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BackgroundThe earliest days of the COVID-19 pandemic in Canada were marked by a significant surge in COVID-19 cases and COVID-19–related deaths among residents of long-term care facilities (LTCFs). As part of Canada’s response to the COVID-19 pandemic, Canadian Armed Forces (CAF) personnel were mobilized for an initial emergency domestic deployment to the hardest-hit LTCFs (Operation LASER LTCF) to support the remaining civilian staff in ensuring the continued delivery of care to residents. Akin to what was observed following past CAF international humanitarian missions, there was an expected increased risk of exposure to multiple stressors that may be psychologically traumatic and potentially morally injurious in nature (ie, related to core values, eg, witnessing human suffering). Emerging data from health care workers exposed to the unprecedented medical challenges and dilemmas of the early pandemic stages also indicated that such experiences were associated with increased risk of adverse mental health outcomes. ObjectiveThis study aims to identify and quantify the individual-, group-, and organizational-level risk and resilience factors associated with moral distress, moral injury, and traditional mental health and well-being outcomes of Operation LASER LTCF CAF personnel. This paper aimed to document the methodology, implementation procedures, and participation metrics. MethodsA multimethod research initiative was conducted consisting of 2 primary data collection studies (a quantitative survey and qualitative interviews). The quantitative arm was a complete enumeration survey with web-based, self-report questionnaires administered at 3 time points (3, 6, and 12 mo after deployment). The qualitative arm consisted of individual, web-based interviews with a focus on understanding the nuanced lived experiences of individuals participating in the Operation LASER LTCF deployment. ResultsCAF personnel deployed to Operation LASER LTCF (N=2595) were invited to participate in the study. Data collection is now complete. Overall, of the 2595 deployed personnel, 1088 (41.93%), 582 (22.43%), and 497 (19.15%) responded to the survey at time point 1 (3 mo), time point 2 (6 mo), and time point 3 (12 mo) after deployment, respectively. The target sample size for the qualitative interviews was set at approximately 50 considering resourcing and data saturation. Interest in participating in qualitative interviews surpassed expectations, with >200 individuals expressing interest; this allowed for purposive sampling across key characteristics, including gender, rank, Operation LASER LTCF role, and province. In total, 53 interviews were conducted. ConclusionsThe data generated through this research have the potential to inform and promote better understanding of the well-being and mental health of Operation LASER LTCF personnel over time; identify general and Operation LASER LTCF–specific risk and protective factors; provide necessary support to the military personnel who served in this mission; and inform preparation and interventions for future missions, especially those more domestic and humanitarian in nature. International Registered Report Identifier (IRRID)DERR1-10.2196/44299

Objective To determine Canadian service members’ level of adherence to a recommendation for mental health services follow-up that was assigned by clinicians during postdeployment screening.Design Retrospective cohort study.Setting Canadian military population.Participants The cohort consisted of personnel (n=28 460) with a deployment within the 2009–2014 time frame. A stratified random sample (n=3004) was selected for medical chart review. However, we restricted our analysis to individuals whose completed screening resulted in a recommendation for mental health services follow-up (sample n=316 (weighted n=2034) or 11.2% of screenings.Interventions Postdeployment health screening.Primary outcome measure The outcome was adherence to a screening-indicated mental health services follow-up recommendation, assessed within 90 days, a preferred delay, and within 365 days, a delay considered partially associated with the screening recommendation.Results Adherence within 90 days of screening was 71.1% (95% CI 59.7% to 82.5%) for individuals with ‘major’ mental health concerns, 36.1% (95% CI 23.9% to 48.4%) for those with ‘minor’ mental health concerns, and 46.8% (95% CI 18.6% to 75.0%), for those with psychosocial mental health concerns; the respective 365-day adherence fractions were 85.3% (95% CI 76.1% to 94.5%), 55.7% (95% CI 42.0% to 69.4%) and 48.6% (95% CI 20.4% to 76.9%). Logistic regression indicated that a 90-day adherence among those with a ‘major’ mental health concern was higher among those screening after 2012 (adjusted OR (AOR) 5.45 (95% CI 1.08 to 27.45)) and lower, with marginal significance, among those with deployment durations greater than 180 days (AOR 0.35 (95% CI 0.11 to 1.06)).Conclusions On an individual level, screening has the potential to identify when a care need is present and a follow-up assessment can be recommended; however, we found that adherence to this recommendation is not absolute, suggesting that administrative checks and possibly, process refinements would be beneficial to ensure that care-seeking barriers are minimised.

Objective Canadian Armed Forces (CAF) post-deployment screening aims to facilitate early care for members with mental health issues. The process consists of a questionnaire to screen for mental health problems, followed by an interview with a healthcare provider during which recommendations for follow-up care are provided if needed. In this study, we examined the association of self-reported mental health from the screening questionnaire with recommendation for follow-up care during the interview.Design Using screening data collected from CAF members who deployed from 2009 to 2012 (n=14 957), logistic regression analysis was conducted to examine the association of self-reported mental health from the screening questionnaire with clinicians’ recommendation for follow-up care.Results In total, 19.7% of screened individuals were recommended for follow-up care. In the adjusted logistic regression model, some demographic characteristics, as well current and prior mental healthcare and self-reported mental health problems, had a substantial association with recommendation for follow-up. Compared with each mental health problem’s lowest severity category, recommendation for follow-up care was higher by approximately 12%–17% for those with mild to severe depression, 7% for those with panic disorder, 8%–10% for those with mild to severe anxiety, 8% for those experiencing high levels of stressors, 4%–10% for those at risk of alcohol use disorder and 7%–12% for those at risk of post-traumatic stress disorder.Conclusions Although the presence of mental health problems was significantly associated with receiving a follow-up recommendation, the relationships between self-reported mental health and subsequent recommendations for care were not as high as expected. Although this may partly reflect time delays between the questionnaire and interview, further research is needed on the extent to which other factors contributed to referral decisions.

Objective To determine whether post-deployment screening is associated with a shorter delay to diagnosis and care among individuals identified with a deployment-related mental disorder.Design Retrospective cohort study.Setting Canadian military population.Participants The cohort consisted of personnel (n=28 460) with a deployment within the 2009 to 2014 time frame. A stratified random sample (n=3004) was selected for medical chart review. We restricted our analysis to individuals who had an opportunity to undergo screening and were subsequently diagnosed with a mental disorder that a clinician indicated was deployment-related (n=1157).Interventions Post-deployment health screening.Main outcome measure The outcome was delay to diagnosis and care, the latency from individuals’ deployment return to their mental disorder diagnosis date. Cox proportional hazards regression assessed screening’s influence on this outcome.Results 74.4% of the study population had screened. Overall, the median delay to care was 766 days, 578 days among screeners and 928 days among non-screeners—a 350-day difference. Cox regression indicated that screeners had a significantly shorter delay to care (adjusted HR (aHR), 1.43 (95% CI, 1.11 to 1.86)). Screening findings had a substantial influence on delay to care. Identification of a mental health concern, whether a ‘major’ concern (aHR, 3.36 (95% CI, 2.38 to 4.73)) or a ‘minor’ concern (aHR, 1.46 (95% CI, 1.08 to 1.99)), and a recommendation for mental health services follow-up (aHR, 2.35 (95% CI, 1.73 to 3.21)) were strongly associated with shorter delays to care relative to non-screeners.Conclusions Reduced delays to care are anticipated to lead to beneficial outcomes for both the individual and military organisation. We found that screening was associated with a shortened delay to care for mental disorders that were deployment-related. Future work will further explore this screening’s components and optimisation strategies.

Mild traumatic brain injury (mTBI, also known as a concussion) as a consequence of battlefield blast exposure or blunt force trauma has been of increasing concern to militaries during recent conflicts. This concern is due to the frequency of exposure to improvised explosive devices for forces engaged in operations both in Iraq and Afghanistan coupled with the recognition that mTBI may go unreported or undetected. Blasts can lead to mTBI through a variety of mechanisms. Debate continues as to whether exposure to a primary blast wave alone is sufficient to create brain injury in humans, and if so, exactly how this occurs with an intact skull. Resources dedicated to research in this area have also varied substantially among contributing NATO countries. Most of the research has been conducted in the US, focused on addressing uncertainties in management practices. Development of objective diagnostic tests should be a top priority to facilitate both diagnosis and prognosis, thereby improving management. It is expected that blast exposure and blunt force trauma to the head will continue to be a potential source of injury during future conflicts. An improved understanding of the effects of blast exposure will better enable military medical providers to manage mTBI cases and develop optimal protective measures. Without the immediate pressures that come with a high operational tempo, the time is right to look back at lessons learned, make full use of available data, and modify mitigation strategies with both available evidence and new evidence as it comes to light. Toward that end, leveraging our cooperation with the civilian medical community is critical because the military experience over the past 10 years has led to a renewed interest in many similar issues pertaining to mTBI in the civilian world. Such cross-fertilization of knowledge will undoubtedly benefit all. This paper highlights similarities and differences in approach to mTBI patient care in NATO and partner countries and provides a summary of and lessons learned from a NATO lecture series on the topic of mTBI, demonstrating utility of having patients present their experiences to a medical audience, linking practical clinical care to policy approaches.

Background: Significant resources have been allocated to decreasing the number of preventable deaths in hospitals, but identifying preventable factors and then leveraging them to effect system-wide change remains challenging., Objective: To determine the ability of a novel in-person, multidisciplinary "rapid mortality review" process to identify deaths that are preventable and action items that lead to improvements in care., Methods: Rapid mortality review sessions were conducted weekly for patients who died in the medical intensive care unit. Patient data and clinician opinions regarding preventable deaths were discussed and recorded. Bivariate analyses were done to detect associations between case variables and the formation of an action item., Results: From 2013 to 2018, 542 patient deaths were reviewed; of those, 36 deaths (7%) were deemed potentially preventable. Facilitators identified issues in 294 cases (54%). A total of 253 action items were identified for 175 cases (32%); 60% of those action items were subsequently completed and led to tangible systemic change in 29 instances (11%). Action items were more likely to be identified for patients who had not been receiving comfort care (P < .001), for patients who had received cardiopulmonary resuscitation (P < .001), when the treatment team (P < .001) or the rapid mortality review facilitator (P < .001) had care-related concerns, and when the patient's death had been preventable (P < .001)., Conclusions: Even in settings with low reported rates of preventable deaths, an in-person multidisciplinary mortality review can successfully identify areas where care can be improved, leading to systemic change., (©2021 American Association of Critical-Care Nurses.)