Effectiveness of Instructional Interventions for Hemorrhage Control Readiness for Laypersons in the Public Access and Tourniquet Training Study (PATTS)
Authors: Eric Goralnick, Muhammad A. Chaudhary, Justin C. McCarty, Edward J. Caterson, Scott A. Goldberg, Juan P. Herrera-Escobar, Meghan McDonald, Stuart Lipsitz, Adil H. Haider
Journal: JAMA Surgery (2018)

<h3>Importance</h3> 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. <h3>Objective</h3> 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. <h3>Design, Setting, and Participants</h3> 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. <h3>Interventions</h3> 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. <h3>Main Outcomes and Measures</h3> Correct tourniquet application in a simulated scenario. <h3>Results</h3> 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];<i>P</i> &lt; .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). <h3>Conclusions and Relevance</h3> 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. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT03479112