The COT at 100: The Critical Role of Trauma Advocacy and Injury Prevention

Highlights

• Describes how advocacy and injury prevention have been goals of the COT since its inception
• Identifies the evolution of state, federal, and professional programs and policies that optimize prehospital injury care
• Summarizes the creation and growth of the STOP THE BLEED^® program
• Highlights current COT advocacy and injury prevention priorities, including the development of a National Trauma Care System

Advocacy is the action of achieving support for a particular position or policy. Surgeon involvement in advocacy-related healthcare policy is key to safeguarding patient-centered care. Although advocacy is commonly considered an activity that involves engagement with local and federal policymakers to pass specific legislation, this work also involves communicating our healthcare-related priorities with practices, hospitals, and healthcare systems to achieve better care for our patients and communities. Successful advocacy motivates collective attention and action and has an explicit intended outcome, such as a change in actions, policies, rules, laws, or funding.

One of the first standing committees of the ACS, the Committee on Trauma (COT), has been an ardent advocacy organization. Over the last century, the COT has been an effective advocate for policies and programs that prevent injuries, maximize survival of the injured, and optimize the return to a productive and meaningful life after injury. Throughout the 1950s, 1960s, and 1970s, the COT’s advocacy efforts focused on the prevention of motor vehicle crashes and creation of a trauma and emergency care system. This eventually led to the creation of the National Highway Traffic Safety Administration (NHTSA). The COT informed and supported historic legislation such as the National Traffic and Motor Vehicle Safety Act (1966), Highway Safety Act (1970), and the Emergency Medical Services Systems Act (1973). Through the 1980s and 1990s—as the structure for trauma systems evolved along with the implementation of the Advanced Trauma Life Support^® (ATLS^®) Program, the COT Verification, Review, and Consultation Program, and the Trauma System Consultation Program—state and regional advocacy efforts by members of the COT began to advance legislation supporting trauma system development. In the 2000s, the COT’s advocacy efforts further advanced the systems of care for the injured and led to publications such as the 2006 Guidelines for Field Triage of Injured Patients and the 2008 systems consultation guide, Regional Trauma Systems: Optimal Elements, Integration, and Assessment.

Recognizing the role of advocacy to ensure injury prevention and high-quality trauma care remain a priority at the state and national levels, the COT leadership created the Injury Prevention and Advocacy Pillar in 2010. Today, the COT’s advocacy pillar engages with the ACS Division of Advocacy and Health Policy (ACS DAHP), the ACS Professional Association Political Action Committee (ACSPA-SurgeonsPAC), and ACS congressional lobbyists to support legislative priorities that ensure optimal outcomes for injured patients.

As the concept of trauma centers gained momentum, the need to develop injury prevention research and programs as a regional resource began to take hold.

A Tradition of Injury Prevention

Injury prevention has been an integral component of the educational efforts and advocacy priorities of the COT. Over the last century, US life expectancy has increased from 62 to nearly 80 years, mostly due to a decreased incidence of injury-related deaths. This decrease in injury-related deaths is multifactorial and includes the following:

• A general reduction in exposure to dangerous jobs and enhancements to safety improvements in the areas of transportation and housing
• Improvements in the medical care provided to injured patients
• The development of a wide array of evidence-based injury control strategies

Examples of injury prevention successes occurred throughout the history of the COT. Beginning in 1939, Charles Scott Venable, MD, FACS, encouraged surgeons to actively become involved with efforts to reduce morbidity and mortality from motor vehicle collisions. In February 1955, the ACS Board of Regents approved a resolution proposed by the COT acknowledging that motor vehicle crash injury prevention was both a civic and professional obligation of the College. That same year, a subcommittee on Traffic Injury Prevention was appointed by COT Chair R. Arnold Griswold, MD, FACS (1952–1957). Additionally, Dr. Griswold testified on behalf of the ACS at a hearing in the US House of Representatives in August 1956, where he offered additional suggestions for effectively managing motor vehicle-related injuries. Another advocate for motor vehicle safety, Horace E. Campbell, MD, FACS, worked collaboratively with the COT to advocate for shatterproof glass and doors that do not open on impact.

The COT was not singularly focused on traffic-related injury. In the 1960s, the ACS, along with partner organizations, identified pediatric burns as an area that could greatly benefit from preventive measures.

As the concept of trauma centers gained momentum, the need to develop injury prevention research and programs as a regional resource began to take hold. Injury prevention was recognized as a foundational component of trauma center resources in the first iteration of the Optimal Hospital Resources for the Care of the Injured Patient published in 1976. As injury prevention activity by the COT continued to evolve, Donald D. Trunkey, MD, FACS, COT Chair (1982–1986) established the Trauma Prevention Committee in 1985, naming John G. West, MD, FACS as the first Chair. The 1993 edition of Resources for the Optimal Care of the Injured Patient increased visibility for injury prevention with its own dedicated chapter on that topic, eventually requiring Level I and II centers to perform screening for alcohol abuse disorders with that manual’s 2014 revision. In 1998, the Trauma Prevention Committee was renamed the Injury Prevention and Control Committee (IPCC) and led the way for the COT to recognize injury as a public health issue and one that needed to be addressed using scientific methodology and a public health approach. Over the years, the COT has been involved in a wide array of injury prevention efforts including bicycle/motorcycle helmet safety, child safety seat usage, pediatric injury prevention, firearm injury and interpersonal violence, and suicide prevention.

Current Advocacy and Injury Prevention Priorities of the COT

STOP THE BLEED^®

Over the past decade, a key advocacy priority of the COT has been to reduce preventable deaths after injury by transforming the public’s awareness and skillset to address hemorrhage control in the prehospital setting. Because it is a top cause of preventable death in the injured patient, the control of active hemorrhage has been prioritized in trauma care. Yet, as hemorrhage control at the trauma center was progressively refined by applying ATLS Program “C-Circulation” principles, techniques in prehospital hemorrhage control were variable. Tragically, the nation’s attention has been turned to the value of bystander hemorrhage control through numerous mass shooting events such as the 2009 Virginia Tech shooting in Blacksburg, VA, the 2012 Sandy Hook Elementary School shooting in Newton, CT, and the 2018 Stoneman Douglas High School Shooting in Parkland, FL. Within this context, the COT led a massive advocacy movement to transform prehospital hemorrhage control in the US and around the world.

In the wake of the Sandy Hook shooting, leaders from the ACS and the COT, led by Lenworth M. Jacobs Jr., MD, MPH, FACS, worked alongside federal agencies, the National Security Council, the US military, and emergency medical response organizations to create a national policy to enhance survivability from active shooter and intentional mass casualty events. These efforts led to the 2013 Hartford Consensus which developed three key recommendations: support early hemorrhage control at the scene; develop an integrated response by law enforcement, emergency medical services, fire, rescue, and public safety officials; and enhance public education to support national resilience. The Harford Consensus adopted a model of effective grassroots advocacy:

• Define a problem
• Identify a solution
• Build a broad coalition of public and private partners
• Maintain a consistent message
• Leverage multiple channels for communication (“STOP THE BLEED^®” [STB] became a rallying cry to gain public attention on the importance of bleeding control)

Early precursors of STOP THE BLEED were developed for professional prehospital personnel and in 2013, the National Association of Emergency Medical Technicians (NAEMT) released the first bleeding control course for nonmedical first responders called Law Enforcement and First Response Tactical Casualty Care. However, the need for a course to engage the public in bleeding control was quickly apparent, which led to the development of a course that focused on civilian bystanders similar to how cardiopulmonary resuscitation (CPR) training prepares bystanders for a cardiac emergency. In 2014, the NAEMT Bleeding Control Basic (B-Con) Course was introduced to the public. That course formed the foundation of today’s STB Course.

 The STB campaign was officially launched at the White House in 2015, and the formal launch of the ACS COT STB program occurred during the 2016 Clinical Congress in Washington, DC (see Figure 1, this page). Since its launch, COT leadership has focused on three key priorities: large-scale training in STB, public access to bleeding control tools, and public policy that supports STB and other trauma priorities. These efforts have resulted in more than 2 million people in 129 countries that are trained as immediate responders. Realizing that defibrillators are ubiquitous, but bleeding control supplies are less commonly available in public places, the Prevent Blood Loss with Emergency Equipment Devices (BLEEDing) Act, shaped by the ACS COT, was introduced in the House in 2019 and the Senate in 2020 to provide grant funding at the state level for bleeding control kits and training. Regarding public policies and public advocacy, multiple state legislatures have passed bills supporting the installation of bleeding control kit stations and STB training in public schools, and multiple corporations have implemented STB training for their employees. Over the last decade, the STB program has demonstrated the rapid impact of comprehensive advocacy through standards, professional education, cross-sector collaboration, citizen training, and public policy.

Advocating for the Development of a National Trauma Care System

In 2016, the National Academy of Sciences, Engineering, and Medicine (NASEM) published the report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury. The ACS was a sponsor of this project, and the COT, under the leadership of Ronald M. Stewart, MD, FACS, COT Chair (2014–2018), accepted responsibility to advocate for implementation of the recommendations from this report. Dr. Stewart convened a multidisciplinary meeting in Washington, DC, in 2017 to discuss strategies to address these issues.

The COT Advocacy Pillar has supported efforts to advance key recommendations from this report including: The Mission Zero Act, which authorizes funding to support integration of military teams into civilian trauma centers for ongoing training; increases in research funding appropriations to support US Department of Defense-funded trauma research; and increases in funding support for firearm injury prevention research from the Centers for Disease Control and Prevention.

Regional Medical Operations Centers to Support Disaster Response

COT leaders have been working with the US Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response (now the Administration for Strategic Preparedness and Response) and the Department of Homeland Security for a regionalized approach to disaster management based on the trauma system framework. The COVID-19 pandemic has added focus to the need for infrastructure to support regional coordination of the healthcare system for more effective management of these large-scale events. As a result, the COT has been advocating for the widespread adoption of Regional Medical Operations Centers (RMOCs), also known as Medical Operations Coordination Cells (MOCCs). These centers help rapidly mobilize and coordinate all relevant stakeholders for large-scale response, including public health agencies, emergency management, and all components of the acute healthcare system. Dr. Eileen Bulger, MD, FACS (COT Chair 2018–2022), and Dr. Stewart have participated in several webinars and panel discussions related to this issue, including a session sponsored by the Federal Emergency Management Agency, also known as the Federal Emergency Management Agency Healthcare Resilience Task Force, which has developed a toolkit for MOCC development.

Firearm Injury Prevention

The Injury Prevention and Control Committee uses a multifaceted approach to address firearm injury prevention. One of the most innovative ideas to come out of IPCC work on firearm injury prevention was the creation of the Firearm Strategy Team (FAST) Workgroup in 2018. Broad representation of surgeons from distinct backgrounds, geographic locations, and with varying firearm experience comprise the FAST Workgroup. In a 2018 article published in the Journal of the American College of Surgeons titled, “Freedom with responsibility: A consensus strategy for preventing injury, death, and disability from firearm violence,” the FAST Workgroup described a path forward creating an effective and durable strategy for reducing firearm-related injury, death, and disability in the US (see Figure 2).

In February 2019, in collaboration with 44 leading US professional organizations, the ACS convened a historic Medical Summit on Firearm Injury Prevention in Chicago, IL. The leadership of these organizations came together to discuss using a public health approach to minimize death and disability related to firearm injuries. The report outlined the current evidence for specific interventions to address suicide, unintentional injury, and intentional interpersonal violence. These interventions include counseling patients and families regarding safe firearm storage; lethal means safety for suicide prevention; hospital-based violence intervention programs; identifying patients at risk for violence; examining the relationship between mental health and firearm injury; and issues related to public policy. A second Medical Summit on Firearm Injury Prevention, also hosted at the ACS offices in Chicago, IL, took place in September 2022.

To truly understand the impact of injury prevention efforts, research on trends related to injury and violence is essential. To that end, the COT welcomed the inaugural ACS COT Firearm Injury Prevention Clinical Scholar in Residence (a 2-year, fully funded, mentored fellowship) Arielle Thomas, MD, in July 2020. Shelbie Kirkendoll, DO, MS, began her term in this role in July 2022. This fellowship was made possible through a collaboration with the COT’s partner organizations, including the American Foundation for Firearm Injury Reduction in Medicine, the American Association for the Surgery of Trauma, the Eastern Association for the Surgery of Trauma, the Pediatric Trauma Society, and the Western Trauma Association.

Improving the Social Determinants to Attenuate Violence (ISAVE)

Minority populations have historically had to bear a disproportionate burden of violent injury and death in the US, and they continue to do so. In the last several years there has been a growing interest and effort among trauma providers to look beyond addressing the physical injury to identify impactful ways to address the risk factors associated with violent injury. One focus of discussion during the Medical Summit on Firearm Injury Prevention involved addressing violence via an upstream approach to understand and mitigate the root causes of violence. In fact, significant attention gravitated toward the social determinants of health (SDOH) as the focal point when addressing upstream factors associated with violence. According to the National Academy of Medicine, SDOH account for 40% of the factors that affect health and wellness. To address these issues, COT leadership established the Improving the Social Determinants to Attenuate Violence (ISAVE) Workgroup under the leadership of Rochelle A. Dicker, MD, FACS (see Figure 3). ISAVE is a multidisciplinary group with a common goal of creating a more holistic approach to caring for victims of violent injury. The ISAVE group is composed of representatives from community-based organizations, hospital-based violence intervention programs, and law enforcement.

During their first meeting in December 2019, four main ISAVE initiatives were developed with corresponding work groups: Development of a trauma-informed care curriculum, investment in at-risk communities, integrating social care into trauma care, and advocacy.

Looking to the Future

Despite many remarkable gains in injury prevention, the care of the injured, and optimization of post-injury recovery over the last century, much work remains to be done. Significant gaps in the availability and quality of trauma care across US communities remain. Thus, one of the COT’s advocacy goals for the next decade is to create a National Trauma and Emergency Preparedness System, which will:

Establish and implement national standards for trauma care, injury prevention, and system readiness

• Support system-wide performance improvement activities
• Ensure readiness through the development of a network of Regional Medical Operations Centers
• Support research to advance the field

Lessons from the COT’s long legacy of effective advocacy will inform the inclusive approach needed to achieve these goals while emphasizing partnerships and stakeholder coalitions

Ultimately, the vision for the future is to ensure that traumatic injury is widely recognized as a worldwide, public health problem and that injury prevention research will be well-supported and identify the best evidence-based interventions to reduce death and disability from injury. The COT IPCC will remain committed to multidisciplinary collaboration in developing strategies to implement these interventions with the support of trauma centers, trauma systems, and like-minded organizations around the world.

Establishing a new norm in trauma care is essential. This new norm will value holistic care and embrace a trauma-informed care model, support investment in our communities, and play a vital role in working with social care practitioners to provide ongoing support after hospital discharge. The outcome will be safer communities and a chance for violently injured patients to not only survive, but to thrive.

The concurrent evolution of the science of injury prevention and the advocacy efforts within the COT has culminated in active engagement in structured research, education and training, community prevention, and outreach programs that guide both state and federal policy advocacy initiatives. This work has not only been effective in reducing injuries and deaths in the US, but it also serves as a model for other professional organizations that promote injury prevention using collaborative, community-based, and data-driven programs.

Acknowledgments

The authors would like to acknowledge the contributions of Rochelle A. Dicker, MD, FACS, Deborah A. Kuhls, MD, FACS, Mark L. Gestring, MD, FACS, Lenworth M. Jacobs Jr., MD, MPH, FACS, Melanie Neal, Holly Michaels, and Jean Clemency to the content of this article.

Dr. John Scott is assistant professor of surgery, Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor.

Bibliography

American College of Surgeons. Dateline DC—STOP THE BLEED demonstrates how advocacy has the power to effect change. Bull Am Coll Surg. June 1, 2019. Available at: https://bulletin.facs.org/2019/06/dateline-dc-stop- the-bleed-demonstrates-how-advocacy-has-the-power-to-effect-change. Accessed September 5, 2021.

Bulger EM, Kuhls DA, Campbell BT, et al. Proceedings from the Medical Summit on Firearm Injury Prevention: A public health approach to reduce death and disability in the US. J Am Coll Surg. 2019 Oct;229(4):415-430.

Bulger EM, Rasmussen TE, Jurkovich GJ, et al. Implementation of a National Trauma Research Action Plan (NTRAP). J Trauma Acute Care Surg. 2018;84(6):1012-1016.

Bulger EM, Snyder D, Schoelles K, et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014;18(2):163-173.

Carrico JC. In Search of a Voice. Bull Am Coll Surg. 1999;84(5):14-22.

Dicker RA, Thomas A, Bulger EM, et al; ISAVE Workgroup; Members of the ISAVE Workgroup. Strategies for Trauma Centers to Address the Root Causes of Violence: Recommendations from the Improving Social Determinants to Attenuate Violence (ISAVE) Workgroup of the American College of Surgeons Committee on Trauma. J Am Coll Surg. 2021 Sep;233(3):471-478.

Jacobs LM, McSwain NE, Rotondo MF, et al. Improving survival from active shooter events: The Hartford Consensus. J Trauma Acute Care Surg. 2013;74(6):1399-1400.

Jacobs LM. Implementation of The Hartford Consensus initiative to increase survival from active shooter and intentional mass casualty events and to enhance the resilience of citizens. Bull Am Coll Surg. 2015;100(1Suppl):83-86.

Jacobs LM, Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass-Casualty and Active Shooter Events. The Hartford Consensus III: Implementation of Bleeding Control: If you see something do something. Bull Am Coll Surg. 2015;100(7):20-26.

National Academies of Science, Engineering, and Medicine. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press; 2016.

Price MA, Kozar RA, Bulger EM, et al. Building the future for national trauma research. Trauma Surg Acute Care Open. 2020;5(1):e000421.

Rasmussen TE. A national trauma care system: From call to action. J Trauma Acute Care Surg. 2016;81(5):813-815.

Stewart RM, Kuhls DA, Rotondo MF, Bulger EM. Freedom with Responsibility: A Consensus Strategy for Preventing Injury, Death, and Disability from Firearm Violence. J Am Coll Surg. 2018 Aug;227(2):281-283.

Talley CL, Campbell BT, Jenkins DH, et al. Recommendations from the American College of Surgeons Committee on Trauma’s Firearm Strategy Team (FAST) Workgroup: Chicago Consensus I. J Am Coll Surg. 2019 Feb;228(2):198-206.

Winchell RJ, Eastridge BJ, Moore MM, et al. Developing a national trauma system: Proposed governance and essential elements. J Trauma Acute Care Surg. 2018;85(3):637-641.