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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 105-109

Stop the Bleed: A nurse-driven community outreach initiative


1 Department of Nursing, New York-Presbyterian Hospital, New York, NY, USA
2 Department of Surgery, Weill Cornell Medicine, New York, NY, USA
3 Perioperative Services, New York-Presbyterian Hospital, New York, NY, USA

Date of Submission28-Jan-2019
Date of Decision26-Feb-2019
Date of Acceptance26-Mar-2019
Date of Web Publication29-Aug-2019

Correspondence Address:
Ms. Susan I Liu
BSN, RN, CCRN, TCRN, 525 E 68th Street, Box 137, L706, New York 10065, NY
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_6_19

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  Abstract 


Introduction: As part of a national public health initiative, our Level I Trauma Center has committed to training the public in bleeding control (B-Con) as part of the Stop the Bleed (StB) campaign. Our primary objectives were for nurse-led teams to present course materials to people with no healthcare background and to evaluate the impact of this training by participants' perceived ability to respond to life-threatening bleeding.
Methods: We initially launched trainings for hospital medical staff, followed by courses for community members, business entities, and academic institutions. Trainings consisted of a 30-minute lecture, followed by a skills session during which participants practiced wound compression, wound packing, and tourniquet application. Participants completed pre- and posttraining questionnaires to assess learning. Answers were scored on a five-point Likert scale. Results were entered into Qualtrics (Provo, UT).
Results: A total of 345 laypersons attended 43 StB training sessions. Nurses participated as skills' instructors at 100% of the trainings. Sixty-one percent of participants had previous cardiopulmonary resuscitation (CPR) or first aid training, while 9% reported prior B-Con training. Seventy-three percent of participants reported increased confidence in responding to an emergency medical situation after training, and 86% reported increased confidence in their ability to stop someone from bleeding.
Conclusion: Nurses are well equipped to teach healthcare topics in a community-based setting and represent an ideal instructor pool for the large-scale implementation of StB. Given the positive impact of this program, nurses should continue to play a crucial role in growing this nationwide hemorrhage control campaign.
The following core competencies are addressed in this article: Practice-based learning and improvement, Communication skills, and Medical knowledge.

Keywords: Education, hemorrhage control, nurse, Stop the Bleed


How to cite this article:
Liu SI, Curren J, Sobocinski K, Zambardino D, Smith LA, Rosenberg JO, Leahy NE, Winchell RJ, Narayan M. Stop the Bleed: A nurse-driven community outreach initiative. Int J Acad Med 2019;5:105-9

How to cite this URL:
Liu SI, Curren J, Sobocinski K, Zambardino D, Smith LA, Rosenberg JO, Leahy NE, Winchell RJ, Narayan M. Stop the Bleed: A nurse-driven community outreach initiative. Int J Acad Med [serial online] 2019 [cited 2019 Nov 20];5:105-9. Available from: http://www.ijam-web.org/text.asp?2019/5/2/105/265684




  Introduction Top


Trauma is the third leading cause of death around the world and is the most common cause of death among people aged 1–44 years.[1] In the United States in 2016, there were 231,991 reported deaths resulting from traumatic injuries.[2] Traumatic hemorrhage remains a leading cause of death in 30%–40% of patients, many of whom die before arrival to the hospital.[1] Hemorrhage control at the scene of an injury has the potential to reduce mortality by minimizing blood loss and preventing the development of an “early post-traumatic coagulopathic state.”[3] In addition, patients who develop hemorrhagic shock are more likely to develop complications such as organ failure and sepsis.[4] These findings present an opportunity for life-saving interventions in the prehospital setting.

In response to the mass shooting incident at Sandy Hook Elementary School in 2013, the American College of Surgeons (ACS), the Hartford Consensus, and the ACS Committee on Trauma developed the national “Stop the Bleed” (StB) campaign to improve survivability from traumatic hemorrhage. The StB curriculum, B-Con (bleeding control) was specifically designed to teach the principles of basic hemorrhage control to members of the public with no prior medical experience.[5] Laypersons who participate in StB training are provided basic knowledge and skills to act as immediate responders and control hemorrhage at the scene of an injury, improving the likelihood of victims surviving to reach definitive trauma care.[6]

As part of the national StB initiative, our Level I Trauma Center has committed to engaging and training the public in hemorrhage control techniques. Our primary objective was to empower members of our community to provide immediate life-saving hemorrhage control, whether in an isolated or multi-casualty response. The challenge of training large numbers of the lay public presented an ideal opportunity to engage in a nursing-led, community-based education program focused on the StB campaign. We developed nurse-led teams to teach B-Con to laypersons with no healthcare background and little to no prior training in emergency medical care (CPR/first aid or hemorrhage control). To ensure maximal benefit and efficacy of this program, we developed a survey to assess the impact of this nurse-led training on the participants' perceived ability to respond to an emergency bleeding scenario and to pass on acquired skills to others. We hypothesized that nursing-led teams could effectively teach B-Con and that laypersons that participated in our StB trainings would gain knowledge of hemorrhage control techniques and report increased confidence in their ability to perform these skills successfully.


  Methods Top


We developed nurse-led teams to teach B-Con to laypersons with no healthcare background and little to no prior training in emergency medical care (CPR/first aid or hemorrhage control). Trainings consisted of a 30-minute lecture using the standard B-Con curriculum given by a certified StB instructor, followed by a skills session during which participants practiced three B-Con skills: wound compression, wound packing, and tourniquet application. We utilized commercially available StB training kits containing rubber mannequins, hemostatic gauze, and tourniquets. Certified StB instructors observed that participants demonstrate correct application of each of the three hemorrhage control techniques. Skill sessions were held with a maximum ratio of eight trainees per instructor. Key concepts and demonstrations were repeated until each participant had mastered all of the skills.

Each participant completed pre- and posttraining questionnaires to assess comprehension of course content [Figure 1]. The pretraining questionnaire consisted of ten questions with five-point Likert scale answer choices. The posttraining questionnaire contained 17 questions with five-point Likert scale answer choices and one free response field for additional feedback. Questionnaires were completed on paper, and results were entered into Qualtrics (Provo, UT), a software program for survey distribution and data collection. Only questionnaires from laypersons were included in the analysis; data from medical professionals were excluded from the study.
Figure 1: Page 1 of pre- and posttraining survey

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This study received Institutional Review Board (IRB) exemption for utilization of survey results from StB participants. The first StB training was provided to the hospital security department's leadership, as they would be among the first responders to any in-hospital disaster. The next phase of training focused on building a team of StB trainers that could assist in community-based trainings. Medical professionals (physicians, nurses, physician assistants, nurse practitioners, and medical students) that completed the B-Con training became certified StB instructors. Courses were then expanded to community members and offered to business entities and academic institutions throughout the region. For each community course offered, nurse leaders organized training locations, advertised courses, recruited participants, and scheduled volunteer trainers to assist with instruction.


  Results Top


Forty-three StB training sessions were conducted between July 2017 and February 2018. Nurses participated as skills instructors at 100% of the trainings and presented the lecture portion at 40 of the 43 trainings (93%). A total of 345 laypersons, ranging in age from 18 to 80 years, completed the course. Data from 145 participants were excluded due to incomplete survey responses. Complete pre- and posttraining survey data from 200 participants were included in the analysis. Of these 200 participants, 126 (63%) had a 4-year college or advanced degree, and the remaining 74 (37%) completed a high school education, some college, or a 2-year degree. Among lay participants, 61% had previously taken a CPR or first aid training course, while only 9% reported receiving prior bleeding control training [Figure 2].
Figure 2: Participants' emergency medical training and hemorrhage control experience

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Ninety-four percent of lay participants reported that the course was taught in terms that were easy to understand, 73% reported an increase in their confidence in responding to an emergency medical situation after training, and 86% reported increased confidence in their ability to stop someone from bleeding [Figure 3]. In addition, 95% of StB trainees reported feeling somewhat or extremely comfortable teaching newly acquired B-Con skills to someone else.
Figure 3: Pre- and postcourse self-reported confidence in performing the three hemorrhage control techniques

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  Discussion Top


The StB initiative is a critical component in the fight against fatalities from traumatic hemorrhage, especially in the setting of mass casualty events. The role of bystanders as immediate responders has increasingly emerged as a focus for public safety efforts to minimize mortality from severe hemorrhage.[6] StB aims to provide the skills necessary to allow people to provide life-saving care at the time of injury, regardless of prior medical training or experience assisting in emergency medical situations. Tourniquets applied by civilians in the prehospital setting are associated with a significant reduction in mortality from traumatic hemorrhage.[7] This finding has been demonstrated in reports of injuries suffered following several recent mass casualty events. Of the 243 bystanders injured in the Boston Marathon bombing, 27 people arrived at hospitals with tourniquets applied; all of them survived.[8] Similarly, bleeding control assistance provided by bystanders after the Las Vegas shooting in 2017 is believed to have saved many lives.[9]

Education and communication with patients and family members are fundamental aspects of nursing care. Nurses are experienced in the use of nontechnical terminology and using multiple teaching methods (verbal discussion, written materials, hands-on training, and teach-back method).[10] StB trainings employ the use of several related teaching methods. The lecture is presented using non-technical terminology, and participants are encouraged to ask questions throughout. The presentation includes diagrams, photographs, and videos to enhance the quality of education. During the hands-on portion, participants are asked to perform the three hemorrhage control techniques. Trainers use the teach-back method to confirm that participants have understood the material presented and can successfully perform the skills.

In our StB initiative, nurses successfully taught B-Con to laypersons, who reported increased comfort levels applying the skills they learned. Laypersons who participated in StB courses taught by our team self-reported increased ability to recognize life-threatening hemorrhage, control bleeding, and even teach others these skills. Participants overwhelmingly reported that information was taught using language that was easy to understand and that they would feel confident teaching the skills learned to others. This study demonstrates that nurses are well equipped to teach healthcare topics in a community-based setting and therefore represent an ideal instructor pool for the large-scale implementation of StB.[11]

Our study had several limitations as a result of the nonrandomized, cross-sectional design. As course participants self-selected to complete the training, the results may reflect a positive learning experience which may not be generalizable to all students who are eligible to complete the course. Since there were no existing validated tools specifically for the StB training, we created our own. By making it publically available, we hope to give others the opportunity to use and improve on it. The surveys were anonymous, and contact information was not collected from participants for follow-up, precluding evaluation of long-term retention of knowledge and skills. This raises questions for how often participants need a refresher to maintain their skill set. Finally, the ability to perform skills in a simulated setting may not translate to clinical outcomes. More research is needed to assess whether participants can truly control and/or stop bleeding.


  Conclusion Top


Our study demonstrates that nurse-led teams can effectively teach B-Con techniques within the structure of the StB program. These nurse-led courses were well received by participants and effective in improving the participant's perceived knowledge and ability to intervene to control hemorrhage. Our study highlights the crucial role of nurses in growing this nationwide hemorrhage control campaign to save lives. Next steps may include working with local nursing schools to include hemorrhage control training in curriculum plans to engage new nurses to play an active role in continuing these efforts.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical conduct of research

This study was approved by the Institutional Review Board of Weill Cornell Medicine. The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines during the conduct of this research project.



 
  References Top

1.
El Sayad M, Noureddine H. Recent advances of hemorrhage management in severe trauma. Emerg Med Int 2014;2014:638956.  Back to cited text no. 1
    
2.
WISQARS Fatal Injury Reports. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2017. Available from: https://www.webappa.cdc.gov/sasweb/ncipc/mortrate.html. [Last accessed on 2019 Jan 11].  Back to cited text no. 2
    
3.
Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, et al. The European guideline on management of major bleeding and coagulopathy following trauma: Fourth edition. Crit Care 2016;20:100.  Back to cited text no. 3
    
4.
Kauvar DS, Wade CE. The epidemiology and modern management of traumatic hemorrhage: US and international perspectives. Crit Care 2005;9 Suppl 5:S1-9.  Back to cited text no. 4
    
5.
Bleeding Control. Available from: http://www.bleedingcontrol.org/. [Last accessed on 2019 Jan 11].  Back to cited text no. 5
    
6.
Jacobs L. (2015). The Hartford consensus III: Implementation of bleeding control. Available from: http://www.bulletin.facs.org/2015/07/the-hartford-consensus-iii-implementation-of-bleeding-control/. [Last accessed on 2019 Jan 11].  Back to cited text no. 6
    
7.
Teixeira PG, Brown CV, Emigh B, Long M, Foreman M, Eastridge B, et al. Civilian prehospital tourniquet use is associated with improved survival in patients with peripheral vascular injury. J Am Coll Surg 2018;226:769-76.e1.  Back to cited text no. 7
    
8.
King DR, Larentzakis A, Ramly EP, Boston Trauma Collaborative. Tourniquet use at the Boston marathon bombing: Lost in translation. J Trauma Acute Care Surg 2015;78:594-9.  Back to cited text no. 8
    
9.
Fink S. After the Las Vegas Shooting, Concertgoers Became Medics; 15 October, 2017. Available from: https://www.nytimes.com/2017/10/15/us/las-vegas-shooting-civilian-first-aid.html. [Last accessed 2019 Mar 15].  Back to cited text no. 9
    
10.
Ha Dinh TT, Bonner A, Clark R, Ramsbotham J, Hines S. The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: A systematic review. JBI Database System Rev Implement Rep 2016;14:210-47.  Back to cited text no. 10
    
11.
Smith LA, Caughey S, Liu S, Villegas C, Kilaru M, Gupta A, et al. World trauma education: Hemorrhage control training for healthcare providers in India. Trauma Surg Acute Care Open 2019;4:e000263.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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