[Skip to Content]
Sign In
Individual Sign In
Create an Account
Institutional Sign In
OpenAthens Shibboleth
[Skip to Content Landing]
Figure 1.  Flowchart for the 3 Rounds of Modified Delphi Process
Flowchart for the 3 Rounds of Modified Delphi Process
Figure 2.  Attendees per Discipline
Attendees per Discipline
Table 1.  Thematic Definitions and Corresponding Index Cards
Thematic Definitions and Corresponding Index Cards
Table 2.  Top Research Priorities and Questions by Theme
Top Research Priorities and Questions by Theme
1.
Centers for Disease Control and Prevention; National Centers for Injury Prevention and Control. Web-based injury statistics query and reporting system (WISQARS). Updated March 30, 2020. Accessed January 20, 2019. https://www.cdc.gov/injury/wisqars/
2.
Howard  JT, Kotwal  RS, Stern  CA,  et al.  Use of combat casualty care data to assess the US military trauma system during the Afghanistan and Iraq conflicts, 2001-2017.   JAMA Surg. 2019;154(7):600-608. doi:10.1001/jamasurg.2019.0151 PubMedGoogle ScholarCrossref
3.
Berwick  DM, Downey  AS, Cornett  EA.  A national trauma care system to achieve zero preventable deaths after injury: recommendations from a national academies of sciences, engineering, and medicine report.   JAMA. 2016;316(9):927-928. doi:10.1001/jama.2016.8524 PubMedGoogle ScholarCrossref
4.
Jacobs  LM; Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events.  The Hartford Consensus IV: a call for increased national resilience.   Bull Am Coll Surg. 2016;101(3):17-24.PubMedGoogle Scholar
5.
Jacobs  LM  Jr.  Out of unspeakable tragedy comes progress in bleeding control.   Bull Am Coll Surg. 2017;102(6):11-16.PubMedGoogle Scholar
6.
Stop the Bleed. Home Page. Accessed November 6, 2019. https://www.stopthebleed.org/
7.
Standards for Quality Improvement Reporting Excellence. (SQUIRE 2.0). Updated February 1, 2017. Accessed March 5, 2020. https://www.equator-network.org/reporting-guidelines/squire/
8.
Fitch  K, Bernstein  SJ, Aguilar  MD, Burnand  B, LaCalle  JR.  The RAND/UCLA Appropriateness Method User’s Manual. RAND Corporation; 2001.
9.
Murphy  MK, Black  NA, Lamping  DL,  et al.  Consensus development methods, and their use in clinical guideline development.   Health Technol Assess. 1998;2(3):i-iv, 1-88. doi:10.3310/hta2030PubMedGoogle ScholarCrossref
10.
Ezeibe  C, McCarty  JC, Chaudhary  MA,  et al.  Haemorrhage control in the prehospital setting: a scoping review protocol.   BMJ Open. 2019;9(7):e029051. doi:10.1136/bmjopen-2019-029051 PubMedGoogle Scholar
11.
Mukherjee  N, Huge  J, Sutherland  WJ,  et al.  The Delphi technique in ecology and biological conservation: applications and guidelines.   Methods Ecol Evol. 2015;6(9):1097-1109. doi:10.1111/2041-210X.12387 Google ScholarCrossref
12.
Goolsby  C, Rouse  E, Rojas  L,  et al.  Post-mortem evaluation of potentially survivable hemorrhagic death in a civilian population.   J Am Coll Surg. 2018;227(5):502-506. doi:10.1016/j.jamcollsurg.2018.08.692 PubMedGoogle ScholarCrossref
13.
Teixeira  PGR, Brown  CVR, Emigh  B,  et al; Texas Tourniquet Study Group.  Civilian prehospital tourniquet use is associated with improved survival in patients with peripheral vascular injury.   J Am Coll Surg. 2018;226(5):769-776.e1. doi:10.1016/j.jamcollsurg.2018.01.047 PubMedGoogle ScholarCrossref
14.
Scerbo  MH, Holcomb  JB, Taub  E,  et al.  The trauma center is too late: major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock.   J Trauma Acute Care Surg. 2017;83(6):1165-1172. doi:10.1097/TA.0000000000001666 PubMedGoogle ScholarCrossref
15.
Smith  ER, Shapiro  G, Sarani  B.  Fatal wounding pattern and causes of potentially preventable death following the Pulse Night Club shooting event.   Prehosp Emerg Care. 2018;22(6):662-668. doi:10.1080/10903127.2018.1459980 PubMedGoogle ScholarCrossref
16.
Drake  SA, Holcomb  JB, Yang  Y,  et al.  Establishing a regional trauma preventable/potentially preventable death rate.   Ann Surg. 2020;271(2):375-382. doi:10.1097/SLA.0000000000002999PubMedGoogle ScholarCrossref
17.
Sabino  J, Mohan  R, Jessie  E,  et al.  Outcomes comparisons between civilian and military trauma patients undergoing limb salvage.   J Am Coll Surg. 2014;219(4):e140. doi:10.1016/j.jamcollsurg.2014.07.762 Google Scholar
18.
Kapur  GB, Hutson  HR, Davis  MA, Rice  PL.  The United States twenty-year experience with bombing incidents: implications for terrorism preparedness and medical response.   J Trauma. 2005;59(6):1436-1444. doi:10.1097/01.ta.0000197853.49084.3c PubMedGoogle ScholarCrossref
19.
Dwyer-Lindgren  L, Bertozzi-Villa  A, Stubbs  RW,  et al.  Trends and patterns of geographic variation in mortality from substance use disorders and intentional injuries among US counties, 1980-2014.   JAMA. 2018;319(10):1013-1023. doi:10.1001/jama.2018.0900 PubMedGoogle ScholarCrossref
20.
Groeneveld  PW, Owens  DK.  Cost-effectiveness of training unselected laypersons in cardiopulmonary resuscitation and defibrillation.   Am J Med. 2005;118(1):58-67. doi:10.1016/j.amjmed.2004.08.014 PubMedGoogle ScholarCrossref
21.
Groeneveld  PW, Kwong  JL, Liu  Y,  et al.  Cost-effectiveness of automated external defibrillators on airlines.   JAMA. 2001;286(12):1482-1489. doi:10.1001/jama.286.12.1482 PubMedGoogle ScholarCrossref
22.
Cram  P, Vijan  S, Fendrick  AM.  Cost-effectiveness of automated external defibrillator deployment in selected public locations.   J Gen Intern Med. 2003;18(9):745-754. doi:10.1046/j.1525-1497.2003.21139.x PubMedGoogle ScholarCrossref
23.
Winkle  RA.  The effectiveness and cost effectiveness of public-access defibrillation.   Clin Cardiol. 2010;33(7):396-399. doi:10.1002/clc.20790 PubMedGoogle ScholarCrossref
24.
Nichol  G, Huszti  E, Birnbaum  A,  et al; PAD Investigators.  Cost-effectiveness of lay responder defibrillation for out-of-hospital cardiac arrest.   Ann Emerg Med. 2009;54(2):226-235.e352. doi:10.1016/j.annemergmed.2009.01.021 PubMedGoogle ScholarCrossref
25.
Ross  EM, Mapp  JG, Redman  TT, Brown  DJ, Kharod  CU, Wampler  DA.  The tourniquet gap: a pilot study of the intuitive placement of three tourniquet types by laypersons.   J Emerg Med. 2018;54(3):307-314. doi:10.1016/j.jemermed.2017.09.011 PubMedGoogle ScholarCrossref
26.
McCarty  JC, Hashmi  ZG, Herrera-Escobar  JP,  et al.  Effectiveness of the American College of Surgeons bleeding control basic training among laypeople applying different tourniquet types: a randomized clinical trial.   JAMA Surg. 2019;154(10):923. doi:10.1001/jamasurg.2019.2275 PubMedGoogle ScholarCrossref
27.
Leonard  J, Zietlow  J, Morris  D,  et al.  A multi-institutional study of hemostatic gauze and tourniquets in rural civilian trauma.   J Trauma Acute Care Surg. 2016;81(3):441-444. doi:10.1097/TA.0000000000001115 PubMedGoogle ScholarCrossref
28.
Lee  C, Porter  KM, Hodgetts  TJ.  Tourniquet use in the civilian prehospital setting.   Emerg Med J. 2007;24(8):584-587. doi:10.1136/emj.2007.046359 PubMedGoogle ScholarCrossref
29.
Committee on Tactical Combat Casualty Care. TCCC Guidelines for Medical Personnel. Published September 5, 2019. Accessed November 19, 2019. https://www.deployedmedicine.com/market/11/content/475
30.
Goralnick  E, Chaudhary  MA, McCarty  JC,  et al.  Effectiveness of instructional interventions for hemorrhage control readiness for laypersons in the Public Access and Tourniquet Training Study (PATTS): a randomized clinical trial.   JAMA Surg. 2018;153(9):791-799. doi:10.1001/jamasurg.2018.1099 PubMedGoogle ScholarCrossref
31.
Goolsby  C, Branting  A, Chen  E, Mack  E, Olsen  C.  Just-in-Time to Save Lives: a pilot study of layperson tourniquet application.   Acad Emerg Med. 2015;22(9):1113-1117. doi:10.1111/acem.12742 PubMedGoogle ScholarCrossref
32.
Goolsby  C, Chen  E, Branting  A,  et al.  Analysis of layperson tourniquet application using a novel color-coded device.   Disaster Med Public Health Prep. 2016;10(2):274-280. doi:10.1017/dmp.2016.4 PubMedGoogle ScholarCrossref
33.
Goolsby  CA, Strauss-Riggs  K, Klimczak  V,  et al.  Brief, web-based education improves lay rescuer application of a tourniquet to control life-threatening bleeding.   AEM Educ Train. 2018;2(2):154-161. doi:10.1002/aet2.10093 PubMedGoogle ScholarCrossref
34.
Andrade  EG, Hayes  JM, Punch  LJ.  Enhancement of Bleeding Control 1.0 to reach communities at high risk for urban gun violence: acute bleeding control.   JAMA Surg. 2019;154(6):549-550. doi:10.1001/jamasurg.2019.0414 PubMedGoogle ScholarCrossref
35.
Schroll  R, Smith  A, Zeoli  T,  et al.  Efficacy of medical students as stop the bleed participants and instructors.   J Surg Educ. 2019;76(4):975-981. doi:10.1016/j.jsurg.2019.02.006 PubMedGoogle ScholarCrossref
36.
Evans  KM, Longshore  SW, Lake  B, Toschlog  EA, Pories  WJ, Walsh  DS.  Stop the bleed: an assessment of medical student knowledge of bleeding control techniques.   J Am Coll Surg. 2018;227(4):S230-S231. doi:10.1016/j.jamcollsurg.2018.07.504 Google ScholarCrossref
37.
Gallagher  KC, Evans  PT, Robinette  JP,  et al.  Hemorrhage control training for medical students: implementation of the American College of Surgeons’ Stop the Bleed training at Vanderbilt University School of Medicine.   J Am Coll Surg. 2018;227(4):e206. doi:10.1016/j.jamcollsurg.2018.08.557 Google Scholar
38.
Zwislewski  A, Nanassy  AD, Meyer  LK,  et al.  Practice makes perfect: the impact of Stop the Bleed training on hemorrhage control knowledge, wound packing, and tourniquet application in the workplace.   Injury. 2019;50(4):864-868. doi:10.1016/j.injury.2019.03.025 PubMedGoogle ScholarCrossref
39.
Levic  T, McAna  J, Kramer  N. 1, 2, 3, Stop the Bleed: Analysis of a Bleeding Control Educational Course. Published June 22, 2018. Accessed November 19, 2019. https://jdc.jefferson.edu/mphcapstone_presentation/259
40.
Chambers  JA, Seastedt  K, Krell  R, Caterson  E, Levy  M, Turner  N.  “Stop the Bleed”: a US military installation’s model for implementation of a rapid hemorrhage control program.   Mil Med. 2019;184(3-4):67-71. doi:10.1093/milmed/usy185 PubMedGoogle ScholarCrossref
41.
Saraç  L, Ok  A.  The effects of different instructional methods on students’ acquisition and retention of cardiopulmonary resuscitation skills.   Resuscitation. 2010;81(5):555-561. doi:10.1016/j.resuscitation.2009.08.030 PubMedGoogle ScholarCrossref
42.
Kauvar  DS, Lefering  R, Wade  CE.  Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations.   J Trauma. 2006;60(6 suppl):S3-S11. doi:10.1097/01.ta.0000199961.02677.19 PubMedGoogle ScholarCrossref
43.
Kauvar  DS, Wade  CE.  The epidemiology and modern management of traumatic hemorrhage: US and international perspectives.   Crit Care. 2005;9(suppl 5):S1-S9. doi:10.1186/cc3779 PubMedGoogle ScholarCrossref
44.
Peden  M, Scurfield  R, Sleet  D,  et al; World Health Organization. World report on road traffic injury prevention. Published February 9, 2004. Accessed November 18, 2019. https://www.who.int/violence_injury_prevention/publications/road_traffic/world_report/
45.
Delaney  PG, Bamuleke  R, Lee  YJ.  Lay first responder training in eastern Uganda: leveraging transportation infrastructure to build an effective prehospital emergency care training program.   World J Surg. 2018;42(8):2293-2302. doi:10.1007/s00268-018-4467-3 PubMedGoogle ScholarCrossref
46.
Tiska  MA, Adu-Ampofo  M, Boakye  G, Tuuli  L, Mock  CN.  A model of prehospital trauma training for lay persons devised in Africa.   Emerg Med J. 2004;21(2):237-239. doi:10.1136/emj.2002.002097 PubMedGoogle ScholarCrossref
47.
Galante  JM, Smith  CA, Sena  MJ, Scherer  LA, Tharratt  RS.  Identification of barriers to adaptation of battlefield technologies into civilian trauma in California.   Mil Med. 2013;178(11):1227-1230. doi:10.7205/MILMED-D-13-00127 PubMedGoogle ScholarCrossref
48.
Hawkins  G. Act relating to the placement of bleeding control kits in public schools and to required training of school personnel. Posted April 15, 2019. Accessed November 19, 2019. https://capitol.texas.gov/tlodocs/86R/billtext/html/HB00496I.htm
49.
ACS State Affairs Team. State Legislatures Consider Bleeding Control Legislation. American College of Surgeons News. Published March 2019. Accessed November 19, 2019. https://www.facs.org/advocacy/surgeonsvoice/news/031519-bc
50.
Frye  R, Barrett  B, Judy  C, Macer  K. House Bill 1063. Posted April 18, 2019. Accessed November 19, 2019. http://iga.in.gov/legislative/2019/bills/house/1063/#digest-heading
51.
American College of Surgeons Louisiana Chapter. 2019 LA-ACS Priority Legislation. 2019. Accessed November 19, 2019. https://laacs.org/2019-la-acs-priority-legislation/
52.
Neal  MD, Reynolds  BR, Bertoty  D, Murray  KJ, Peitzman  AB, Forsythe  RM.  Design and implementation of the Western Pennsylvania regional Stop the Bleed initiative.   J Trauma Acute Care Surg. 2018;85(4):684-690. doi:10.1097/TA.0000000000002027 PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Consensus Statement
    Emergency Medicine
    July 6, 2020

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

    Author Affiliations
    • 1Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
    • 2Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
    • 3Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
    • 4Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland
    • 5National Center for Disaster Medicine and Public Health, Rockville, Maryland
    • 6National Health Care Preparedness Program, Department of Health and Human Services, Washington, DC
    • 7Office of the Dean, Medical School, Aga Khan University, Karachi, Pakistan
    • 8Department of Surgery, Hartford Hospital, Hartford, Connecticut
    JAMA Netw Open. 2020;3(7):e209393. doi:10.1001/jamanetworkopen.2020.9393
    Key Points español 中文 (chinese)

    Question  What are the key areas and questions on which future research of prehospital hemorrhage control by laypersons should be focused?

    Findings  In this consensus statement, a cohort of 45 subject matter experts, professional society leaders, and funding agency representatives conducted a 3-round modified Delphi consensus process to identify and prioritize key research gaps in prehospital hemorrhage control by laypersons. Participants identified 113 high-priority questions in the themes of epidemiology and effectiveness, materials, education, global health, and health policy, with the top 24 questions constituting the prioritized national research agenda.

    Meaning  The National Stop the Bleed Research Consensus Conference identified and prioritized a research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage.

    Abstract

    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.

    Introduction

    Trauma is the second leading cause of death in the United States and the leading killer of people younger than 45 years.1 Uncontrolled hemorrhage is the second most common cause of trauma mortality.1,2 The US military’s combat experience and improvements in trauma care during the past 18 years have resulted in a 44% mortality reduction for combat trauma.2 Therefore, in its 2016 report, the National Academies of Sciences, Engineering, and Medicine recommended translating military health care experience to civilian care with an aim of zero preventable deaths.3 In parallel, the Hartford Consensus focused on training public safety professionals and bystanders on performing bleeding control and providing immediate response.4 In 2015 the White House launched the Stop the Bleed (STB) initiative to provide immediate responders with the tools and knowledge to stop life-threatening bleeding.5,6

    After the Hartford Consensus4 and the White House launch of STB, many key questions remain to advance this initiative. Despite support from many national health care organizations, to date, there has not been an integrated approach to research regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector. Funding has also been limited. In addition, notwithstanding the great strides in the battlefield, limited research on the effectiveness of military techniques within the civilian sector has been performed.

    In this context, the National STB Research Consensus Conference (a gathering of national and international subject matter experts, cosponsored by multiple national organizations and institutes) was convened. The aims of this conference were to identify critical gaps within current literature on prehospital hemorrhage control by laypersons, develop a consensus on research priorities, and create a national research agenda for future work on layperson prehospital hemorrhage control.

    Methods

    This study consisted of a 3-round modified in-person Delphi process and follows the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines.7 The modified Delphi approach is an iterative process of multiple rounds of voting to achieve consensus among experts in situations where evidence is scarce or expert opinion is important.8,9 The Partners institutional review board approved the study, and verbal consent was obtained from all participants. The consensus conference took place on February 27 to 28, 2019.

    Participants were selected by a planning committee and included subject matter experts, professional society representatives, government and private funding agency representatives, and a Delphi expert advisor (Box). Some subject matter experts from other public health fields were also invited to provide context from prior successful public health initiatives.

    Box Section Ref ID
    Box.

    Representation of Disciplines, Professional Societies, and Government Agenciesa

    Disciplines
    • Biomedicine

    • Emergency medicine

    • Engineering

    • General surgery

    • Health care policy/Delphi processes

    • Human factors studies

    • Implementation sciences

    • Industry

    • Military medicine

    • Ophthalmology

    • Plastics/reconstructive surgery

    • Psychiatry

    • Trauma and acute and critical care surgery

    Professional societies
    • American Academy of Family Medicine

    • American Academy of Optometry

    • American Academy of Pediatrics

    • American College of Emergency Physicians

    • American College of Physicians

    • American College of Surgeons

    • American Red Cross

    • National Association of EMS Physicians

    • Society of Academic Emergency Medicine

    Government agencies
    • Committee on Tactical Combat Casualty Care

    • National Institutes of Health

    • National Center for Disaster Medicine and Public Health

    • US Department of Defense: Joint Trauma System

    • US Department of Health and Human Services

    • US Department of Homeland Security

    • US Department of Transportation

    • Uniformed Services University of the Health Sciences

    Abbreviation: EMS, emergency medical services.

    a Attendees represent 1 or more of each of these categories.

    Before the conference, a scoping review on layperson prehospital hemorrhage control encompassing both peer-reviewed and non–peer-reviewed literature was conducted.10 The results of the review were categorized into 5 themes based on available literature and investigator discussion: (1) epidemiology and effectiveness, (2) materials, (3) education, (4) global health, and (5) health policy. The scoping review was distributed to participants before the conference, and each participant was assigned 2 of the 5 themes for rating. Assignments were based on participants’ stated preferences balanced against the need to have an even number of raters across themes.8 This process resulted in 16 participants per theme.

    All 3 rounds of the modified Delphi process were conducted during the 2-day conference (Figure 1). On the first day of the conference, participants were provided a folder that included an agenda and index cards color-coded for themes (Table 1). For each theme, there was a presentation by a research fellow (C.E., M.A.C., J.M., J.P.H.-E., T.A., E.de J., and D.O.-D.) providing the overview of current literature. A faculty discussant (C.G., R.H., J.S.W., L.J., S.K., and R.R.) followed with reflections on the summary and potential research gaps. This was followed by a facilitated open discussion among participants aimed at soliciting perspectives on research questions within that theme. Additional presentations included presentations on (1) the history of STB, (2) implementation science, (3) psychological perspective, and (4) public agency perspectives.

    Round 1: Question Generation

    Throughout day 1, participants wrote research questions on the color-coded index cards. There was no limit on how many research questions a participant could write. Study team members (E.G., C.E., M.A.C., J.M., J.P.H.-E., T.A., E.de J., D.O.-D., T.U.-L., M.P.J., and G.O.) collected the cards and grouped, deduplicated, and condensed them into candidate research questions that would populate the theme-specific questionnaires for round 2.

    Round 2: Prioritization

    On day 2, Delphi questionnaires were created. The questionnaires were modeled after the classic studies by the RAND Corporation and contained the research questions grouped by theme.8 Conference participants were asked to prioritize each item using a Likert scale of 1 to 9 (1 indicates lowest priority; 9, highest priority). Team members then collected questionnaires before the morning panels and recorded the results. These results were sorted into high-, low-, and uncertain-priority groups based on previously defined strict criteria (eTable in the Supplement) to ensure high specificity in categorizing high- and low-priority questions.

    Round 3: Reprioritization of Uncertain Category Questions

    In round 3, participants were given their marked questionnaires back for context on how they voted in round 2. The results for consensus on each question, with its median rating and measure of dispersion, were presented to the participants. The entire audience then discussed these as summary results were displayed. This discussion allowed the voters to visualize how they prioritized research questions compared with the rest of their thematic group. High- and low-priority questions were recorded and not discussed. Discussion was limited to the uncertain-priority questions and was open to all participants. As noted by Mukherjee et al,11 the Delphi technique is often reported to be time-consuming, which can lead to high dropout levels by experts between rounds. We addressed the possibility of excessive dropout by limiting the discussion for each question to 2 minutes. In this round, questions were reprioritized using a real-time digital audience polling system (Poll Everywhere) with the same 9-point Likert scale used in round 2. Revoting was restricted to the original members of each thematic group. The results from digital audience polling were analyzed and recategorized using the relaxed criteria (eTable in the Supplement) to maximize the number of questions that were sorted into high- or low-priority groups.

    Finally, the highest-ranked questions in rounds 2 and 3 (with a median rating of 8 or more on a Likert scale ranging from 1-9) were identified and became part of the national STB research agenda. The results were shared with participants for any additional commentary or feedback. All conference proceedings were recorded and transcribed for qualitative analysis.

    Results

    A total of 45 attendees participated in conference proceedings; 44 were present on day 1 and 41 on day 2. Participants possessed a wide range of expertise, including individuals from various surgical subspecialties and national organizations, emergency and military medicine, and implementation experts (Box). The 3 best represented groups were emergency medicine (14 [31.1%]); acute, critical, and trauma care surgery (13 [28.9%]); and military medicine (4 [8.9%]) (Figure 2). The open discussion sessions at the conference highlighted the following issues in each predefined theme:

    • Theme 1: Epidemiology and effectiveness included the lack of prospective trials and prehospital data on layperson hemorrhage control in the civilian setting; differences in wounding patterns in the civilian setting compared with the military setting; geographic variations in wounding patterns; and cost-effectiveness of different interventions.

    • Theme 2: Materials included the efficacy of different tourniquet types and the need for standardization and the disproportionate emphasis on tourniquet use over direct pressure and wound packing.

    • Theme 3: Education included the efficacy and scalability of various training modalities, including in-person training, video-based lectures, and written instructions.

    • Theme 4: Global health included the economic effects of preventable trauma-associated deaths due to uncontrolled hemorrhage and the epidemiology of injury-related preventable deaths in lower- and middle-income countries.

    • Theme 5: Health policy included the true incidence of preventable deaths due to exsanguination to help advocacy groups highlight the potential effect of layperson hemorrhage control initiatives; policy implementation and enforcement issues in the civilian setting; and the need for understanding the true effects of large public implementation programs.

    During round 1, a total of 487 research questions were generated. After categorization and deduplication, 162 research questions remained within the 5 themes: epidemiology and effectiveness (34 questions), materials (equipment and supplies) (33 questions), education (30 questions), global health (31 questions), and health policy (34 questions). These questions were then added to the theme-based Delphi questionnaires.

    During round 2, attendees completed the Delphi questionnaires based on their assigned thematic groups. Of the 162 questions assessed, 92 were scored as high priority and 70 were scored as uncertain priority. No questions achieved consensus as low priority.

    During round 3, the 70 uncertain-priority questions were rated. Using the relaxed criteria, 21 of these were reprioritized to high priority and 22 to low priority, and 27 remained in the uncertain-priority category.

    A total of 113 questions rated as high priority, 22 as low priority, and 27 as uncertain priority were included in the final consensus (eFigure in the Supplement) . Among the high-priority questions, 24 questions (8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy) had a median score of 8 or greater and formed the national research agenda for prehospital hemorrhage control by layperson immediate responders (Table 2).

    Discussion

    Using a modified Delphi approach, we engaged a diverse stakeholder group of subject matter experts, professional society leaders, and funders to reach consensus on research priorities for STB. Participants came to consensus on high-priority questions within 5 themes: (1) epidemiology and effectiveness, (2) materials, (3) education, (4) global health, and (5) health policy. The top 24 highest-ranked research questions, based on participant voting, constitute the National STB Research Agenda. To our knowledge, these findings constitute the first consensus-driven research agenda for civilian prehospital bleeding control techniques to date.

    Theme 1: Epidemiology and Effectiveness

    One of the most pressing gaps identified was the paucity of prospective trials and prehospital data on implementation of a program of layperson-initiated hemorrhage control among the civilian population. Although various estimates of prehospital preventable trauma deaths exist, we do not have a true understanding of the effect of a broad STB implementation on mortality.12-14 Prehospital trauma registries are often inadequate and rarely integrated with hospital electronic health records in a way that can capture reliable, actionable data. To combat the challenges of scarce high-quality prehospital data, the Military Health System used the concept of focused empiricism. Focused empiricism is essentially “using the best data available in combination with experience to develop clinical practice guidelines that, through an iterative process, continue to be refined until high-quality data can be generated to further inform clinical practice and standards of care.”3(p165)

    A primary area of discussion was the controversy over the variation of wounding patterns in civilian vs battlefield trauma. Retrospective preventable death analyses in the civilian population have reached varied conclusions about the utility of prehospital hemorrhage control.15,16 Although some studies highlight the younger age of patients and higher injury severity encountered in the military compared with civilian trauma centers, others relay an increased incidence of military-style mechanisms of injury among civilians owing to blast injuries and firearms.17,18 Patterns of injury and which interventions are most effectively used by bystanders to treat these injuries are important questions still to be addressed in the civilian population.

    Another topic of discussion was the geographic variation in injury patterns and trauma outcomes.19 Finally, the limited understanding of cost-effectiveness of prehospital hemorrhage control interventions was highlighted. Comparisons were drawn to existing layperson public health interventions, including cardiopulmonary resuscitation and automated external defibrillators as implementation models.20 Multiple studies that have demonstrated the cost-effectiveness of these interventions in different settings may serve as a roadmap.21-24

    Theme 2: Materials

    Materials, that is, the equipment and supplies used to control hemorrhage, yielded the third-most high-priority questions among all themes (n = 4). With many types and manufacturers of tourniquets now available to the public, an area of major concern was their ease of use, effectiveness, and lack of standardization. Correct tourniquet application is not intuitive, and skill training provided on one type of device may not translate well or at all to other types of tourniquets.25,26 Since the STB’s inception, an increased number of publicly available hemorrhage control products have not been evaluated for effectiveness. In this context, experts proposed the establishment of formal standards for tourniquet design that take into account effectiveness, ease of use, and cost.

    Another area of discussion was the disproportionate attention to tourniquet use compared with direct pressure and wound packing. Leonard et al27 conducted a retrospective analysis on military data to compare the success rate and complications associated with combat application tourniquets and hemostatic gauze. The success rate was 98% for the combat application tourniquets and 89% for the gauze. Another study by Lee et al28 examined the use of tourniquet and direct pressure in conjunction with one another. The authors posit that for most civilian trauma settings, the hemorrhage can be controlled by a stepwise approach of direct pressure, hemostatic agents, and wound packing.28 Tourniquets are rarely required in these settings, except when massive bleeding or situations such as entrapment occur. These findings, in concert with the discrepancies in wounding patterns highlighted in the epidemiology theme, suggest that STB materials beyond tourniquets are a topic for essential future investigation.

    Theme 3: Education

    The primary gaps identified within this theme were around the efficacy of various modalities: in-person training, virtual (eg, phone-based applications, video) training, or a mix of modalities. The foundation of STB rests on providing the general public at large with the knowledge and tools to control life-threatening hemorrhage, but the most effective means of accomplishing such training at scale remain unresolved.

    Multiple programs have been developed to train laypeople in hemorrhage control. Many programs use the Trauma Combat Casualty Care course, a 2-day course that trains military personnel in first aid in combat, as their template.29 The adaptation of this approach to the lay population has primarily been via the Bleeding Control Basic course, a joint product of the American College of Surgeons Committee on Trauma and the National Association of Emergency Medical Technicians’ Prehospital Trauma Life Support, that focuses on hemorrhage control. The Bleeding Control Basic course simplifies Trauma Combat Casualty Care to a 1-hour course with lecture and hands-on components.6,30 The primary limitations with this educational modality are scalability and retention.

    Educational modalities to address scalability include “just-in-time” instructions to accompany bleeding control kits to inform laypeople how to control bleeding, similar in concept to the automated instructions that accompany automated external defibrillators. The first randomized clinical trial of Bleeding Control Basic training vs these other modalities demonstrated that 88% of laypersons can perform tourniquet application successfully.30 However, unlike automated external defibrillators, where the instructions are tethered to the device, bleeding control kits do not have instructions attached, negating the positive effects of the instructions.30 Two other trials31,32 found that without prior training, just-in-time instructions are effective in approximately 50% of cases in teaching laypeople with no prior training in tourniquet application. When those laypeople watched a brief web-based video, however, success rates increased to 75%.31,33 A recent trial30 found that skill degradation over time is significant and laypeople could correctly apply a tourniquet only 55% of the time 3 to 9 months after the Bleeding Control Basic course. Multiple entities have implemented either independent or modified versions of these programs, but limited evaluation beyond subjective participant or instructor feedback is available.34-40

    Key gaps exist in measurement of efficacy of curriculum, modalities of training, and identification of barriers to skill application in real-life environments. Educational initiatives in hemorrhage control must look beyond the fields of surgery and emergency medicine to learn and understand how best to educate and train the greatest number of people in an effective, consistent, scalable, and cost-effective manner.41

    Theme 4: Global Health

    Hemorrhage is a major contributor to global trauma morbidity and mortality.42 Thus, conference attendees stressed the possible need to measure the economic effect of deaths due to bleeding. Traumatic injuries not only cause an emotional burden on individuals, but can also result in significant financial costs.43 According to the World Health Organization,44 road traffic crashes cost governments a mean of 1% to 2% of their gross national product. Furthermore, in 2000, approximately 10% of medical expenditures in the US were estimated to be injury-related medical care.43 How much of this expenditure is a result of preventable hemorrhage requires future evaluation.

    Another important topic of discussion was the epidemiology of preventable hemorrhage-related deaths in lower- and middle-income countries. The reason for scarcity of literature on this topic is the lack of reliable prehospital data in these settings. Most of the studies in lower- and middle-income countries are limited to surveys and incident reports.45,46 More robust evaluations of the burden of hemorrhage-related morbidity and mortality in these countries will help to inform education and intervention.

    Theme 5: Health Policy

    Identifying the true incidence of preventable trauma deaths owing to hemorrhage was highlighted as a policy priority. This knowledge would help policy makers, advocacy groups, and the public to understand the STB campaign’s potential effect compared with other public health campaigns aimed at combating issues such as opioid abuse, smoking, or drunk driving. In contrast to the military, where leaders have the ability to mandate, implement, and enforce an STB program, mandate and enforcement are limited in the civilian setting. A variety of gaps exist in Good Samaritan laws and helpers’ liability associated with hemorrhage control, placement of bleeding control kits in public facilities, and mandated training in schools or by employers. Fear of complications or further harm has been cited as 1 of the top 3 reasons for bystanders to decline to intervene in an emergency, supporting a need for clarification of Good Samaritan legislation.47 Several states have introduced legislation on public access kit placement in public facilities and/or schools to require training of students and/or staff, but cost-effectiveness, optimal kit location, and contents of kits are unspecified.48-51

    Understanding the real effect of public programs in terms of the number of preventable deaths avoided was another gap highlighted. The Western Pennsylvania STB Campaign created a network of hospitals in a hub-and-spoke pattern for STB implementation in 72 counties across 4 states.52 Although this campaign trained more than 27 000 individuals, including trainers, law-enforcement agents, and laypeople, markers of program success remain poorly defined. Future work must examine meaningful and reproducible benchmarks for program success, including assessment of program infrastructure, cost and funding mechanisms, and patient-centered outcomes. Furthermore, the effect of STB programs on the community must be evaluated to inform policy decisions.

    Limitations

    The findings of this study are not without limitations. First, the results and the resultant research agenda represent the consensus of 45 subject-area experts, government officials, and representatives of private organizations at a single 2-day meeting. Stakeholders from affiliated fields, including legislature, academia, public health, and philanthropy must be included in the ongoing dialogue on layperson prehospital hemorrhage control. In addition, representation of experts from a wider array of public and private sector entities would have been beneficial. For example, law-enforcement officials and medical product developers would have added to the diversity of perspectives. Second, the language of the questions generated could be interpreted differently, in the absence of context. Person-to-person dialogue played a critical role to clarify the language of the questions, but owing to the limited time frame, some ambiguity remained. This was addressed by sharing a draft of the prioritized questions with all conference participants for review and final approval.

    Conclusions

    The National STB Research Consensus Conference developed a national research agenda for civilian prehospital hemorrhage control. Investigators, clinicians, professional societies, and funding agencies should use this agenda to inform future research and funding priorities to achieve the goal of zero preventable deaths due to trauma.

    Back to top
    Article Information

    Accepted for Publication: April 3, 2020.

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Goralnick E et al. JAMA Network Open.

    Corresponding Author: Eric Goralnick, MD, MS, Department of Emergency Medicine, Center for Surgery and Public Health, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 (egoralnick@bwh.harvard.edu).

    Published: July 6, 2020. doi:10.1001/jamanetworkopen.2020.9393

    The Stop the Bleed National Research Agenda Consensus Conference Working Group Authors: Erin Andrade, MD, MPH; Jeremy Brown, MD; Eileen M. Bulger, MD; Frank K. Butler, MD; David Callaway, MD, MPA; Edward J. Caterson, MD, PhD; Niteesh K. Choudhry, MD, PhD; Michael R. Davis, MD; Alex Eastman, MD, MPH; Brian J. Eastridge, MD; Jonathan L. Epstein, MEMS, NRP; Conor L. Evans, PhD; Marianne Gausche-Hill, MD; Mark L. Gestring, MD; Scott A. Goldberg, MD, MPH; Dan Hanfling, MD; John Bradley Holcomb, MD; Carl-Oscar Jonson, PhD; David R. King, MD; Sean Kivlehan, MD, MPH; Russ S. Kotwal, MD, MPH; Jon R. Krohmer, MD; Nomi Levy-Carrick, MD, MPhil; Matthew Levy, DO, MSc, NRP; Joan José Meléndez Lugo, MD; David P. Mooney, MD, MPH; Matthew D Neal, MD; Robert Niskanen, MSEE; Patrick O’Neill, BS; Habeeba Park, MD; Peter T. Pons, MD; Erik Prytz, PhD; Todd E. Rasmussen, MD; Michael A. Remley, ATP; Robert Riviello, MD; Ali Salim, MD; Stacy Shackelfold, MD; E. Reed Smith, MD; Ronald M. Stewart, MD; Mamta Swaroop, MD; Kevin Ward, MD; Tarsicio Uribe-Leitz, MD, MPH; Molly P. Jarman, PhD, MPH; Gezzer Ortega, MD, MPH.

    Affiliations of The Stop the Bleed National Research Agenda Consensus Conference Working Group Authors: Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts (Goldberg, Kivlehan); Department of Surgery, Washington University in St Louis, Missouri (Andrade); Department of Emergency Medicine, George Washington University School of Medicine, Washington, DC (Brown, Smith); Department of Surgery, University of Washington, Seattle (Bulger); Defense Health Agency, Joint Trauma System, Joint Base San Antonio–Fort Sam Houston, Texas (Butler); Department of Emergency Medicine, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina (Callaway); Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts (Caterson); Center for Healthcare Delivery Sciences, Harvard Medical School, Boston, Massachusetts (Choudhry); Combat Casualty Care Research Program Army Medical Research and Materiel Command, Fort Detrick, Maryland (Davis); Countering Weapons of Mass Destruction Office Department of Homeland Security, Washington, DC (Eastman); Department of Surgery, The University of Texas Health Science Center at San Antonio (Eastridge); Training Services Division, American Red Cross, American Red Cross, Washington, DC (Epstein); Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (Evans); Department of Emergency Medicine, Harbor–University of California, Los Angeles Medical Center, Torrance (Gausche-Hill); Department of Surgery, Rochester Medical Center, Rochester, New York (Gestring); Forum on Medical and Public Health Preparedness for Catastrophic Events, National Academies of Science, Washington, DC (Hanfling); Department of Surgery, University of Alabama at Birmingham (Holcomb); Center for Disaster Medicine and Traumatology, Linköping University, Linköping, Sweden (Jonson); Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden (Jonson); Department of Surgery, Massachusetts General Hospital, Boston (King); Joint Trauma System, Defense Health Agency Combat Support, San Antonio, Texas (Kotwal, Remley, Shackelfold); Office of Emergency Medical Services, National Highway Traffic Safety Administration, Washington, DC (Krohmer); Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts (Levy-Carrick); Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland (Levy); Department of Surgery, Fundacion Valle del Lili, Cali, Colombia (Meléndez Lugo); Department of Surgery, Boston Children’s Hospital, Boston, Massachusetts (Mooney); Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania (Neal); Resurgent Biomedical Consulting, Shoreline, Washington (Niskanen); Amp Your Good, Inc, Mendham, New Jersey (O’Neill); Department of Surgery, University of Maryland Shock Trauma Center, Baltimore (Park); Department of Emergency Medicine, University of Colorado School of Medicine, Denver (Pons); Department of Computer and Information Science, Linköping University, Linköping, Sweden (Prytz); Department of Surgery, F. Edward Hébert School of Medicine Uniformed Services University, Bethesda, Maryland (Rasmussen); Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts (Riviello, Salim, Uribe-Leitz, Jarman, Ortega); Department of Surgery, The University of Texas Health Science Center at San Antonio (Stewart); Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois (Swaroop); Department of Emergency Medicine, University of Michigan, Ann Arbor (Ward); Department of Biomedical Engineering, University of Michigan, Ann Arbor (Ward).

    Author Contributions: Drs Goralnick and Chaudhary had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Goralnick, Ezeibe, Chaudhary, McCarty, Herrera-Escobar, Andriotti, de Jager, Goolsby, Hunt, Haider, Jacobs, Brown, Caterson, Davis, Eastman, Epstein, Gausche-Hill, Gestring, Krohmer, Levy-Carrick, Levy, Mooney, Niskanen, Park, Rasmussen, Remley, Riviello, Salim, Smith, Ortega.

    Acquisition, analysis, or interpretation of data: Goralnick, Ezeibe, Chaudhary, McCarty, Herrera-Escobar, Andriotti, de Jager, Ospina-Delgado, Weissman, Andrade, Bulger, Butler, Callaway, Caterson, Choudhry, Eastman, Eastridge, Evans, Goldberg, Hanfling, Holcomb, Jonson, King, Kivlehan, Kotwal, Meléndez Lugo, Neal, O’Neill, Pons, Prytz, Shackelfold, Smith, Stewart, Swaroop, Ward, Uribe-Leitz, Jarman, Ortega.

    Drafting of the manuscript: Goralnick, Ezeibe, Chaudhary, McCarty, Herrera-Escobar, Andriotti, de Jager, Ospina-Delgado, Weissman, Eastman, Epstein, Park, Ortega.

    Critical revision of the manuscript for important intellectual content: Goralnick, Ezeibe, Chaudhary, McCarty, Herrera-Escobar, Andriotti, de Jager, Goolsby, Hunt, Weissman, Haider, Jacobs, Andrade, Brown, Bulger, Butler, Callaway, Caterson, Choudhry, Davis, Eastman, Eastridge, Evans, Gausche-Hill, Gestring, Goldberg, Hanfling, Holcomb, Jonson, King, Kivlehan, Kotwal, Krohmer, Levy-Carrick, Levy, Meléndez Lugo, Mooney, Neal, Niskanen, O’Neill, Park, Pons, Prytz, Rasmussen, Remley, Riviello, Salim, Shackelfold, Smith, Stewart, Swaroop, Ward, Uribe-Leitz, Jarman, Ortega.

    Statistical analysis: Goralnick, Ezeibe, McCarty, Andriotti.

    Obtained funding: Goralnick, McCarty, Goolsby, Haider, Caterson.

    Administrative, technical, or material support: Goralnick, Ezeibe, Chaudhary, McCarty, Andriotti, de Jager, Ospina-Delgado, Goolsby, Hunt, Weissman, Haider, Jacobs, Bulger, Callaway, Caterson, Davis, Eastman, Eastridge, Epstein, Evans, Gestring, Jonson, King, Kivlehan, Krohmer, Levy-Carrick, Niskanen, O'Neill, Park, Prytz, Shackelfold, Stewart, Swaroop, Uribe-Leitz, Ortega.

    Supervision: Goralnick, Ezeibe, Andriotti, Brown, Callaway, Davis, Eastman, Holcomb, King, Meléndez Lugo, Rasmussen, Salim, Ortega.

    Conflict of Interest Disclosures: Dr Goralnick reported receiving grants from the Gillian Reny Stepping Strong Center for Trauma Innovation, the National Center for Disaster Medicine and Public Health, and the Henry M. Jackson Foundation during the conduct of the study. Dr McCarty reported receiving grants from the Gillian Reny Stepping Strong Center for Trauma Innovation during the conduct of the study. Dr Goolsby reported having a patent to tourniquet and method of use pending. Dr Callaway reported participating in the Committee for Tactical Emergency Casualty Care, a nonprofit, best practice clinical practice guideline development group, for no financial compensation. Dr Evans reported receiving grants from Uniformed Services University during the conduct of the study; grants from the Air Force Office for Scientific Research, Proctor & Gamble Company, and Avon Products, Inc, outside the submitted work; and having a patent to systems and methods for measuring the surface of a subject issued, a patent to compounds systems and methods for monitoring the surface of a subject issued, a patent to system and method for photoluminescence detection issued, a patent to optical transcutaneous oxygen monitor pending, and a patent to real-time oxygenation and force-sensing toolkit for augmenting emergency tourniquet application pending. Dr Holcomb reported receiving personal fees from Arsenal Medical, Cellphire, Inc, Prytime Medical Devices, Inc, and Decisio Health outside the submitted work; and being the coinventor of the Junctional Emergency Tourniquet Tool (JETT) and receiving royalties from The University of Texas Health. Dr Jonson reported receiving grants from Swedish Civil Contingencies Agency during the conduct of the study and having a patent to 16/636,408 pending. Dr Levy reported serving as the uncompensated chairperson of the Stop the Bleed Coalition, a registered 501(c)3 nonprofit organization. Dr Neal reported receiving grants from National Institute of General Medical Sciences and the Department of Defense during the conduct of the study; grants and personal fees from Janssen Pharmaceuticals and Haemonetics Corporation, grants from Instrument Laboratories and Noveome Biotherapeutics, Inc, and personal fees from CSL Behring outside the submitted work. Dr Prytz reported receiving grants from Swedish Civil Contingencies Agency during the conduct of the study and having a patent to 16/636,408 pending. Dr Stewart reported receiving grants from American College of Surgeons outside the submitted work. Dr Ward reported having a patent to tourniquet issued, a patent to Hemostatic Agent issued and with royalties paid, a patent to hemostatic compression device issued, and a patent to noncompressible torso hemorrhage pending. No other disclosures were reported.

    Funding/Support: This study was supported by the Gillian Reny Stepping Strong Center for Trauma Innovation and the National Center for Disaster Medicine and Public Health.

    Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    The Stop the Bleed National Research Agenda Consensus Conference Working Group Members: Audrey Epstein Reny, MBA (The Abbey Group and the Gillian Reny Stepping Strong Center for Trauma Innovation, Boston, Massachusetts); Nish Acharya, MBA (the Gillian Reny Stepping Strong Center for Trauma Innovation, Boston, Massachusetts); Melissa Poleo, MS (Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts); Gina Tonogbanua Custer (Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts); Caroline Demko, BS (Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts); Rebecca Doucette, BS (Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts); Wendy Williams, JD (Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts); Luis Rojas (Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland); Victoria Klimczak (Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland); and Alexandra J. Roberts, JD, MA (The University of New Hampshire Franklin Pierce School of Law, Concord).

    References
    1.
    Centers for Disease Control and Prevention; National Centers for Injury Prevention and Control. Web-based injury statistics query and reporting system (WISQARS). Updated March 30, 2020. Accessed January 20, 2019. https://www.cdc.gov/injury/wisqars/
    2.
    Howard  JT, Kotwal  RS, Stern  CA,  et al.  Use of combat casualty care data to assess the US military trauma system during the Afghanistan and Iraq conflicts, 2001-2017.   JAMA Surg. 2019;154(7):600-608. doi:10.1001/jamasurg.2019.0151 PubMedGoogle ScholarCrossref
    3.
    Berwick  DM, Downey  AS, Cornett  EA.  A national trauma care system to achieve zero preventable deaths after injury: recommendations from a national academies of sciences, engineering, and medicine report.   JAMA. 2016;316(9):927-928. doi:10.1001/jama.2016.8524 PubMedGoogle ScholarCrossref
    4.
    Jacobs  LM; Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events.  The Hartford Consensus IV: a call for increased national resilience.   Bull Am Coll Surg. 2016;101(3):17-24.PubMedGoogle Scholar
    5.
    Jacobs  LM  Jr.  Out of unspeakable tragedy comes progress in bleeding control.   Bull Am Coll Surg. 2017;102(6):11-16.PubMedGoogle Scholar
    6.
    Stop the Bleed. Home Page. Accessed November 6, 2019. https://www.stopthebleed.org/
    7.
    Standards for Quality Improvement Reporting Excellence. (SQUIRE 2.0). Updated February 1, 2017. Accessed March 5, 2020. https://www.equator-network.org/reporting-guidelines/squire/
    8.
    Fitch  K, Bernstein  SJ, Aguilar  MD, Burnand  B, LaCalle  JR.  The RAND/UCLA Appropriateness Method User’s Manual. RAND Corporation; 2001.
    9.
    Murphy  MK, Black  NA, Lamping  DL,  et al.  Consensus development methods, and their use in clinical guideline development.   Health Technol Assess. 1998;2(3):i-iv, 1-88. doi:10.3310/hta2030PubMedGoogle ScholarCrossref
    10.
    Ezeibe  C, McCarty  JC, Chaudhary  MA,  et al.  Haemorrhage control in the prehospital setting: a scoping review protocol.   BMJ Open. 2019;9(7):e029051. doi:10.1136/bmjopen-2019-029051 PubMedGoogle Scholar
    11.
    Mukherjee  N, Huge  J, Sutherland  WJ,  et al.  The Delphi technique in ecology and biological conservation: applications and guidelines.   Methods Ecol Evol. 2015;6(9):1097-1109. doi:10.1111/2041-210X.12387 Google ScholarCrossref
    12.
    Goolsby  C, Rouse  E, Rojas  L,  et al.  Post-mortem evaluation of potentially survivable hemorrhagic death in a civilian population.   J Am Coll Surg. 2018;227(5):502-506. doi:10.1016/j.jamcollsurg.2018.08.692 PubMedGoogle ScholarCrossref
    13.
    Teixeira  PGR, Brown  CVR, Emigh  B,  et al; Texas Tourniquet Study Group.  Civilian prehospital tourniquet use is associated with improved survival in patients with peripheral vascular injury.   J Am Coll Surg. 2018;226(5):769-776.e1. doi:10.1016/j.jamcollsurg.2018.01.047 PubMedGoogle ScholarCrossref
    14.
    Scerbo  MH, Holcomb  JB, Taub  E,  et al.  The trauma center is too late: major limb trauma without a pre-hospital tourniquet has increased death from hemorrhagic shock.   J Trauma Acute Care Surg. 2017;83(6):1165-1172. doi:10.1097/TA.0000000000001666 PubMedGoogle ScholarCrossref
    15.
    Smith  ER, Shapiro  G, Sarani  B.  Fatal wounding pattern and causes of potentially preventable death following the Pulse Night Club shooting event.   Prehosp Emerg Care. 2018;22(6):662-668. doi:10.1080/10903127.2018.1459980 PubMedGoogle ScholarCrossref
    16.
    Drake  SA, Holcomb  JB, Yang  Y,  et al.  Establishing a regional trauma preventable/potentially preventable death rate.   Ann Surg. 2020;271(2):375-382. doi:10.1097/SLA.0000000000002999PubMedGoogle ScholarCrossref
    17.
    Sabino  J, Mohan  R, Jessie  E,  et al.  Outcomes comparisons between civilian and military trauma patients undergoing limb salvage.   J Am Coll Surg. 2014;219(4):e140. doi:10.1016/j.jamcollsurg.2014.07.762 Google Scholar
    18.
    Kapur  GB, Hutson  HR, Davis  MA, Rice  PL.  The United States twenty-year experience with bombing incidents: implications for terrorism preparedness and medical response.   J Trauma. 2005;59(6):1436-1444. doi:10.1097/01.ta.0000197853.49084.3c PubMedGoogle ScholarCrossref
    19.
    Dwyer-Lindgren  L, Bertozzi-Villa  A, Stubbs  RW,  et al.  Trends and patterns of geographic variation in mortality from substance use disorders and intentional injuries among US counties, 1980-2014.   JAMA. 2018;319(10):1013-1023. doi:10.1001/jama.2018.0900 PubMedGoogle ScholarCrossref
    20.
    Groeneveld  PW, Owens  DK.  Cost-effectiveness of training unselected laypersons in cardiopulmonary resuscitation and defibrillation.   Am J Med. 2005;118(1):58-67. doi:10.1016/j.amjmed.2004.08.014 PubMedGoogle ScholarCrossref
    21.
    Groeneveld  PW, Kwong  JL, Liu  Y,  et al.  Cost-effectiveness of automated external defibrillators on airlines.   JAMA. 2001;286(12):1482-1489. doi:10.1001/jama.286.12.1482 PubMedGoogle ScholarCrossref
    22.
    Cram  P, Vijan  S, Fendrick  AM.  Cost-effectiveness of automated external defibrillator deployment in selected public locations.   J Gen Intern Med. 2003;18(9):745-754. doi:10.1046/j.1525-1497.2003.21139.x PubMedGoogle ScholarCrossref
    23.
    Winkle  RA.  The effectiveness and cost effectiveness of public-access defibrillation.   Clin Cardiol. 2010;33(7):396-399. doi:10.1002/clc.20790 PubMedGoogle ScholarCrossref
    24.
    Nichol  G, Huszti  E, Birnbaum  A,  et al; PAD Investigators.  Cost-effectiveness of lay responder defibrillation for out-of-hospital cardiac arrest.   Ann Emerg Med. 2009;54(2):226-235.e352. doi:10.1016/j.annemergmed.2009.01.021 PubMedGoogle ScholarCrossref
    25.
    Ross  EM, Mapp  JG, Redman  TT, Brown  DJ, Kharod  CU, Wampler  DA.  The tourniquet gap: a pilot study of the intuitive placement of three tourniquet types by laypersons.   J Emerg Med. 2018;54(3):307-314. doi:10.1016/j.jemermed.2017.09.011 PubMedGoogle ScholarCrossref
    26.
    McCarty  JC, Hashmi  ZG, Herrera-Escobar  JP,  et al.  Effectiveness of the American College of Surgeons bleeding control basic training among laypeople applying different tourniquet types: a randomized clinical trial.   JAMA Surg. 2019;154(10):923. doi:10.1001/jamasurg.2019.2275 PubMedGoogle ScholarCrossref
    27.
    Leonard  J, Zietlow  J, Morris  D,  et al.  A multi-institutional study of hemostatic gauze and tourniquets in rural civilian trauma.   J Trauma Acute Care Surg. 2016;81(3):441-444. doi:10.1097/TA.0000000000001115 PubMedGoogle ScholarCrossref
    28.
    Lee  C, Porter  KM, Hodgetts  TJ.  Tourniquet use in the civilian prehospital setting.   Emerg Med J. 2007;24(8):584-587. doi:10.1136/emj.2007.046359 PubMedGoogle ScholarCrossref
    29.
    Committee on Tactical Combat Casualty Care. TCCC Guidelines for Medical Personnel. Published September 5, 2019. Accessed November 19, 2019. https://www.deployedmedicine.com/market/11/content/475
    30.
    Goralnick  E, Chaudhary  MA, McCarty  JC,  et al.  Effectiveness of instructional interventions for hemorrhage control readiness for laypersons in the Public Access and Tourniquet Training Study (PATTS): a randomized clinical trial.   JAMA Surg. 2018;153(9):791-799. doi:10.1001/jamasurg.2018.1099 PubMedGoogle ScholarCrossref
    31.
    Goolsby  C, Branting  A, Chen  E, Mack  E, Olsen  C.  Just-in-Time to Save Lives: a pilot study of layperson tourniquet application.   Acad Emerg Med. 2015;22(9):1113-1117. doi:10.1111/acem.12742 PubMedGoogle ScholarCrossref
    32.
    Goolsby  C, Chen  E, Branting  A,  et al.  Analysis of layperson tourniquet application using a novel color-coded device.   Disaster Med Public Health Prep. 2016;10(2):274-280. doi:10.1017/dmp.2016.4 PubMedGoogle ScholarCrossref
    33.
    Goolsby  CA, Strauss-Riggs  K, Klimczak  V,  et al.  Brief, web-based education improves lay rescuer application of a tourniquet to control life-threatening bleeding.   AEM Educ Train. 2018;2(2):154-161. doi:10.1002/aet2.10093 PubMedGoogle ScholarCrossref
    34.
    Andrade  EG, Hayes  JM, Punch  LJ.  Enhancement of Bleeding Control 1.0 to reach communities at high risk for urban gun violence: acute bleeding control.   JAMA Surg. 2019;154(6):549-550. doi:10.1001/jamasurg.2019.0414 PubMedGoogle ScholarCrossref
    35.
    Schroll  R, Smith  A, Zeoli  T,  et al.  Efficacy of medical students as stop the bleed participants and instructors.   J Surg Educ. 2019;76(4):975-981. doi:10.1016/j.jsurg.2019.02.006 PubMedGoogle ScholarCrossref
    36.
    Evans  KM, Longshore  SW, Lake  B, Toschlog  EA, Pories  WJ, Walsh  DS.  Stop the bleed: an assessment of medical student knowledge of bleeding control techniques.   J Am Coll Surg. 2018;227(4):S230-S231. doi:10.1016/j.jamcollsurg.2018.07.504 Google ScholarCrossref
    37.
    Gallagher  KC, Evans  PT, Robinette  JP,  et al.  Hemorrhage control training for medical students: implementation of the American College of Surgeons’ Stop the Bleed training at Vanderbilt University School of Medicine.   J Am Coll Surg. 2018;227(4):e206. doi:10.1016/j.jamcollsurg.2018.08.557 Google Scholar
    38.
    Zwislewski  A, Nanassy  AD, Meyer  LK,  et al.  Practice makes perfect: the impact of Stop the Bleed training on hemorrhage control knowledge, wound packing, and tourniquet application in the workplace.   Injury. 2019;50(4):864-868. doi:10.1016/j.injury.2019.03.025 PubMedGoogle ScholarCrossref
    39.
    Levic  T, McAna  J, Kramer  N. 1, 2, 3, Stop the Bleed: Analysis of a Bleeding Control Educational Course. Published June 22, 2018. Accessed November 19, 2019. https://jdc.jefferson.edu/mphcapstone_presentation/259
    40.
    Chambers  JA, Seastedt  K, Krell  R, Caterson  E, Levy  M, Turner  N.  “Stop the Bleed”: a US military installation’s model for implementation of a rapid hemorrhage control program.   Mil Med. 2019;184(3-4):67-71. doi:10.1093/milmed/usy185 PubMedGoogle ScholarCrossref
    41.
    Saraç  L, Ok  A.  The effects of different instructional methods on students’ acquisition and retention of cardiopulmonary resuscitation skills.   Resuscitation. 2010;81(5):555-561. doi:10.1016/j.resuscitation.2009.08.030 PubMedGoogle ScholarCrossref
    42.
    Kauvar  DS, Lefering  R, Wade  CE.  Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations.   J Trauma. 2006;60(6 suppl):S3-S11. doi:10.1097/01.ta.0000199961.02677.19 PubMedGoogle ScholarCrossref
    43.
    Kauvar  DS, Wade  CE.  The epidemiology and modern management of traumatic hemorrhage: US and international perspectives.   Crit Care. 2005;9(suppl 5):S1-S9. doi:10.1186/cc3779 PubMedGoogle ScholarCrossref
    44.
    Peden  M, Scurfield  R, Sleet  D,  et al; World Health Organization. World report on road traffic injury prevention. Published February 9, 2004. Accessed November 18, 2019. https://www.who.int/violence_injury_prevention/publications/road_traffic/world_report/
    45.
    Delaney  PG, Bamuleke  R, Lee  YJ.  Lay first responder training in eastern Uganda: leveraging transportation infrastructure to build an effective prehospital emergency care training program.   World J Surg. 2018;42(8):2293-2302. doi:10.1007/s00268-018-4467-3 PubMedGoogle ScholarCrossref
    46.
    Tiska  MA, Adu-Ampofo  M, Boakye  G, Tuuli  L, Mock  CN.  A model of prehospital trauma training for lay persons devised in Africa.   Emerg Med J. 2004;21(2):237-239. doi:10.1136/emj.2002.002097 PubMedGoogle ScholarCrossref
    47.
    Galante  JM, Smith  CA, Sena  MJ, Scherer  LA, Tharratt  RS.  Identification of barriers to adaptation of battlefield technologies into civilian trauma in California.   Mil Med. 2013;178(11):1227-1230. doi:10.7205/MILMED-D-13-00127 PubMedGoogle ScholarCrossref
    48.
    Hawkins  G. Act relating to the placement of bleeding control kits in public schools and to required training of school personnel. Posted April 15, 2019. Accessed November 19, 2019. https://capitol.texas.gov/tlodocs/86R/billtext/html/HB00496I.htm
    49.
    ACS State Affairs Team. State Legislatures Consider Bleeding Control Legislation. American College of Surgeons News. Published March 2019. Accessed November 19, 2019. https://www.facs.org/advocacy/surgeonsvoice/news/031519-bc
    50.
    Frye  R, Barrett  B, Judy  C, Macer  K. House Bill 1063. Posted April 18, 2019. Accessed November 19, 2019. http://iga.in.gov/legislative/2019/bills/house/1063/#digest-heading
    51.
    American College of Surgeons Louisiana Chapter. 2019 LA-ACS Priority Legislation. 2019. Accessed November 19, 2019. https://laacs.org/2019-la-acs-priority-legislation/
    52.
    Neal  MD, Reynolds  BR, Bertoty  D, Murray  KJ, Peitzman  AB, Forsythe  RM.  Design and implementation of the Western Pennsylvania regional Stop the Bleed initiative.   J Trauma Acute Care Surg. 2018;85(4):684-690. doi:10.1097/TA.0000000000002027 PubMedGoogle ScholarCrossref
    ×