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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

Educational Objective To evaluate the effectiveness of different instructional point-of-care interventions and in-person training for hemorrhage control compared with no intervention and and to what extent these skills are retained at 3 and 9 months.
1 Credit CME
Key Points

Question  How effective are point-of-care audio instructions, visual instructions, and in-person training at enabling laypeople to control hemorrhage using a tourniquet, and will they retain this skill?

Findings  In this randomized clinical trial, 465 participants were randomized to 4 arms to evaluate tourniquet application, and 303 (65.25) were assessed for retention 3 to 9 months after completing their training. Bleeding control training (88% correct application) was superior to control (16%) while flashcards (20%) and audio kits (23%) were not, and 3 to 9 months after training, 256 (55%) correctly applied a tourniquet.

Meaning  In-person training is currently the most efficacious means of enabling bystanders to control hemorrhage; however, investigating refresher training or improved point-of-care instructions is critical.


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 < .001) was superior to control (n = 104 [16%]) while instructional flashcards (n = 117 [19.6%]) and audio kit (n = 122 [23%]) groups were not. More than half of participants in point-of-care arms did not use the educational prompts as intended. Of 303 participants (65%) who were assessed 3 to 9 months after undergoing B-Con training, 165 (54.5%) could correctly apply a tourniquet. Over this period, there was no further skill decay in the adjusted model that treated time as either linear (odds ratio [OR], 0.98; 95% CI, 0.95-1.03) or quadratic (OR, 1.00; 95% CI, 1.00-1.00). The only demographic that was associated with correct application at retention was age; adults aged 18 to 35 years (n = 58; OR, 2.39; 95% CI, 1.21-4.72) and aged 35 to 55 years (n = 107; OR, 1.77; 95% CI, 1.04-3.02) were more likely to be efficacious than those older than 55 years (n = 138).

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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Article Information

Accepted for Publication: March 10, 2018.

Corresponding Author: Adil H. Haider, MD, MPH, Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, 1620 Tremont St, Ste 4-020, Boston, MA 02115 (ahhaider@bwh.harvard.edu).

Published Online: May 9, 2018. doi:10.1001/jamasurg.2018.1099

Author Contributions: Drs Goralnick and Haider had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Goralnick, Chaudhary, McCarty, Caterson, Goldberg, Lipsitz, Haider.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Goralnick, McCarty, Lipsitz.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Goralnick, Chaudhary, McCarty, Herrera-Escobar, Lipsitz, Haider.

Obtained funding: Goralnick, Chaudhary, McCarty, Caterson.

Administrative, technical, or material support: Goralnick, Chaudhary, McCarty, Caterson, Goldberg, Herrera-Escobar, McDonald, Haider.

Supervision: Goralnick, McCarty, Caterson, Haider.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was partially supported by the Gillian Reny Stepping Strong Center for Trauma Innovation.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The North American Rescue donated combat application tourniquets for the study.

Disclaimer: Dr Haider is Deputy Editor of JAMA Surgery, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.

Additional Contributions: We thank the Boston Medical Flight, Fallon Ambulance, Brigham and Women’s Hospital, and Gillette Stadium Team Operations for providing logistic support for the study.

Berwick  D, Downey  A, Cornett  E, eds.  A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: National Academies Press; 2016.
Rhee  P, Joseph  B, Pandit  V,  et al.  Increasing trauma deaths in the United States.  Ann Surg. 2014;260(1):13-21.PubMedGoogle ScholarCrossref
Eastridge  BJ, Mabry  RL, Seguin  P,  et al.  Death on the battlefield (2001-2011): implications for the future of combat casualty care.  J Trauma Acute Care Surg. 2012;73(6)(suppl 5):S431-S437.PubMedGoogle ScholarCrossref
Kragh  JF  Jr, Walters  TJ, Baer  DG,  et al.  Survival with emergency tourniquet use to stop bleeding in major limb trauma.  Ann Surg. 2009;249(1):1-7.PubMedGoogle ScholarCrossref
Kotwal  RS, Montgomery  HR, Kotwal  BM,  et al.  Eliminating preventable death on the battlefield.  Arch Surg. 2011;146(12):1350-1358.PubMedGoogle ScholarCrossref
Kotwal  RS, Howard  JT, Orman  JA,  et al.  The effect of a golden hour policy on the morbidity and mortality of combat casualties.  JAMA Surg. 2016;151(1):15-24.PubMedGoogle ScholarCrossref
Mell  HK, Mumma  SN, Hiestand  B, Carr  BG, Holland  T, Stopyra  J.  Emergency medical services response times in rural, suburban, and urban areas.  JAMA Surg. 2017;152(10):983-984.PubMedGoogle ScholarCrossref
Schenk  E, Wijetunge  G, Mann  NC, Lerner  EB, Longthorne  A, Dawson  D.  Epidemiology of mass casualty incidents in the United States.  Prehosp Emerg Care. 2014;18(3):408-416.PubMedGoogle ScholarCrossref
Haider  AH, Haut  ER, Velmahos  GC.  Converting bystanders to immediate responders: we need to start in high school or before.  JAMA Surg. 2017;152(10):909-910.PubMedGoogle ScholarCrossref
Knudson  MM, Velmahos  G, Cooper  ZR.  Response to mass casualty events: from the battlefield to the Stop the Bleed campaign.  Trauma Surg & Acute Care Open. 2016;1(1):1-3. doi:10.1136/tsaco-2016-000023Google ScholarCrossref
Federal Emergency Management Agency. You are the help until help arrives. https://community.fema.gov/until-help-arrives. Accessed October 19, 2017.
American College of Surgeons. BleedingControl.org—about us. http://www.bleedingcontrol.org/about-bc. Accessed July 17, 2017.
Jacobs  LM; Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events.  The Hartford Consensus IV: a call for increased national resilience.  Bull Am Coll Surg. 2016;101(3):17-24.PubMedGoogle Scholar
Zideman  DA, Singletary  EM, De Buck  ED,  et al; First Aid Chapter Collaborators.  Part 9: first aid: 2015 International Consensus on First Aid Science with treatment recommendations.  Resuscitation. 2015;95:e225-e261.PubMedGoogle ScholarCrossref
Van de Velde  S, Heselmans  A, Roex  A, Vandekerckhove  P, Ramaekers  D, Aertgeerts  B.  Effectiveness of nonresuscitative first aid training in laypersons: a systematic review.  Ann Emerg Med. 2009;54(3):447-457, 457.e1-457.e5.PubMedGoogle ScholarCrossref
He  Z, Wynn  P, Kendrick  D.  Non-resuscitative first-aid training for children and laypeople: a systematic review.  Emerg Med J. 2014;31(9):763-768.PubMedGoogle ScholarCrossref
Blair  J, Schwiet  K. A study of active shooter incidents in the United States between 2000-2013. https://www.fbi.gov/file-repository/active-shooter-study-2000-2013-1.pdf/view. Accessed December 10, 2017.
Biddinger  PD, Baggish  A, Harrington  L,  et al.  Be prepared—the Boston Marathon and mass-casualty events.  N Engl J Med. 2013;368(21):1958-1960.PubMedGoogle ScholarCrossref
Campion  EW, Morrissey  S, Malina  D, Sacks  CA, Drazen  JM.  After the mass shooting in Las Vegas—finding common ground on gun control.  N Engl J Med. 2017;377(17):1679-1680.PubMedGoogle ScholarCrossref
Anderson  GS, Gaetz  M, Statz  C, Kin  B.  CPR skill retention of first aid attendants within the workplace.  Prehosp Disaster Med. 2012;27(4):312-318.PubMedGoogle ScholarCrossref
Woollard  M, Whitfeild  R, Smith  A,  et al.  Skill acquisition and retention in automated external defibrillator (AED) use and CPR by lay responders: a prospective study.  Resuscitation. 2004;60(1):17-28.PubMedGoogle ScholarCrossref
Mpotos  N, De Wever  B, Cleymans  N,  et al.  Repetitive sessions of formative self-testing to refresh CPR skills: a randomised non-inferiority trial.  Resuscitation. 2014;85(9):1282-1286.PubMedGoogle ScholarCrossref
Einspruch  EL, Lynch  B, Aufderheide  TP, Nichol  G, Becker  L.  Retention of CPR skills learned in a traditional AHA Heartsaver course versus 30-min video self-training: a controlled randomized study.  Resuscitation. 2007;74(3):476-486.PubMedGoogle ScholarCrossref
Caffrey  SL, Willoughby  PJ, Pepe  PE, Becker  LB.  Public use of automated external defibrillators.  N Engl J Med. 2002;347(16):1242-1247.PubMedGoogle ScholarCrossref
Page  RL, Joglar  JA, Kowal  RC,  et al.  Use of automated external defibrillators by a U.S. airline.  N Engl J Med. 2000;343(17):1210-1216.PubMedGoogle ScholarCrossref
Goolsby  C, Branting  A, Chen  E, Mack  E, Olsen  C.  Just-in-time to save lives: a pilot study of layperson tourniquet application.  Acad Emerg Med. 2015;22(9):1113-1117.PubMedGoogle ScholarCrossref
Schulz  KF, Altman  DG, Moher  D, Group  C; CONSORT Group.  CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials.  Ann Intern Med. 2010;152(11):726-732.PubMedGoogle ScholarCrossref
Lipsitz  SR, Fitzmaurice  GM, Orav  EJ, Laird  NM.  Performance of generalized estimating equations in practical situations.  Biometrics. 1994;50(1):270-278.PubMedGoogle ScholarCrossref
Petry  NM.  A comparison of young, middle-aged, and older adult treatment-seeking pathological gamblers.  Gerontologist. 2002;42(1):92-99.PubMedGoogle ScholarCrossref
Goolsby  C, Chen  E, Branting  A,  et al.  Analysis of layperson tourniquet application using a novel color-coded device.  Disaster Med Public Health Prep. 2016;10(2):274-280.PubMedGoogle ScholarCrossref
Saraç  L, Ok  A.  The effects of different instructional methods on students’ acquisition and retention of cardiopulmonary resuscitation skills.  Resuscitation. 2010;81(5):555-561.PubMedGoogle ScholarCrossref
Jacobs  LM, Burns  KJ.  Tourniquet application training for individuals with and without a medical background in a hospital setting.  J Trauma Acute Care Surg. 2015;78(2):442-445.PubMedGoogle ScholarCrossref
Baruch  EN, Kragh  JF  Jr, Berg  AL,  et al.  Confidence-competence mismatch and reasons for failure of non-medical tourniquet users.  Prehosp Emerg Care. 2017;21(1):39-45.PubMedGoogle ScholarCrossref
Schreckengaust  R, Littlejohn  L, Zarow  GJ.  Effects of training and simulated combat stress on leg tourniquet application accuracy, time, and effectiveness.  Mil Med. 2014;179(2):114-120.PubMedGoogle ScholarCrossref
Unlu  A, Kaya  E, Guvenc  I,  et al.  An evaluation of combat application tourniquets on training military personnel: changes in application times and success rates in three successive phases.  J R Army Med Corps. 2015;161(4):332-335.PubMedGoogle ScholarCrossref
Hegvik  JR, Spilman  SK, Olson  SD, Gilchrist  CA, Sidwell  RA.  Effective hospital-wide education in hemorrhage control.  J Am Coll Surg. 2017;224(5):796-799.e1.PubMedGoogle ScholarCrossref
Gonzalez  M, Leary  M, Blewer  AL,  et al.  Public knowledge of automatic external defibrillators in a large US urban community.  Resuscitation. 2015;92:101-106.PubMedGoogle ScholarCrossref
Folke  F, Lippert  FK, Nielsen  SL,  et al.  Location of cardiac arrest in a city center: strategic placement of automated external defibrillators in public locations.  Circulation. 2009;120(6):510-517.PubMedGoogle ScholarCrossref
Winkle  RA.  The effectiveness and cost effectiveness of public-access defibrillation.  Clin Cardiol. 2010;33(7):396-399.PubMedGoogle ScholarCrossref
Baruch  EN, Benov  A, Shina  A,  et al.  Does practice make perfect? prospectively comparing effects of 2 amounts of practice on tourniquet use performance.  Am J Emerg Med. 2016;34(12):2356-2361.PubMedGoogle ScholarCrossref
Mosesso  VN  Jr, Shapiro  AH, Stein  K, Burkett  K, Wang  H.  Effects of AED device features on performance by untrained laypersons.  Resuscitation. 2009;80(11):1285-1289.PubMedGoogle ScholarCrossref
Kragholm  K, Wissenberg  M, Mortensen  RN,  et al.  Bystander efforts and 1-year outcomes in out-of-hospital cardiac arrest.  N Engl J Med. 2017;376(18):1737-1747.PubMedGoogle ScholarCrossref
Rasmussen  TE, Kellermann  AL.  Wartime Lessons—Shaping a National Trauma Action Plan.  N Engl J Med. 2016;375(17):1612-1615.PubMedGoogle ScholarCrossref
Blom  MT, Beesems  SG, Homma  PC,  et al.  Improved survival after out-of-hospital cardiac arrest and use of automated external defibrillators.  Circulation. 2014;130(21):1868-1875.PubMedGoogle ScholarCrossref
Cummins  RO, Ornato  JP, Thies  WH, Pepe  PE.  Improving survival from sudden cardiac arrest: the “chain of survival” concept. a statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association.  Circulation. 1991;83(5):1832-1847.PubMedGoogle ScholarCrossref
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