This comprehensive publication presents recommendations from the Hartford Consensus developed in response to a Presidential Policy Directive.

A compendium of expert recommendations on strengthening the security and resilience of U.S. citizens after mass casualty events was released in September 2015 as a supplement to the Bulletin of the American College of Surgeons.

The compendium, titled Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events: A Compendium, contains reports that represent the deliberations of the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events.  The recommendations of this collaborative committee are called the “Hartford Consensus.”

The compendium comes in response to a Presidential Policy Directive from President Barack H. Obama, “aimed at strengthening the security and resilience of the U.S. through systematic preparation for the threats that pose the greatest risk to the security of the Nation, including acts of terrorism, cyber-attacks, pandemics, and catastrophic natural disasters.”

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Executive Summary

Increasing survival, enhancing citizen resilience
David B. Hoyt, MD, FACS
Executive Director, American College of Surgeons

This one-page article describes the process of the Hartford Consensus and summarizes its work and major principles. The leadership of Dr. Lenworth Jacobs in bringing about the Hartford Consensus is highlighted.

Letter from the Vice-President
Joseph R. Biden, Jr.
Vice-President of the United States

This letter states that the lessons learned on the battlefield to control external hemorrhage must now be applied to civilian life. It concludes that the common sense recommendations of the Hartford Consensus have the potential to equip citizens with the skills and confidence to save lives.

Presidential Policy Directive: National preparedness
Barack H. Obama
President of the United States

This directive from the President of the United States outlines national preparedness goals and the necessary processes for building and sustaining preparedness. It highlights that preparedness for the United States is a shared responsibility of all levels of government, the private and nonprofit sectors, and individual citizens. A national preparedness system is described and roles and responsibilities within the federal government are outlined.

A systematic response to mass trauma: The public, organized first responders, and the American College of Surgeons
Andrew L. Warshaw, MD, FACS, FRCSEd(Hon)
President (2014–2015), American College of Surgeons

This article summarizes the role of the American College of Surgeons in convening the Hartford Consensus and endorsing its recommendations. It describes the new, integrated response system that is needed to increase survival in active shooter and intentional mass casualty events.

Strategies to enhance survival in active shooter and intentional mass casualty events
Lenworth M. Jacobs, Jr., MD, MPH, FACS
Chairman, Hartford Consensus; Vice-President, Academic Affairs, Hartford Hospital; Member, Board of Regents, American College of Surgeons

This article describes the purpose of the compendium, Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events, as a means of assisting President Obama’s directive to strengthen the security and resilience of U.S. citizens. Topics presented in the compendium are reviewed.

Roundtable meetings

A description of the roundtable meetings at the White House in 2015 is presented. The meetings served as educational platforms of those involved in the management and care of injured victims as well as organizations at risk for active shooter or intentional mass casualty events. Attendees included physician leaders of major medical organizations, those involved in emergency response, key federal personnel, and the National Security Council staff. Lists of attendees and organizations represented are provided.

The military experience and integration with the civilian sector
Jonathan Woodson, MD, FACS
Assistant Secretary of Defense for Health Affairs, Department of Defense

This article reviews the success of the military health system in improving survival of those injured in a battle and how knowledge gained from the military can be incorporated into civilian partnerships. The integration of the military health system and the American College of Surgeons is highlighted.

The Department of Homeland Security’s role in enhancing and implementing the response to active shooter and intentional mass casualty events
Kathryn H. Brinsfield, MD, MPH, FACEP
Assistant Secretary for Health Affairs and Chief Medical Officer, Department of Homeland Security

Ernest (Ernie) Mitchell, Jr., MPA
U.S. Fire Administrator, Federal Emergency Management Agency, Department of Homeland Security

The Department of Homeland Security’s support of first responders is reviewed. The key themes in responding and managing casualties from active shooter and intentional mass casualty events are presented. These are early and aggressive hemorrhage control, the use of protective equipment by first responders, and greater response and incident management.

Initial management of mass-casualty incidents due to firearms: Improving survival
Lenworth M. Jacobs, MD, MPH, FACS; Karyl J. Burns, RN, PhD; the late Norman McSwain, MD, FACS; and Wayne Carver, MD

This article describes aspects of mass casualty firearm events that require a renewed examination of medical scene management and tactical emergency medical support. The implementation for military-like response to enhance the rapid assessment, treatment, and triage of victims is proposed.

Improving survival from active shooter events: The Hartford Consensus
The Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events

This is the document produced from the first Hartford Consensus meeting. The concept of THREAT (Threat suppression, Hemorrhage control, Rapid Extrication to safety, Assessment by medical providers, and Transport to definitive) highlights the critical response actions. The need for a fully integrated response is emphasized. Care of victims is identified as a shared responsibility of law enforcement, fire/rescue, and EMS.

Active shooter and intentional mass-casualty events: The Hartford Consensus II 
The Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events

This is the document produced from the second meeting of the Hartford Consensus. A call to action to achieve the overarching goal of the Hartford Consensus that no one should die from uncontrolled bleeding is presented. Steps that need to be enacted by the public, law enforcement, EMS/fire/rescue, and definitive care are identified.

The Hartford Consensus III: Implementation of bleeding control 
Lenworth M. Jacobs, Jr., MD, MPH, FACS, and the Joint Committee to Create a National Policy to Enhance Survivability from Intentional-Mass Casualty and Active Shooter Events

The third document of the Hartford Consensus identifies three levels of responders. These are immediate responders or civilians at the scene, professional first responders, and trauma professionals. Steps for building educational and equipment capabilities, and resources for bleeding control programs are presented.

The continuing threat of intentional mass casualty events in the U.S.: Observations of federal law enforcement
William P. Fabbri, MD, FACEP
Director, Operational Medicine, Federal Bureau of Investigation

This article reviews statistics and characteristics of active shooter incidents in the United States. It discusses law enforcement response at the national level with highlights of what the Federal Bureau of Investigation has done to be prepared and to prepare police across country for active shooter events.

Public health education: The use of unique strategies to educate the public in the principles of the Hartford Consensus
Richard H. Carmona, MD, MPH, FACS
17th Surgeon General of the United States

This article focuses on what is needed to educate the public to be immediate responders to all-hazards threats. Retention of perishable skills, competency, and certification issues are discussed as is the need for developing health-literate and culturally competent content for an immediate responder curriculum.

The continuing threat of active shooter and intentional mass casualty events: Local law enforcement and hemorrhage control
Alexander L. Eastman, MD, MPH, FACS 
Major Cities Chiefs Police Association

This article presents hemorrhage control as a law enforcement responsibility and describes the progress that has been made to train and equip police officers across the country for hemorrhage control. The role of the Major Cities Chiefs Association in adopting the principles of the Hartford Consensus is discussed. An example of a local law enforcement response to an attempted mass casualty event is reviewed.

Military history of increasing survival: The U.S. military experience with tourniquets and hemostatic dressings in the Afghanistan and Iraq conflicts 
Frank K. Butler, MD, FAAO, FUHM
Chairman, Committee on Tactical Combat Casualty Care, Department of Defense, Joint Trauma Systems

The resurgence of tourniquet use in the U.S. military that originated from the Tactical Combat Casualty Care program is discussed as are the specific events that contributed to the expanded use of tourniquets in the military. Statistics regarding the decrease in preventable battlefield deaths in the from extremity hemorrhage are presented. The use of hemostatic dressings in the military is reviewed.

Hemorrhage control devices: Tourniquets and hemostatic dressings
John B. Holcomb, MD, FACS; Frank K. Butler, MD, FAAO, FUHM; and Peter Rhee, MD, MPH, FACS, FCCM
Committee on Tactical Combat Casualty Care, Department of Defense, Joint Trauma Systems

This article draws from the military’s experience with tourniquet use to describe what type of trauma victims are appropriate for tourniquet use in a civilian setting. Teaching points about tourniquets are presented as are common mistakes regarding their use. The role of the Committee on Tactical Combat Casualty Care in recommending tourniquets and hemostatic dressings is reviewed.

Intentional mass casualty events: Implications for prehospital emergency medical services systems
Matthew J. Levy, DO, MSc, FACEP
Senior Medical Officer, Johns Hopkins Center for Law Enforcement Medicine

This article describes what changes are needed in the prehospital emergency response to increase survival due to hemorrhage from active shooter and intentional mass casualty events. The necessary education, training, equipment, partnerships, and pre-planning are discussed.

Role of the American College of Surgeons Committee on Trauma in the care of the injured
Leonard J. Weireter, MD, FACS, and Ronald M. Stewart, MD, FACS
Vice-Chair and Chair, respectively, American College of Surgeons Committee on Trauma

The history of the American College of Surgeons Committee on Trauma (COT) is reviewed as are its major functions. It is suggested that the COT, through its educational programs, can expand its outreach to teach bleeding control to anyone who might be in a position to stop bleeding. This is virtually everyone.

Integrated education of all responders
(the late) Norman E. McSwain, MD, FACS
Medical Director, Prehospital Trauma Life Support

This article describes resources available to meet the recommendation of the Hartford Consensus, calling for multidisciplinary education. It emphasizes that for integrated emergency responses, all potential responders should train and drill together. The specific education needs of the public, law enforcement, EMS/fire/rescue, and definitive care are presented. Courses offered that teach hemorrhage control are presented and described.

Implementation of the Hartford Consensus initiative to increase survival from active shooter and intentional mass casualty events and to enhance the resilience of citizens
Lenworth M. Jacobs, MD, MPH, FACS
Chairman, Hartford Consensus; Vice-President, Academic Affairs, Hartford Hospital; Member, Board of Regents, American College of Surgeons

This article calls for response systems that can be effective 24 hours a day, seven days a week in any locale at any level. To develop such systems it is critical to identify the organizations and government entities that are responsible for ensuring that a plan can be executed immediately. Strategies used to achieve the recommendations of the Hartford Consensus by Hartford Hospital, the City of Hartford, the metropolitan region of Greater Hartford, and the State of Connecticut are discussed.