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Original Investigation
September 2018

Effectiveness of Instructional Interventions for Hemorrhage Control Readiness for Laypersons in the Public Access and Tourniquet Training Study (PATTS): A Randomized Clinical Trial

Author Affiliations
  • 1Brigham and Women’s Hospital, Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
  • 2Brigham and Women’s Hospital, Center for Surgery and Public Health, Department of Surgery, Harvard Medical School, Boston, Massachusetts
  • 3Brigham and Women’s Hospital, Division of Plastic Surgery, Department of Surgery, Harvard Medical School, Boston, Massachusetts
  • 4Brigham and Women’s Hospital, Division of Trauma, Department of Surgery, Harvard Medical School, Boston, Massachusetts
  • 5Deputy Editor, JAMA Surgery
JAMA Surg. 2018;153(9):791-799. doi:10.1001/jamasurg.2018.1099
Key Points

Question  How effective are point-of-care audio instructions, visual instructions, and in-person training at enabling laypeople to control hemorrhage using a tourniquet, and will they retain this skill?

Findings  In this randomized clinical trial, 465 participants were randomized to 4 arms to evaluate tourniquet application, and 303 (65.25) were assessed for retention 3 to 9 months after completing their training. Bleeding control training (88% correct application) was superior to control (16%) while flashcards (20%) and audio kits (23%) were not, and 3 to 9 months after training, 256 (55%) correctly applied a tourniquet.

Meaning  In-person training is currently the most efficacious means of enabling bystanders to control hemorrhage; however, investigating refresher training or improved point-of-care instructions is critical.


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

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