Design and implementation of the Western Pennsylvania regional Stop the Bleed initiative

Independent factors of preventable death in a mature trauma center: a propensity-score analysis

INTRODUCTION

The rate of potentially preventable deaths (PPD) and preventable deaths (PD) can reach more than 20% of overall trauma mortality. Bleeding is the leading cause of preventable mortality. The aim of our study is to define the independent factors of preventable or potentially preventable mortality in our mature trauma system.

MATERIALS AND METHODS

We conducted a single-center retrospective study in the Sainte Anne Military Teaching Hospital, Toulon, France, including all severe trauma patients admitted to our trauma center and discharged alive as well as all severe trauma patients who died with a death considered preventable or potentially preventable from January 2013 to December 2020. We matched the two groups using a propensity score and searched for independent factors using a generalized linear model.

RESULTS

846 patients were included and analyzed. After matching, our cohort consisted of 245 patients in the survivor group and 49 patients in the preventable deaths group. Pre-hospital delays (73 min vs 54 min P = 0.003) as well as delays before incision in the operating room (80 min vs 52 min P < 0.001) were significantly longer in the PD group. These delays were independent factors of preventable mortality OR 10.35 (95% CI [3.44-31.11] P < 0.001) and OR 37.53 (95% CI [8.51-165.46] P < 0.001) as well as pelvic trauma OR 6.20 (95% CI [1.53-25.20] P = 0.011).

CONCLUSION

Delays in pre-hospital care, delays in access to the operating room from arrival at the trauma center, and pelvic injuries are independent factors associated with an increased risk of preventable mortality in trauma.

A framework for the design and implementation of Stop the Bleed and public access trauma equipment programs

Traumatic injuries remain the leading cause of death for those under the age of 44 years old. Nearly a third of those who die from trauma do so from bleeding. Reducing death from severe bleeding requires training in the recognition and treatment of life-threatening bleeding, as well as programs to ensure immediate access to bleeding control resources. The Stop the Bleed (STB) initiative seeks to educate and empower people to be immediate responders and provide control of life-threatening bleeding until emergency medical services arrive. Well-planned and implemented STB programs will help ensure program effectiveness, minimize variability, and provide long-term sustainment. Comprehensive STB programs foster consistency, promote access to bleeding control education, contain a framework to guide the acquisition and placement of equipment, and promote the use of these resources at the time of a bleeding emergency. We leveraged the expertise and experience of the Stop the Bleed Education Consortium to create a resource document to help inform and guide STB program developers and implementers on the key areas for consideration when crafting strategy. These areas include (1) equipment selection, (2) logistics and kit placement, (3) educational program accessibility and implementation, and (4) program oversight, facilitation, and administration.

Age-related injury patterns resulting from knife violence in an urban population

Interpersonal violence involving knives is a major public health problem. The majority of patients are young people in urban areas, but little is known about age-specific patterns of injury and recent trends in injury characteristics. We performed a retrospective cohort study of all patients presenting to an urban major trauma centre with stab injuries resulting from assault between 2012 and 2018. A total of 3583 patients were included. Young people (age under 25) were more likely to have sustained multiple stab wounds compared to older people (43% vs 35%, p < 0.001) and had significantly higher rates of stab injuries involving the lower limbs, groin and buttocks. The annual number of injuries increased steadily during the study period in patients aged under 25 (r² = 0.82, p = 0.005) and those over 25 (r² = 0.95, p < 0.001). Over time, limb and junctional injuries accounted for an increasing proportion of stab wounds in young people, overtaking torso injuries as most common pattern of injury by the end of the study period. These findings illustrate the influence of age on injury patterns resulting from knife violence, and support the expansion of outreach initiatives promoting bystander-delivered haemorrhage control of extremity wounds.

Video-Based Stop the Bleed Training: A New Era in Education

INTRODUCTION

Uncontrolled bleeding is a leading cause of preventable death. The "Stop the Bleed" (StB) program trains laypersons in hemorrhage control. This study evaluated the efficacy of video-based StB training.

METHODS

Participants watched two different videos: a didactic video (DdV) and a technical video (TeV) demonstrating proper techniques for StB skills (i.e., direct pressure [DP], wound packing [WP], and tourniquet application [TA]). Then, they completed a standardized skills examination (SE). Participants were surveyed at three different time points (baseline, post-DdV, and post-SE) for comparison. We compared paired categorical and continuous variables with the McNemar-Bowker test and Wilcoxon signed-rank test, respectively. Alpha was set at 0.05.

RESULTS

One hundred six participants were enrolled: 52% were female and the median age was 23 y (22, 24). At baseline, 29%, 8%, and 13% reported being somewhat or extremely confident with DP, WP, and TA, respectively. These percentages increased to 92%, 79%, and 76%, respectively, after the DdV (all, P < 0.0001). After the TeV and SE, percentages increased further to 100%, 96%, and 100% (all, P < 0.0001). During the SE, 96%, 99%, and 89% of participants were able to perform DP, WP, and TA without prompting. Among participants, 98% agreed that the video course was effective and 79% agreed that the DdV and TeV were engaging.

CONCLUSIONS

We describe a novel paradigm of video-based StB learning combined with an in-person, standardized SE. Confidence scores in performing the three crucial StB tasks increased significantly during and after course completion. Through remote learning, StB could be disseminated more widely.

Evaluation of Stop the Bleed Training Among High School Personnel: A Qualitative Study

BACKGROUND

Uncontrolled hemorrhage is the primary preventable cause of death following trauma. Stop the Bleed training exists to promote identification and basic treatment of life-threatening bleeding in the prehospital or community setting. Limited qualitative research is available on participant evaluation of hemorrhage control training for laypersons.

OBJECTIVE

To evaluate the experience and satisfaction with Stop the Bleed training among lay community members in an urban public school setting.

METHODS

Three group interviews were conducted with public high school personnel (faculty and staff) who received Stop the Bleed training. Personnel were asked to evaluate the training and provide suggestions for improvement. Responses were digitally recorded and transcribed verbatim. Content analysis for common themes was performed using NVivo.

RESULTS

A total of eight participants were interviewed. Participants expressed satisfaction with hands-on training and dissatisfaction with crowded and rushed training conditions. Major themes included: (1) skill acquisition, retention, and decay, (2) training format and setting, and (3) use of simulation.

CONCLUSIONS

Current Stop the Bleed training is considered satisfactory among public school educators. Suggestions for improvement include annual retraining programs and simulation-enhanced training opportunities.

Student Perspectives on Implementing Stop the Bleed Training into Medical School Curriculum

BACKGROUND

Following the Hartford Consensus guidelines and recommendations, third-year medical students from a single institution were offered an optional Stop the Bleed (STB) training course in August 2018. The aim of this study was to assess medical students' confidence in performing bleeding control techniques and teaching others after completing the STB course. The secondary goal was to assess student perception on integrating mandatory STB training into the medical school curriculum.

MATERIALS AND METHODS

A 24-question survey using a 4-point Likert scale was administered to all medical students who completed STB training. Students were anonymously asked to self-report their confidence in performing bleeding control techniques, training others after STB training, and their perception on integrating STB training into medical school curriculum.

RESULTS

After completing the STB course, 95% of students were comfortable applying a tourniquet, 92% of students were confident in packing wounds, and 99% of students could apply direct pressure to wounds to stop bleeding. Overall, 94% of students reported that STB training would be helpful for their clinical rotations.

CONCLUSION

These results demonstrate that medical students are positively impacted by Stop the Bleed courses and validate that the implementation of mandatory STB courses into medical school curriculum will improve medical students' knowledge and skills for hemorrhage control.

Protect Our Kids: a novel program bringing hemorrhage control to schools

Background

Following the shooting at Sandy Hook Elementary School, the Hartford Consensus produced the Stop the Bleed program to train bystanders in hemorrhage control. In our region, the police bureau delivers critical incident training to public schools, offering instruction in responding to violent or dangerous situations. Until now, widespread training in hemorrhage control has been lacking. Our group developed, implemented and evaluated a novel program integrating hemorrhage control into critical incident training for school staff in order to blunt the impact of mass casualty events on children.

Methods

The staff of 25 elementary and middle schools attended a 90-minute course incorporating Stop the Bleed into the critical incident training curriculum, delivered on-site by police officers, nurses and doctors over a three-day period. The joint program was named Protect Our Kids. At the conclusion of the course, hemorrhage control kits and educational materials were provided and a four-question survey to assess the quality of training using a ten-point Likert scale was completed by participants and trainers.

Results

One thousand eighteen educators underwent training. A majority were teachers (78.2%), followed by para-educators (5.8%), counselors (4.4%) and principals (2%). Widely covered by local and state media, the Protect Our Kids program was rated as excellent and effective by a majority of trainees and all trainers rated the program as excellent.

Conclusions

Through collaboration between trauma centers, police and school systems, a large-scale training program for hemorrhage control and critical incident response can be effectively delivered to schools.

Increasing the Effectiveness of "Stop the Bleed" Training Through Stepwise Mastery Learning with Deliberate Practice

OBJECTIVE

The Stop the Bleed (STB) Campaign supported by the American College of Surgeons Committee on Trauma (ACSCT) and numerous other national organizations aspires to translate lifesaving military successes into reductions in civilian hemorrhagic deaths. While a curricular framework has been described, precise approaches to hands-on training are not specified and training success rates are not yet optimized. Our aim was to test the feasibility and effectiveness of an STB program enhanced by stepwise mastery learning with deliberate practice.

STUDY DESIGN

Learners participated in an STB program combining evidence-based training models: the Peyton 4-stage model and simulation-based mastery learning with deliberate practice. ASCTC-certified STB coaches used a 3-point, behaviorally explicit checklist to test 4 skills: apply direct pressure; apply standard and improvised tourniquets; pack a wound. An anonymous questionnaire was administered.

SETTING

Simulation Center, Emory University School of Medicine.

PARTICIPANTS

College students (N = 30) with no previous trauma training.

RESULTS

100% of participants reached mastery level for all 4 hemorrhage control skills within 4 tries. Additionally, 87% could state a definitive sign of life-threatening bleeding. 76% predicted comfort using a tourniquet in a real-life emergency; among 6 who would be very uncomfortable, 5 nonetheless would definitely recommend the course.

CONCLUSIONS

We demonstrate feasibility and increased effectiveness of an STB course using evidence-based procedural training techniques. Adopting these techniques in current STB programs could close the current trainee performance gap and substantially increase the annual number of successfully trained laypersons over current reported levels with no increase required in enrollees, programs, or resources. Future studies should address the challenges of knowledge retention and skill decay, just-in-time innovations, implementation science methods to broaden access, and barriers to responding to real-life crisis events. Surgery education leaders can close performance gaps and make a unique contribution to the Hartford Consensus principle: No one should die from uncontrolled bleeding.

Stop the Bleed: Effective Training in Need of Improvement

BACKGROUND

The "Stop the Bleed" (StB) campaign aims to educate laypersons on performing bleeding control techniques in any setting that requires hemorrhage control, such as motor vehicle crashes or mass casualty incidents. Participants undergo a didactic and practical session, the latter incorporating a mannequin. We hypothesized that participants would increase content knowledge after StB participation and that the training could be improved by a more life-like bleeding modification of the mannequin.

MATERIALS AND METHODS

From July 2017 to January 2018, hospital and community members from a major metropolitan area participated in StB training. Participants provided demographic data regarding prior emergency training and were asked pre- and post-test questions (five-point Likert scale) regarding their response to hemorrhage. Individuals also evaluated the mannequin on bleeding simulation. Scores were reported as means with standard deviation or medians with interquartile ranges (IQRs) with subset analysis stratified by experience.

RESULTS

Of 402 participants, 310 provided complete data. On the composite, pre-test self-assessment, participants had a median score of 24 of 30 points (IQR 16-30). Post-testing demonstrated a statistically significant increase with a median score of 29 (IQR 25-30, P < 0.05). Subset analysis by prior emergency training (n = 102) demonstrated that both those with prior emergency training and those with no prior emergency training had significant improvement. On evaluation of the mannequin, participants reported that a more realistic model would increase their confidence in technique. Both subgroups reported that training would be enhanced if the mannequins were more realistic.

CONCLUSIONS

StB is an effective education program. Those without prior experience or training in hemorrhage cessation demonstrated the most improvement. Regardless of background, participants reported overwhelmingly that the training would be more effective if it were more realistic. Future work to design and develop cost-effective mannequins demonstrating pulsatile blood flow and cessation of hemorrhage could enable learners to actually "Stop the Bleed".

Defining a Research Agenda for Layperson Prehospital Hemorrhage Control: A Consensus Statement

IMPORTANCE

Trauma is the leading cause of death for US individuals younger than 45 years, and uncontrolled hemorrhage is a major cause of trauma mortality. The US military's medical advancements in the field of prehospital hemorrhage control have reduced battlefield mortality by 44%. However, despite support from many national health care organizations, no integrated approach to research has been made regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector.

OBJECTIVE

To create a national research agenda to help guide future work for prehospital hemorrhage control by laypersons.

EVIDENCE REVIEW

The 2-day, in-person, National Stop the Bleed (STB) Research Consensus Conference was conducted on February 27 to 28, 2019, to identify and achieve consensus on research gaps. Participants included (1) subject matter experts, (2) professional society-designated leaders, (3) representatives from the federal government, and (4) representatives from private foundations. Before the conference, participants were provided a scoping review on layperson prehospital hemorrhage control. A 3-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items, with median rating of 8 or more on a Likert scale of 1 to 9 points, were identified and became part of the national STB research agenda.

FINDINGS

Forty-five participants attended the conference. In round 1, participants submitted 487 research questions. After deduplication and sorting, 162 questions remained across 5 a priori-defined themes. Two subsequent rounds of rating generated consensus on 113 high-priority, 27 uncertain-priority, and 22 low-priority questions. The final prioritized research agenda included the top 24 questions, including 8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy.

CONCLUSIONS AND RELEVANCE

The National STB Research Consensus Conference identified and prioritized a national research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage. Investigators and funding agencies can use this agenda to guide their future work and funding priorities.

Educating the Public on Hemorrhage Control: Methods and Challenges of a Public Health Initiative

Purpose of Review

We aim to determine the various models of training and identify educational strategies that would be efficacious in teaching bleeding control to the public.

Recent Findings

Recent studies have examined various educational strategies of bleeding control education including lectures, web-based classes, and hands-on training. The effectiveness of these trainings can not only be measured in increases in knowledge, but also in feelings of confidence, preparedness, and willingness to assist in a bleeding emergency. When looking at retention or skills and knowledge, we found that multiple studies showed decreases in ability to stop life-threatening bleeding when retested weeks or months after training. These issues of retention and a lack of education in general lead to a discussion about the possible benefits of having just-in-time (JiT) information during a bleeding emergency.

Summary

Based on the recent findings, bleeding control trainings have proven to be a very effective method of providing the general public with necessary skills. Therefore, moving forward, it is crucial to look at retention and the use of JiT information in longitudinal studies.