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

Abstract

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.

Conflict of interest statement

Conflict of Interest Disclosures: None reported.

Figures

Figure 1.. Consolidated Standards of Reporting Flowchart for Enrollment, Randomization, and Evaluation of Participants in the Public Access and Tourniquet Training Study (PATTS) Trial

aThe Gillette Stadium Operational Team includes employees who work in access control, as parking staff members, in food and beverage operations, or in general stadium operations. bAudio kit point-of-care instructions included a combination of audio instructions and pictorial diagrams describing hemorrhage control techniques. cFlashcards are a pictorial diagram with accompanying text describing hemorrhage control techniques. dThe American College of Surgeons Bleeding Control for the Injured (B-Con), which is a 1-hour combined lecture and hands-on skills hemorrhage control training course.

Figure 2.. Proportion of Correct Tourniquet Application at Initial Testing

aStatistically significant (Bonferroni-corrected with P < .05) when compared with the control. B-Con indicates Bleeding Control Basic.

Figure 3.. Proportion of Correct Tourniquet Application During Retention Testing Over 3 to 9 Months