Trauma System Resource Manual – Minnesota Department of Health

Level 3 & 4 Trauma Hospital Resource Manual

Table of Contents

Trauma Hospital Designation
   Verification vs. Designation
   Designation Process

Hospital Organization

Trauma Team Activation


Performance Improvement
   Morbidity and Mortality Review Committee
   Multidisciplinary Trauma Review
   The Performance Improvement Loop
      Recognition of the Issue
      Corrective Action
      Evaluation of the Result

Trauma Diversion

Trauma Registry

Injury Prevention

Required Equipment

Individualized Consultation

Online Resources

Sample Policies and Documents

Hospital Board Resolution (MS Word)  (PDF)

Medical Staff Resolution (MS Word)  (PDF)

Trauma Medical Director Job Description (MS Word)  (PDF)

Trauma Program Manager/Coordinator Job Description (MS Word)  (PDF)

Suggested Position of Trauma Program (MS Word)  (PDF)

Single-Tier Trauma Team Activation (TTA) Guideline (MS Word)   (PDF)

Multi-Tier Trauma Team Activation (TTA) Guideline (MS Word)  (PDF)

Trauma Bay Configuration (MS Word)   (PDF)

Suggested Criteria for Consideration of Transfer (MS Word)   (PDF)

Level 3 Transfer Guideline (MS Word)   (PDF)

Level 4 Transfer Guideline (MS Word)   (PDF)

Transfer Agreement Example (MS Word)   (PDF)

Level 4 Trauma Admission Guideline (MS Word)  (PDF)

PI Flowchart (MS Word)   PDF

Level 3 Diversion Guideline (MS Word)   (PDF)

Trauma Registry Inclusion Criteria (PDF)

Sample Forms

Resuscitation Record (MS Word)   (PDF)

Level 3 Filter Tracking Worksheet (MS Word)

Level 4 Performance Metric Worksheet (MS Word)

PI Tracking Form (MS Word)

Diversion Tracking Log (MS Word)   (PDF)


Equipment Checklist (PDF)

Recommended (not required) Pediatric Equipment Checklist (PDF)

RN Standing Orders (MS Word)  (PDF)

Minnesota Trauma System Statute

This manual contains a description of the designation process as well as examples of sample policies and forms to help you develop your hospital’s trauma program.


Trauma Hospital Designation

Verification vs. Designation

For many years Minnesota has had level I and II-verified trauma hospitals located in population-dense areas. These hospitals were evaluated by the American College of Surgeons (ACS) that verified that they met at least the minimum criteria for a trauma hospital established by the ACS.

Until recently, Minnesota had no statewide criteria for trauma hospitals.  In 2005 the Minnesota legislature passed a bill charging the commissioner of health to develop a statewide trauma system, including a process to designate hospitals as level I, II, III or IV trauma hospitals. The term “designation” is an official label that is assigned by a political authority. Designated trauma hospitals in Minnesota must demonstrate to the Commissioner of the Minnesota Department of Health (MDH) that they meet the state’s criteria for a trauma hospital. The establishment of a trauma system in Minnesota was accomplished by Minnesota Statute §144.602-144.608.

Designation Process

Level I and II trauma hospitals obtain designation in Minnesota by first obtaining verification by the ACS then applying to MDH to be recognized as a trauma hospital. The MDH currently accepts ACS level I, II or III verification as adequate evidence that a hospital meets the standards for a trauma hospital in Minnesota.

To obtain a level III designation, a hospital has two options. It may become verified by the ACS and then apply for designation subsequent to that, just as level I and II hospitals do, or it may apply for designation directly through the MDH trauma program. A hospital desiring to become a level IV trauma hospital may only achieve designation through the MDH Trauma Program.

Hospitals seeking designation as a level III or IV trauma hospital through the MDH trauma program must first establish a trauma program within their facility that meets the required criteria as set forth by the state. The hospital then completes the Trauma Hospital Profile

Once the Profile is complete, it is submitted to the MDH trauma program. Level III applicants will be contacted to schedule a site visit. Level IV applicants will be notified of the Commissioner’s designation decision as soon as possible and a site visit will be scheduled within the three-year designation period.

During the site visit, MDH trauma program reviewers will tour the facility and evaluate the trauma program components.

If a trauma hospital experiences a change in their ability to meet the minimum required criteria at any time during the designation period, it must notify the State Trauma Advisory Council (STAC) immediately. This element is critical to the effectiveness of the statewide trauma program because it may require other regional hospitals and local EMS providers to adjust their operating guidelines.


Trauma hospital designation in Minnesota is valid for three years, during which time the facility must apply for and complete the re-designation process, or be awaiting the site visit or site visit results. Trauma hospitals should apply for re-designation six months before their expiration date. An existing designation may be provisionally extended up to 18 months if the hospital applied for re-designation in a timely manner and is either scheduled for a site visit, awaiting the results of the visit or responding to deficiencies identified during the visit. (See Minnesota Statutes §144.605, sub. 2.)

The re-designation site visits will focus on three areas: 1) compliance with the designation criteria, 2) progress made toward strengthening the weaknesses identified during prior site visits and 3) identifying how the system can collaboratively support the ongoing and future needs of the hospital’s trauma care commitment. Specific suggestions for improvement will, again, have an educational focus. The visits are intended to be constructive, not punitive.


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Hospital Organization

Before becoming designated, a formal trauma program must be established within the hospital. In addition to developing policies and guidelines that address trauma team deployment, emergent transfers and performance improvement, the hospital board and medical staff must demonstrate a commitment to providing trauma care commensurate with the standards published by MDH. Support for a hospital’s participation in the statewide trauma system is demonstrated when both the board of directors and the medical staff resolve to provide the resources necessary to attain and sustain designation. (See Sample Hospital Board Resolution (MS Word) and Sample Medical Staff Resolution (MS Word).)

The hospital’s trauma program will require both a medical director/advisor which is a physician who will provide clinical oversight for the program and a manager/coordinator which is usually a nurse who will be responsible for the administrative functions of the trauma program. (See Sample Trauma Program Medical Director Job Description (MS Word) and Sample Trauma Program Manager/Coordinator Job Description (MS Word).)

The trauma program must be integrated into the hospital’s organizational structure, appearing on the organizational chart. The position of the trauma program should be such that the medical director and program manager/coordinator have sufficient authority to effect change across several departments. (See Suggested Position of Trauma Program (MS Word).)

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Trauma Team Activation

A clear procedure for assembling the team that will provide immediate resuscitation to the seriously injured patient is vital to the efficient functioning of a trauma hospital. This procedure should specify when the team must be assembled, who is to respond and how they are to be notified. The guideline should build upon existing facility-specific internal operating procedures, staffing resources and established state minimum criteria. (See Sample Single-Tier Trauma Team Activation Guideline (MS Word) and Sample Multi-Tier Trauma Team Activation Guideline (MS Word).)

Documentation of the patient’s resuscitation can be easily accomplished with the use of a trauma flow sheet. A comprehensive flow sheet can also be used to easily identify data elements in the patient’s chart that are required for trauma and SCI/TBI reporting (through the registry) or for performance improvement activities (PI). (See Trauma Resuscitation Record (MS Word) [Registry, TBI/SCI and PI elements are shaded to help facilitate data abstraction.])

Hospitals must work with their emergency medical services (EMS) providers to establish and train with guidelines designed to quickly identify seriously injured patients and route them directly to appropriate trauma hospitals. It is expected that the hospital trauma team will be activated upon notice by EMS. It is up to the individual hospital to determine if EMS personnel will activate the team or if EMS will consult with the emergency department provider, who will then establish the need for activation. Continued work with the EMS professionals in your area will help to control over and under triaging.


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A well-functioning trauma system is able to not only treat seriously injured trauma patients effectively and efficiently, but it is able to recognize the need to transfer patients to the trauma hospital that can best provide the resources that patient needs in a timely manner. To this end, level I, II, III and IV designations do not reflect the quality of care provided in those hospitals, but rather the resources available. Improved outcomes are closely associated with the time it takes for a facility to determine the need for and to accomplish the transfer.

Trauma hospitals must establish procedures that direct the process for quickly and efficiently transferring a trauma patient to definitive care. Guideline elements include anatomical and physiological criteria that if met, will immediately initiate transfer. (See Suggested Criteria for Consideration of Transfer (MS Word), Sample Level 3 Trauma Transfer Guideline (MS Word) and Sample Level 4 Trauma Transfer Guideline (MS Word) .)

Ambulance service personnel, with the guidance of medical direction and in cooperation with their local hospitals, may establish a process to request aero medical transport to meet them at the emergency department. The establishment of a close working relationship with local EMS providers will contribute to the development of an efficient transfer process.

Transfer agreements must be established and maintained with trauma hospitals capable of caring for patients with major trauma, severe burns and acute spinal cord injuries. An agreement with a second burn facility must also be maintained. (See Transfer Agreement Examples (MS Word).) Receiving trauma hospitals may provide the transfer agreement for the referring hospital.

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Performance Improvement

Every hospital in Minnesota is expected to measure, evaluate and improve their performance with respect to numerous objectives in health care from patient care standards to fiscal solvency to materials management. A successful performance improvement process is designed to identify weaknesses within an organization that prevent the organization from providing the optimal care it is capable of providing.

The process used to facilitate performance improvement may be referred to by other names, such as quality assurance or continuous quality improvement. Regardless of by what means your facility employs, it is important that there be a process in place to provide an intentional process, or loop, to continuously identify shortcomings in patient care, determine the likely cause, employ a plan to correct it then evaluate whether or not the shortcoming has been resolved, thus “closing the loop.” A PI program will assist your facility to constantly improve itself by identifying and confronting problems within the institution. The process can be applied to virtually any element of performance within the hospital.


While the required PI components must be in place in a trauma hospital, the structure is left to the discretion of the facility and will depend on the facility size and available resources. It is anticipated that hospitals have an existing PI structure in place. The trauma program PI activities ideally are incorporated into that structure. The description of the PI process contained herein is not meant to be prescriptive, but illustrative. It is understood that facilities will accomplish PI in a variety of ways. Trauma hospitals are expected to be able to demonstrate the effectiveness of their program.

The trauma program should have a standing trauma PI team, usually made up of the trauma program manager/coordinator, the trauma program medical director and possibly the trauma program registrar. All information and reports pertaining to trauma program performance are funneled through this team. The data is then either used by the team to address system concerns or referred to one or more PI committees to address patient care concerns.

Both system and patient care-related issues can be identified via several methods:

  • Chart abstraction
  • Emails
  • Hospital informatics/database systems/registries
  • Provider case review meetings
  • Multidisciplinary committee meetings
  • Patient or family complaints
  • Personal observations
  • Rounds
  • Staff reports
Reports from staff can be generated via a PI tracking form. (See PI Tracking Form (MS Word)

Morbidity and Mortality Review Committee

The trauma program PI requirements include the establishment of a morbidity and mortality review committee, which is analogous to a physician peer review committee. Its purpose is to provide for review of physician performance. Membership on this committee should be physicians from several disciplines and may include non-physicians (such as nurse practitioners [NPs] or physician assistants [PAs]), at the discretion of the trauma program and hospital administration. The format and activities of this committee are left largely to the discretion of the hospital. Physicians may not review their own care.

The morbidity and mortality review committee should meet regularly and review the physician care from patient charts, focusing on cases wherein problems, shortcomings, weaknesses or concerns have been identified by the trauma program PI team. If the committee identifies provider-related problems, they should recommend a corrective action plan; if they identify system-related concerns they should forward their findings to the trauma PI team.

Multidisciplinary Trauma Review

Unlike the morbidity and mortality review committee, membership of the multidisciplinary trauma review committee is not limited to physician providers. The participants in this review are both clinical and non-clinical representatives from all disciplines involved in the care of the trauma patient. Potential participants may be:

  • Administrators
  • Department managers
  • Emergency department nurses
  • Emergency department physicians
  • EMS staff
  • Financial management
  • Floor nurses
  • ICU/PACU staff nurses
  • Laboratory technicians
  • Operating room nurses
  • Patient relations personnel
  • Radiologists
  • Radiology technicians
  • Rehabilitation professionals
  • Risk management staff
  • Social services staff
  • Surgeons
The trauma PI team should identify the cases for presentation to this committee. Again, the focus should be on problematic cases or educational opportunities presented by particular cases.


In addition to system problems and weakness, the team also seeks to identify occurrences of significant events. These events are represented by PI filters. Each filter reflects either an area of patient care that the trauma program would like to scrupulously observe, a standard of care that the facility has established for itself or an ideal expectation of the industry. These are essentially characteristics of system performance or patient care that automatically prompt the process of evaluating that element of the system or care of the patient to determine whether or not it met the standards defined by the industry or the hospital. The primary mechanism in which the trauma program will assess its performance is through the use of these filters.

The Minnesota Statewide Trauma Plan requires that the filters listed in Table 1 be perpetually included in the hospital’s PI process.

Table 1

PI filter

Level 3

Level 4

ED provider non-compliance with on-call response times

General surgeon non-compliance with ED contact and response times


Trauma patients admitted to non-surgeons and no surgeon consult

Trauma care provided by physicians who do not meet the educational requirement of the plan (e.g., ATLS or CALS)

TTA and length of stay in ED >60 minutes before transfer


Patient met transfer criteria and admitted locally


Trauma transfers

Trauma deaths

Trauma care provided by advance practice providers


It is anticipated that each hospital will also select its own filters to monitor. The filters will change constantly as the facility’s need to evaluate various elements of the trauma program changes. Some filters may be watched for six months while others may need to be watched for years before enough cases have been through the hospital and enough data has been collected to effectively assess the system’s performance. Examples of filters commonly used include:

  • Under-triaged/trauma team not activated when criteria met
  • Length of stay in ED >60 minutes before transfer
  • Absent hourly charting
  • C-spine injury missed on initial evaluation
  • EMS report not in patient chart
  • EMS scene time >20 minutes
  • GCS <9, no endotracheal tube or surgical airway within 15 minutes of arrival
  • Head CT >2 hours after admission with GCS <14
  • Pneumothorax or hemothorax and no chest tube placed within 15 minutes of diagnosis
  • Pneumothorax w/ hemodynamic and/or respiratory compromise and no chest decompression
  • >65, fall w/ head injury and no C collar
  • Spine board removal >30 minutes after arrival
  • IV fluids not warmed
  • Pain level persistently >5
  • Patient <18 years old and not weighed
  • Initial GCS not recorded
There is no ideal way to quickly and easily identify patients who are characterized by filters. Although some patients will be identified by querying the registry, most will have to be identified by abstracting the information from the patient record manually. The process of abstracting a chart may be assisted by employing the use of a trauma flow sheet to document the resuscitation. (See Trauma Resuscitation Record (MS Word).) Many performance elements can be easily identified by abstracting this single record. Additionally, filters can be captured with the use of a tracking worksheet (see Level 3 Filter Tracking Worksheet (MS Word) and Level 4 Performance Metric Worksheet (MS Word). A worksheet is completed on every major trauma patient by abstracting the chart. If filters are identified, the chart is routed to the trauma PI team for review.

The Performance Improvement Loop

Performance improvement can be thought of as a continuous loop of activity surrounding a given issue. The three distinct phases of the PI loop are 1) recognition of the issue 2) corrective action and 3) evaluation of the result. (See Trauma PI Flowchart (MS Word).)

Recognition of the Issue

Enough data must be collected to identify a system or patient care issue. This may be a single occurrence of an event that is reported by a staff member or PI committee or it may be a recurrence of a similar or same event several times, which is discovered by chart abstraction or by a registry query.

For example: The trauma PI team routinely evaluates all trauma patients transferred. (To identify these patients, they might use the trauma registry to create an ad hoc report.) An expectation established by the hospital is that a trauma patient’s condition is accurately assessed and the patient transferred to definitive care within two hours. The team discovers that 20 percent of these transfers occurred >2 hours after arrival.

The team then reviews the identified cases with the charge of determining why the patients’ treatment did not meet the standard of care established by the facility. They may discover that, given the circumstances of the individual patients, the cases were managed as well as they could have been. However, the committee may identify a problem with a guideline, an individual provider or a system policy that contributed to the shortcomings.

For example:

  • The committee discovers that the patients were transferred days after admission to their hometown hospitals after their conditions had stabilized. Therefore, there is no corrective action necessary.
  • The committee finds that the transfers were initiated >2 hours after arrival when earlier CTs initially read by emergency department providers were reviewed by radiologists and found to reveal abnormalities requiring transfer to a facility with more resources.

Corrective Action

The problem can now be classified as disease-related, system-related or provider-related and referred, if necessary, to any another appropriate person or committee for review. Corrective action may be unnecessary or may consist of education, guideline revision, practitioner counseling, etc. The team should develop a corrective plan, consulting any in-house and out-of-hospital resources as necessary.

For example, the committee may recommend:

  • Implementing a continuing education program for the emergency department providers to improve their CT scan interpretation capabilities.
  • Making educational or reference resources available for interpreting CT scans to the emergency department providers.
  • Employing the use of an off-site, 24-hour radiology service.

Evaluation of the Result

Once the corrective action is in place, the trauma program again collects data and the team determines whether or not the action corrected the problem. If it did, the loop is closed and the issue is resolved. If not, the committee revisits the case and repeats the PI process again.


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Trauma Diversion

On rare occasions, critical resources needed to care for seriously injured patients become unavailable at one hospital due to an unusually great demand for those resources, a mechanical plant failure preventing the use of those resources or other event that renders resources unavailable or inaccessible. (More isolated hospitals that are a significant distance from their neighboring hospitals may not be able to safely divert trauma patients simply because of high patient volumes.) In such cases it is important that trauma hospitals have a contingency plan to divert trauma patients to a nearby facility. (See Trauma Diversion Guideline (MS Word).

The decision to divert trauma patients should be carefully considered. It should only occur if, in the judgment of the lead medical staff person, it would be in the patient’s best interest to be transported to a different facility rather than attempting to accomplish the resuscitation in an environment lacking critical resources. Trauma hospitals should track both the number of times the facility goes on divert and the number of patients diverted. (See Trauma Divert Tracking Log (MS Word).)


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Trauma Registry

The collection and use of data is of paramount importance to a successful trauma program: locally, statewide and nationally. A trauma registry is established primarily to ensure quality of care, but it has a secondary benefit of providing data for the surveillance of morbidity and mortality. Trauma hospitals are required to submit a number of data points to the MDH trauma program. Additionally, each hospital can design a unique data set to collect and analyze to further their PI objectives. (See Trauma Registry Inclusion Criteria (MS Word).)

There are several commercial registries available for purchase. However, the MDH trauma program has established a Web-based trauma registry, MNTrauma, which is available for use by every hospital in the state at no cost. Trauma hospitals utilizing their own registries can submit data to the MDH trauma program without duplicating data entry.

The function and purpose of the statewide trauma registry is threefold:

  • To facilitate simple and accurate trauma data reporting to the state trauma program.
  • To assist trauma hospitals in identifying patients who match their filter characteristics via the report-generating features.
  • To collect and report the state-required TBI/SCI data, eliminating the need to duplicate data submission to MDH.

To begin using the Web-based registry:

  1. Contact MDH staff to obtain a user name and password.
  2. Go to
  3. Log on!

Technical assistance for MNTrauma is available through the MDH trauma program.


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Injury Prevention

While the vast majority of a hospital’s trauma resources are committed to managing the injured patient, injury prevention cannot be ignored. A trauma hospital’s injury prevention program may most effectively be incorporated into existing outreach activities. Ideally, prevention activities will be driven by epidemiological data for the community.

Steps to Implementing a Prevention Activity

Recognize opportunities: Seek out existing public venues for your prevention activities such as school or church fairs and community events such as national night out.

Identify a desired outcome: The goal of the prevention activity may be to reduce the occurrence of a particular injury, raise awareness of a threat or hazard, increase knowledge of a subject or alter behaviors or attitudes.

Identify the target audience: Begin by determining what message you would like to communicate and who the recipients of that message should be. This may be driven by injury data—such as frequency, severity or location of a particular traumatic event within the community—where the audience is specific or by forum opportunity, such as a community fair, where the target audience is diverse.

Develop objectives: Describe the actions necessary to achieve the desired outcomes of the prevention activity. Consider staff and material resources needed, as well as program evaluation tools.

Develop strategies for reaching the targeted audience: Adults, adolescents and children all have different learning styles. By defining the target audience, the curriculum can be customized. For example, characters appeal to children from ages 3 to 7. Children older than 7 relate well to video and slide presentations. Teenagers are most engaged when the forum allows them to voice their own viewpoints and opinions.

Obtain staff and funding for the activity: Do not limit yourself to hospital staff. Often, the goals of other community organizations coordinate well with injury prevention goals of the hospital. Consider the age and cultural dynamics of both the audience and the presenters. Sometimes coordinating the two can improve the effectiveness of the message. Trauma survivors or their family members can be powerful spokespeople. Funding may come from within the facility or from foundations, businesses, civic groups and government agencies.

Evaluate the effectiveness of the activity: Although effectiveness can be assessed by determining the number of people reached or by surveying program participants, ideally, effectiveness should be measured by evaluating whether or not the activity actually accomplished the desired outcome. Outcome evaluation should measure progress toward the goal of decreasing injury occurrence or changing the knowledge, attitude or behaviors of the target audience. Techniques may include data collection, surveying and direct observation.

Examples of prevention activities include:

  • Bicycle helmet campaigns
  • Bicycle rodeos
  • Blood pressure screening
  • Car seat clinics
  • Domestic violence awareness
  • Fall prevention
  • Firearm safety
  • Health fairs
  • Intoxicated driving campaigns
  • Posters/pamphlet publication
  • Red light running campaigns


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Required Equipment

Trauma hospitals must have certain equipment capabilities for all ages of trauma patients. See Equipment Checklist (PDF) for a checklist that can be used to verify the existence of the minimum required equipment in your facility. In order to assist trauma hospitals to care for children more effectively, the Emergency Medical Services for Children Resource Center of Minnesota (MN-EMSC) has recommended the equipment listed in Recommended Pediatric Equipment Capabilities Checklist (MS Word).


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Individualized Consultation

If at any time you have questions about the trauma program and its requirements, contact MDH Trauma Program staff. The staff is in place largely to answer your questions, provide you with reference material, consult with your facility regarding trauma hospital designation and assist you with the establishment and development of your trauma program. Contact us for:

  • Application preview
  • Assistance establishing or developing a PI or injury prevention program
  • Documentation evaluation
  • Examples of program policies, forms, tools
  • Guidance regarding the existence or establishment of required criteria
  • One-on-one consultation/guidance
  • Pre-site visit consultation
  • Telephone and in-person technical advice
  • Web-based registry training

To take advantage of these resources, contact the Designation Coordinator.

The MDH trauma program is always eager to hear your feedback. If you have recommendations for resources that can be provided in this manual or elsewhere, please contact program staff.

We rely on you to tell us what you need!


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Online Resources


American Academy of Orthopedic Surgeons

The American Association for the Surgery of Trauma

American College of Emergency Physicians

American College of Surgeons Trauma Program

Brain Injury Association of America

Eastern Association for the Surgery of Trauma

Emergency Nurses Association

National Highway Traffic Safety Administration

Society of Critical Care Medicine

Society of Trauma Nurses

Toward Zero Deaths

Western Trauma Association


American College of Surgeons Trauma Publications

American Trauma Society

Brain Trauma Foundation TBI Guidelines

Eastern Association for the Surgery of Trauma, Trauma Practice Management Guidelines

Gift from Within (Survivors of Trauma and Victimization)

Minnesota CALS Program

National Trauma Data Bank

Society of Critical Care Medicine

Trauma Survivors Network

Western Trauma Association, Algorithms


American Academy of Pediatrics

Safe Kids

Children’s Safety Network

Minnesota Emergency Medical Services for Children

National Center for Missing and Exploited Children

National Child Traumatic Stress Network


Helmets R Us

I Keep Safe (internet safety for kids)

National Center for Injury Prevention and Control

National Highway Traffic Safety Administration

Safety Belt Safe U.S.A.


Stop the Bleed

Stop the Bleeding Coalition


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