The COT’s consensus-based approach to firearm injury: An introduction

The American College of Surgeons Committee on Trauma (ACS COT) has developed a strategy aimed at reducing death and disability from firearm injury, which is built on a trauma system (public health) model. The goals of this strategy are as follows:

  • Prevent injuries from occurring through firearm injury and violence prevention programs
  • Achieve immediate bleeding control at the scene of injury before emergency medical services (EMS) professionals arrive by turning bystanders into immediate responders through the proliferation of Stop the Bleed® and and by providing support for EMS
  • Ensure the delivery of rapid and effective on-site medical care with bleeding control through the COT’s partnership with the National Association of Emergency Medical Technicians (NAEMT) and its Prehospital Trauma Life Support (PHTLS) course
  • Provide rapid, definitive, high-quality trauma center treatment of the injured patient through the ACS COT’s Trauma Center Verification, Review, and Consultation (VRC) Program, the Trauma Quality Improvement Program (TQIP®), the ACS COT Performance Improvement and Patient Safety (PIPS) Program, and the Advanced Trauma Life Support Course (ATLS®)
  • Promote robust rehabilitation and reintegration programs designed to minimize disability (VRC and our recent efforts to achieve zero preventable deaths and disability from injury)

These techniques are described in greater detail later in the article, which starts with a look at the epidemiology of firearm injuries and the COT’s efforts to build consensus on the prevention of firearm injuries. This introductory article sets the stage for the three features on firearm injury prevention that follow, and concludes with a more detailed discussion of the previously listed bullet points.

Epidemiology of firearm injuries

In the last five decades, dramatic improvements have occurred in trauma care through the ongoing development of verified trauma centers and of regional trauma systems. The nation’s communities and patients have all benefitted from these enhancements.

In most U.S. trauma centers, firearm injuries account for a fraction of the injured patients who receive care. The COT recently queried all levels of trauma centers that submit data to the National Trauma Data Bank® and found that fewer than 5 percent of trauma patients who receive care at these facilities are seen for firearm injuries.1 Owing to the lethality of firearm injury, many of these patients die before they have the opportunity to enter the trauma and EMS system. Therefore, it is probably of little surprise that many trauma surgeons and nurses sometimes underestimate the substantial impact of firearm injuries on the burden of death in the U.S.

Three mechanisms account for most trauma injuries and deaths in the U.S: motor vehicle crashes, firearm injuries, and falls. Interestingly, each of these mechanisms accounts for almost identical rates of death: motor vehicle, 10.6 deaths per 100,000 per year; firearms, 10.5 deaths per 100,000 per year; and falls, 10.4 deaths per 100,000 per year (see Figure 1). So, although firearm injuries account for less than 5 percent of the patients who receive care in trauma centers, firearm injuries account for roughly the same number of deaths as motor vehicle crashes. This difference is attributable to the increased lethality of firearms in comparison with vehicular injury or falls.

Figure 1. Burden of Death in the U.S. by Mechanism of Injury

Figure 1. Burden of Death in the U.S. by Mechanism of Injury

Centers for Disease Control (CDC) National Center for Health Statistics, 2014

Trends over time demonstrate that from 1979 to 2014, adult firearm homicide rates decreased by approximately 50 percent (from 8.22 to 4.16 deaths per 100,000), whereas firearm suicide rates have remained largely unchanged (from 8.93 to 8.21 deaths per 100,000). Firearm suicides account for approximately 65 percent of all firearm deaths in the U.S. Unintentional firearm death rates have significantly improved, while intentional mass shootings have significantly increased over the same period. The net effect over four decades is that firearm injury death has declined slightly but not to the same extent as other injuries, such as those deaths related to motor vehicle crashes (see Figure 2). Although the true toll includes the human cost of suffering and loss of productivity, the total cost of firearm injuries in the U.S. was estimated to be $174 billion in 2010.2

Figure 2. Age-adjusted death rate: motor vehicle crashes versus gunshot wounds

Figure 2. Age-adjusted death rate: motor vehicle crashes versus gunshot wounds

CDC National Center for Health Statistics, 1999–2015


Prevention of firearm injuries

For more than three decades, the ACS COT has advocated for effective prevention of firearm injuries. From a practical perspective, a number of these efforts have stalled because of a lack of consensus among surgeons (and the public) regarding how best to proceed. Most recently, the COT initiated a concerted and dedicated effort to achieving consensus on how best to eliminate unnecessary death and suffering related to firearm injury. We began by publishing a description of our view on a public health approach to firearm injury prevention and on how consensus might be reached to address this significant public health challenge in “Firearm injury prevention: A consensus approach to reducing preventable deaths,” published in the Journal of Trauma and Acute Care Surgery.3

From a naïve starting point, the issue of firearm injury prevention may not seem so controversial; however, even a superficial examination of the issue reveals significant disagreement among otherwise reasonable and knowledgeable Americans. The members of the COT believe, and the data support, that the concept of personal liberty is the major issue of discord in the discussion of firearms and injury. Indeed, the controversy is less about the facts of firearm injury and death than the stories we use to explain the facts.

Americans hold personal liberty and individual rights dear, and two dominant contrasting narratives emerge in the discussion of firearms in the U.S. Based on the COT’s survey data of its U.S. members—with 254 members surveyed and 237 responses—approximately 15 percent have no strong opinion regarding firearms and freedom; however, about 80 to 85 percent support or strongly support one of two contrasting narratives.

Adherents to the first narrative (a little more than half of the surgeons surveyed) believe firearms are important for personal safety and defense and are an emblem of personal liberty. The COT has hosted discussions with all our members regarding their opinions and in conversations regarding firearm injury prevention has found that people who adhere to this first narrative tightly link the meaning of guns and freedom. In this case, a discussion over gun control roughly translates into freedom control. Members of this group tend to focus on guns as beneficial to personal safety and freedom.

In contrast, adherents to the second narrative (approximately 30 percent of the surgeons surveyed) believe that the large number of firearms on the streets and in U.S. homes puts their personal safety and the safety of their families at risk, thereby reducing their personal liberty. People who adhere to this narrative tend to view firearms as emblematic of the violence in the U.S. Based on the COT’s conversations regarding firearm injury prevention, it is clear that adherents to this narrative tightly link the guns to violence, so a discussion over gun control translates roughly into violence control. Thus, this group tends to focus on decreasing guns and limiting access to guns.

These two dominant narratives create a perceived chasm that may seem unbridgeable. The gap is further magnified by the fact that this issue is often a surrogate for a broader polarizing political discussion. From the COT’s vantage point, the net effect of this situation is limited constructive dialogue, resulting in few pragmatic, constructive ideas or actions to reduce death and disability related to firearm injury. The ACS COT has openly worked within its membership to build bridges across this perceived chasm. The COT has done so by respectfully including and engaging individuals on both sides of the debate in a constructive dialogue centered on the goal of preserving life and improving the patient care (see Table 1).

Although this exchange proved difficult to initiate, the COT is optimistic about the future. ACS COT members have learned consensus-building skills through the process of leading and participating in trauma systems. Trauma system development has flourished in regions where patient-centered consensus decisions are made, balancing freedom and autonomy with responsibility. The principles in Table 1 are as applicable to leading performance improvement and patient safety initiatives in trauma centers as they are to firearm injury prevention.

Table 1. Bridging the chasm

Table 1. Bridging the chasm

The COT’s initial pilot work demonstrates that a professional, collegial dialogue is achievable, and that when ACS COT surgeons engage in such discussions, they tend to agree more than they disagree, and when they disagree, they are able to continue the dialogue with a common goal of reducing injury and death. Once the COT survey was fully analyzed, the survey results were shared with COT members in a Town Hall at the COT Annual Meeting in March 2016. This was a purposeful forum to facilitate a discussion regarding firearm injury prevention. This Town Hall meeting was a model of collegiality and professionalism. The attendees provided input on interpreting the study and their ideas and thoughts with how best to proceed. One of the foci to emerge from the conversation was development of comprehensive programs aimed at reducing violence. It was determined that verified ACS trauma centers should be leveraged as a platform to reduce all forms of violence in our communities.

Based on these consensus principles, the COT Injury Prevention and Control Committee has moved forward with a comprehensive strategy aimed at reducing violence and injury. The first step was to conduct a survey to assess the views of COT members. This survey had a greater than 93 percent response rate and was presented at the 2016 American Association for the Surgery of Trauma’s annual meeting, a meeting of the ACS Board of Regents, and at the 2016 ACS Clinical Congress. In brief, more than 80 percent of COT surgeons agree on 10 of 15 policies directed toward reducing firearm injury, highlighted in Table 2. The complete results of this survey are published in the Journal of Trauma and Acute Care Surgery and are available in an open access article on the ACS website.4

Table 2. COT survey results

Table 2. COT survey results

In the article on page 30, Mark W. Puls, MD, FACS, and his colleagues from the Board of Governors present their Board of Governors’ survey results.

Following the COT survey and Town Hall, the ACS COT Injury Prevention and Control Committee moved forward with an approach aimed at addressing interpersonal violence, the perceived “root cause” of a significant portion of firearm injuries and death. The article “Violence intervention programs: A primer for developing a comprehensive program for trauma centers” offers a comprehensive resource for use in establishing violence intervention programs that leverage existing research on how best to address interpersonal violence (see related article). The article is an abbreviated version of a more comprehensive guide available on our COT Injury Prevention and Control web page, along with a PowerPoint presentation that may be helpful when trauma centers are meeting with stakeholders. This approach also is embodied in the work of Stephanie Bonne, MD, FACS, who describes her experience as the recipient of Claude Organ, Jr., MD, FACS Traveling Fellowship (see related article), which enabled her to research how to bring a hospital-based violence intervention program to her trauma center in Newark, NJ.

COT approach to the optimal care of patients with firearm injuries

The COT has developed a strategy for providing optimal care to the injured patient. This approach involves the following activities.

Stop bleeding immediately at the scene

The COT’s Stop the Bleed/Bleeding Control program is being promulgated with the goal of turning bystanders into immediate first responders to stop compressible bleeding until medical personnel arrive. This initiative grew out of the Hartford Consensus led by ACS Regent Lenworth M. Jacobs, Jr., MD, MPH, FACS. This program was developed with numerous critical partners including the U.S. Department of Defense, the Tactical Combat Casualty Care Committee, and NAEMT. Easy-to-learn principles and techniques to control active bleeding can truly make the difference between life and death.

The ACS Bleeding Control Course is a critical COT initiative that is engaging communities while working to achieve zero preventable deaths by ensuring that every American understands the fundamentals of bleeding control.5 To date, 5,334 instructors in 40 countries have been trained, teaching more than 28,000 students in 2,762 individual courses.

Promote high-quality EMS care

The EMS Committee of the COT partners with several organizations with the mission of improving prehospital care through high-quality education and provider support and the development of national EMS guidelines. For decades, the EMS Committee has worked with the NAEMT to develop and promulgate the Prehospital Trauma Life Support (PHTLS) course. The EMS Committee partners with other key stakeholder groups to set national standards and triage criteria for trauma patients. These standards are aimed at improving prehospital care and minimizing the time to definitive care for seriously injured trauma patients.

Improve trauma center care

The ACS COT works to ensure that trauma patients receive timely and appropriate care through the multiple hospital-based programs aimed at evaluating and improving trauma center standards, processes, and outcomes. Developed in 1987, the VRC Program for hospitals provides external review of trauma centers, verifying that centers have essential resources and processes in place to provide an organized and systemic approach to the care of the injured patient as outlined in the Resources for Optimal Care of the Injured Patient. These guidelines span the continuum of trauma care, from prevention through rehabilitation. To date, almost 500 trauma centers across the U.S. participate in the COT VRC Program. 

ACS TQIP serves as an institutional vehicle to improve quality and outcomes at trauma centers through risk-adjusted benchmarking, ongoing education, and the sharing of best practices among participants. More than 600 trauma centers participate in TQIP.

As a part of the COT’s mission to improve quality in trauma care, the COT PIPS Committee develops model PIPS programs for trauma centers and publishes best practice guidelines annually, which provide recommendations for managing patient populations or injury types with special consideration to trauma care providers, while also setting standards for optimum performance improvement.

At the individual health care professional level, the COT offers multiple educational programs aimed at advancing the skills of trauma care professionals across a number of domains. The flagship program of the COT Trauma Education Programs, ATLS, has been taught to more than 1 million students in 75 countries and continues to grow internationally and domestically.

Improve rehabilitation and reintegration

The rehabilitation of patients is an important, but often overlooked, part of the trauma care continuum. To optimize the recovery of trauma patients and assist  with their reintegration into society, the COT requires ACS-verified centers to meet standards in many areas of rehabilitation. The COT has made rehabilitation a priority within national trauma system development by adding the goal of decreasing preventable disability to its strategy of implementing the National Academies of Sciences, Engineering, and Medicine’s landmark report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.5


The ACS COT employs a comprehensive strategy aimed at reducing death and disability from firearm injury. This strategy is built upon a trauma system and public health model. The intent of this approach is to reduce unnecessary death and disability through a combination of prevention and optimal clinical care.

In the following three articles in this issue of the Bulletin, members of the COT highlight and describe our injury and violence prevention strategies. We believe these approaches can and will significantly reduce fatal firearm injuries and disability. The degree to which these initiatives are successful depends not only on the quality of our science, but also on the quality of our conversation. We want to thank all members of the ACS COT and all members of the Board of Governors for their willingness to work together for the betterment of our patients and our communities.


The authors would like to thank members of the ACS Board of Regents; the Executive Committee of the Board of Governors; the COT Executive Committee; the COT Injury Prevention and Control Committee; and (all MD, FACS)David B. Hoyt, ACS Executive Director; Patricia L. Turner, Director, ACS Division of Member Services; Michael F. Rotondo, Medical Director, ACS Trauma Programs; ACS Regent James K. Elsey; ACS Regent Beth Sutton; Michael J. Zinner, Chair, ACS Board of Regents; Diana L. Farmer, Chair, ACS Board of Governors Executive Committee; ACS Regent Henri R. Ford, MHA, FAAP; ACS Regent Lenworth M. Jacobs, Jr., MPH; and numerous staff of the ACS; as well as Trudy Lerer, MS, senior biostatistician, Connecticut Children’s Medical Center, Hartford, for their support and guidance on this important initiative.


American College of Surgeons. National Trauma Database. Available at: Accessed August 21, 2017.

Lee J, Quraishi SA, Bhatnagar S, Zafonte RD, Masiakos PT. The economic cost of firearm-related injuries in the United States from 2006 to 2010. Surgery. 2014;155(5):894-898.

Stewart RM, Kuhls DA. Firearm injury prevention: A consensus approach to reducing preventable deaths. J Trauma Acute Care Surg. 2016;80(6):850-852.

Kuhls DA, Campbell BT, Burke PA, et al. Survey of American College of Surgeons Committee on Trauma members on firearm injury: Consensus and opportunities. J Trauma Acute Care Surg. 2016;82(5):877-886.

National Academies of Sciences, 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. Available at: Accessed August 21, 2017.


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