Importance Several national initiatives have emerged to empower laypersons to act as immediate responders to reduce preventable deaths from uncontrolled bleeding. Point-of-care instructional interventions have been developed in response to the scalability challenges associated with in-person training. However, to our knowledge, their effectiveness for hemorrhage control has not been established. Objective To evaluate the effectiveness of different instructional point-of-care interventions and in-person training for hemorrhage control compared with no intervention and assess skill retention 3 to 9 months after hemorrhage control training. Design, Setting, and Participants This randomized clinical trial of 465 laypersons was conducted at a professional sports stadium in Massachusetts with capacity for 66 000 people and assessed correct tourniquet application by using different point-of-care interventions (audio kits and flashcards) and a Bleeding Control Basic (B-Con) course. Non-B-Con arms received B-Con training after initial testing (conducted from April 2017 to August 2017). Retesting for 303 participants (65%) was performed 3 to 9 months after training (October 2017 to January 2018) to evaluate B-Con retention. A logistic regression for demographic associations was performed for retention testing. Interventions Participants were randomized into 4 arms: instructional flashcards, audio kits with embedded flashcards, B-Con, and control. All participants received B-Con training to later assess retention. Main Outcomes and Measures Correct tourniquet application in a simulated scenario. Results Of the 465 participants, 189 (40.7%) were women and the mean (SD) age was 46.3 (16.1) years. For correct tourniquet application, B-Con (88% correct application [n = 122]; P Conclusions and Relevance In-person hemorrhage control training for laypersons is currently the most efficacious means of enabling bystanders to act to control hemorrhage. Laypersons can successfully perform tourniquet application after undergoing a 1-hour course. However, only 54.5% retain this skill after 3 to 9 months, suggesting that investigating refresher training or improved point-of-care instructions is critical. Trial Registration ClinicalTrials.gov Identifier:NCT03479112

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Effectiveness of Instructional Interventions for Hemorrhage Control Readiness for Laypersons in the Public Access and Tourniquet Training Study (PATTS): A Randomized Clinical Trial.

Background The "Stop the Bleed" campaign advocates for non-medical personnel to be trained in basic hemorrhage control. However, it is not clear what type of education or the duration of instruction needed to meet that requirement. The objective of this study was to determine the impact of a brief hemorrhage control educational curriculum on the willingness of laypersons to respond during a traumatic emergency. Methods This "Stop the Bleed" education initiative was conducted by the University of Texas Health San Antonio Office of the Medical Director (San Antonio, Texas USA) between September 2016 and March 2017. Individuals with formal medical certification were excluded from this analysis. Trainers used a pre-event questionnaire to assess participants knowledge and attitudes about tourniquets and responding to traumatic emergencies. Each training course included an individual evaluation of tourniquet placement, 20 minutes of didactic instruction on hemorrhage control techniques, and hands-on instruction with tourniquet application on both adult and child mannequins. The primary outcome in this study was the willingness to use a tourniquet in response to a traumatic medical emergency. Results Of 236 participants, 218 met the eligibility criteria. When initially asked if they would use a tourniquet in real life, 64.2% (140/218) responded "Yes." Following training, 95.6% (194/203) of participants responded that they would use a tourniquet in real life. When participants were asked about their comfort level with using a tourniquet in real life, there was a statistically significant improvement between their initial response and their response post training (2.5 versus 4.0, based on 5-point Likert scale; P Conclusion In this hemorrhage control education study, it was found that a short educational intervention can improve laypersons' self-efficacy and reported willingness to use a tourniquet in an emergency. Identified barriers to act should be addressed when designing future hemorrhage control public health education campaigns. Community education should continue to be a priority of the "Stop the Bleed" campaign. Ross EM , Redman TT , Mapp JG , Brown DJ , Tanaka K , Cooley CW , Kharod CU , Wampler DA . Stop the bleed: the effect of hemorrhage control education on laypersons' willingness to respond during a traumatic medical emergency. Prehosp Disaster Med. 2018;33(2):127-132.

Stop the Bleed: The Effect of Hemorrhage Control Education on Laypersons' Willingness to Respond During a Traumatic Medical Emergency.

Following the 2015 White House launch of the Stop the Bleed (STB) campaign various educational programs have emerged to teach hemorrhage control principles to the public. The STB campaign seeks to translate battlefield medicine successes to the civilian sector by empowering the general public to sto

Stop the Bleed Education Consortium: Education program content and delivery recommendations.

Objective To determine whether a color-coded tourniquet designed for public use increases successful tourniquet application by laypeople. Methods This was a randomized study conducted on April 25, 2015. The study occurred during the Maryland Day activity at the University of Maryland in College Park, Maryland. Investigators recruited participants with posters displayed at major crosswalks around a central testing area. A total of 157 volunteers aged 18 years or older and without prior military service or medical training were enrolled. A participant stood in front of a waist-down mannequin with an isolated leg injury while an investigator read aloud a mass causality scenario. The investigator then asked the participant to apply a tourniquet to the mannequin’s leg. All participants received a 4-step illustrated just-in-time (JiT) instruction card designed to facilitate layperson tourniquet application. Test participants received a color-coded tourniquet designed for layperson use with instructions printed on the device. Control participants received a black Combat Application Tourniquet (C-A-T; Composite Resources, Rock Hill, SC). Participants were randomized in a 1:1 ratio in blocks of 50. The primary outcome was the proportion of successful tourniquet applications by those who received color-coded tourniquets compared to those who received black tourniquets. Secondary outcomes included validation of previous data analyzing layperson success with tourniquet application, time for successful placement, reasons for failed applications, and participant self-willingness and comfort using tourniquets. We also analyzed demographic data on the study population and inter-rater reliability regarding the assessment of successful tourniquet application. Results Participants supplied with color-coded tourniquets successfully placed the device 51.38% of the time, compared to 44.71% of the time for controls using a black tourniquet (risk ratio: 1.15; 95% confidence interval: 0.83-1.59; P=0.404). Participants’ self-reported willingness to use a tourniquet rose from 40.8% before the study to 80.3% after the study (P<0.05). Conclusions The color-coded device did not significantly increase laypeople’s proportion of successful tourniquet applications when compared with a standard black device. However, this study reproduced pilot study data showing that laypeople can successfully apply tourniquets about half the time if provided JiT instructions. Age, sex, race, income, and highest level of education were not found to impact one’s ability to properly apply a tourniquet. Laypeople’s willingness to apply tourniquets doubled to 80% after brief exposure to the device. These results affirm the feasibility of engaging laypeople as immediate lifesavers of trauma victims and justify further efforts to boost rates of proper application. (Disaster Med Public Health Preparedness. 2016;10:274–280)

Analysis of Layperson Tourniquet Application Using a Novel Color-Coded Device.

Objective The objective was to determine whether brief, Web-based instruction several weeks prior to tourniquet application improves layperson success compared to utilizing just-in-time (JiT) instructions alone. Background Stop the Bleed is a campaign to educate laypeople to stop life-threatening hemorrhage. It is based on U.S. military experience with lifesaving tourniquet use. While previous research shows simple JiT instructions boost laypeople's success with tourniquet application, the optimal approach to educate the public is not yet known. Methods This is a prospective, nonblinded, randomized study. Layperson participants from the Washington, DC, area were randomized into: 1) an experimental group that received preexposure education using a website and 2) a control group that did not receive preexposure education. Both groups received JiT instructions. The primary outcome was the proportion of subjects that successfully applied a tourniquet to a simulated amputation. Secondary outcomes included mean time to application, mean placement position, ability to distinguish bleeding requiring a tourniquet from bleeding requiring direct pressure only, and self-reported comfort and willingness to apply a tourniquet. Results Participants in the preexposure group applied tourniquets successfully 75% of the time compared to 50% success for participants with JiT alone (p < 0.05, risk ratio = 1.48, 95% confidence interval = 1.21-1.82). Participants place tourniquets in a timely fashion, are willing to use them, and can recognize wounds requiring tourniquets. Conclusions Brief, Web-based training, combined with JiT education, may help as many as 75% of laypeople properly apply a tourniquet. These findings suggest that this approach may help teach the public to Stop the Bleed.

Brief, Web-based Education Improves Lay Rescuer Application of a Tourniquet to Control Life-threatening Bleeding.

Objectives

The objective was to determine whether just-in-time (JiT) instructions increase successful tourniquet application by laypersons.



Methods

This was a randomized pilot study conducted in August 2014. The study occurred at the Uniformed Services University campus in Bethesda, Maryland. A total of 194 volunteers without prior military service or medical training completed the study. The participant stood in front of a waist-down mannequin that had an exposed leg. An observer read a scenario card aloud that described a mass casualty event. The observer then asked the participant to apply a Combat Application Tourniquet (C-A-T) to the mannequin. Test participants received a 4 × 6-inch card, with JiT instructions, in addition to their C-A-T; controls received no instructions. Participants were randomized in a 3:1 ratio of instructions to no instructions. The study's primary outcome was the proportion of successfully applied tourniquets by participants receiving JiT instructions compared to participants not receiving instructions. Secondary outcomes included the time for successful tourniquet placement, reasons for failed tourniquet application, and participants' self-reported willingness and comfort using tourniquets in real-life settings.



Results

Just-in-time instructions more than doubled successful tourniquet placement. Participants supplied with JiT instructions placed a tourniquet successfully 44.14% of the time, compared to 20.41% of the time for controls without instructions (risk ratio = 2.16; 95% confidence interval = 1.21 to 3.87; p = 0.003).



Conclusions

Just-in-time instructions increase laypeople's successful application of C-A-T. This pilot study provides evidence that JiT instructions may assist the lay public in providing effective point-of-injury hemorrhage control.


Resumen
Justo a Tiempo Para Salvar Vidas: Estudio Piloto de la Aplicacion de Torniquete por un Lego

Objetivos

Determinar si las instrucciones “justo a tiempo” (JAT) incrementan la aplicacion de forma exitosa de un torniquete por legos.



Metodologia

Estudio piloto aleatorizado llevado a cabo en agosto del 2014. El estudio tuvo lugar en el campus de la Uniformed Services University (USU) en Bethesda, Maryland. Ciento noventa y cuatro voluntarios sin servicio militar o formacion medica previos completaron el estudio. El participante estuvo frente a un maniqui sin ropa por debajo de la cintura y tenia una pierna expuesta. Un observador leyo en voz alta una tarjeta del escenario que describio un acontecimiento con multiples victimas. El observador posteriormente ordeno al participante aplicar un torniquete de accion de combate (TAC) al maniqui. Los participantes recibieron una tarjeta 4x6 pulgadas, con las instrucciones JAT, ademas de su TAC; los controles no recibieron ninguna instruccion. Los participantes se aleatorizaron en una proporcion 3:1 a instrucciones frente no instrucciones. El resultado principal del estudio fue la proporcion de torniquetes aplicados de forma exitosa por los participantes que recibieron las instrucciones del JAT en comparacion con los participantes que no recibieron instrucciones. Los resultados secundarios incluyeron el tiempo para la aplicacion del torniquete de forma exitosa, las razones para el fallo en la aplicacion del torniquete, y la disposicion autoreportada de los participantes y su comodidad en el uso de torniquetes en escenarios de la vida real.



Resultados

El grupo de las instrucciones del grupo JAT aplicaron torniquetes de forma exitosa en mas del doble de los casos. Los participantes con las instrucciones JAT proporcionaron un torniquete de forma exitosa en enl 44,14% de casos, en comparacion con un 20,41% de los participantes control sin instrucciones (riesgo relatico [RR] 2,16; IC95% = 1,21 a 3,87; p = 0,003).



Conclusiones

Las instrucciones JAT incrementan la aplicacion de TAC de forma exitosa por legos. Este estudio piloto proporciona evidencia que las instrucciones JAT pueden ayudar a los legos a proporcionar de forma efectiva un control de la hemorragia en el lugar de la lesion.

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Just-in-Time to Save Lives: A Pilot Study of Layperson Tourniquet Application.

Background: Advanced simulation capabilities have provided medical educators novel approaches for learners. Simulation has successfully replaced many aspects of medical education that previously used animal live-tissue training (LTT) for physician education. However, prehospital trauma providers, such as combat medics, currently used LTT to prepare for patient care. This use of LTT has sparked a debate about the optimal educational modality for this unique learner population. At this time, there is no clear evidence-based recommendation available to recommend either LTT or simulation as a superior modality. Methods: The authors performed a systematic review of observational studies and randomized control trials (RCTs) to examine the use of LTT versus simulation in the trauma education of prehospital providers. The authors judged studies for inclusion and data abstraction independently and in duplicate, while also assessing quality and risk of bias. Since the literature demonstrated a heterogeneou...

Andrew Branting

Papers

Just-in-Time to Save Lives: A Pilot Study of Layperson Tourniquet Application.

Analysis of Layperson Tourniquet Application Using a Novel Color-Coded Device.

Systematic Review of Live Tissue Versus Simulation Education for Prehospital Trauma Providers.