Early control of life-threatening bleeding has long been a focus of trauma medicine. Although commonly studied in the context of the military, the prevalence of mass casualties and gun violence in the United States have highlighted the importance of using current intervention strategies for the general population. From 2016 to 2017, the Federal Bureau of Investigation reported 50 active shooter incidents, 20 of which met the criteria for mass shootings resulting in 943 casualties. This increased from 231 casualties across 40 incidents in 2014 to 2015 and includes two of the deadliest mass shootings in U.S. history: the Harvest Festival shooting in Las Vegas, Nevada, and the Pulse Night Club shooting in Orlando, Florida. In the context of school shootings, of the 50 active shooter incidents in 2016 to 2017, seven were on school grounds (U.S. Department of Justice & Federal Bureau of Investigation, 2018). With no current solution for eliminating incidents of this nature, emphasis on educating responders about appropriate intervention for life-threatening bleeding has become a topic for discussion with policy makers, law enforcement, and health care providers.
In an attempt to improve intervention, the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events was established by the American College of Surgeons. Since 2013, the committee has published a series of reports collectively known as the Hartford Consensus. Of these reports, The Hartford Consensus III: Implementation of Bleeding Control describes the need for creating resources, equipment, and education programs for mass-casualty responders. The committee believes that developments in each of these areas can lower mortality associated with external hemorrhage and empower those at the site of injury to respond confidently and effectively (Jacob, 2015).
One bleeding-control program growing in popularity and currently supported by the Hartford Consensus and American College of Surgeons is “Stop the Bleed” (STB). The goal of STB is to teach responders how to identify and stop external hemorrhaging. In addition, STB trains responders when and how to use two important life-saving technologies—commercial grade tourniquets and hemostatic dressings—in the event of a traumatic injury (Pons & Jacobs, 2017). When used correctly, tourniquet application and wound packing have proven effective for controlling hemorrhage in civilian populations with minimal contribution to morbidity (Leonard et al., 2016).
Although limited, the literature regarding STB's potential efficacy is promising. Ross, Redman, et al. (2018) performed a study to determine layperson willingness and confidence in using tourniquets. Participants (n = 218) completed a preseminar questionnaire related to their comfort levels, knowledge, and attitudes about tourniquets. Following the completion of a training that involved recognizing signs of life-threatening hemorrhage and hands-on wound packing and tourniquet training, participants reported an increased willingness and comfort with tourniquet application. The researchers also noted statistically significant increases in general tourniquet knowledge and tourniquet placement knowledge from pre- to postseminar. Further, the misbelief about tourniquets being unsafe was almost completely eliminated (Ross, Redman, et al., 2018).
With respect to hands-on skills prior to any training, the successful use of commercial grade tourniquets in laypersons has been reported to be as low as 16.9% and 20.4% (Goolsby, Branting, Chen, Mack, & Olsen, 2015; Ross, Mapp, et al., 2018). In one study, Ross, Mapp, et al. (2018) gave participants without medical training (n = 218) a questionnaire to determine their willingness to use a tourniquet in response to a life-threatening bleeding event before and after formal training. Prior to training, only 62.4% of individuals stated they would use a tourniquet in real life, compared with 95.6% following the hands-on training. Further, comfort with using a tourniquet in real life increased from a mean rating of 2.5 on a 5-point Likert scale prior to training to a rating of 4.0 following hands-on training. This study demonstrated that both willingness to use a tourniquet and confidence in one's ability to correctly apply a tourniquet increased significantly following an STB education seminar.
Even though successful tourniquet use has not been assessed following STB, Goolsby et al. (2015) provided some insight that a minor increase in knowledge can improve application technique by demonstrating that a simple instructional card can double successful application while using a common commercial grade tourniquet, the Combat Application Tourniquet (CAT; Goolsby et al., 2015). In their study, the researchers randomized participants (n = 200) in a 3:1 ratio to either receive a 4 × 6 inch just-in-time instruction card group or to the no-instruction card control group. This study demonstrated that simply having a just-in-time instruction card for reference to apply a tourniquet led to statistically significantly higher rates of successful application and the amount of time required to successfully apply a tourniquet. The most common reason for failure in both groups was the tourniquet being applied too loosely. Consistent with Ross, Redman, et al. (2018), comfort with using a tourniquet improved significantly for laypersons after participating in the study.
Following a thorough review of the literature, it appeared to the authors that school nurses, important responders to life-threatening bleeding in educational environments such as active-shooter incidents, were a group that has not been assessed following STB training. In addition, there are many other bleeding emergencies that they may be required to handle including, but are not limited to, car accidents, fights that may involve a weapon, and any unexpected injuries. The concept of nursing competency was used to guide the study. Competency is a common structure used to enhance nursing practice and ensure quality of care and, most importantly, patient safety (Fukada, 2018). The following study was designed to assess the efficacy of a lecture-style STB seminar on improving school nurses' knowledge related to bleeding control basics, competence in packing a wound and applying a tourniquet, self-confidence, and belief in school preparedness.
A pretest–posttest cross-sectional design was chosen to evaluate the efficacy of the STB seminar to determine the impact of the educational workshop. Mean scores on responses from the pretest were compared to mean scores on responses from the posttest to determine if there were statistically significant differences in nurse knowledge, hands-on skill for wound packing and tourniquet application, self-confidence, and belief in school preparedness for responding to a life-threatening bleeding emergency.
Participants and Setting
Seventeen school nurses present during the STB seminar participated in the study. The only exclusionary criterion was prior participation in the STB seminar, which was determined at the start of the seminar prior to assessment administration. One nurse's assessment was excluded from analysis because the STB course was previously completed prior to the seminar. This nurse's data from the pre- and postassessments were not included in analyses because they were exposed to the content at a previous training, which could have affected baseline knowledge, self-confidence, and perceptions of school preparedness. All participants were employed by the same school district in the northeast region of the United States and worked at schools ranging from kindergarten to grade 12, serving approximately 4,000 students within the district in total. The study was held in a classroom as a form of in-service education within the school district and lasted approximately 1.5 hours. Participation in the STB seminar was mandatory, but participation in the seminar evaluation was not mandatory although all nurses opted to partake. Data from 16 of the 17 school district nurses present during the STB seminar were included in analyses.
Variables and Instruments
Institutional review board (IRB) approval was obtained from the performing institution's local IRB. The IRB determined that this project was not deemed human subjects research but rather an evaluation of a program's efficacy; therefore, informed consent was not required. Demographic or personally identifying information was not collected. The purpose of the current study was to evaluate the influence of the STB seminar on nurse knowledge, hands-on skill for tourniquet application and wound packing, self-confidence, and belief in school preparedness for responding to a life-threatening bleeding emergency.
The preassessment consisted of three separate evaluations. A preassessment and duplicate postassessment consisting of eight questions (three true-or-false, two rank order, one check all that apply, and two multiple choice) were developed in collaboration by two freestanding level I trauma centers in the northeast region of the United States based on the goals outlined in the STB seminar. The goal of the assessment was to measure the following four concepts: basic knowledge about how to appropriately intervene and control life-threatening bleeding, identification of life-threatening bleeding characteristics, level of self-confidence (e.g., “I am confident in my ability to respond to a life threatening bleeding emergency.”), and perceptions of school preparedness for responding to a bleeding emergency (e.g., “I think my school is prepared to handle a life threatening bleeding emergency.”). To protect the identity of each participant, the nurses were asked to come up with a unique five-digit identifier that was used to link their pre- and postassessments, as no identifiable information was recorded. Knowledge-based evaluation questions regarding basic knowledge about how to appropriately intervene and control life-threatening bleeding were scored on a binary scale for correct or incorrect responses. School preparedness and self-confidence for responding to a life-threatening emergency were graded on a 5-point Likert scale, with 5 being the highest level of preparedness and confidence. Content validity of the test questions were assessed by both trauma program medical directors and two master's-prepared college educators.
Hands-on skills were scored against checklists created by the level I trauma centers outlining standard STB protocol for tourniquet application and wound packing (Table 1). All evaluations were scored by member of the study team, comprising trained STB instructors with health care experience, on a binary scale for completion or omission of checkpoints outlined by the STB protocol and Save a Life booklet (Pons & Jacobs, 2017). Psychomotor aspects of the checklists were assessed by both trauma program medical directors, two master's-prepared college educators, and the trauma educator/outreach coordinator for content validity and feasibility.
Preassessment and Postassessment Checklists to Evaluate Hands-On Wound Packing and Tourniquet Application Skills
An instructional seminar was given by a STB-trained RN and followed a lecture-style format. Basic principles, such as establishing the safety of the immediate responder, the importance of early activation of the 9-1-1 systems and EMS response to the incident location, and a review of the ABC's of bleeding control, were discussed during the seminar. Further, information about how to identify life-threatening bleeding was reviewed through descriptors and visual aids. Following the lecture, participants were divided into smaller groups with members of the study team for live demonstrations of tourniquet application and wound packing directly followed by hands-on guided practice.
Data Collection and Procedure
The study team, comprising a trauma educator/out-reach coordinator, a trauma program manager, a trauma research coordinator, and two medical students, introduced the assessments as part of an evaluation to determine the efficacy of the STB program. During that time, the following tasks were completed respectively: preassessment, instructional seminar with live demonstration, hands-on practice, postassessment, and open discussion for ways to improve school preparedness.
The preassessment consisted of a knowledge-based evaluation, tourniquet application, and wound packing. First, to evaluate baseline knowledge about best practices for bleeding control, self-confidence, and belief in school preparedness, each participant took a written quiz about life-threatening bleeding prior to the educational workshop. Second, participants were given a CAT to perform self-application for a hypothetical injury to the upper extremity to determine the baseline hands-on skill for tourniquet application. Third, participants were asked to demonstrate wound packing on a manikin using gauze to determine the baseline hands-on skill for wound packing. After participants completed the three components of the preassessment, a member of the study team proceeded with the STB lecture. The seminar concluded with live demonstrations of tourniquet application and wound packing before participants divided into groups for hands-on practice. Each group consisted of two to four nurses per instructor and instructors answered questions and provided assistance during the hands-on training. The seminar and supervised practice lasted approximately 50 minutes, with the remaining time dedicated to an open forum for discussion. The study concluded with knowledge-based and hands-on skill postassessments identical to the preassessments.
The pre- and postassessments were scored, averaged, and compared. Descriptive statistics, such as mean and standard deviation, were calculated. Wilcoxon signed rank and paired samples t tests were used to compare preand postassessment for means with unequal and equal variance, respectively, to determine if there was a statistically significant increase in nurse knowledge, hands-on skill for wound packing and tourniquet application, self-confidence, and belief in school preparedness for responding to a life-threatening bleeding emergency from pre- to postassessment.
Bleeding Control Knowledge
Demographic or personally identifying information was not collected from participants. All participants' scores improved following training compared to pretraining measures related to knowledge, hands-on skill for tourniquet application and wound packing, self-confidence, and belief in school preparedness for responding to a life-threatening bleeding emergency. Increases in knowledge were statistically significant from pre- to postassessment (p ≤ .05; Table 2). All nurses received a perfect score on the postassessment evaluation of their basic knowledge about how to appropriately intervene and control life-threatening bleeding. Increases in identification of characteristics of life-threatening bleeding were statistically significant from pre- to postassessment (p ≤ .05; Table 2). Following the STB training, all nurses were able to identify each characteristic of life-threatening bleeding, which should in turn result in informing taking subsequent action to stop life-threatening bleeding.
Comparison of Pretraining and Posttraining Measures
Tourniquet Application and Wound Packing
Hands-on skills competency also increased to a statistically significant level following training (p ≤ .05; Table 2). Only two of the 16 nurses performed all wound-packing actions correctly prior to training, but following the training 14 of the 16 nurses received a perfect score on the wound-packing assessment. The two fallouts were attributed to not applying steady pressure while packing the wound. In terms of tourniquet application, only one nurse performed all of the tourniquet application actions correctly prior to training but following the assessment eight of the 16 nurses scored perfectly on the tourniquet application assessment. The most common fallout on the posttest (n = 4) was failure to note the time that the tourniquet was applied.
Self-Confidence and School Preparedness
In addition to increases in knowledge and hands-on skills, results demonstrated statistically significant increases in both self-confidence and nurses' perceptions of school preparedness following the STB training (p ≤ .05; Table 2). Prior to the training, most nurses felt relatively neutral about their ability to respond to a life-threatening bleeding emergency (M = 3.31), but following the training all but one nurse agreed or strongly agreed that they that they were confident in their ability to respond to a life-threatening bleeding emergency.
The unfortunate frequency of school shootings highlights the need for school nurses to possess the ability to control life-threatening bleeding. This study aimed to evaluate the effectiveness of a STB training seminar on improving knowledge and hands-on skills for such emergencies through pre- and posttraining assessments. The study also examined changes in self-confidence and belief in school preparedness before and after the training.
Results from the current study demonstrate that individuals scored significantly higher on knowledge-based questions regarding STB concepts and protocol following the seminar. Specifically, knowledge improved relating to basic hemorrhage control knowledge and identification of signs of life-threatening bleeding, which should also inform appropriate interventions in the event one encounters a life-threatening bleeding event. The success of training seminars for improving emergency preparedness and response knowledge has been shown across several studies. For example, knowledge regarding emergency preparedness among school nurses increased for those that participated in online education modules compared with those who did not receive the intervention (Elgie, Sapien, Fullerton, & Moore, 2010). Similarly, Merchant et al. (2015) reported that hospital personnel showed improved knowledge about trauma intervention and basic resuscitation following an education seminar that included hands-on training (Merchant et al., 2015). Although these studies did not directly assess bleeding control, together they indicate that education and hands-on training can increase relevant knowledge.
With respect to hands-on skills, and consistent with the literature, significantly higher scores were reported for both tourniquet application and wound packing following the seminar. Although intuitive, simply providing prior knowledge about correct protocol likely increased success rates. The impact of protocol knowledge was demonstrated in a study where an instructional card doubled the rate of tourniquet success (Goolsby et al., 2015). Furthermore, increased tourniquet application success was seen following a 15-minute learning session that was held 4 to 8 weeks prior to assessment (Goolsby et al., 2018). Although prior instruction and knowledge will not always translate to increased skills across all emergency interventions, STB protocol simplicity may allow for easy internalization and application of the relevant skills.
Second, increased application success may be due to STB seminar content covering previously identified application mistakes. Ross, Mapp, et al. (2018), stated in their study assessing tourniquet application for three commercial grade tourniquets, that participants most commonly failed to apply the tourniquet with adequate tightness, placement, and/or positioning. Correct tightness, positioning, placement, and use of the windlass knob were all described and demonstrated in this study during the seminar. Further, our study addresses improvements related to wound packing following the seminar, which has not been previously addressed in the literature but remains a vital component of the STB seminar.
Additionally, prior research with layperson participants has reported that the most common mistakes made using the CAT-style tourniquet was failing to use windlass knob properly (Ross, Mapp, et al., 2018) and applying the tourniquet too loosely (Goolsby et al., 2015). Interestingly, although hands-on skills significantly increased following training, it was observed that the most common tourniquet application mistakes for both pre- and postassessment were securing the tail of the tourniquet through the clips and noting the application time. Placing the tail of the tourniquet through the clip limits the tail's interference during application and aids in securing the windlass knob within the clip. Noting the time informs downstream trauma personnel how long blood flow has been blocked. For wound packing, participants most commonly failed to apply direct, steady pressure while packing the wound. Early and consistent pressure is important to limit bleeding. Because these steps are crucial in the process of bleeding control, future STB seminar sessions should put greater emphasis on these actions. The relationship between increased application success and continued training has been previously demonstrated when comparing single and multiple training seminars, therefore the use of follow-up seminars may achieve the same result (Baruch et al., 2016).
Finally, STB training lead to significantly higher levels of self-confidence and perceptions of school preparedness for responding to a life-threatening bleeding event. An increased level of self-confidence is consistent with the finding by Ross, Redman, et al. (2018) that showed higher levels self-confidence in laypersons following STB training. The increased belief in school preparedness may be attributed to the school's decision to train their nursing staff.
To further expand the potential role of STB training in educational environments for saving lives, future studies should attempt to address limitations of the current study. First, despite the positive change in school preparedness, many nurses felt that more actions could be taken. Common suggestions included addressing a lack of equipment, training additional faculty, and developing a school-wide protocol for intervention. These concerns were especially noteworthy when considered in the scope of a lock down event for active shooters. In this situation, school nurses would have limited contact with potential victims, requiring other faculty to have access to equipment and knowledge of appropriate intervention. Second, although the protocol checklist was detailed and left little room for interpretation, instructors were not blind to the hypothesis. Finally, because this was a preliminary study evaluating the influence of the training, the current study did not control for demographics or level of nursing education or experience, which should be considered in future studies. In addition to addressing the study's limitations, future studies can measure the degree of knowledge atrophy in STB training over time through follow-up assessments. If skill and knowledge atrophy is observed, certification and recertification programs for STB may be necessary, similar to those used for cardiopulmonary resuscitation.
Given that uncontrolled bleeding is the number one cause of preventable death from trauma, STB training should be endorsed because of its ability to increase knowledge, hands-on skills, and self-confidence in school nurses. Endorsement should occur at the level of policy makers, health care providers, and educators to ensure that as many schools as possible understand the importance of being prepared for such emergencies and participate in STB, or similar, training programs. In the event of life-threatening bleeding in the educational setting, being adequately informed and trained may be the difference in saving lives.
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- Goolsby, C.A., Strauss-Riggs, K., Klimczak, V., Gulley, K., Rojas, L., Godar, C. & Kirsch, T.D. (2018). Brief, web-based education improves lay rescuer application of a tourniquet to control life-threatening bleeding. AEM Education and Training, 2, 154–161. doi:10.1002/aet2.10093 [CrossRef]30051082
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Preassessment and Postassessment Checklists to Evaluate Hands-On Wound Packing and Tourniquet Application Skillsa
|Wound-packing psychomotor assessment|
| Pack (stuff) the wound with bleeding control gauze (preferred), plain gauze, or clean cloth.|
| Apply steady pressure while packing the bleeding wound with both hands directly.|
| Continue to hold pressure after packing complete.|
|Tourniquet application psychomotor assessment|
| Wrap the tourniquet around the bleeding arm or leg.|
| Ensure tourniquet is about 2 to 3 inches above the bleeding site.|
| Pull the free end of the tourniquet to make it as tight as possible and secure the free end.|
| Twist or wind the windlass until bleeding stops.|
| Secure the windlass to keep the tourniquet tight.|
| Secure the tail of the tourniquet through the clips.|
| Put the time strap over the secured tail.|
| Note the time the tourniquet was applied.|
Comparison of Pretraining and Posttraining Measures
|Measure||Maximum Score||Pretest M (SD)||Posttest M (SD)|
|Knowledge assessment||6||3.69 (1.14)||5.81 (0.54)*|
|Life-threatening bleeding||7||5.38 (1.75)||7.00 (0.00)**|
|Hands-on wound packing||3||1.25 (1.06)||2.88 (0.34)*|
|Hands-on tourniquet application||8||4.00 (1.59)||7.25 (0.93)*|
|Self-confidence||5||3.31 (0.70)||4.50 (0.63)**|
|School preparedness||5||2.88 (0.81)||3.31 (1.26)**|