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Stop Bleed Training-Rescuer Skill Knowledge Attitude
Stop Bleed Training-Rescuer Skill Knowledge Attitude
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Rebecca Schroll, MD,a Alison Smith, MD, PhD,a,* Morgan S. Martin, MD,a
Tyler Zeoli, BA,a Marcus Hoof, BS,a Juan Duchesne, MD,a
Patrick Greiffenstein, MD,b and Jennifer Avegno, MDb
a
Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
b
Section of Emergency Medicine, Louisiana State University School of Medicine, New Orleans, Louisiana
Article history: Background: Bystanders play a significant role in the immediate management of life-
Received 15 April 2019 threatening hemorrhage. The Stop the Bleed (STB) program was designed to train lay
Received in revised form rescuers (LRs) to identify and control life-threatening bleeding. The aim of this study was to
7 August 2019 evaluate the efficacy of STB training for rescuers from different backgrounds. We hy-
Accepted 15 August 2019 pothesized that STB training would be appropriate to increase skills and knowledge of
Available online 13 September 2019 bleeding control techniques for all providers, regardless of level of medical training.
Study design: Course participants anonymously self-reported confidence in six major areas.
Keywords: A five-point Likert scale was used to quantitate participant’s self-reported performance.
Hemorrhage control Results were stratified into medical rescuers (MR) and LRs. Students’ ability to perform STB
Education skills were objectively assessed using an internally validated 15-point objective assessment
Mass shootings tool. Data were pooled and analyzed using Student’s t-test and chi-Squared test with
Mass casualty P < 0.05 considered significant. Results are presented as average with standard deviation
Lay rescuers (SD) unless otherwise stated.
Results: A total of 1974 participants were included in the study. Precourse confidence was
lowest for both groups in management of active severe bleeding and ability to pack a
bleeding wound. Postcourse confidence improved significantly for both groups in all 6 core
areas measured (P < 0.001). The most significant increases were reported in the two pre-
vious areas of lowest precourse confidence-management of active severe bleedingdLRs 2.0
(SD 1.2) versus 4.2 (SD 0.9) and MRs 2.6 (SD 1.4) versus 4.6 (SD 0.6), P < 0.001dand ability to
pack a bleeding wounddLR 2.1 (SD 1.3) versus 4.4 (SD 0.8) and MR 2.7 (SD 1.3) versus 4.7 (SD
0.05), P < 0.001. Objective assessment of LR skills at the end of the course demonstrated
combined 99.3% proficiency on postcourse objective assessments.
Conclusions: This study provides quantitative evidence that Stop the Bleed training is
effective, with both LRs and MRs demonstrating improved confidence and skill proficiency
after a 1-h course. Future program development should focus on building a pool of in-
structors, continued training of LRs, and determining how often skills should be recertified.
ª 2019 Elsevier Inc. All rights reserved.
Meeting presentation: This research was presented at the American College of Surgeons Clinical Congress on October 21-25, 2018, in
Boston, MA.
* Corresponding author. Department of Surgery, Tulane School of Medicine, 1430 Tulane Ave, SL-22 New Orleans, LA, 70112. Tel.: þ412
607-3047; fax: þ504-988-1882.
E-mail address: alison.annette.smith@gmail.com (A. Smith).
0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jss.2019.08.011
s c h r o l l e t a l e f fi c a c y o f “ s t o p t h e b l e e d ” t r a i n i n g 637
training. Participant level of medical training was not reported was significantly increased for both LRs (A: 65.5% [n ¼ 130/198]
for 15.9% (n ¼ 374/2348). The overall response rate for partic- versus 95.8% [n ¼ 799/834]; B: 77.5% [n ¼ 142/183] versus 98.3%
ipants who completed both precourse and postcourse surveys [n ¼ 819/833]; and C: 68.9% [n ¼ 125/181] versus 96.7% [n ¼ 803/
was 76.6% (MR 89.6%, n ¼ 1004/1120; and LR 63.6%, n ¼ 524/ 830]) and MRs (A: 40.7% [n ¼ 230/564] versus 93.8% [n ¼ 915/975];
854). Unknown responses for precourse surveys was 18.5% B: 53.6% [n ¼ 282/527] versus 99.0% [n ¼ 959/969]; and C: 49.0%
(n ¼ 374/2018) and 7.1% (n ¼ 142/2000) for postcourse surveys. [n ¼ 281/574] versus 94.0% [n ¼ 914/972]) with P < 0.001 for all
The breakdown of course participants is presented in Figure. three areas in both groups.
MRs represented 56.7% (n ¼ 1120/1974) of course partici-
pants who completed surveys with the largest group repre- Precourse and postcourse confidence
sented by medical students (22.4%, n ¼ 443/1974). Surgeons
represented 32.1% (n ¼ 18/56) of attending physicians, and MRs had significantly higher precourse confidence compared
general surgery residents made up 63.5% of residents (n ¼ 66/ with LRs in all six areas measured (P < 0.001). In both groups,
104). Average age of course participants was 32 y (range, 7- the areas of lowest precourse confidence significantly
88 y), and 60.0% were female. improved after course, including management of active se-
vere bleedingdLRs 2.0 (SD 1.2) versus 4.2 (SD 0.9) and MRs 2.6
Precourse and postcourse knowledge (SD 1.4) versus 4.6 (SD 0.02), P < 0.001dand ability to pack a
bleeding wounddLRs 2.1 (SD 1.3) versus 4.2 (SD 0.9) and MRs
Knowledge of the Hartford Consensus (LR: 4.4% [n ¼ 22/504] 2.7 (SD 1.3) versus 4.7 (SD 0.5), P < 0.001. Overall, MRs achieved
versus 63.9% [n ¼ 484/758], P < 0.001; and MR: 6.6% [n ¼ 72/1098] significantly higher postcourse confidence than LRs
versus 77.9% [n ¼ 725/933], P < 0.001) and the STB campaign (P < 0.001). These results are presented in Table 2.
(LR: 27.8% [n ¼ 141/508] versus 95.6% [n ¼ 757/792], P < 0.001;
and MR: 40.3% [n ¼ 443/1100] versus 97.9% [n ¼ 941/963], Objective skills assessment
P < 0.001) improved significantly for both groups following the
course. Participants also expressed increased knowledge of A total of 493 (n ¼ 493/1974, 25.0%) objective skills assessments
what to do in the event of an active shooter (LR: 35.7% [n ¼ 178/ were completed by instructors for 313 LRs and 180 MRs. All
499] versus 88.5% [n ¼ 682/771], P < 0.001; and MR: 44.6% forms completed by instructors could be linked to either MRs or
[n ¼ 481/1078] versus 89.4% [n ¼ 839/940], P < 0.001). Finally, LRs. From the LR group, 121 incomplete forms were excluded
participants were able to more accurately identify the “ABC’s” from the final analysis. The majority of providers achieved
of bleeding control following the course. This increase in high scores on the final objective skills assessment. Assess-
postcourse ability to identify the basics of bleeding control ment of LR skills at the end of the course demonstrated a
s c h r o l l e t a l e f fi c a c y o f “ s t o p t h e b l e e d ” t r a i n i n g 639
Table 2 e Self-reported confidence of lay rescuers, medical rescuers, and unknown rescuer level to manage severe
hemorrhage before and after STB training.
Lay rescuers Precourse, n ¼ 524 Postcourse, n ¼ 854 P value
Identification of life-threatening bleeding 2.7 (1.3) 4.4 (0.8) <0.001
Appropriate tourniquet use 2.3 (1.3) 4.4 (0.7) <0.001
Ability to apply direct pressure 2.7 (1.3) 4.5 (0.7) <0.001
Ability to pack a wound 2.1 (1.3) 4.4 (0.8) <0.001
Treat severe active bleeding 2.0 (1.2) 4.2 (0.9) <0.001
Teach bleeding control techniques to others 2.4 (1.3) 4.3 (0.9) <0.001
Confidence level was reported on a 5-point Likert scale with 1 ¼ not confident at all and 5 ¼ very confident. Average values are presented with
the standard deviation in parentheses.
combined 99.3% proficiency on postcourse objective assess- disappears; locks rod in place in windlass clip), whereas LRs did
ments compared with MRs who had 98.0% proficiency. Average not receive perfect scores in any of the categories tested.
total scores for LRs and MRs were 14.9 (SD 0.9) and 14.7 (SD 0.7), However, LRs demonstrated significantly better performance
respectively. MRs did receive perfect scores in 6 categories in asking for a trauma first aid kit (LR: n ¼ 191/192 [99.5%] and
(identifies life-threatening bleeding; uses 2 hands for direct MR: n ¼ 173/180 [96.1%], P ¼ 0.03) and securing the windlass
pressure; firm and continuous pressure; packs gauze into an strap of a tourniquet (LR: n ¼ 191/192 [99.5%] and MR n ¼ 144/180
open wound; tighten windlass to stop bleeding or until pulse [80.0%], P < 0.001). These data are shown in Table 3.
Table 3 e Comparison of average objective assessment scores of STB Skills for lay rescuers, medical rescuers, and
unknown rescuer level.
Skill assessed, n (%) Lay rescuers, n ¼ 192 Medical rescuers, n ¼ 180 P value
Personal safety/active response
Ensure scene safety 192 (99.5) 177 (98.3) 0.11
Put on gloves 191 (99.0) 174 (96.7) 0.06
Call 911 or ask someone to call 191 (99.0) 178 (98.1) 0.61
Identifies life-threatening bleeding 191 (99.0) 180 (100.0) 1.0
Asks for a trauma first-aid kit 191 (99.0) 173 (96.1) 0.03
Holding direct pressure
Uses 2 hands for direct pressure 191 (99.0) 180 (100.0) 1.0
Applies firm and continuous pressure 191 (99.0) 180 (100.0) 1.0
Packs gauze into open wound 191 (99.0) 180 (100.0) 1.0
Tourniquet application
Applies above bleeding site 191 (99.0) 180 (100.0) 1.0
Avoids placing over knee or elbow joint 190 (98.4) 180 (100.0) 0.50
Removes slack before twisting windlass 191 (99.0) 174 (96.7) 0.06
Tighten windlass until bleeding stops or pulses disappears 191 (99.0) 180 (100.0) 1.0
Locks rod in place in windlass clip 191 (99.0) 180 (100.0) 1.0
Adheres remaining strap around extremity 191 (99.0) 179 (99.0) 1.0
Secures windlass strap 191 (99.0) 144 (80.0) <0.001
Score of “1” if the skill was performed correctly, and a score of “0” if it was not performed correctly. Results are presented as the number of
participants who performed the skill correctly for lay rescuers and medical rescuers with the percentage in parentheses.
640 j o u r n a l o f s u r g i c a l r e s e a r c h j a n u a r y 2 0 2 0 ( 2 4 5 ) 6 3 6 e6 4 2
Comparison of LRs and medical students training videos as important to improving the course. In
addition, several participants reported that the Hartford
A subgroup analysis of LRs and medical students were per- Consensus was not explained well. Seven participants (3 LRs
formed to determine if there was any difference between LRs and 4 MRs) wanted the course to include more information on
and MRs with the least amount of clinical experience. On the how to deal with mass shootings. Interestingly, 7 MR partici-
precourse assessment, the medical students only had signif- pants suggested to teach how to make tourniquets if a com-
icantly higher confidence in the ability to allow direct pressure mercial device is not available.
to a wound than the LR group: 2.7 (1.3) versus 3.1 (1.1), P < 0.001.
On the postcourse assessment, medical students demon-
strated significantly higher confidence in all 6 areas evaluated
Discussion
(P < 0.001) than the LR group (Table 4).
Table 4 e Comparison of precourse knowledge and confidence in bleeding control techniques for lay rescuers versus
medical students.
Precourse assessment Lay rescuers, n ¼ 524 Medical students, n ¼ 152 P value
Identification of life-threatening bleeding 2.7 (1.3) 2.7 (1.0) 1.0
Appropriate tourniquet use 2.3 (1.3) 2.4 (1.0) 0.4
Ability to apply direct pressure 2.7 (1.3) 3.1 (1.1) <0.001
Ability to pack a wound 2.1 (1.3) 2.2 (1.1) 0.4
Treat severe active bleeding 2.0 (1.2) 2.0 (1.0) 1.0
Teach bleeding control techniques to others 2.4 (1.3) 2.5 (1.2) 0.4
Confidence level was reported on a 5-point Likert scale with 1 ¼ not confident at all and 5 ¼ very confident. Average values are presented with
the standard deviation in parentheses.
s c h r o l l e t a l e f fi c a c y o f “ s t o p t h e b l e e d ” t r a i n i n g 641
among course participants with no medical knowledge or recertification of CPR/automated external defibrillator skills at
baseline skills. a minimum of every 2 y.29 Currently, there are no recom-
Our study identified that, while less than half of LRs re- mendations regarding the length of time after which STB
ported that the course was too easy, the majority of MRs training should be recertified. We propose that the ACS should
thought the STB course was too basic for their level of training. recommend recertification at a minimum of every 1-2 y for
Interestingly, although both MRs and LRs were able to rescuers depending on their experience and level of comfort
demonstrate skill with overall high proficiency at the end of with bleeding control techniques. This recertification could
the course, there were a few areas in which the MRs per- take place during an abbreviated course for appropriately
formed less proficiently on average than the LRs. We suspect enrolled rescuers. Recertification of skills may have to be
that this may be due to overconfidence of some MRs. This approached in a different manner for LRs and MRs. Further
finding, as well as the significant increases in knowledge and studies are needed to determine the optimal timing of STB
confidence in STB course skills in MRs, underscores the need skill recertification.
for STB training even in MRs. Much like the training of MRs on Several other interesting suggestions for the course
cardiopulmonary resuscitation (CPR) skills, this course is included the possibility of LRs serving as instructors. Recently,
likely necessary to ensure that MRs adhere to certain stan- medical students have been allowed to serve as assistant in-
dards when managing bleeding outside of the workplace.24-26 structors for the course. Several of our study participants
A subgroup analysis of medical students compared with suggested that members of the lay public be allowed to serve
LRs showed that medical students had a more significant as assistant instructors; we agree with this suggestion, as we
improvement in postcourse confidence of skills than the LRs. showed that LRs were able to master STB skills after a 1-hr STB
This observation shows that medical students, who have less course, and adding to our pool of potential instructors would
clinical experience compared with other MRs in our study, significantly increase our ability to widely disseminate cour-
were able to proficiently achieve the confidence for mastering ses and educate our community. Numerous LRs requested
STB skills. additional videos or visual aids to help emphasize teaching
The STB campaign also seeks to distribute bleeding control points. Such supplemental materials may indeed be beneficial
kits to the public. As demonstrated in a recent study of particularly to LRs who do not have clinical acumen or expe-
American College of Surgeons Bleeding Control Basic (B-Con) rience to draw from to help them recognize life-threatening
class participants, LRs may have interest in performing bleeding and injury patterns. Finally, an additional common
bleeding control techniques. However, they failed to obtain suggestion was to have STB courses available in other lan-
the necessary supplies to perform.20 This indicates that bar- guages to help reach additional non-English-speaking res-
riers remain in the implanting of techniques to the lay public. cuers. Although we are aware that this has been done
We found similar evidence as multiple course participants, sporadically, it may be beneficial for the American College of
both LRs and MRs, expressed a desire to have tourniquets and Surgeons to make standardized translated materials widely
wound packing materials available. The likely solution to this available.
issue will require legislative changes that require vulnerable Our study has several limitations to discuss. First, we were
public spaces to make these tools available to use during MCIs. not able to obtain responses for both the precourse and
Neal et al. reported the vital support of the Pennsylvania State postcourse surveys for all participants. In addition, unfortu-
Senate of STB and making training opportunities and bleeding nately, we were unable to link many of the objective skills
kits available.21 assessments by level of medical training. This lack of com-
In our study, both LRs and MRs were able to achieve high plete responses may have impacted our results, although we
scores on the objective assessment for the performance of suspect that the trends we observed do indeed reflect the
bleeding control techniques. A statistically higher percentage larger population of STB participants as this was the case for
of MRs reported that increasing hands-on practice time, case the unknown rescuer-level group. An improved methodology
scenarios, and bleeding simulation were important to the STB to ensure more complete information for all participants will
course. We believe that this observation likely highlights that be necessary in future studies to minimize this limitation.
MRs recognize the need for simulation and practice when Another potential limitation is that we only assessed the
learning and maintaining skills. A recent study by Zwislewski initial training of course participants. It remains critical to
et al. also confirmed this observation.27 LRs who performed perform a follow-up analysis of knowledge and skill retention
hands-on training of wound packing and tourniquet place- between both LRs and MRs at various intervals.
ment outperformed rescuers who only listened to the lecture.
This study demonstrated what we observed regarding the
importance of hands-on practice. Conclusion
Minimal data are available on the retention of rescuer skills
and confidence to apply skills. We completed the assessment This study demonstrates that both MRs and LRs have signifi-
of rescuer skills and confidence immediately after the course. cantly increased knowledge of bleeding control techniques
It is likely that rescuers provided high scores due to the timing and confidence in their skills after completing a 1-h STB
of their responses. A study by Pasley et al. evaluated STB skills course. Both groups were able to demonstrate proficiency in
1 mo after the course.28 The authors found significant deteri- performing bleeding control skills. In addition, we provide the
oration of confidence in skills. An analogy of STB training largest critical assessment of course participants’ perceptions
could be made to CPR/automated external defibrillator and attitudes surrounding STB and identify important di-
training. The American Heart Association recommends rections for future course development. Future initiatives
642 j o u r n a l o f s u r g i c a l r e s e a r c h j a n u a r y 2 0 2 0 ( 2 4 5 ) 6 3 6 e6 4 2
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Acknowledgment
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