Committee on Trauma advocates for improved care of severely injured patients

The American College of Surgeons (ACS) has waged a continuous effort to improve care for injured patients since 1922, when it established the Committee on Fractures. Now known as the ACS Committee on Trauma (COT), the committee has more than 3,500 Fellows working to develop and implement meaningful programs for trauma care in local, regional, national, and international arenas. The COT looks to develop and implement programs that support injury prevention and ensure optimal patient outcomes across the continuum of care.

Advocacy at both the local and federal levels is a pillar of the COT and is vital to the effort to improve trauma care. Support for trauma systems, injury prevention, and research funding are all affected by state and federal representatives and agencies, and the College continues to be a trusted resource on Capitol Hill and in state governments.

Federal legislation

The ACS Division of Advocacy and Health Policy (DAHP) advances the College’s health policy agenda, which includes a robust trauma portfolio. The ACS COT advocacy team encourages members of Congress to support bipartisan trauma legislation that strengthens trauma care with the goal of minimizing injury and preventable deaths. Specific pieces of trauma-related legislation are as follows.

PAHPAI

After extensive efforts by the DAHP staff, surgeon advocates, and in conjunction with our trauma partners, on June 24, 2019, President Donald Trump signed S. 1379, the Pandemic and All-Hazards Preparedness and Advancing Innovation (PAHPAI) Act of 2019. This legislation was created to improve the nation’s response to public health and medical emergencies and called for appointing an Assistant Secretary of Preparedness and Response (ASPR) to oversee the nation’s disaster response. The ASPR’s responsibilities would include implementation of the recommendations from the June 2016 National Academy of Sciences, Engineering and Medicine report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.

Included in this reauthorization is the ACS-supported Mission Zero Act. Mission Zero builds upon the legislative framework passed in the fiscal year 2017 National Defense Authorization Act by further incorporating military trauma care providers into the civilian setting. These military-civilian trauma care partnerships will increase military health care readiness and ensure the provision of high-quality trauma care both domestically and abroad. The grant was authorized for $11.5 million for fiscal years 2019–2023 and will be facilitated by the ASPR.

Now that Mission Zero has been authorized, the Appropriations Committees will need to fund these grants at the authorized amount. DAHP staff and its partners have begun to lay the groundwork to ask Congress for full funding.

Stop the Bleed initiatives

Over the last several years, the staff of the ACS DAHP and Fellows of the College have offered bleeding control training to members of Congress and congressional staff.¹ DAHP staff hosts quarterly training with the Senate Sergeant at Arms to train Senate staff and actively pursues large-scale training courses in both congressional chambers. Through this effort, the ACS has demonstrated the importance of Stop the Bleed^® on Capitol Hill and in district offices across the nation.

These training courses have resulted in bipartisan legislation focused on further disseminating Stop the Bleed training. On May 7, 2019, Reps. Alcee Hastings (D-FL) and Brad Wenstrup, DPM (R-OH), introduced H.R. 2550, the Prevent Blood Loss with Emergency Equipment Devices (BLEEDing) Act of 2019. This legislation would provide grant funding to states for bleeding control kits and training. With 27 cosponsors, this bill continues to gain traction and raise awareness about Stop the Bleed. DAHP staff is working with the House champions to identify senators to introduce a companion bill in the Senate.

Similar to cardiopulmonary resuscitation training, a civilian familiar with basic bleeding control techniques is better equipped to save a life. The effort to make this training and bleeding control kits available to the public through a Department of Homeland Security grant program will help to drive the goal of reducing or eliminating preventable deaths from bleeding.

Firearms morbidity and mortality prevention

Despite the polarizing political rhetoric around firearms, the ACS COT has promoted a nonpartisan public health approach to firearm injury prevention. This strategy includes implementing evidence-based violence prevention programs through ACS COT-verified trauma centers and fostering a dialogue with professional organizations to create consensus around reducing firearm injury and death.

The College has had numerous opportunities to share the work of the COT before Members of Congress and their staff. The ACS testified before the U.S. House of Representatives Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies at a hearing titled Addressing the Public Health Emergency of Gun Violence² and before the U.S. House of Representatives Energy and Commerce Subcommittee on Health at a hearing titled A Public Health Crisis: The Gun Violence Epidemic in America.³

Research funding

Federally funded research from the perspective of public health has contributed to reductions in motor vehicle crashes, smoking, and sudden infant death syndrome. The ACS believes this same approach should be applied to firearm-related injuries and gun safety. The ACS has repeatedly supported funding for the Centers for Disease Control and Prevention (CDC) to conduct public health research into firearm morbidity and prevention.

Last year, the College joined more than 100 medical, public health, and research organizations asking Congress to appropriate $50 million in funding for firearm morbidity and mortality prevention research.⁴ Subsequently, the House passed H.R. 2740, the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act. This legislation passed on June 19, 2019, with a vote of 226–203 and included ACS-supported language providing $50 million for firearm morbidity and mortality prevention research.

Background checks

The House passed H.R. 8, the Bipartisan Background Checks Act of 2019 February 27, 2019, by a vote of 240−190. This legislation requires all firearm sales to go through the National Instant Background Check System established under the Brady Handgun and Violence Prevent Act.

This legislation is supported by the recommendations outlined in the ACS Firearm Strategy Team Work Group Consensus Statement and is a key step in addressing this public health crisis.⁵

Liability protections for trauma care providers

Under the Emergency Medical Treatment and Labor Act, physicians are mandated to stabilize a patient who presents at a hospital emergency department (ED). Surgeons in emergency settings provide complex, high-risk surgical care for severely injured patients, often with minimal information about the patient. Unfortunately, the high liability risk associated with providing such care is broadly acknowledged as a key factor in the growing shortage of specialists participating in emergency on-call panels.

The Health Care Safety Net Enhancement Act, H.R. 3984, introduced by Reps. Bill Flores (R-TX); Roger Marshall, MD (R-KS); and Brian Babin, DDS (R-TX), would address the problem by providing Federal Tort Claims Act liability protections to on-call and ED physicians.

State legislation

Stop the Bleed

The Stop the Bleed campaign made significant advancements in 2019 with the enactment of legislation in three states: Arkansas, Indiana, and Texas. In Arkansas, H.B. 1014 requires high school students to complete a Stop the Bleed course, whereas Indiana (H.B. 1063) and Texas (H.B. 496) both passed bills that nearly mirror the ACS’ model legislation requiring public school personnel to be trained in bleeding control and that schools have bleeding control kits on site. The Illinois Terrorism Task Force announced in September that the state would fund the installation of bleeding control kits for all public schools.

Other legislation to install bleeding control kits in schools or public places was introduced in the following states: California, A.B. 1705; Illinois, H.B. 3432; Michigan, H.B. 4334; Missouri, H.B. 1005, H.B. 249; Massachusetts, H. 1870, S. 1337; New York, A. 4484; North Carolina, H.B. 288; Pennsylvania, H.B. 1072; and Tennessee, S.B. 259, H.B. 215.

Trauma funding

The Connecticut Chapter opposed legislation, S.B. 46, which would prohibit trauma centers from charging a trauma activation fee that helps provide the resources required to ensure the state’s trauma system has the necessary health care professionals, facilities, and equipment to save lives. At present, Connecticut does not allocate public funding for the state’s trauma centers. Grassroots efforts by the chapter and testimony from ACS Fellows garnered enough opposition to the bill to successfully prevent its passage.

The Louisiana Chapter sounded a call to action in support of H.B. 380 to increase driver’s license fees by $2.75 and to direct the funding to the Louisiana Emergency Response Network, the state’s trauma system. Despite support from the Louisiana Chapter and the state’s trauma hospitals, the legislation failed to gain enough support to pass.

Meanwhile, the Texas legislature passed H.B. 2048, which eliminates the Texas Driver Responsibility Program, which generates $71 million to fund the statewide trauma system. The revenue for the trauma system will be replaced with a mix of traffic fines and fees. On April 3, 2019, Ronald M. Stewart, MD, FACS, Medical Director, ACS Trauma Programs, testified before the Texas House Homeland Security and Public Safety Committee in support of the bill.

The Michigan Chapter received the 2019 ACS Enhanced Advocacy Grant to pursue legislation to establish a comprehensive statewide trauma system. The chapter is a member of the Michigan Trauma Coalition, composed of more than 90 member hospitals and trauma centers across Michigan, which is pushing for the legislation.

Violence prevention and firearms

In 2019, ACS Fellows and chapters added the surgeon perspective on state legislation to help stem the prevalence of violence and firearm injury and death. In California, Fellows supported two bills related to violence prevention. A.B. 166 would establish a pilot Medi-Cal program to fund violence prevention services, and A.B. 521 would fund the University of California Firearm Violence Research Center at UC Davis to develop multifaceted education and training programs for medical and mental health providers on the prevention of firearm-related injury and death. The Governor signed A.B. 521 but vetoed A.B. 166.

The New Jersey legislature enacted a package of safety bills—S. 3301, S. 3309, S. 3312, and S. 3323—that will create and fund the New Jersey Violence Intervention Program and Hospital-Based Violence Intervention Program Initiative.

The Delaware Chapter supported passage and enactment of H.B. 63, which revises the charge of “unlawfully permitting a child access to a firearm” to “unsafe storage of a firearm,” placing the emphasis on firearm safety and proper storage. Under the revised statute, a crime is committed when a person intentionally or recklessly stores or leaves a loaded firearm where a minor or another unauthorized person can access the weapon.

The Virginia Chapter submitted comments to the State Crime Commission charged with studying and taking public comments on potential firearm-related legislation in response to the May 31, 2019 Virginia Beach shooting. The chapter’s comments included the ACS Statement on Firearm Injuries and a copy of “Firearm-related injury and death in the United States: A call to action from the nation’s leading physician and public health professional organizations,” which was published in Annals of Surgery.

Distracted driving

State legislatures continue to pass legislation to address distracted driving. A total of 131 bills on various forms of distracted driving were introduced in 2019. Legislation enacted or vetoed include the following:

• Arizona H. 2318 includes an all driver texting ban, handheld ban, and a ban on viewing and transmitting of non-navigational video. However, the Governor vetoed S. 1141 to classify distracted driving as “reckless driving” in certain circumstances.
• Arkansas S. 534 bans use of handheld devices in work and school zones, as well as a cell phone ban for drivers with graduated licenses. Enforcement will charge perpetrators with a primary offense.
• H.B. 107 in Florida upgrades the texting ban enforcement to a primary offense, but permits video chatting when the vehicle is stationary and exempts autonomous vehicles.
• Illinois S.B. 85 prohibits the viewing of video or using a hand or finger to compose, send, read, access, browse, transmit, save, or retrieve e-mails, text messages, instant messages, photographs, or other electronic data. H.B. 2386 increases the fine and penalties for crashes involving electronic device use that cause great bodily harm.
• Louisiana legislation, H.R. 303, creates the Wireless Telecommunications and Vehicle Safety Study Commission to study the use of a wireless telecommunications device while operating a motor vehicle.
• Minnesota H.F. 50/S.F. 91 broadens the state’s handheld ban to prohibit video viewing while in traffic. It permits the use of hands-free mode for composing, reading, or sending electronic messages.
• Rhode Island H. 6186/S. 785 bans the use of wireless handset for text messages.
• Tennessee H.B. 164/S.B. 173 extends the handheld ban in school zones and prohibition on viewing and recording video, gaming, and engaging with other electronic entertainment.
• Virginia S.B. 1768 prohibits the use of any personal electronic device in a work zone.
• In New Hampshire, the Governor vetoed H.B. 198, which would have repealed the prohibition on texting while driving.

Motorcycle helmets

The Connecticut Chapter testified at a hearing of the Joint Transportation Committee in support of H.B. 7140, which would require anyone on a motorcycle to wear a helmet. The bill passed out of the legislature after it was amended to remove the universal helmet requirement. A similar bill in Iowa to create a universal helmet law for all motorcycle riders and passengers failed.

Legislation was introduced in Arizona, Maryland, Massachusetts, Missouri, Nebraska, New Jersey, North Carolina, Virginia, Washington, and West Virginia to weaken existing state law by exempting adults 21 years or older from the requirement to wear a helmet, whereas legislation in New York called for the state Department of Transportation to study the efficacy of motorcycle helmets in preventing injury.

All the proposed bills failed except Missouri’s, which the state legislature passed, but the governor vetoed. The ACS sent a letter urging Missouri Gov. Mike Parson (R) to veto the bill. The North Carolina Chapter initiated a call to action resulting in more than 7,000 e-mails sent to the House Health Committee opposing the legislation to repeal the state’s universal helmet law.

Seat belts

A total of 75 bills were introduced in 2019 related to seat belt and child restraints in motor vehicles. The Louisiana Chapter engaged the legislature with grassroots in support of S.B. 76 to update the state’s child safety guidelines to mirror the requirements set by the American Academy of Pediatrics. The Louisiana bill passed and become law August 1, 2019, when Gov. Jon Bel Edwards (D) signed it.

The New York Chapter initiated a call to action in support of A. 6163/S. 4346, legislation that would require the use of seat belts by all passengers age 16 and older riding in any seating position in a motor vehicle. The New York bill failed despite the chapter’s efforts.

In Alabama, S.B. 254 requires that all passengers wear a seat belt while the car is in motion; however, only front seat belt usage is subject to primary enforcement. In Maine, S.B. 389 exempts passengers older than 18 years of age from wearing a seat belt if the number of passengers exceeds the vehicle seating capacity and all the seat belts are in use.

Oregon enacted H.B. 2347, which clarifies that a person driving a vehicle for the purpose of delivering newspapers or mail is exempt from wearing a seat belt. Texas Gov. Greg Abbott (R) vetoed H.B. 448, a child safety restraint bill, which requires children younger than two years old, shorter than three feet four inches, or less than 40 pounds to be secured in a rear-facing child passenger safety seat system.

Washington’s H.B.1901 provides an exemption from seat belt use for individuals who have a physician’s order that they not use the restraints for medical reasons. H.B. 1012 requires that a child younger than two years old must be secured in a rear-facing child restraint system, a child younger than four in a forward-facing secured seat, and a child less than four feet nine inches must be in a booster seat.

What’s ahead

The COT will continue to build on the momentum of the past year to achieve advocacy priorities by supporting the grants created by Mission Zero, continuing Stop the Bleed trainings for members of Congress and their staff, and serving as a resource on firearm-related legislation. ACS State Affairs is working with the Stop the Bleed Advocacy Workgroup to develop an advocacy guide and model legislation to assist with lobby days and local efforts.

The DAHP staff is continuing efforts to introduce legislation that follows recommendations from the National Academies of Science, Engineering and Medicine report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. The goal of potential legislation would be to create a trauma taskforce that would create a national trauma system and establish a National Institute on Trauma Research.

For questions or additional information on trauma priorities, contact Hannah Chargin, Congressional Lobbyist, at hchargin@facs.org. For information on state trauma legislation, contact Christopher Johnson, MPP, State Affairs Associate, at cjohnson@facs.org.

References

1. Dateline DC—Stop the Bleed demonstrates how advocacy has the power to effect change. Online exclusive. June 1, 2019. Bull Am Coll Surg. Available at: bulletin.facs.org/2019/06/dateline-dc-stop-the-bleed-demonstrates-how-advocacy-has-the-power-to-effect-change/. Accessed January 6, 2020.
2. American College of Surgeons. Statement of the American College of Surgeons on Addressing the Public Health Emergency of Gun Violence. March 7, 2019. Available at: facs.org/-/media/files/advocacy/federal/acs_house_lhhse_statement_march_2019.ashx. Accessed January 6, 2020.
3. American College of Surgeons. Statement of the American College of Surgeons on a Public Health Crisis: The Gun Violence Epidemic in America. October 3, 2019. Available at: facs.org/-/media/files/advocacy/federal/acs_house_commerce_energy_statement_october_2019. Accessed January 6, 2020.
4. American College of Surgeons. Firearms Research Funding Letter. February 21, 2019. Available at: facs.org/-/media/files/advocacy/federal/cdc_gvp_research_funding_letter_2019.ashx. Accessed January 6, 2020.
5. Stewart RM, Bulger EM, Kuhls DA, 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;228(2):198-206.