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Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
All Surgeons Can Help Advance a National Trauma and Emergency Preparedness System
John H. Armstrong, MD, FACS, Eileen M. Bulger, MD, FACS, Warren C. Dorlac, MD, FACS, and Jeffrey D. Kerby, MD, PhD, FACS
May 6, 2025
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Dr. John Armstrong
Injury affects every community in the US and is the leading cause of death for people under the age of 75 and the principal cause of death of children and adults up to age 45.
There are nearly 200,000 deaths each year from injury—the same “size” as the populations of cities such as Ft. Lauderdale, Florida, Rochester, New York, and Salt Lake City, Utah.
Injury care is organized locally and to a lesser extent, regionally; yet, despite multiple calls for almost 60 years, starting with the 1966 report of the National Academy of Sciences, Accidental Death and Disability: The Neglected Disease of Modern Society, we remain without a national trauma system (see Figure 1, below).
Instead, the US continues to have a fragmented and incoherent patchwork of trauma centers, hospitals, emergency medical services, rehabilitation organizations, and public health agencies.
Beyond daily injuries, we face mass casualty incidents from natural, industrial, and intentional sources, in which physical injury predominates. Further, the potential for combat casualty repatriation looms on the horizon from large-scale combat operations not seen since World War II. The military health system will need help to manage combat casualties that may exceed 2,000 per day within the first 100 days of conflict.
For more than 100 years, work done by the ACS Committee on Trauma (COT) has improved the care of injured patients by defining and verifying standards for care through Advanced Trauma Life Support, Optimal Resources for Care of the Injured Patient, and the Trauma Systems Consultation Guide: Essential Elements, Framework, and Assessment for State and Regional Trauma Systems. Combined, the application of these standards has decreased the risk of dying from injury at trauma centers and in trauma systems. Trauma centers and systems function as learning communities, consistently assessing their outcomes through data to improve care in communities, regions, and states.
The ACS sponsors two key sources of aggregated trauma patient data, the National Trauma Data Bank® (NTDB®) and the ACS Trauma Quality Improvement Program® (TQIP). These programs have contributed to trauma quality research and performance improvement within trauma centers, healthcare systems, and regions.
The ACS COT created a 12-page blueprint for a National Trauma and Emergency Preparedness System (NTEPS) that originated through work completed by its Advocacy Pillar in 2022.
NTEPS 2.0 was updated and approved by the ACS Board of Regents in February 2025 (see Figure 2, below). This version broadens the context and refines the structure for NTEPS by articulating the aims of this national trauma system and strategies for accomplishing these goals. This viewpoint article highlights what you can do to help move NTEPS forward.
Figure 1. Decades of reports and research show a concerted effort to develop a national trauma system in the US.
Getting to Know NTEPS 2.0
NTEPS 2.0 envisions a system of timely, accessible, and high-quality trauma care that serves communities and everyone who is injured, spanning injury prevention activities, prehospital and trauma center acute injury care, rehabilitation, and return to home and work.
The system applies to the individually injured, mass casualties, and mass population events. NTEPS supports a connected network of Regional Medical Operations Coordinating Centers (RMOCCs) to align the distribution of daily injured patients and mass casualties, as well as resources, across trauma centers and non-trauma acute care hospitals.
An RMOCC is an entity that coordinates daily disposition of trauma patients and scales to balance mass casualties and critical resources across the healthcare system.
There are five core NTEPS functions: public health readiness, standards, performance improvement, research, and public outreach.
These functions mutually reinforce each other and are intended to reduce rates of injury, enhance survivability and attenuate disability among all injured patients, maximize critical survivability in mass casualties, and accelerate research collaboration to advance injury care and prevention.
Figure 2. The NTEPS Blueprint provides background information on the impetus for a National Trauma and Emergency Preparedness System, the request to Congress, strategic elements, and proposed structure and governance.
NTEPS recognizes the need in mass casualty and population events for a coordinated response by public health, emergency management, and healthcare systems across geographies for casualty clinical disposition and deployment of medical assets.
Public health readiness includes the coordination of patient/casualty movement that scales for mass casualty events, situational awareness through a comprehensive, time-sensitive data system of critical data elements (e.g., patient/casualty volumes, hospital bed capacity, and EMS resources), mutual military-civilian healthcare response, and surveillance for emerging state, regional, and national events.
Standards focus on the establishment of best practices informed by evidence for injury prevention, field triage, emergency response, acute hospital care, rehabilitation, and recovery. These standards also concentrate on the verification process for trauma system standards across the continuum of care, delivery of clinical consultation within regional and state systems, and delineation of optimal resources for the care of injured patients within a specified geography.
Performance improvement remains important for trauma system operations, just like it is in trauma centers. It serves as the basis for an annual needs assessment to define system gaps in trauma and emergency preparedness, evaluates operational readiness within regions and states, uses risk-adjusted benchmarking for system improvement, provides rural hospital support, and offers state EMS system assistance.
Research enhances maintenance of a national trauma dataset the includes all elements along the injury, care, and recovery timeline and establishes a mechanism for the coordination and funding of research with dissemination of findings.
Public outreach engages communities, regions, and states in injury prevention activities, supports ACS Stop the Bleed training and kit placement, and develops awareness of how trauma systems improve the care of the injured patient.
NTEPS 2.0 core functions are guided by five principles. The NTEPS should:
Have administrative and regulatory oversight through RMOCCs
Span the medical response to daily trauma and mass casualty incidents
Strengthen the role and involvement of EMS
Reflect a collaboration of trauma and community stakeholders from the private and public sectors
Be a learning healthcare system that reviews system data, identifies gaps, and applies performance improvement and research methods to drive system change
The proposed structure for NTEPS 2.0 is based on a network of RMOCCs. The RMOCC is the organizing private-public entity and includes acute medical care, public health, emergency management systems, the military health system, and the National Disaster Medical System. It coordinates daily trauma patient and mass casualty movement for load balancing across trauma centers and hospitals and manages critical resources. By operating daily, RMOCCs are conditioned to scale rapidly for mass casualty response (see Figure 3 below).
RMOCCs can link horizontally and vertically to form state and federal levels of medical operations coordination. Such neural networks become state and federal Medical Operations Coordinating Centers (MOCCs), from which the core elements of NTEPS can emerge. The most efficient way to develop NTEPS is through state and national integration of RMOCCs.
Resources for RMOCCs start with an agreement among all stakeholder participants for data-sharing and decision-making. From this agreement, optimal resources are determined for administrative staff, physical space with connection to the local/regional emergency operations center (EOC) is set up, an information technology platform with reliable, secure, and rapid information flow is established, a communication system that connects the RMOCC, EOC, and all stakeholders is secured, performance improvement processes and research staff are organized, and funding for daily and surge operations is secured. Funding sources include the federal Hospital Preparedness Program, local and state appropriations, business contributions, and healthcare organizations.
Surgeons’ Role in NTEPS Development
ACS members are essential advocates for NTEPS development, which requires a multipronged advocacy strategy at community, state, and national levels. Advocacy initiatives inspire hearts and minds to act by expanding influence and gaining the attention of decision-makers in the public and private sectors. Injury care and prevention improve the quality of life in communities, and as a former Speaker of the House of Representatives observed, “All politics is local.”
Get Started
Review the NTEPS 2.0 blueprint and the March 2025 Journal of the American College of Surgeons RMOCC commentary.
Shine a spotlight regularly on your trauma system (inclusive of EMS) by hosting visits with your public officials and business leaders.
Meet with your local public health department director to discuss the vitality of injury care and prevention in your community.
Visit your local EOC to discuss trauma system support of Emergency Support Function 8 (Public Health and Medical).
Engage with your healthcare coalition to review trauma system action for readiness and response.
Completing this initial work positions you for a conversation about NTEPS and RMOCCs with your hospital executive and governing body leadership.
Advance the Cause in Your State
Deliver ACS Stop the Bleed training and kits frequently across communities in your state and in your state capital.
Meet your state legislators in district to discuss the relevance of RMOCCs for state readiness and response.
Present an overview of RMOCCs to your state hospital association leadership.
Engage your state committee on trauma, state ACS chapter, and state medical association to emphasize the necessity of a vibrant state trauma system and RMOCC development.
Ask your state health department for an initial or follow-up ACS Trauma Systems Consultation.
The ACS COT Regional Committee has created an RMOCC workgroup to share further ideas for spread of RMOCCs in states.
Figure 3. The RMOCC facilitates patient flow from prehospital point of injury to initial care facilities and transfer between lower-level trauma care/nontrauma acute care hospitals and Level I and II trauma centers.
Promote Federal Action
Send a SurgeonsVoice email to your members of Congress to ask for their support of ACS priorities in reauthorization of the Pandemic and All-Hazards Preparedness Act (PAHPA). These priorities include continuation of (1) the Hospital Preparedness Program with a requirement that funded entities sustain capabilities for coordination of regional medical operations within a coalition or between multiple coalitions within close proximity; and (2) the MISSION ZERO grant program for support of military-civilian trauma training partnerships.
Visit your legislators in district offices during House and Senate recesses to share the NTEPS blueprint, ask for reauthorization of PAHPA with inclusion of ACS priorities, and request stable appropriation of these programs.
Visit your legislators and their staff in their Capitol Hill offices in Washington, DC.
Verify that your hospital is a participating facility in the National Disaster Medical System.
Engage with military treatment facilities, Veterans Administration hospitals, and regional disaster health response systems within your area to enhance response for mass casualties and large-scale combat casualty repatriation.
The COT seeks collaboration for NTEPS advocacy with trauma professional and other medical societies, healthcare industry organizations, and external stakeholders in business, education, and nonprofit services. National standards for RMOCCs are being developed by the COT Trauma Systems Pillar.
Optimal care for injuries in daily life, mass casualties, and mass population events requires a systems approach that brings together local, state, and regional systems in a data-driven framework for continuous readiness, performance improvement, and research.
After 60 years of reports about the problem, professional societies and the private sector have exhausted what they can do to generate a national trauma system. NTEPS, expressed as a network of RMOCCs, is the best approach to reduce death and disability from injury.
Disclaimer
The thoughts and opinions expressed in this column are solely those of the authors and do not necessarily reflect those of the ACS.
Dr. John Armstrong is a trauma surgeon, professor of surgery, and distinguished educator at the University of South Florida Morsani College of Medicine in Tampa. He also is an adjunct professor of surgery at the Uniformed Services University of the Health Sciences in Bethesda, MD.
Armstrong JH, Scherer E, Dorlac W, Eastridge BJ, et al. regional medical operations coordinating centers promote readiness for daily trauma care and mass casualty incidents. J Am Coll Surg.; March 13, 2025. Epub ahead of print.
