TCCC Skills, Training and Education

#### TCCC SKILLS, TRAINING & EDUCATION

JAMA Surg. 2018 Sep 1;153(9):791-799

# Effectiveness of instructional interventions for hemorrhage control readiness for laypersons in the public access and tourniquet training study (PATTS): a randomized clinical trial.

Goralnick E, Chaudhary M, McCarty J, Caterson E, Goldberg S, Herrera-Escobar J, McDonald M, Lipsitz S, Haider A

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.

J Trauma Acute Care Surg. 2018 Jul 17. doi: 10.1097/TA.0000000000002027. [Epub ahead of print]

# Desin and implementation of the western Pennsylvania regional Stop the Bleed initiative.

Neal M, Reynolds B, Bertoty D, Murray K, Peitzman A, Forsythe R

BACKGROUND: Hemorrhage is the leading cause of preventable death in trauma, and nearly 40% of prehospital deaths can be attributable to blood loss. The Stop The Bleed program provides a structured curriculum for teaching hemorrhage control and the use of bleeding control kits. In order to overcome implementation barriers and to achieve the goal of making education on bleeding control as common as cardiopulmonary resuscitation, widespread implementation with outreach to the public and law enforcement is necessary.

METHODS: We provide a description and analysis of the implementation of a regional Stop The Bleed program which includes a step-by-step guide to the design of this program provided as a template to guide attempts at largescale Stop The Bleed program development.

RESULTS: Combining the efforts of regional trauma and non-trauma centers as a hub-and-spoke design, a region covering four states, 72 counties, and 30,000 square miles was targeted. 27,291 individuals were trained in a 21 month period including 3,172 trainers, 19,310 lay public, and 4,809 law enforcement officers. A total of 436 bleeding control kits were distributed to 102 public schools, and tourniquets were provided to 4,809 law enforcement officers. Program development and community outreach resulted in official recognition of the program by the Pennsylvania State Senate.

CONCLUSIONS: Utilizing a multi-center outreach program design with emphasis on law enforcement and public education while developing a train-the-trainer program, widespread and rapid dissemination of Stop The Bleed teaching is feasible. The general steps described in this manuscript may serve as a template for new or developing programs in other areas to increase the national exposure to Stop The Bleed.

LEVEL OF EVIDENCE: IV STUDY TYPE: economic/decision.

J Emerg Med. 2018 Sep;55(3):383-389

# A novel expeditionary perfused cadaver model for trauma training in the out-of-hospital setting.

Redman T, Ross E

BACKGROUND: Cadaver training for prehospital surgical procedures is a valid training model. The limitation to date has been that perfused cadavers have only been used in wet laboratories in hospitals or university centers. We endeavor to describe a transportable central-perfused cadaver model suitable for training in the battlefield environment. Goals of design were to create a simple, easily reproducible, and realistic model to simulate procedures in field and austere conditions.

METHODS: We conducted a review of the published literature on cadaver models, conducted virtual-reality simulator training, performed interviews with subject matter experts, and visited the laboratories at the Centre for Emergency Health Sciences in Spring Branch, TX, the Basic Endovascular Skills in Trauma laboratory in Baltimore, MD, and the Fresh Tissue Dissection Laboratory at Los Angeles County and University of Southern California, Keck School of Medicine, Los Angeles, CA.

PROCEDURE: This article will describe a five-step procedure that utilizes extremity tourniquets, right common carotid intra-arterial and distal femur intraosseous (IO) access for perfusion, and oropharynx preparation for airway procedures. The model will then be ready for all tactical combat casualty care procedures, including nasopharyngeal airway, endotracheal intubation, cricothyroidotomy, central-line access, needle decompression, finger and tube thoracostomy, resuscitative endovascular balloon occlusion of the aorta, junctional tourniquets, IO lines, and field amputations.

CONCLUSIONS: This model has been used in the laboratory, field, ground ambulance, and military air ambulance (UH-60) settings with good results. The model described can be used in the field setting with minimal resources and accurately simulates the critical skills for all combat trauma procedures.

J Trauma Acute Care Surg. 2018 Jul;85(1S Suppl 2):S27-S32. Doi 10.1097/TA.0000000000001800.

# Assessment of prehospital hemorrhage and airway care using a simulation model.

Skube M, Witthuhn S, Mulier K, Boucher B, Lusczek E, Beilman G

BACKGROUND: The quality of prehospital care impacts patient outcomes. Military efforts have focused on training revision and the creation of high-fidelity simulation models to address potentially survivable injuries. We sought to investigate the applicability of models emphasizing hemorrhage control and airway management to a civilian population.

METHODS: Prehospital health care providers (PHPs) undergoing their annual training were enrolled. A trauma scenario was simulated with two modules: hemorrhage control and airway management. Experienced raters used a validated tool to assess performance. Pearson correlation, logistic regression, and χ tests were used for analysis.

RESULTS: Ninety-five PHPs participated with a mean experience of 15.9 ± 8.3 years, and 7.4% reported past military training. The PHPs' overall execution rate of the six hemorrhage control measures varied from 38.9% to 88.4%. The median blood loss was 1,700 mL (interquartile range, 1,043-2,000), and the mean global rater score was 25.0 ± 7.4 (scale, 5-40). There was a significant relationship between PHP profession and past military experience to their consideration of blood transfusion and tranexamic acid. An inverse relationship between blood loss and global rater score was found (r = -0.59, n = 88, p = 1.93 × 10). After simulated direct laryngoscope failure in the airway module, 58% of PHPs selected video laryngoscopy over placement of a supraglottic airway. Eighty-six percent of participants achieved bilateral chest rise in the manikin regardless of management method. Participants reported improved comfort with skills after simulation.

CONCLUSION: Our data reveal marginal performance in hemorrhage control regardless of the PHP's prior experience. The majority of PHPs were able to secure an advanced airway if direct laryngoscope was unavailable with a predisposition for video laryngoscopy over supraglottic airway. Our findings support the need for continued training for PHPs highlighting hemorrhage control maneuvers and increased familiarity with airway management options. Improved participant confidence posttraining gives credence to simulation training.

LEVEL OF EVIDENCE: Prognostic/epidemiological study, level III.

J Spec Oper Med. 2018 Fall;18(3):136-146.

# Tactical Combat Casualty Care for medical personnel (TCCC-MP): recommended post-course metrics (24 July 2018).