRSS has
demonstrated the potential of far forward resuscitative surgery
to reduce battlefield mortality among the most seriously
wounded.
--Patient evacuation with Enroute Care. The Marine Corps has also
successfully used specially trained nurses and hospital
corpsmen to provide enroute care during the evacuation of
critically injured casualties onboard its helicopters.
Providing enroute care for these critically injured casualties
has contributed to reducing battlefield mortality.
Question. What tools and equipment are still required to improve
the care provide to combat casualties?
Answer. While the number of Killed in Action has been greatly
reduced by the aforementioned capabilities. Much work is need now for
those who are wounded in action.
--Improved Body Armor for extremities.
--Treatments to prevent/treat blast trauma and long term neurological
deficits resulting from exposure to blast.
--Research on Combat and Operational Stress to include enhanced
research on Mental Health and Post Traumatic Stress (PTSD).
--Blood substitutes and improved resuscitation strategies.
--Technologies to stop internal hemorrhage.
--Technologies to sustain life support and reduce logistical burden
during delayed/prolonged evacuation.
--Technologies to treat brain injury.
--Technologies to improve limb and organ viability from trauma.
--Microbiology of blast and bullet injuries in returning troops.
--Research on Musculoskeletal Injuries (including epidemiology,
prevention, and footwear).
--Research on Effectiveness of Current Body Armor (i.e., how many
casualties prevented).
--Research on the Causes and Prevention of Motor Vehicle Accidents
(almost 10 percent of casualties resulting from hostile enemy
action were due to motor vehicle accidents).
--Improved Medical Diagnostic Capabilities in Field of operations.
--Improved Bioenvironmental Tools for Operational Risk Management and
Deployment of Medical Resources and Identification of Routes of
Evacuation.
--Research on the Impact of Multiple Stressors (Noise, Heat, Chemical
Exposure, etc.) on Recuperation of Casualties.
--Development of Antioxidant Treatment Protocols for Laser Eye
Injuries.
--The Submarine Force Needs Better Casualty Movement and Evacuation
Equipment for casualty transfer and MEDEVAC. Currently
available stretchers and evacuation equipment do not permit
rapid movement of casualties in and out of the tight confines
of submarines.
--Anti-Hypothermia Warming Blankets.
--Improved Non-Performance Degrading Analgesia.
--Improved Means for Combat Medic Training.
--Easy to Use Vascular Shunts for Limb Salvage.
--Research on Use of Antioxidant Supplementation for Performance
Enhancement and Rehabilitation.
--Research on Development of Back Packs to Transfer Load Carriage
From the Shoulders to the Hips to Reduce Injuries.
--Research to Reduce Concussive Injury from Blast and Bullet Strikes
to the Head.
______
Question Submitted by Senator Richard C. Shelby
ANTHRAX VACCINE
Question. During the height of the Iraq invasion, concern, and more
specifically controversy, surrounded vaccinating our armed forces for
Anthrax. This debate has not died down. The FDA has reported that there
are over 50 side effects to the Anthrax vaccination, and this is taking
into account that former FDA Director David Kessler has stated that
only 10 percent of reactions ever get reported. In 1998 the former
Secretary of the Army Luis Caldera acknowledged the Anthrax vaccine was
linked to ``unusually hazardous risks.'' There have been documented
cases of DOD continuing shots after major reactions, which violates
vaccine instruction and documented cases of DOD administering shots
from expired lots. Further, Senate Report 103-97 stated that the
vaccine has still not been eliminated as a cause of the Gulf War
Syndrome. In the past 5 years, thousands of cases of adverse reactions,
causing serious health problems, have been linked to the Anthrax
vaccine. Several soldiers have even died from the shots. In light of
the inherent risks in the program, I would appreciate hearing the
panels' views as to why are we still mandating that our service members
receive these shots?
Answer. DOD's mandatory Anthrax Vaccine Immunization Program is
currently on a court-ordered pause. We are offering the Anthrax vaccine
to personnel in high threat areas under an Emergency Use Authorization.
Anthrax is the #1 threat on the Joint Chiefs bioweapon threat list.
Anthrax spores make lethal weapons that can be easily disseminated
through non-traditional means. This was demonstrated in the 2001
Anthrax attacks, which killed several U.S. Postal Employees. Reports
continue to be published in newspapers about the attack's infected
survivors and their persistent health consequences. During the Anthrax
attacks, city hospitals had only one or two patients requiring
extensive and lengthy treatment for their illness. In a widespread
attack, the number of patients requiring hospitalization would
overwhelm the medical infrastructure. The Department of Defense uses
Anthrax vaccine to ensure service members are protected against an
attack using Anthrax.
Over 1.3 million service members have been protected against
Anthrax spores since March 1998. While some individuals have expressed
concern about Anthrax vaccine, a detailed review of 34 peer-reviewed
medical journal articles shows that people vaccinated or unvaccinated
against Anthrax have similar health experiences. In 2002, the National
Academy of Sciences published a congressionally commissioned report
that concluded Anthrax vaccine has a side-effect profile similar to
that of other vaccines licensed by the Food and Drug Administration
[www.iom.edu/Object.File/Master/4/150/0.pdf]. DOD policy requires that
anyone who develops adverse health conditions after any vaccination be
evaluated by a physician. This policy also specifies that all necessary
care be provided and that a determination be made as to whether further
doses of that vaccine are indicated. It is well recognized that minor
temporary side effects are underreported, which is the point Dr.
Kessler was making. Serious adverse events are much more likely to be
reported, especially in a well-monitored integrated health system, such
as the Military Health System.
The civilian Anthrax Vaccine Expert Committee (AVEC) issued two
publications regarding adverse vaccine events that occurred from 1998-
2001 with respect to multi-symptom syndrome (MSS) described by some
veterans of the Persian Gulf war. The panel found no evidence of a
pattern of MSS after Anthrax vaccination. As explained in these
publications, the vast majority of vaccine adverse-event reports
involve temporary symptoms that resolve on their own.
DOD reviews death reports after any vaccination very carefully. One
death of a DOD service member has been classified as ``possibly''
related to the receipt of multiple (Anthrax, Smallpox and others)
immunizations. The civilian physicians on AVEC evaluated other deaths
and did not attribute them to Anthrax vaccination.
The question for the record misstates the former Secretary of the
Army's position, which was the business situation posed an unusually
hazardous risk for BioPort Corporation as a small vaccine manufacturer.
At no time has anyone shipped expired lots or vials of Anthrax
vaccine to any military facilities. However in an isolated case,
Anthrax vaccine from vials a few weeks beyond their potency dating was
inadvertently administered. This 1999 incident was thoroughly
investigated and correct vaccine management procedures were re-
emphasized to prevent future incidents.
______
Question Submitted by Senator Patrick J. Leahy
CHCS II
Question. I have followed the evolution of CHCS II and TRICARE
Online with interest, and it strikes me that there is a confluence of
maturing technologies that can be leveraged to empower the patient to
improve health care quality while reducing health care costs. If
Department of Defense service members and beneficiaries are given the
ability to securely enter data about themselves and their medical
problems into CHCS II via TRICARE Online, it will solve a huge problem
facing the military health system, namely how to get standardized
clinical information into the medical record without using expensive
and scarce medical personnel. Physicians would get better information
about their patients, and patients would get immediate guidance from
the tools mounted on TRICARE Online to help them with their problems. I
know there are knowledge tools in CHCS II, but I would like each of you
to comment on any plans your service has to offer them to beneficiaries
on TRICARE Online. What are your thoughts about using TRICARE Online to
help populate subjective clinical information into CHCS II?
Answer. TRICARE Online (TOL) has the potential to provide our
beneficiaries the ability to convey information about their health
status and concerns to providers. Our vision is in line with this goal,
a clinical intervention tool informing beneficiaries, Primary Care
Managers (PCMs), and Military Treatment Facility (MTF) administrators
about required preventive services, health risk factors, chronic
disease history, and health status. This tool assists the MHS at the
Enterprise, Service, TRICARE Region and MTF level with population
health management by providing estimates of the health needs and health
status of the enrolled and non-enrolled TRICARE populations. Currently
in development are the appropriate screening tools and alert
functionality to mitigate the medical-legal risk of not being able to
respond to a concern ``real-time'' while empowering beneficiaries to
enter historical and screening information at their own pace. This
information will be saved to the Clinical Data Repository making the
data accessible via CHCS II.
______
Questions Submitted by Senator Barbara A. Mikulski
MENTAL HEALTH AND POST TRAUMATIC STRESS DISORDER
Question. The major mental health problem being faced by the
returning veteran is Post Traumatic Stress Disorder (PTSD).
The New York Times recently reported that an Army study shows that
about one in six soldiers in Iraq reports symptoms of major depression,
serious anxiety or post-traumatic stress disorder, a proportion that
some experts believe could eventually climb to one in three, the rate
ultimately found in Vietnam veterans (NY Times, Dec. 16, 2004)
(Reference for the above Army study is: New England Journal of
Medicine, Vol. 351, No. 1, pg. 13).
According to the Times and the Army report, ``through the end of
September, the Army had evacuated 885 troops from Iraq for psychiatric
reasons, including some who had threatened or tried suicide. But those
are only the most extreme cases. Often, the symptoms of post-traumatic
stress disorder do not emerge until months after discharge.'' (NY
Times, Dec. 16, 2004).
The Times also referenced a report by the GAO that found similarly
alarming results: ``A September report by the Government Accountability
Office found that officials at six of seven Veterans Affairs medical
facilities surveyed said they `may not be able to meet' increased
demand for treatment of post-traumatic stress disorder.'' (NY Times,
Dec. 16, 2004).
However, despite this well-documented crisis, I am concerned that
we are not doing enough to combat PTSD.
In light of these very serious concerns, what is the Department of
Defense doing to address well-documented examples of PTSD in our men
and women returning from the battlefields of Iraq, Afghanistan and
elsewhere?
Answer. Navy medicine is directly involved in the management of
PTSD both on the battlefield and at home. Last year, we initiated our
Operational Stress Control and Readiness (OSCAR) Project with the U.S.
Marine Corps. This project places mental health assets directly with
Marine Corps fighting units, and those mental health providers stay
with the unit both during the period of deployment and in garrison.
Thus, our Marine Corps mental health providers are truly organic assets
to the Marine divisions. Likewise, we have psychologists stationed
aboard each aircraft carrier in the Navy to provide direct services to
deployed service members. Following on the highly successful example of
our shipboard psychologists, we have deployed psychologists and
psychiatrists with Expeditionary Strike Groups (ESGs) to provide
similar services to detachments of Marines and other service members
being transported via ESGs.
Question. Are clinical trials being conducted in conjunction with
our nation's pharmaceutical industry?
Answer. Medical Departments of the uniformed services do not work
directly with pharmaceutical manufacturers as we are legally proscribed
from doing so. However, under the auspices of the Henry M. Jackson
Foundation, military researchers may participate as investigators in
clinical trials with various sources of funding. Military medical
personnel, both at the Uniformed Services University and at our
teaching hospitals, may devise and submit for approval through
appropriate institutional review boards clinical studies that involve
post-traumatic stress disorder and other conditions. Several joint
projects with the VA are presently ongoing, including a study at Naval
Medical Center San Diego of virtual reality technology to assist
patients with PTSD.
Question. Is the Department aware that there exists a not-for-
profit organization in Maryland that is committed to pulling together
all developing new technologies for the treatment of PTSD?
Answer. Yes. Several not-for-profit organizations exist in the
State of Maryland that can and have in the past provided expert
assistance to the DOD in its efforts to understand PTSD and ameliorate
its effects. For instance, trainers from the International Critical
Incident Stress Foundation, in Ellicott City, routinely provide
training in critical incident stress debriefing gratis to military
mental health providers and military first responders. The Maryland
Psychological Association has offered the services of its members to
family members of servicemen and women who may be suffering from the
effects of combat stress or related disorders. Additionally, the
Maryland Psychological Association partners with the American Red Cross
to train its members in disaster response. The services take advantage
of the expertise of faculty at the Uniformed Services University in
Bethesda who are world renowned experts in the study of combat stress
and related disorders, we apply their research findings in our clinical
practice to better serve active duty members and their families. We
also work closely with other agencies, both in the federal and private
sector, such as the VA's National Centers for PTSD, to identify sources
of expertise in the management of stress and apply findings to our
service members.
Question. What is the Department doing to identify these and other
innovative approaches to the treatment of PTSD?
Answer. Navy medical resources are intensely involved in the study
of innovative treatment strategies for PTSD. We work closely with our
colleagues in the VA and at the Uniformed Services University, as well
as various private and publicly funded institutions of higher
education, to educate our providers regarding most effective
treatments. In addition to collaboration in research endeavors as
mentioned above, we have jointly produced with the VA a number of
Clinical Practice Guidelines, including guidelines for the management
of acute and chronic stress, depression, and other disorders. We co-
sponsor conferences for our clinicians and decision makers regarding
the management of PTSD, and are involved in a number of joint working
groups designed to create a true continuum of mental health care for
our active duty, disabled, and retired service members.
______
Questions Submitted to Lieutenant General George Peach Taylor, Jr.
Questions Submitted by Senator Ted Stevens
SUPPORTING TRANSFORMATION
Question. Would each of you please describe some of the new
technologies and tactics that have proven most effective in caring for
our front line troops?
Answer. The Air Force Medical Service has clearly played a
tremendous role in the delivery of health care to our front line
troops. To open, let me say that prevention has proven to be enormously
successful in preventing injury and providing superb safe environments
for our personnel. Our deployed Preventive Medicine Teams have provided
direct preventive medicine support to military personnel throughout
Operation Iraqi Freedom, providing such resources as occupational and
environmental health surveillance, environmental health programs, field
sanitation training, disease and non-battle injury prevention, health
risk assessments, and medical force protection.
The lighter, leaner footprint of Air Force medical resources has
been extremely effective in providing a consistent clinical capability
to the Combatant Commander and warfighter. The hard work accomplished
with focus on interoperability in capability was proven a success
during the transition from the Army Combat Support Hospital to the Air
Force Expeditionary Medical System this past fall. Shortly after that
transition, the vast majority of casualties from the battle of Fallujah
were received and cared for at that very same facility. The dedication
and teamwork of our Army and Air Force medics ensured seamless medical
care, timely evacuation, and lifesaving care to the injured warfighter.
In December of 2004, the Assistant Secretary of Defense (Health
Affairs) directed the Services to implement the Joint Theater Trauma
Registry. Air Force clinicians played a tremendous role in the
development of the first Joint Theater Trauma System (JTTS). Modeled
after the successes of the civilian sector, the JTTS keeps us at the
cutting edge, bringing the skills of trauma centers to the battlefield.
The goal is to provide a system for routing casualties to destinations
that are best able to provide the required care: ``The Right patient,
to the Right place, at the Right time.''
The employment of critical care capability during aeromedical
transport and the role of evidence-based medical innovations have also
been important. Our community has been aggressive in meeting the needs
of the aeromedically evacuated critical care patients through
implementation of new technology for intra-cranial pressure monitoring
ensuring the safe transport of patients with head trauma, as well as
the latest in pain management using the non-electronic Stryker Pain
Pump. Additionally, the move to universally qualify aeromedical
evacuation crew has further ensured the safe passage of our sick and
injured.
The Air Force Medical Service clearly plays a critical role in the
delivery of health care to our front line troops. It has only been
through the collaborative efforts between the medical and operations
communities, multi-service and multi-national forces abroad that our
delivery of health care during the most challenging of contingencies
has become the best in the world.
Question. What tools and equipment are still required to improve
the care provided to combat casualties?
Answer. Our medical forces are doing tremendous work in the
delivery of health care to our front line troops and their experience
provides us with valuable lessons learned. These lessons learned deal
primarily with the tools and equipment still required to improve the
care provided to combat casualties. Based on lessons learned, we still
need solutions for the following requirements to provide the best
combat casualty care possible. I would be happy to discuss these with
you at your convenience in greater detail.
Rapid diagnostics capabilities for deployed and homeland stationed
medics: This shortfall includes deployment of systems similar to
Epidemiology Outbreak Surveillance to rapidly diagnose emerging
threats, as they happen to give commanders the information they need to
preserve the fighting force through prevention and prophylaxis.
Near real-time medical surveillance or environmental factors to
include water sources: This capability enables monitoring of sources to
allay the damage or illness from weapons of mass destruction.
Water and Intravenous purification: Exploitation of current
technology trends to allow on-site water purification to two standards,
potable and infusion quality. This capability dramatically decreases
the pallet space and logistical footprint needed to provide water to
troops.
Oxygenation capabilities integrated with Aeromedical Evacuation and
Expeditionary Medical Support: There is an increasing need for deployed
medical personnel to provide their own oxygen.
Acute care and local extracorporeal membrane oxygenation to
facilitate stabilization for transport of critically injured patients.
Instant reach-back communications for facilitation of inter-service
patient care coordination: There are considerable shortfalls in
interoperability for rapid communication leading to delays in
treatment, transport and communication of care rendered.
Blood substitutes are needed to not only expand the fluid volume of
injured patients but to also include increased oxygen carrying
capability that standard volume expanders lack.
Medical Scancorder development must be accomplished so that
Soldiers and Airmen can be monitored for instability of vital signs/
hemodynamics before they experience symptoms.
Portable anesthesia is now limited by respirator availability or
intravenous access; stable, simple and effective anesthesia devices are
needed to allow humane and safe anesthesia to injured patients.
Patient controlled anesthesia is the standard of care: This
standard is not currently met by most equipment/personnel medical
support packages deployed and on modes of transportation available for
evacuation.
Trauma registry information as required by DOD Health Affairs
Policy #04-031: Non-technological solutions are being used, which
hinders the evacuation and medical care of injured Soldiers and Airmen.
Despite the challenges we face, it is my privilege to share
successes of improved combat casualty. The proud men and women of the
Air Force Medical Service have recently fielded Telehealth initiatives
within the CENTCOM Area of Responsibility (AOR), which provide reach-
back via Telehealth consultations and Teleradiology. We have also
provided telephonic FAX capabilities for asynchronous reach-back
consultations. Pumpless extra-corporeal lung assist has been used to
evacuate critically ill patients that formerly would have been too
unstable to transport. And, based on the most recent recommendations
from our surgeons who have seen large numbers of severe orthopedic
injuries, the addition of pneumatic tourniquet systems for extremity
surgery, and compartment pressure monitors to diagnose limb-threatening
compartment syndrome are examples of improve combat care to our front
line troops. However, there are more tools needed to achieve improved
treatment outcomes based largely on lessons learned from the AOR.
The management of shock is probably the most basic element of
trauma care. The replacement of fluid, administration of blood
products, and maintenance of the body at normal temperature are all key
to this lifesaving process. The thromboelastography (TEG) analyzer is
a powerful clinical monitor to evaluate the interaction of platelets
and plasma factors, plus any additional effects of other cellular
elements (e.g., WBCs, RBCs). To guide administration of blood products,
TEG has been recommended by our trauma surgeons, as the analysis
provided by this tool would clearly benefit the management of our
critically injured casualties. Forced-air warming therapy has become
the standard choice for preventing hypothermia. Maintaining patient
normothermia is proven to reduce increased complications for the post-
operative patient as well as the massive trauma patient. The Bair
Hugger temperature management devices, such as the warming blanket and
warming units, are those being specifically recommended for addition to
the deployed inventory.
There is currently discussion underway about having basic
diagnostic cardiology in theater, such as a treadmill and
echocardiogram capability. We are working with the Army and Navy,
analyzing the benefits of accomplishing basic stress testing in
theater, prior to evacuation, with the increased chance of returning
more troops back to their unit rather than being evacuated to
Landstuhl, Germany.
Also critical to the effective management of patients is the
continuity of information transfer. As casualties travel from the
battlefield and through the military health care system, clinicians are
known for writing on the dressings of casualties to ensure critical
information goes with the patient and is readily accessible by all that
will care for the casualty along the way. Use of the Battlefield
Medical Information System, ``BMIST,'' has been initiated. This
wireless electronic information carrier has been successful; however,
the challenge has been to ensure that every field medic is issued the
hand-held element so they can complete the casualty's electronic record
on-site and be able to ``beam'' or give it on a memory chip to the air
ambulance or aeromedical evacuation crew who can take it with the
casualty on to their final destination.
Finally, the challenges of communication between the multiple
Service medical assets have unfortunately continued through the years.
There is a wide array of communications tools and equipment among the
different Services, each fulfilling their own requirements, but
unfortunately most often not linking with the sister Services. While
there are numerous initiatives underway addressing this very issue at
the Joint and individual Service level, the critical key, as with every
initiative regarding the management and care of our forces, is to
ensure integration of these efforts.
______
Question Submitted by Senator Pete V. Domenici
ACCESS TO MENTAL HEALTH SERVICES
Question. I understand from your statements that you are diligently
pursuing incidences of mental health issues such as depression, anxiety
and post-traumatic stress disorder. I commend you for that. It is my
understanding that to date the Department of Defense has done a good
job reaching out to soldiers upon their return.
My concern is for mental health services for rural Guard and Air
Guard members in particular. Those Guardsmen in places like Springer,
New Mexico are far from metropolitan areas and do not have access
following demobilization to military mental treatment facilities with
mental health services.
I understand that this rural demographic is a small portion of your
total population, but do you share my concerns about mental health
access for rural Guard and Reserve members and if so can you give me
your thoughts on how we might best address this issue?
Answer. Our best efforts address the concern by requiring all
redeploying members to receive a medical screening to include mental
health conditions by completing DD Form 2796, Post-Deployment Health
Assessment prior to theater departure or within five days upon return
to home station. This screening provides the first sign of the need for
additional health care and prompt access to care within our Military
Healthcare System.
To aid continuity of care and address health conditions frequently
identified several months following redeployment, Assistant Secretary
of Defense (Health Affairs) recently announced an extension of the
deployment health screening process projected to start June 10, 2005.
Post-Deployment Health Reassessment will involve each member completing
an additional health screening form three to six months following
redeployment to specifically address mental and other health concerns.
The member's responses in coordination with a healthcare provider's
review will determine the need for additional care, which may then be
obtained through TRICARE health system referral or through the Veterans
Health Administration. Additional sources of care for mental health
concerns in rural areas may include the local department of public
health and safety and military Family Assistance Centers. In the
National Guard, the Adjutant General determines the need and location
of the Family Assistance Center in support of deployment activities,
and the State Family Program Coordinator is the point of contact.
Of note, Veterans who serve in a theater of combat operations
during war are eligible for care for two years from their date of
active duty discharge provided they first enroll in the Veterans Health
Administration. Access to Veterans Health Administration-sponsored care
is visible at: http://www1.va.gov/directory/guide/home.asp?isFlash=1.
______
Question Submitted by Senator Richard C. Shelby
ANTHRAX VACCINATION
Question. During the height of the Iraq invasion, concern, and more
specifically controversy, surrounded vaccinating our armed forces for
anthrax. This debate has not died down. The FDA has reported that there
are over 50 side effects to the anthrax vaccination, and this is taking
into account that former FDA Director David Kessler has stated that
only 10 percent of reactions ever get reported. In 1998 the former
Secretary of the Army Luis Caldera acknowledged the anthrax vaccine was
linked to ``unusually hazardous risks.'' There have been documented
cases of DOD continuing shots after major reactions, which violates
vaccine instruction and documented cases of DOD administering shots
from expired lots. Further, Senate Report 103-97 stated that the
vaccine has still not been eliminated as a cause of the Gulf War
Syndrome. In the past 5 years, thousands of cases of adverse reactions,
causing serious health problems, have been linked to the anthrax
vaccine. Several soldiers have even died from the shots. In light of
the inherent risks in the program, I would appreciate hearing the
panels' views as to why are we still mandating that our service members
receive these shots?
Answer. From the Air Force perspective, the use of anthrax as a
bio-weapon poses a significant threat to military operations. The
anthrax vaccine is the most effective means available today to protect
our forces. Although antibiotics were used following the anthrax
attacks in 2001, they provide effective treatment only if exposure is
known before symptoms appear. Unfortunately, we do not always have the
necessary warning time necessary for antibiotics to work alone.
Although we will continue to work to increase warning time of pending/
existing attacks, our men and women must be prepared to carry out their
duties in defense of this country regardless of circumstances. To that
end, the best currently available round-the-clock protection to prepare
our forces to counter the threat of anthrax is vaccination. The vaccine
provides a critical layer of protection that may be augmented by
antibiotics and other measures.
Since March 1998, over 1.3 million DOD personnel have been
protected against anthrax exposure. Over 150,000 Air Force personnel--
Active, Guard and Reserve--in service today have received the anthrax
vaccination. While some individuals have expressed concern about
anthrax vaccine, a detailed analysis of 34 peer-reviewed medical
journal articles shows that people vaccinated or unvaccinated against
anthrax have the same health experiences. In 2002, the National Academy
of Sciences published a Congressionally commissioned report that
concluded anthrax vaccine has a side-effect profile similar to that of
other vaccines licensed by the FDA (www.iom.edu/Object.File/Master/4/
150/0.pdf). It is well recognized that minor temporary side effects are
underreported (the point Dr. Kessler makes); however, serious adverse
events are reported, especially in a well-monitored integrated health
system, such as the Military Health System.
In addition, the Air Force--along with the other Services--utilizes
the Vaccine Adverse Event Reporting System (VAERS), a national vaccine
safety surveillance program co-sponsored by the FDA and the Centers for
Disease Control and Prevention. This system collects and analyzes
information from reports of adverse events that occur after the
administration of all U.S. licensed vaccines. Reports are encouraged
from all concerned individuals: patients, parents, health care
providers, pharmacists and vaccine manufacturers. All anthrax vaccine
recipients receive information via the Anthrax Vaccination Immunization
Program trifold brochure and other means on how to access VAERS.
With reference to adverse events, Air Force policy requires anyone
who presents to medical personnel with a significant adverse health
condition after receiving any vaccination (e.g., anthrax, smallpox,
typhoid) to be evaluated by a physician to provide all necessary care
for that event. The physician must determine whether further doses of
that vaccine should be given, delayed, or a medical exemption--either
temporary or permanent--be granted. Air Force medical personnel are
trained how to manage perceived or actual adverse events after
vaccination with any vaccine (i.e., how to assess, treat and report).
As for links between anthrax vaccinations and Gulf War Syndrome,
two publications by the civilian Anthrax Vaccine Expert Committee
concluded that multi-symptom syndromes among some veterans of the
Persian Gulf War were not reported more often among anthrax vaccinees
than expected by chance. As explained in these articles, the vast
majority of adverse-event reports involve temporary symptoms that
resolve on their own. While one death has been classified as
``possibly'' related to a set of vaccinations, these civilian
physicians did not attribute other reported deaths to anthrax
vaccination in particular.
With respect to expired lots, at no time has anyone shipped expired
anthrax vaccine to any military facility. We are, however, aware of one
incident involving vaccine from expired vials being administered to
approximately 59 Marines at a military Medical Treatment Facility (MTF)
in April 1999. That incident involved vaccine that expired after it had
been stored on site at the medical treatment facility--it was not
expired at the time of shipment. Corrective measures have been
implemented to prevent a reoccurrence. For example, the handling
procedures for vaccines were changed to ensure that, upon receipt by
the MTF, the lot number and expiration of all vials of vaccine in the
shipment are recorded. Also, the Distribution Operation Center at the
United States Army Medical Materiel Agency issues a message to all
Service Logistic Centers to pre-alert them to when any anthrax vaccine
lot is about to expire. This message ensures all anthrax vaccine is
used prior to expiration, and aids in the prevention of a reoccurrence
of the situation encountered by the Marines.
All information concerning this expired-vaccine incident was
forwarded to the Armed Forces Epidemiological Board (AFEB), an
independent, nationally recognized group of civilian scientific experts
that advises the DOD on the prevention of disease and injury and the
promotion of health.
After reviewing the details of the incident, the AFEB concluded
that the expired vaccine administered to the Marines posed little or no
safety risk and any decrement in potency of the expired vaccine would
be minimal and clinically irrelevant.
______
Question Submitted by Senator Patrick J. Leahy
CHCSII AND TRICARE ONLINE
Question. I have followed the evolution of CHCS II and TRICARE
Online with interest, and it strikes me that there is a confluence of
maturing technologies that can be leveraged to empower the patient to
improve health care quality while reducing health care costs. If
Department of Defense servicemembers and beneficiaries are given the
ability to securely enter data about themselves and their medical
problems into CHCS II via TRICARE Online, it will solve a huge problem
facing the military health system, namely how to get standardized
clinical information into the medical record without using expensive
and scarce medical personnel. Physicians would get better information
about their patients, and patients would get immediate guidance from
the tools mounted on TRICARE Online to help them with their problems. I
know there are knowledge tools in CHCS II, but I would like each of you
to comment on any plans your service has to offer them to beneficiaries
on Tricare Online. What are your thoughts about using Tricare Online to
help populate subjective clinical information into CHCS II?
Answer. Any technology that helps our providers take better care of
our patients is worth exploring. As a matter of fact, the TRICARE
Medical Authority (TMA) is already working on expanding the ability of
beneficiaries to input data directly into CHCS II. The technology is
not quite there yet, but TMA has a short-term solution that uses the
internet and e-mail to allow patients to communicate directly with
their providers. TMA is also working on an internet based Health
Insurance Portability and Accountability Act compliant solution
involving the movement of patient data from TRICARE Online to the
provider via e-mail.
______
Questions Submitted by Senator Barbara A. Mikulski
POST-TRAUMATIC STRESS DISORDER
Question. The major mental health problem being faced by the
returning veteran is Post Traumatic Stress Disorder (PTSD). The New
York Times recently reported that an Army study shows that about one in
six soldiers in Iraq report symptoms of major depression, serious
anxiety or post-traumatic stress disorder, a proportion that some
experts believe could eventually climb to one in three, the rate
ultimately found in Vietnam veterans. (NY Times, Dec. 16, 2004).
(Reference for the above Army study is: New England Journal of
Medicine, Vol. 351, No. 1, pg. 13).
According to the Times and the Army report, ``through the end of
September, the Army had evacuated 885 troops from Iraq for psychiatric
reasons, including some who had threatened or tried suicide. But those
are only the most extreme cases. Often, the symptoms of post-traumatic
stress disorder do not emerge until months after discharge''. (NY
Times, Dec. 16, 2004).
The Times also referenced a report by the GAO that found similarly
alarming results: ``A September report by the Government Accountability
Office found that officials at six of seven Veterans Affairs medical
facilities surveyed said they ``may not be able to meet'' increased
demand for treatment of post-traumatic stress disorder.'' (NY Times,
Dec. 16, 2004).
However, despite this well-documented crisis, I am concerned that
we are not doing enough to combat PTSD.''
In light of these very serious concerns, what is the Department of
Defense doing to address well-documented examples of PTSD in our men
and women returning from the battlefields of Iraq, Afghanistan and
elsewhere?
Answer. The Air Force currently screens all Airmen for PTSD
symptoms upon redeployment. Because PTSD symptoms often emerge over
time, the Air Force will begin reassessing Airmen 90-180 days after
return from deployment, starting in June 2005. This reassessment
screens for PTSD as well as other common mental health related
concerns. Any deployer, whether active duty or reserve component, who
endorses any psychological symptoms will receive a full evaluation be a
healthcare provider, and referred for care when indicated.
While review of post-deployment health assessment data indicate
that Air Force deployers face significantly less exposure to traumatic
stress than Army and Marine ground combat, the Air Force is nonetheless
committed to identifying and treating all deployment related health
concerns in an expeditious and thorough manner.
Question. Are clinical trials being conducted in conjunction with
our nation's pharmaceutical industry?
Answer. The Air Force is not currently involved in clinical drug
trials for the treatment of Post Traumatic Stress Disorder (PTSD) due
to the very low incidence rate of PTSD within the Air Force.
Question. Is the Department aware that there exists a not-for-
profit organization in Maryland that is committed to pulling together
all developing new technologies for the treatment of PTSD?
Answer. The Air Force relies on the VA/DOD Clinical Practice
Guidelines for Post Traumatic Stress Disorder (PTSD) management. We are
open and interested in any and all technologies and innovations in the
area of PTSD treatment that meet clinical standards of care.
Question. What is the Department doing to identify these and other
innovative approaches to the treatment of PTSD?
Answer. The Air Force has joined a working group with the other
services, the Department of Veterans Affairs, and the National Center
for Post Traumatic Stress Disorder (PTSD) to identify state-of-the-art,
empirically validated treatment approaches to PTSD.
Our goals are to identify and treat PTSD symptoms as soon as
possible, and to ensure continuity of care as Airmen move to new
assignments or separate from the Air Force.
______
Questions Submitted to Colonel Barbara J. Bruno
Questions Submitted by Senator Ted Stevens
RECRUITING AND RETENTION
Question. How does the Uniformed Services University of the Health
Sciences support military nursing?
Answer. The Uniformed Services University of the Health Sciences
(USUHS) supports military nursing by providing a ``signature
curriculum'' designed to prepare nurses for practice and research in
federal health care and military systems. The USUHS Graduate School of
Nursing is dedicated to quality education that prepares both advanced
practice nurses and nurse scientists with a Ph.D. to deliver care,
conduct research and improve services to all military beneficiaries.
Programs that are currently offered at USUHS include three Masters
level programs; Perioperative Certified Nurse Specialist, Certified
Nurse Anesthetist and Family Nurse Practitioner and a Ph.D. program in
Nursing Science.
Question. With the current nursing shortage nationwide, and
continued need for medical support at home and overseas, what is the
status of your recruiting and retention efforts?
Answer. The Active Component (AC) Army Nurse Corps (ANC) has a
requirement of 365 new officers for fiscal year 2005. As of June 30,
2005, 187 new officers have been commissions and reported for active
duty. It is projected that the AC ANC will meet 88 percent (322 of 365)
of its accession requirements this year. The Reserve Component (RC) ANC
has a requirement of 485 new officers for fiscal year 2005. As of June
30, 2005, 236 new RC ANC officers have been commissioned. U.S. Army
Recruiting Command projects that they will achieve 75 percent (366/485)
of the RC ANC accession requirements this year.
The ANC recruiting and retention programs are critical to our
competitiveness in a tight nursing market. Active and Reserve programs
are detailed below. Program gaps include funding a second baccalaureate
degree for commissioned officers interested in becoming an Army Nurse
and a scholarship program to fund enlisted Reserve Soldiers interested
in obtaining a Bachelors of Science in nursing and pursuing a
commission as a Reserve ANC officer.
Active Component
The Health Professions Loan Repayment Program (HPLRP) is a
successful recruiting and retention tool for the ANC. HPLRP provides
payment of up to $29,323 toward qualifying educational loans incurred
from undergraduate nursing education. Currently, all eligible Active
Component ANC officers have been offered the opportunity to participate
in HPLRP, either at the time of accession or as a retention incentive,
or both. Since its inception in 2003, 272 officers have participated in
this program. Thus far in fiscal year 2005, 17 new direct accession AC
officers have received HPLRP.
The ANC offers a $15,000 accession bonus in exchange for a four-
year active duty service obligation. This bonus is projected to
increase to $20,000 in fiscal year 2006. Thus far in fiscal year 2005,
15 new AC AN officers have elected this incentive. Officers may also
choose to receive an accession bonus and participate in HPLRP. They
receive an $8,000 accession bonus combined with the HPLRP of up to
$29,323 for a six-year active duty service obligation. Thus far in
fiscal year 2005, 37 new AC officers have elected to take this option.
Nursing scholarships are offered through ROTC, the Army Nurse Candidate
Program, and the Enlisted Commissioning Program. Scholarships vary in
length from two, three, or four years depending on the program with at
least a three year active duty service obligation. ROTC nursing cadets
may participate in the Nurse Summer Training Program (NSTP), a three-
week internship in which they work with an ANC officer caring for
patients. While ROTC has struggled in recent years to meet nurse
mission, projections indicate that ROTC will commission the required
175 nurses by fiscal year 2007. This year's projection is for 131
nurses.
The ANC has robust programs for training nurses in specialty areas,
which also serve as excellent recruiting and retention tools. Under the
Generic Course Guarantee program new officers can choose critical care,
perioperative, psychiatric/mental health, or obstetrical/gynecological
training. All company grade officers are also eligible to apply to
those courses, as well as courses in emergency and community health
nursing.
The Long Term Health Education and Training program is a highly
successful retention tool for mid-level officers. This program offers
the opportunity to obtain a fully funded Masters degree or Doctoral
degree. Officers who participate in the program incur at least a four-
year active duty service obligation depending on the length of the
program. This past year, the U.S. Army Graduate Program in Nurse
Anesthesia was ranked second in the nation by U.S. News and World
Report.
The ANC also offers specialty pay to nurse anesthetists, nurse
practitioners, and certified nurse midwives. This year, the ANC
successfully increased the specialty pay for nurse anesthetists for the
first time in 10 years. Incentive specialty pay (ISP) is now $15,000 to
$40,000, depending on their status and length of service agreement.
Family nurse practitioners and certified nurse-midwives may also
qualify for special pay that ranges from $2,000 to $5,000 annually.
The AC ANC centrally manages the deployments of its officers in an
effort to ensure equity throughout the organization. In terms of
routine assignments, the ANC works aggressively to meet the personal
and professional needs of its officers while ensuring both the needs of
the Army and the officer are met as much as possible. Direct accessions
usually receive one of their top three choices for their first
assignment. Additionally, 98 percent of ANC officers married to other
Army officers and enrolled in the Army Married Couples Program are co-
assigned with their spouse.
Reserve Component
The HPLRP is available for all for Reserve ANC officers. It
provides up to $50,000 over a three-year period for repayment of
educational loans for nurse anesthetists, critical care, psychiatric/
mental health, medical-surgical, and perioperative nurses who agree to
serve in the Selected Reserve. The Reserve ANC also offers an accession
bonus of $5,000 per year for up to three years of Selective Reserve
duty. This year, 283 officers have received this incentive. New Reserve
ANC officers may take advantage of both of these programs sequentially,
but not in combination. The Specialized Training Assistance Program
(STRAP), which provides a monthly stipend of $1,279, is available only
to officers enrolled in nurse anesthesia and critical care masters of
science in nursing programs. Currently, there are 120 officers
receiving STRAP. All are nurse anesthesia students. STRAP for bachelors
of science in nursing programs is currently being staffed at Department
of the Army. It is anticipated that it will be available in fiscal year
2006.
Question. Can you describe the effects continued deployments have
had on staffing for Medical Treatment Facilities?
Answer. The effects continued deployments have had on staffing for
Medical Treatment Facilities are numerous. Military hospitals are not
receiving nursing replacements at the same ratio as those nurses
deploying and overtime for government service employees is not
mandatory. Therefore, military nurses are required to work additional
and many times erratic hours to maintain the same level of healthcare
services offered to our beneficiary population. Army Nurse Corps exit
surveys reveal lack of compensation for extra hours, not enough time
spent with family and likelihood of deployment as ``extremely
important'' reasons for leaving active service. In a recent report
commissioned by the United States Army Accession Command, reducing the
length/frequency of overseas deployments has the greatest impact on
nurse accessions.
______
Questions Submitted by Senator Barbara A. Mikulski
NURSING SHORTAGE
Question. How many military nurses do you have on active duty? How
many civilian nurses are employed by your service? How many nurses in
the Guard and Reserves?
Answer. The Army Nurse Corps currently has 3,105 nurses on active
duty; the Army Medical Department had 3,025 civilian registered nurses
employed; the Army National Guard had 651 nurses, and; the Army
Selective Reserve had 5,554 nurses.
Question. What is the deficit/shortage for each, between number on
duty compared with the number you have authority to hire?
Answer. The Army Nurse Corps deficit for the Active Component is
301 nurses. This figure is derived from subtracting current active duty
nurse inventory from 3,406 authorizations. As of March 31, 2005, there
were 337 open recruitment actions for civilian registered nurse
positions with the Army Medical Command. The Army National Guard
deficit is 26 nurses. This figure represents the difference between
reported inventory and 677 authorizations. Army Nurse Corps Selective
Reserves deficit is 270 nurses, the difference between current
inventory and authorizations.
Question. What is the average number of years of service for active
duty nurses? Guard and Reserve nurses?
Answer. The average number of years of service for an active duty
nurse is 8 years. The average number of years of service for National
Guard is 18.0 and for the Reserves is 15.3 years.
NURSING EDUCATION
Question. What percent of your nurses get a graduate degree at
USUHS? What percent of your nurses get a graduate degree somewhere
other than USUHS?
Answer. As of May 31, 2005, 880 Army Nurse Corps officers possess a
Master's degree, of those 8 percent hold a Master's degree from USUHS.
Ninety-two percent possess a Master's Degree from an institution other
than USUHS. The Army Nurse Corps is allotted a set number of seats in
each of the three graduate nursing programs offered at USUHS. Officers
interested in obtaining a Masters degree in a field offered through
USUHS must attend USUHS and may not attend a civilian institution
through the Long Term Health Education and Training (LTHET) program.
The Army consistently fills the seats it is allotted at USUHS. In 2004,
the Army Nurse Corps requested and was granted an expansion to double
the number of seats in the Family Nurse Practitioner Program from 7 to
14.
Question. Does the military pay for advanced degrees for military
nurses (at USUHS or elsewhere)?
Answer. Each year the Army Nurse Corps sends 70-90 officers to
complete graduate studies at USUHS or at a civilian institution through
LTHET.
Question. What is the average level of education for Military
nurses? Civilian nurses?
Answer. The average level of education for the Active Component
Army Nurse Corps is a Bachelor's of Science in Nursing degree or
Bachelor's of Science degree with a major in nursing. The average level
of education for Civilian nurses is an Associate Degree in Nursing.
NURSING EXPERIENCE
Question. What percent of your nurses come directly from nursing
school, and what percent are experienced in nursing when they join the
military? What percent of your nurses are prior service (in any
specialty)? What percent are prior service and from another service
(e.g., former Army nurses now working for the Navy)?
Answer. All active duty officers complete college or university
prior to their accession. Over the past five years, seventy-six percent
of newly assessed Army Nurse Corps officers are new college/university
graduates and twenty-four percent have at least one year of nursing
experience. Forty-five percent of Active Component Army Nurse Corps
officers have prior service experience. Eight percent of Active
Component Army Nurse Corps officers served in another service prior to
becoming an Army Nurse Corps officer.
NURSING DEPLOYMENTS
Question. Where/how are your nurses currently deployed?
Answer. In the interest of answering this question thoroughly and
as succinctly as possible the word ``deployed'' is defined as a nurse
drawing hazardous fire pay in a theater of operations. Army Nurse Corps
officers are deployed in support of both Operation Enduring Freedom in
Afghanistan and Operation Iraqi Freedom in Iraq/Kuwait. These officers
deploy as nurses in Brigade and Division Support Medical Companies; in
Corps-level Area Medical Support Companies; in Forward Surgical Teams;
in Combat Support Hospitals, and; as Chief Nurse in a Corps/Theater-
level Medical Brigade/Medical Command and Control unit.
Question. How often are Reserve/NG nurses activated?
Answer. The current rotation policy for Army Reserve and Army
National Guard units, specified in the Personnel Policy Guidance (PPG)
of the Army, is a 1 year mobilization followed by 3 years of
stabilization. The objective set by the Chief, Army Reserve and the
Department of Defense is a 6 year rotation, 1 year mobilization and 5
years dwell time. Certified Registered Nurse Anesthetists deploy under
the Army's 90-Day Boots-on-the-Ground policy--a 120-day mobilization
(no more than 90-days deployed) followed by at least 12 months
stabilization. This policy was introduced to help retain critical
wartime surgical specialties. According to information from the Army
Reserve 1,272 nurses have been mobilized since November 2001.
CIVILIAN NURSES
Question. Are civilian nurses used any differently than military
nurses?
Answer. Civilian nurses are utilized based on the job description
and scope of practice. Unlike military nurses they do not deploy or
have additional military training requirements. Civilian registered
nurses (Civil Service Employees) are available to pull on-call
schedules, work weekends, holidays and perform overtime within
budgetary feasibility.
Question. Do they fall under the same pay scale as military nurses?
What about retirement benefits?
Answer. Civilian nurses do not fall under the same pay scale as
military nurses. Civilian nurses are paid based on the Department of
Defense General Schedule pay system. Civilian nurses receive the same
retirement benefits as all other Title 5 Federal civilian employees.
Question. What is the relationship between AC military and civilian
nurses, and their counterparts in the Guard and Reserves?
Answer. Active component military and civilian nurses and their
counterparts in the Guard and Reserves are invaluable members of the
healthcare team. Overall a very good working relationship exists
between our Active and Reserve Components and civilian nurses. The
Guard, Selective Reserve, and civilian nurses support our ability to
provide quality nursing care.
Question. What is the average number of years a civilian nurse is
employed by the military health care system (is there a high turnover?)
Answer. The average number of years a civilian nurse is employed by
the military health care system is 9.9 years. The U.S. Army Medical
Command Civilian Personnel Office defines turnover rate as losses/prior
year-end strength. The turnover rate for civilian registered nurses is
17-20 percent. The replacement rate is calculated as the number of
fiscal year fills divided by prior year-end strength. The fiscal year
2004 Replacement Rate was 34 percent.
______
Questions Submitted to Rear Admiral Nancy J. Lescavage
Questions Submitted by Senator Ted Stevens
RECRUITING AND RETENTION
Question. How does the Uniformed Services University of the Health
Sciences support military nursing?
Answer. Programs within the Uniformed Services University of the
Health Sciences Graduate School of Nursing (USUHS GSN) have been
successful in meeting our Navy Nursing specialty requirements. In fact,
the Navy Nurse Corps requires all applicants for Family Nurse
Practitioner, Perioperative Nursing, and Nurse Anesthesia Master's
Degree Programs to seek admission to USUHS GSN as one of their two
schools of choice.
Our graduating nurses have reported that the graduate level
education and clinical experiences obtained at the USUHS GSN are of the
highest caliber, enhancing their medical readiness. During their
program, our students report extreme satisfaction with the advanced
professional clinical competencies they attain and the incorporation of
military relevant practice and mission requirements into the curriculum
(not available in civilian university programs). In addition, gaining
commands report that these graduates meet credentialing requirements
quickly and demonstrate the highest levels of clinical competencies.
Of particular note, our first two Navy Nurses began the newly
established Nursing Ph.D. Program this past fall on a full-time basis.
In our vision, these graduates will take on the ultimate executive
positions to create health policies, advance research and improve
delivery systems. Their valued experience will be critical to advance
and disseminate scientific knowledge, foster nursing excellence, and
improve clinical outcomes across Navy Medicine and Federal agencies.
Question. With the current nursing shortage nationwide, and
continued need for medical support at home and overseas, what is the
status of your recruiting and retention efforts?
Answer. Navy Nurse Corps' recruitment efforts include a blend of
diverse accession sources. Our successful pipeline scholarship programs
(Nurse Candidate Program, Medical Enlisted Commission Program, Reserve
Officer Training Corps, and Seaman to Admiral Program) account for 65
percent of our active duty staffing requirements. The remainder (35
percent) is acquired through direct accession and reserve recalls.
For the first time in ten years, we only attained 68 percent of our
fiscal year 2004 recruitment goal, acquiring 63 out of 92 nurses. As of
March 2005, we have attained 21 percent of our fiscal year 2005
recruitment goal, which is 6 percent less than our recorded status
during the same month of last year. As a result, we carefully monitor
our progress on a weekly basis.
Our overall retention rate remains stable at 91 percent. Various
retention initiatives include: graduate education and training
programs, pay incentives, operational experiences, and quality of life
issues (mentorship, leadership roles, promotion opportunities, job
satisfaction, and full scope of practice). By the end of fiscal year
2005, based on projected gains and losses, we anticipate a deficit of
137 with a billet authorization of 3098 (96 percent end strength).
Question. Can you describe the effects continued deployments have
had on staffing for Medical Treatment Facilities?
Answer. In sync with Navy Medicine's priority of delivering quality
and cost-effective health care, our Navy Nurses span the continuum of
care from promoting wellness to maintaining the optimal performance of
the entire patient. With the deployment of over 400 Active Duty Navy
Nurses along with the mobilization of Reserve Nurses to support our
Military Treatment Facilities (MTFs), there has been neither a
reduction of inpatient bed capacity nor an increase of network
disengagements. Military (active and mobilized reserve components) and
civilian nurses who remained at the homefront continued to be the
backbone and structure in promoting, protecting and restoring the
health of all entrusted to our care. Our success is attributed to
innovative health services programs and joint partnerships across our
MTFs. Ultimately, all MTFs do everything possible to conserve and best
utilize the remaining medical department personnel through appropriate
resource management practices (i.e. leave control, overtime
compensation, streamlined hiring practices).
Through an active Patient Safety Program, our military, civil
service and contract personnel constantly monitor the safe delivery of
patient care. In maintaining consistent superior quality of services,
we utilize research-based clinical practices with a customized
population health approach across the entire health care team. In
addition, we maximize our innovative health services programs and joint
partnerships across our military treatment facilities.
______
Questions Submitted by Senator Barbara A. Mikulski
NURSING SHORTAGES
Question. How many military nurses do you have on Active Duty?
Answer. As of March 2005, there were 2,948 Active Duty Navy Nurse
Corps Officers.
Question. How many civilian nurses are employed by your service?
Answer. Currently Navy Medicine employs 1,210 Registered Nurses
(GS-610); 305 Practical Nurses (GS-620); and 12 Nursing Assistants (GS-
621).
Question. How many nurses in the Guard and Reserves?
Answer. The Navy is not organized like the Air Force or Army, and
does not have a Guard Component. The Reserve Component of the Navy
Nurse Corps, as of the end of March 2005, had a total end-strength of
1,718 officers.
Question. What is the deficit/shortage for each, between number on
duty compared with the number you have authority to hire?
Answer. We have 3,098 authorized Active Duty Nurse Corps Billets.
As of March 2005, we had 2,948 billets filled for a deficit of 150
Nurse Corps Officers. As of March 2005, the authorized number of
billets for the Reserve Nurse Corps is 1,370. There are 1,718 Reserve
Nurse Corps Officers for a total of 348 over our end strength.
Question. What is the average number of years of service for Active
Duty nurses? Guard and Reserve nurses?
Answer. The average number of years of commissioned service for
Active Duty nurses is 9 years. The average number of years of total
Active Duty service (commissioned and enlisted years) is 12 years. The
average number of total years served (enlisted and commissioned) for
Reserve Nurse Corps officers is 16.13 years.
EDUCATION
Question. What percent of your nurses get a graduate degree at
USUHS?
Answer. In calendar year 2004, there were 5 nursing graduates from
USUHS or 7.0 percent of the total (71) Active Duty Navy Nurse Corps
graduates in 2004. In 2005, the number of Navy students graduating from
USUHS is also 5 or 7.0 percent of the total (70) Active Duty Navy
Nurses expected to graduate. This year we are increasing the number of
students attending USUHS. There will be a total of 24 students
attending USUHS beginning fiscal year 2006.
Question. What percent of your nurses get a graduate degree
somewhere other than USUHS?
Answer. In the calendar year 2004, 66 Active Duty Navy Nurse Corps
Officers received graduate degrees outside of USUHS. This is 93 percent
of the total (71) Active Duty Navy Nurse Corps graduates in 2004. For
2005, we anticipate 65 graduates from universities outside of USUHS.
This is 93 percent of the total (70) Active Duty Navy Nurse Corps
graduates.
Question. Does the military pay for advanced degrees for military
nurses (at USUHS or elsewhere)?
Answer. Although a few nurses join the Navy with advanced degrees,
the Navy Medical Education and Training Command is budgeted to fund
approximately 75 graduate nursing students each year. This ``Duty Under
Instruction'' scholarship program allows the Navy Nurse Corps to
prepare Advanced Practice Nurses (APN), Clinical Nurse Specialists
(CNS) and Certified Registered Nurse Anesthetists (CRNA). These
scholarships pay for the advanced training needed to support caring for
those in harm's way.
Question. What is the average level of education for Military
nurses? Civilian nurses?
Answer. Beginning fiscal year 2005, the level of education for
Active Duty military nurses was 64 percent BSN, 30 percent MSN, 0.6
percent Doctorate and 5 percent in graduate school. While aggregate
data is not available on the education levels of our civilian nurses,
they are graduates of two year community college programs, three year
hospital based diploma programs, and the majority are four year college
graduates.
EXPERIENCE
Question. What percent of your nurses come directly from nursing
school, and what percent are experienced in nursing when they join the
military?
Answer. In fiscal year 2004 we had 223 accessions to Active Duty.
Of these, 38 had some experience (17 percent) and the remainder (185)
were new graduates directly from school (83 percent).
Question. What percent of your nurses are prior service (in any
specialty)?
Answer. Approximately 45 percent of the 2,948 Nurse Corps Officers
on Active Duty as of March 2005 have at least 12 months or more of
prior service. This is a result of the excellent pipeline (enlisted to
officer) programs in the form of scholarships, that add stability to
our numbers. This is particularly evident in readiness essential
specialties such as the Certified Registered Nurse Anesthetist (CRNA)
community. In this specialty, 68 of 146 CRNA's (47 percent) are prior
service.
Question. What percent are prior service and from another service
(e.g., former Army nurses now working for the Navy)?
Answer. Of the 2,948 Navy Nurses on Active Duty as of March 2005,
six (0.2 percent) are inter-service transfers. Since the year 2000, the
Navy Reserve has had a total of 37 inter-service transfers which
represents about 2 percent of our total reserve end-strength.
DEPLOYMENTS
Question. Where/how are your nurses currently deployed?
Answer. Navy Nurses have deployed this past year throughout the
world to Kuwait, Iraq, Djibouti, Afghanistan, Bahrain, the Philippines,
Thailand and Guantanamo Bay, Cuba. During these deployments they
support our operational and humanitarian mission via Surgical
Companies, Surgical Teams, Shock Trauma Platoons, the Forward
Resuscitative Surgical System, Fleet Hospitals, Expeditionary Medical
Facilities, on both Navy and Hospital Ships, and our Medical Treatment
Facilities abroad.
Question. How often are Reserve/NG nurses activated?
Answer. As of December 2004, a total of 385 nurses have been
activated for Operation Iraqi Freedom. This represents a total of 23
percent of the Reserve Nurse Corps End-Strength. Current Secretary of
the Navy policy allows for a non-voluntary recall for up to 24 months.
Most officers are recalled for a period of one year, with an option to
serve a second year as needed.
CIVILIAN NURSES
Question. Are civilian nurses used any differently than military
nurses?
Answer. Essentially, civilian nurses are hired primarily for their
clinical expertise. All civilian nurses are hired with a minimum three
years clinical experience, so they supply an immediate clinical support
for all of our specialty areas. However, since we have a greater
deployment requirement for some specialties such as perioperative,
critical care, anesthesia, emergency/trauma, psychiatric/mental health
and surgical nursing, there are often more military nurses in these
specialties. Consequently, there are often more civilian nurses working
in clinical areas such as obstetrical, maternal-infant, pediatrics and
newborn nursery.
Question. Do they fall under the same pay scale as military nurses?
Answer. Civilian nurses are paid under separate pay scales based on
the General Schedule or special salary rates established by the Office
of Personnel Management (OPM) or the Department of Defense under an
agreement with OPM to use certain pay flexibilities granted to the
Veterans Administration. For the most part, civil service Registered
Nurses are paid in the range of $64,000 to $80,000 for base salary.
Question. What about retirement benefits?
Answer. Civil service nurses are covered by two retirement plans
based on when they entered the federal service. Both are contributory
plans and require the employee to make contributions from pay toward
their retirement.
--Civil Service Retirement System--is basically a single
contributory, self-insured program supplemented by the non-
matched Thrift Saving Plan.
--Federal Employees Retirement System--is a combination of social
security, small basic annuity and the Thrift Saving Plan (with
some matching contributions).
Question. What is the relationship between AC military and civilian
nurses, and their counterparts in the Guard and Reserves?
Answer. In support of the One Navy Medicine concept, the
integration of active, reserve and civilian nurses renders a more
effective, efficient and fully mission-ready nursing force both at home
and abroad. With the deployment of over 400 Active Duty Nurses along
with the mobilization of Reserve Nurses to support our Military
Treatment Facilities, this concept of integration has allowed our
civilian staff, reserve backfill and Active Duty nurses to work
seamlessly to care for all of our beneficiaries.
Question. What is the average number of years a civilian nurse is
employed by the military health care system (is there a high turnover?)
Answer. With the keen competition for nurses in many of the more
populated areas, nurses will move from hospital to hospital based on
salary. Turnover is a continuing challenge, but with the flexibilities
in hiring and compensation, we seem to be competitive. At any one point
in time, there are approximately 50 civilian nurse vacancies, or 4.0
percent of the 1,210 total Registered Nurse positions.
______
Questions Submitted to Major General Barbara C. Brannon
Questions Submitted by Senator Ted Stevens
RECRUITING AND RETENTION
Question. How does the Uniformed Services University of the Health
Sciences support military nursing?
Answer. The Uniformed Services University of the Health Sciences
(USUHS) is committed to providing excellence in graduate nursing
education to prepare advanced practice nurses for the delivery of
healthcare during peace, disaster response, homeland security threats
and war. The Graduate School of Nursing (GSN) faculty and staff have an
exceptional blend of experience in the military and/or the federal
health care systems, and are prepared to provide a distinctly unique
educational experience that cannot be found at other universities. The
GSN signature curriculum is specifically designed to prepare nurses for
advanced practice and research roles in support of Active Duty members
of the uniformed services, their families and all other eligible
beneficiaries. This curriculum for graduate students includes
operational readiness, evidence-based practice, population health
outcomes, force health protection, federal health care systems, as well
as leadership.
The Perioperative Clinical Nurse Specialist (PCNS) Program (the
newest Master's program) prepares graduate nurses for clinical
practice, management, leadership, research, teaching and consultation
in advanced practice roles within the perioperative environment. This
is the only program of its kind in the United States focused totally on
perioperative practice and administration. Military unique aspects of
the curriculum stresses concepts directed toward delivering
perioperative care in both the military and federal health care system
with a strong focus on patient safety research and care in austere
environments. USUHS graduates are uniquely qualified to provide quality
care in a variety of settings to include peacetime and wartime
environments.
The Registered Nurse Anesthesia (RNA) Program is dedicated to
providing highly qualified nurse anesthetists for the uniformed
services. The uniformed services require graduates independently
provide quality anesthesia care in diverse settings. The military
unique curriculum is specifically designed to integrate scientific
principles of anesthesia theory and practice, stressing the unique
features of operational readiness throughout the curriculum to prepare
nurse anesthetists ready to deploy immediately upon graduation. USUHS
Graduate School of Nursing students deploy up to six months earlier
than graduates from other RNA programs.
The rigorous curriculum of the Family Nurse Practitioner (FNP)
Program at USUHS prepares graduate nurses for advanced practice roles
in the federal sector. Their curriculum is more heavily weighted in
diagnostic reasoning and clinical decision-making since they practice
more autonomously in remote settings. In addition, the military unique
program includes field training to prepare nurses to support combat
casualties in deployed environment. Like the PCNS and RNA students, FNP
students graduate with a full compliment of operational readiness
skills and can deploy immediately upon graduation.
The Uniformed Services University also prepares military and
federal health nurses through doctoral education to research subjects
from operational readiness and deployment health to patient safety and
population health and outcomes management. This operational plan for
research has been lauded by the Federal Nursing Service Chiefs, members
of the USUHS Board of Regents, as well as the Assistant Secretary of
Defense/Health Affairs.
Operational readiness research areas at both the master's and
doctoral level include Active Duty, Reserve and Guard fitness, health
systems readiness, chemical, biological, radiological, nuclear and
high-yield explosives (CBRNE) defense, decision support and validation
of readiness training. Research also focuses on war injuries, care of
amputees, women's health in the deployed environment and stress and
coping in military families. Patient safety research is aimed at
addressing scientific inquiry in the areas of health literacy and
safety in the emergency room and/or operating room. Finally, research
in the domain of genetics examines the latest in genetic testing and
newborn screening.
The Uniformed Services University provides the nation with premier
nurses dedicated to career service in the Department of Defense and the
United States Public and Federal Health Services. The curriculum
includes military unique content that is not presented at civilian
universities.
Question. With the current nursing shortage nationwide, and
continued need for medical support at home and overseas, what is the
status of your recruiting and retention efforts?
Answer. The nursing shortage continues to pose enormous challenges
in supplying our demand for military nurse accessions and sourcing
civilian nursing workforce. A robust recruiting program is essential to
sustain the Air Force Nurse Corps. We have consistently been below our
goals: 78 percent in fiscal year 2001, 67 percent in fiscal year 2002,
79 percent in fiscal year 2003, and 71 percent in fiscal year 2004. Our
fiscal year 2005 recruiting goal is 357 nurses and it appears we will
end the year around 70 percent of that goal. We use the Health
Professions Loan Repayment Program (HPLRP), accession bonuses and ROTC
scholarships to recruit top quality nurses.
Our most successful tool for recruiting novice nurses has been the
HPLRP. In fiscal year 2004, we filled 118 quotas of up to $28,000 each.
For fiscal year 2005, we could only fund 26 HPLRPs, leaving the
accession bonus as the only financial incentive available. We increased
the accession bonus from $10,000 to $15,000 for a four-year commitment.
This has been moderately successful. We are currently formulating
programs to use the National Defense Authorization Act 2005 authority
to offer an accession bonus with a three-year commitment.
We have increased nursing Air Force ROTC quotas for the last two
years and filled 100 percent of our quotas. We added additional ROTC
scholarships for fiscal year 2005, increasing our quota from 35 in
fiscal year 2004 to 41. We are also enhancing our ``grow our own''
nurses from our enlisted corps. We revised the eligibility requirements
for the Airmen Enlisted Commissioning Program (AECP) to increase the
pool of enlisted to complete a Bachelor of Science in Nursing while on
active duty. Following graduation they commission into the Air Force
Nurse Corps. We have accessed 24 nurses through this program since its
inception in fiscal year 2001.
Advanced practice nurses are difficult to recruit. We primarily
meet our requirements by training our active duty nurses in advanced
specialties. We offer financial incentives to retain board certified
nurse practitioners, certified nurse midwives and certified registered
nurse anesthetists (CRNAs) consistent with our sister services.
Advanced practice nurses earn an additional $2,000 per year for less
than ten years of experience. In fiscal year 2000 we increased the CRNA
special pay to $6,000 per year while they complete any time commitment
for training. For those without a training commitment we increased the
rate in fiscal year 2005 up to $25,000 per year for a three-year
commitment. As a result, retention rates for CRNAs have increased from
a low of 81 percent for fiscal year 2000 to 88 percent for fiscal year
2004.
The nationwide nursing shortage has also affected our ability to
recruit civilian nurses. While the direct hire authority has
significantly improved the hiring process for nurses, numerous
positions remain unfilled in select areas of the country. The retention
of these nurses has also proven to be a challenge. We have difficulty
competing with civilian facilities that continue to offer more
attractive incentive packages.
While this continues to be a challenging time for recruiting, our
retention has been excellent. We have averaged a loss rate of just over
eight percent in the last ten years. Our nurses enjoy the opportunity
for professional development including the opportunity to apply for
advanced degree programs. They also recognize the promotion and
leadership opportunities available in the Air Force that are not as
common in the civilian sector. Our nurses are some of our best
recruiters as they tell their stories and share their experiences. We
continue to advertise our great quality of life and career
opportunities, as we remain focused on attracting top quality
baccalaureate nurses and nurturing them into tomorrow's nursing
leaders.
Question. Can you describe the effects continued deployments have
had on staffing for Medical Treatment Facilities?
Answer. The Air Force Medical Service has been faced with the
challenge of providing consistent medical support to each Air
Expeditionary Force (AEF) while at the same time maintaining critical
home station medical support and formal medical education programs. The
solution has been to optimize use of medical center and large hospital
staffing to meet most AEF requirements. This has multiple benefits
including the ability to provide a constant, predictable, measurable
level of support (same hit for medical treatment facility in every
bucket). This also allows for better programmatic adjustments as well
as increased ability to capitalize on resourcing investments and
enhancement of medical education and training.
While this process has been successful in anticipating the
requirements for deployment, several additional challenges have come to
light. These include tasking for already stressed medical Air Force
specialties, e.g., Critical Care, Surgical Specialties, Mental Health,
and Independent Duty Medical Technicians. Also, the Air Force has been
asked to fill some billets, e.g., Combat Stress Teams, Preventive
Medicine Teams, Detainee Health Team and others. These additional
taskings are met within the AEF cycle when possible to maintain a
predictable level of support. When this cannot be accomplished,
additional deployable assets may be tasked. Another solution has been
to use Air Force medics that have not previously been considered
deployable for medical reasons to fill assignments such as staff
positions to backfill personnel at either Air Force facilities that
deploy personnel or to deploy forward. Air Force medics who might not
be able to deploy forward have also been tasked to fill slots at Army
facilities such as Landstuhl in Germany and Tripler Army Medical Center
in Hawaii.
______
Questions Submitted by Senator Barbara A. Mikulski
NURSING SHORTAGES
Question. How many military nurses do you have on active duty?
Answer. There are 3,673 nurses on active duty as of April 30, 2005.
Question. How many civilian nurses are employed by your service?
Answer. The number of civilian nurses currently employed by Air
Force is 740.
Question. How many nurses in the Guard and Reserves?
Answer. There are currently 797 nurses in the Air National Guard
and 2,062 in the Air Force Reserve.
Question. What is the deficit/shortage for each, between number on
duty compared with the number you have authority to hire?
Answer. The deficit/shortage between number of nurses on duty
compared to the number we have the authority to hire for Active, Guard,
Reserve, and Civilian is as follows:
Active Duty deficit/shortage equals 277 out of 3,673.
Guard deficit/shortage equals 120 out of 797.
Reserve deficit/shortage equals 106 out of 2,062.
Civilian deficit/shortage equals 28 out of 740.
Question. What is the average number of years of service for active
duty nurses? Guard and Reserve nurses?
Answer. The average number of years of service for Active Duty
nurses is 11 years, while the average number of years of service for
Air National Guard and Air Force Reserve nurses is 15 years.
EDUCATION
Question. What percent of your nurses get a graduate degree at
USUHS?
Answer. Currently, 2 percent (92) of all nurses on active duty
(3,675) have a graduate degree from the USUHS. On average, 45.6 percent
(26) of all nurses are selected each year for Air Force-sponsored
education opportunities to attend the USUHS in the following programs:
Masters of Science in Nursing (MSN): Family Nurse Practitioner MSN;
Perioperative Clinical Nurse Specialist; MSN Nurse Anesthesia;
Doctorate (PhD), and Nursing Science.
Question. What percent of your nurses get a graduate degree
somewhere other than at USUHS?
Answer. We currently have 1,443 Nurses with Masters Degrees in the
Air Force. The breakdown is as follows: 915 Other (on their own)--63.4
percent; 407 AFIT (Air Force Institute of Technology) sponsored--27.0
percent; 92 USUHS--7.6 percent; 21 Tuition Assistance--1.4 percent; 6
HPSP (Health Professions Scholarship Program)--0.4 percent; 1 VEAP
(Veterans Education Assistance Program)--0.06 percent; and 1 Education
Delay--0.06 percent.
We currently have 14 Nurses with Ph.D.s in the Air Force. The
breakdown is as follows: 6 AFIT sponsored; and 8 Other (on their own).
There are currently three Air Force students enrolled in the Ph.D.
program at the USUHS.
Question. Does the military pay for advanced degrees for military
nurses (at USUHS or elsewhere)?
Answer. The Air Force has several programs to assist nurses in
pursuing advanced degrees. In fiscal year 2004 we selected 57 nurses
for education opportunities. Of these, 31 attended civilian
institutions for programs not offered at the USUHS. These students are
sponsored by the Air Force Institute of Technology. The remaining 26
nurses selected attended the USUHS. The Air Force also offers tuition
assistance for Airmen that choose to pursue programs during off-duty
time. Officers can receive up to $4,500 per fiscal year for courses
that lead to an advanced degree. We also offer scholarships for nurses
interested in nurse anesthesia and women's health through the Health
Professions Scholarship Program.
Question. What is the average level of education for Military
nurses? Civilian nurses?
Answer. All nurses in the Air Force Nurse Corps hold a bachelors
degree in nursing. Of these, 39.3 percent (1,443) also hold a masters
degree and 0.4 percent (14) hold a Ph.D.
According to the most recent data from the American Association of
Colleges of Nursing, in the year 2000, 34 percent of nurses in the
civilian sector hold an associates degree in nursing (ADN), 22 percent
practice with a diploma, and 43 percent hold a bachelors degree in
nursing. Only 9.6 percent hold a masters degree and 0.6 percent hold a
Ph.D. According to the U.S. Department of Health and Human Services,
only 16 percent of ADNs obtain a post-RN nursing or nursing-related
degree.
EXPERIENCE
Question. What percent of your nurses come directly from nursing
school, and what percent are experienced in nursing when they join the
military?
Answer. Nurses are considered inexperienced until they have
practiced for one year. Experienced nurses, on the other hand, have
worked in clinical nursing for more than one year or have trained in a
specialized area. Over the last four years, the percentage of
inexperienced nurses recruited has steadily increased. In fiscal year
2001, these nurses comprised 22.8 percent of all new accessions with
experienced nurses constituting the remaining 77.2 percent. By the end
of fiscal year 2004 the percentage of inexperienced nurses increased to
39.3 percent of all nurses recruited, bringing the four-year average to
30.9 percent. The four-year average for experienced nurses fell to 69.1
percent.
Question. What percent of your nurses are prior service (in any
specialty)?
Answer. Officers in the Air Force Nurse Corps come from a variety
of backgrounds. Nurses with prior service in any specialty comprise
25.6 percent of the Air Force Nurse Corps. Of these, one percent are
officers commissioned in the Air Force that later transferred to the
Nurse Corps. Nurses with prior enlisted service make up 24.6 percent of
the Air Force Nurse Corps. From this category, eight percent were prior
enlisted in the Air Force and 16.6 percent were prior enlisted in other
services, including the Air Force Reserve and Air National Guard.
Question. What percent are prior service and from another service
(e.g., former Army nurses now working for the Navy)?
Answer. At the end of calendar year 2004, the Air Force Nurse Corps
included 392 nurses (10.8 percent) who had been commissioned in a
different branch of the military and then transferred to the Air Force.
This includes nurses who transferred from the Air Force Reserve and the
Air National Guard.
DEPLOYMENTS
Question. Where/how are your nurses currently deployed?
Answer. The following data is obtained from Deliberate Crisis
Action Planning Execution Segments (DCAPES) and is as of May 24, 2005.
The data reflects personnel deployed on Contingency/Exercise Deployment
(CED) orders at SECRET level and below and includes the type of nurse
currently deployed by the area of responsibility of deployment.
----------------------------------------------------------------------------------------------------------------
TDY--AOR
AFSC5D ------------------------------------------------------- Total
CENTCOM EUCOM NORTHCOM PACOM SOUTHCOM
----------------------------------------------------------------------------------------------------------------
CLINICAL NURSE................................ 40 11 13 1 3 68
CN CRITICAL CARE.............................. 30 15 7 ......... ......... 52
CN Womens Health Care Nurse Prac.............. 1 ......... 1 ......... ......... 2
FLIGHT NURSE.................................. 40 28 45 ......... ......... 113
MENTAL HEALTH NURSE........................... 2 4 6 ......... ......... 12
NURSE-ANESTHETIST............................. 7 ......... ......... ......... 1 8
NURSING ADMINISTRATOR......................... 5 ......... 3 ......... ......... 8
OPERATING ROOM NURSE.......................... 19 ......... 1 ......... ......... 20
NURSE-MIDWIFE................................. ......... ......... ......... ......... 1 1
-----------------------------------------------------------------
Grand Total............................. 144 58 76 1 5 284
----------------------------------------------------------------------------------------------------------------
Question. How often are Reserve/NG nurses activated?
Answer. Based on personnel currently assigned to the Selected
Reserve (SelRes), there are 2,876 nurses in the SelRes. Of this number,
733 individuals have been mobilized 845 times since September 11, 2001.
Specifically, one was mobilized four times; five were mobilized three
times; 99 were mobilized two times; and 628 were mobilized one time.
The average number of mobilizations per month since September 11, 2001
is approximately 19 (about 11 mobilizations a month during the past 12
months). The peak mobilizations were in February-April, 2003 (490
total; with 232 in March 2003)--of those mobilized, 475 individuals
were deployed one or more times. Note: The mobilization data are per
the Military Personnel Data System (MilPDS) and the deployment data are
per the Deliberate Crisis Action Planning Execution Segments (DCAPES)
deployed history file, May, 2005.
CIVILIAN NURSES
Question. Are civilian nurses used any differently than military
nurses?
Answer. During peacetime, civilian nurses are used much the same as
military nurses. One stumbling block to fully integrating civilian
nurses into our nursing teams is the requirement for overtime pay for
time worked beyond forty hours. On Air Force hospital inpatient units,
nurses are scheduled on 12-hour shifts. The rotation requires the
nurses to work four shifts one week and three shifts on the opposite
weeks. Civilian nurses would regularly exceed forty hours in a seven-
day period and have fewer than forty hours in others. This would
increase civilian pay bills. Additionally, when a civilian has a short
notice absence, the extra coverage usually falls to the military
nurses. This is manageable with a small civilian force; however,
scheduling is much more complicated and taxing with a larger civilian
force. Civilian nurses are currently assigned to all settings, but in
the future will be concentrated in the outpatient clinics. We need to
assign military nurses to most of our inpatient and critical care
authorizations for currency in wartime clinical skills.
Question. Do they fall under the same pay scale as military nurses?
Answer. Civilian and military nurses do not fall under the same pay
scale. Civilian nurses currently receive their pay based on the General
Schedule (GS) for federal employees or a contractual agreement. Pay
rates may be adjusted based on locality. The GS rating for nurses may
vary due to kind of work (inpatient versus outpatient), specialized
skills necessary (intensive care versus inpatient ward), and management
responsibilities.
Basic Pay is the fundamental component of military pay. All members
receive it and typically it is the largest component of a member's pay.
A member's grade (usually the same as rank) and years of service
determines the amount of basic pay received. Their basic pay is not
affected by the their duty location. The military does offer
certification pay for our advanced practice nurses and incentive
special pay for our Certified Registered Nurse Anesthetists.
Question. What about retirement benefits?
Answer. The retirement benefits would be computed using the general
formula for the retirement system the employee is covered under the
Civil Service Retirement System (CSRS) or the Federal Employees
Retirement System (FERS). The formulas for the computation of
retirement benefits can be found in the U.S. Office of Personnel
Management CSRS and FERS Handbook For Personnel and Payroll Offices
available on line at http://www.opm.gov/asd/hod/pdf/C050.pdf.
Question. What is the relationship between AC military and civilian
nurses, and their counterparts in the Guard and Reserves?
Answer. Nurses in the Air National Guard (ANG) and in the Air
Reserve Component (ARC) are utilized several ways once activated. Some
of the nurses are used to backfill positions vacated by active duty
nurses deploying. This role has enabled some facilities to continue to
meet their peacetime mission requirements. Other nurses are deployed
along with their units. They have manned contingency air staging
facilities overseas and stateside. They are also responsible for 88
percent of aeromedical evacuation flights.
While on active duty, ANG and ARC nurses receive the same pay and
benefits as their full-time Active Duty counterparts. Civilian nurses
receive their pay based on the General Schedule (GS) for federal
employees or a contractual agreement.
Question. What is the average number of years a civilian nurse is
employed by the military health care system (is there a high turnover?)
Answer. The civilian nurses currently employed by the Air Force
through the military health care system have worked for the Air Force
for an average of 8.26 years. The nurses who left Air Force employment
between January 1, 2004 and May 1, 2005 had an average of 7.81 years of
civilian service some of which may have been performed for other
governmental agencies.
SUBCOMMITTEE RECESS
Senator Stevens. The subcommittee will reconvene tomorrow
at 10 a.m., in this room to review the Missile Defense Program
for 2006. We stand in recess until that time.
[Whereupon, at 11:59 a.m., Tuesday, May 10, the
subcommittee was recessed, to reconvene at 10 a.m., Wednesday,
May 11.]