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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?
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.
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.
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.
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.
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.
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.
ClinicalTrials.gov Identifier: NCT03479112
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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 (email@example.com).
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.
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