SCHOOL-BASED HEMORRHAGE CONTROL TRAINING

School-Based Hemorrhage Control Training

Christina Maddaluna
Edson College of Nursing and Health Innovation, Arizona State University

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Abstract
Preventing deaths from uncontrolled bleeding remains a national priority, as mass causality
events in communities and schools continue to rise. National initiatives have been set in motion
by the Department of Homeland Security, to teach laypersons hemorrhage control techniques
while waiting for emergency personnel to arrive. A full and growing body of evidence supports
the use of hemorrhage control training classes among adult laypeople and is growing steadily in
the adolescent population. With the majority of shooting events occurring at high schools, the
implementation of a hemorrhage control training curriculum can increase survival rates among
high school students in the event of an active shooter. The purpose of this paper is to investigate
current knowledge and hemorrhage control practices among high school students and the
implication of implementing a hemorrhage control educational intervention by evaluating current
knowledge of hemorrhage control as well as their willingness, confidence, and perceived value
in hemorrhage control education. This evidenced-based assessment is proposed utilizing the
Social Learning Theory and Rosswurm and Larrabee’s implementation framework.
Keywords: hemorrhage control training, emergency preparedness, program evaluation,
school health, empowerment

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School-Based Hemorrhage Control Training
The number one cause of preventable death in trauma is uncontrolled bleeding. Even in
an era where emergency response times are approximately seven minutes, death from
uncontrolled bleeding can occur in as little as five minutes (Jones et al., 2019). Regardless of
emergency response times, during disastrous or mass casualty events, bystanders will always be
first on scene and are often the first to assist in an emergency (Zhao et al., 2019). With increasing
high school shootings nationwide, American adolescents are becoming the first bystanders on
scene, indicating a need to incorporate hemorrhage control training in schools.
Problem Statement
Active shooter events are an increasing public health concern affecting our schools,
communities, and nation. Since 2018 alone, there have been 324 injuries and fatalities from a
total of 250 school shooting incidents in the United States (USDHS, 2020). According to the
Centers for Homeland Defense and Security (CHDS), the majority of school shooting incidents
happen in high schools, leaving our adolescents at the highest risk for being involved in an active
shooter event (CHDS, 2020). Schools have a federal obligation to protect and keep safe the
children within their care, to anticipate potential dangers, and take precautions to protect students
from such dangers (Alert Lockdown Inform Counter Evacuate [ALICE], 2015). Federally
regulated Emergency Operating Procedures (EOPs) now require schools to develop a plan for
staff and student response to an active shooter event. Many schools, however, lack proper
emergency plans, supplies, and do not incorporate mass-casualty training events or education on
hemorrhage control techniques, leaving students more vulnerable and less prepared (ALICE,
2015; Kano et al., 2007).
Purpose and Rationale

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The purpose of this project is to distinguish the value and need to implement hemorrhage
control techniques into an already established simulated mass casualty event for adolescents during
high school. This needs assessment will be the first of its kind and will add to the growing body of
literature surrounding hemorrhage control training for the adolescent population. Implementing
hemorrhage control training in a high school simulated mass casualty event provides our most at
risk population with the knowledge, tools, and empowerment they need to survive, and help others
survive, a life-threatening bleeding event (Zhao et al., 2019).
Background and Significance
In the wake of the 2012 Sandy Hook Elementary school shooting, autopsies revealed
more lives could have been saved if bleeding control techniques were applied sooner. With
uncontrolled bleeding being the number one cause of trauma related death in the world, the need to
disseminate hemorrhage control teaching and training to laypeople is evident (ACS, 2020; Stop the
Bleed, 2015). The Hartford Consensus, developed through collaboration of the American College
of Surgeons (ACS), the United States Department of Homeland Security (USDHS), and other
government and nongovernment agencies, determined the need for access to hemorrhage control
kits in public areas as well as public access to hemorrhage control training that could be utilized
in emergencies (ACS, 2020; Zhao et al., 2019). This report prompted the USDHS in 2015 to
implement the national Stop the Bleed (STB) coalition to train laypeople on proper bleeding
control techniques and to instill confidence and willingness to react to a bleeding event (Ali et
al., 2019; Zhao et al., 2019; Ross et al., 2018).
High School Students
With increasing public active shooter events nationwide, high schools remain at the highest
risk for school related active shooter events (Centers for Homeland Security and Defense, 2020).

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While schools are charged with protecting and preparing students for many types of emergency
situations, many schools continue to fall below federal regulations for preparedness in the event of
an active shooter (ALICE, 2015). In response to the increasing number of high school shootings,
USDHS worked to institute measures to offer hemorrhage control training specifically to high
school students. The USDHS created the School-Age Trauma Training program which aims to
create a long-term self-sustaining program among high schools to disseminate lifesaving trauma
training for mass casualty events (USDHS, 2018).
Hemorrhage Control Training
Pre-hospital application of a tourniquet to a major wound before arrival to a trauma center
has been shown to significantly reduced mortality due to hemorrhagic shock (Scerbo et al., 2017;
Kue et al., 2015; Kragh et al., 2008). Many studies have shown that, with STB training, lay people
are more confident in their abilities to tourniquet and more willing to tourniquet in an emergency
situation (Jones et al., 2019; Lei et al., 2019; McCarty et al., 2019; Tsur et al., 2019; Zhao et al.,
2019; Zwislewski et al., 2019; Goralnick et al., 2018; Ross et al., 2018). In person, hands-on STB
hemorrhage control training has shown to be the most successful way to deliver this education
among lay people (Ali et al., 2019; Goralnick et al., 2018; Zwislewski et al., 2019). In person,
hands-on-training has also been shown to improve tourniquet application techniques and showed
an increased likelihood of effective tourniquet application post-training (Ali et al., 2019;
Zwislewski et al., 2019).
Current Hemorrhage Control Training
While schools are federally obligated to plan and prepare for an active shooter event, there
is no current federal guideline supporting the mandatory implementation of hemorrhage control
training in high schools (ALICE, 2015; Kano et al., 2007). Although the USDHS has funded a

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$1.8 million grant to implement the School-Age Trauma Training program, it is still unclear how
the development of this program will translate to high schools nationwide (USDHS, 2020).
Currently, most states have implemented legislation requiring cardiopulmonary resuscitation
(CPR) before high school graduation. However, CPR training does not currently incorporate
lifesaving hemorrhage control techniques with use of conventional and unconventional tourniquet
devices.
Self-efficacy and Willingness to Apply Hemorrhage Control Techniques
Many studies have evaluated participant confidence, competence, and willingness to assist
in an emergency bleeding event post STB and other nationally recognized hemorrhage control
training. Findings from these studies reported increased confidence and competence post in-person
hands-on hemorrhage control training (Bondmass, 2019; Goralnick et al., 2018; Lei et al., 2019;
McCarty et al., 2019; Ross et al., 2018; Schroll et al., 2020, Tsur et al., 2019; Zwislewski et al.,
2019). Along with increased confidence and competence, these studies also reported on retention
of tourniquet skills and have found retention of skills is best with hands-on application of
techniques. However, studies have also concluded that repeated practice of skills and re-fresher
courses increase competence and effective tourniquet application which supports hosting an annual
simulated mass casualty event (Baruch et al., 2016; Pasely et al., 2018; Weinman et al., 2019;
Zwislewski et al., 2019).
Overall, current evidence and national initiatives support the implementation of
hemorrhage control training to the general public, as well as targeted training courses for high
school students. Studies on this topic support hands-on, in-person educational training for skill
acquisition with re-fresher courses to enhance confidence, competence, and retention of tourniquet
application (Ali et al., 2019; Goralnick et al., 2018; McCarty et al., 2019; Tsur et al., 2019;

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Weinman et al., 2019; Zwislewski et al., 2019). Hemorrhage control training has the capacity to
become the standard of care for schools aiming to improve school compliance with federal
guidelines by acknowledging the school’s duty to protect students at the district level by
developing a comprehensive district wide safety plan.
Internal Evidence
A rural high school located in the Southwestern United States, serving 2,200 students
grades nine through 12, currently uses the alert, lockdown, inform, counter, evacuate (ALICE)
enhanced school lockdown procedures. The goals of ALICE procedures are to inform, empower,
and create awareness with teachers and students in an aim to increase survivability in an active
shooter event (ALICE, 2015). Schools have a duty to protect students from injury. ALICE 2015
performed a case study discussing the new federal guidelines, finding many schools missing the
mark on meeting these new guidelines and recommendations. If a school is found to have not used
an appropriate standard of care, the district could be held liable for negligence (ALICE, 2015).
This high school is currently hosting a mass-casualty event although, only students
involved in Junior Reserve Officer’s Training Corps (JROTC), sports medicine, and medical
professional programs are allowed to participate. Besides not providing for participation or
education to students outside these programs, the fundamentals of hemorrhage control are not
incorporated in the current mass-casualty event. With the growing frequency of school shootings,
schools are in a unique position to disseminate theses teachings to their students, and thereby
increase survivability in an active shooter event.
PICOT Question
This inquiry has led to the question: “Among high school students, would receiving
hemorrhage control training in a simulated mass casualty event, compared to traditional first aid

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training, affect students’ report of confidence, performance, knowledge, and willingness to apply
hemorrhage control techniques during high school?”
Search Strategy
To address this PICOT question, an exhaustive literature review was conducted among
three databases; Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed,
and the Cochrane Library. The selection of these databases was based on their relevancy to the
topic of hemorrhage control as well as their consistency, objectivity, and accuracy of published
works supporting the medical professions. Keywords utilized for all three databases were
targeted to each component of the PICOT question with the use of Boolean connectors ‘OR’ to
widen search results as the topic of hemorrhage control training to adolescents is relatively new
and research is limited. All keywords for each component of the PICOT question where searched
collectively and connected with the Boolean phrase ‘AND’ between each of the components
search terms.
Prior to searching each database, filters were set to only include articles that were peerreviewed, English language, and had a date of publication between January 1, 2015 to January 1,
2020. Search terms utilized for population included: high school students, adolescents, young
adults, teens, teenagers, and high schooler. Intervention search terms included: Stop the Bleed,
tourniquet training, tourniquet, hemorrhage control, and bleeding control. Comparison search
terms were specified to current forms of life saving measures including: first aid, CPR, BLS, and
basic life support. Outcome search terms included: knowledge, competence, confidence, and
skills.
The initial PubMed database search utilized all search terms as listed above and resulted
15 articles which then led to a search of similar articles leading to 106 results. Further review of

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the 106 similar articles led to two other similar article searches resulting in another 127 and 130
articles. Titles and abstracts from all four of these searches were reviewed, all of which,
resulted the same original 15 articles populated from the utilization of all PICOT component
search terms. From this search a total of 35 articles were selected for further review.
The initial Cochrane Library search, utilizing all search terms from each component of
the PICOT question, resulted in nine Cochrane reviews that matched the defined search criteria.
All search terms were utilized to broaden search results as well as elimination of certain PICOT
components for new searches that did not yield any new results and resulted in zero matches.
Considering the nature of this PICOT question and its relatively newer aim toward hemorrhage
control teaching to laypersons, none of the original nine Cochrane results met inclusion criteria.
The initial CINAHL search utilized all search terms from each component of the PICOT
question as listed above and resulted in three articles, two of which were selected for review.
Different searches were conducted eliminating different components of the PICOT to widen
search results, however, when search terms from differing components were eliminated the
search resulted in zero articles. All three article abstracts were reviewed and selected for further
evaluation.
Of the 38 chosen studies, 26 studies were identified as relevant from the database
searches. Reference lists were reviewed for other pertinent studies finding no other relevant
studies meeting criteria for this literature review. All 26 relevant studies were further evaluated
against inclusion and exclusion criteria. Inclusion criteria were studies targeting laypersons, any
method of hemorrhage control training or teaching, and review of skill acquisition or skill
retainment. Exclusion criteria included any studies targeting healthcare workers, emergency
services personnel, or any population with previous medical training. Once evaluated against

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inclusion and exclusion criteria 18 articles remained and a rapid critical appraisal was performed
for each, ten of which were chosen for a further in-depth thorough review (Appendix B).
Critical Appraisal and Synthesis
Ten studies were selected for this literature review and were critically appraised utilizing
the Melnyk and Fineout-Overholt’s (2011) rapid critical appraisal checklist to assess quality and
validity. Of the 10 articles, four were randomized control trials (RCTs), four were mixed
methods non-randomized non-controlled studies, and two were cross-sectional observational
studies (Appendix A). Given the relative novelty of hemorrhage control training to laypersons,
no systematic reviews have been conducted, and RCTs were limited due to strict inclusion
criteria. The novelty of this evidence is also seen in the year of publication, with more than half
of the included studies published in 2019 (Appendix B). No bias was noted in any of the selected
articles, only five articles discussed funding, and all but two were conducted in the United States
of America.
All studies utilized adult populations, with a mean participant age between 30 and 60
years, rather than the intended adolescent population age. In all but two studies, the participants
included were exclusively non-medically trained laypersons, as will be the project’s targeted
high school population. Overall, a strong degree of homogeneity was seen in sample
demographics among all 10 studies, as well as variables of interest. All 10 studies evaluated
correct tourniquet placement following an educational intervention, provided hands-on practice,
and evaluated participant knowledge of tourniquet application (Appendix B). Measurement tools
were consistent across all 10 studies utilizing direct observation for skill attainment, and
tourniquet placement via trained study personnel. More than half of the articles also utilized pre
and post questionnaires to evaluate participant responses to educational interventions in relation

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to increased knowledge, willingness, and comfort in tourniquet application. Primary outcomes
across all 10 studies identified correct tourniquet application after an educational intervention,
hands-on practice, as well as increased tourniquet knowledge.
Conclusion
Hemorrhage control training among laypersons is a novel approach thought to improve
survival among community members should a mass casualty event occur. National initiatives,
including the Stop the Bleed campaign, are quickly gaining momentum to help bystanders
intervene and stop blood loss before the arrival of emergency services. While this topic is still
undergoing research and testing, current evidence is already showing success in laypersons’
ability to correctly apply tourniquets after an educational intervention, and hands-on practice.
Evidence has also shown an increased willingness, and preparedness to intervene for a stranger
after completion of hemorrhage control training. With high schools having the highest rates of
active shooter events, this project has the capacity to positively impact high school student
survival rates should an active shooter event occur. By implementing a hemorrhage control
training intervention, nurse practitioners, pediatric and adult alike, can have a profound impact
on the safety, wellbeing, and survival of their community members.
Conceptual Framework and EBP Model
Albert Bandura’s Social Learning Theory (SLT) was chosen as the underpinning theory
of this project as it clarifies how adolescents learn (Appendix C). SLT fits well into the paradigm
of this project and encompasses cognitive, behavioral, and environmental factors of the
adolescent learner. Applying SLT to the adolescent learner will promote observing and role
modeling positive behaviors, encourage confidence in adolescent’s capability of acquiring and
practicing new skills, allow learners to gain a positive attitude toward new skills, and increase

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self-efficacy in implementing and utilizing newly acquired skills (Butts & Rich, 2018). This
project is based on a need’s assessment for the implementation of an educational intervention
thus, understanding the way adolescents learn will help guide and predict the outcomes and best
measures to take during the implementation of the proposed educational intervention.
While the SLT presents a way to understand and predict the cognitive, behavioral, and
environmental needs necessary to develop a successful educational intervention, Rosswurm and
Larrabee’s model guided the application and implementation of evidence for this project
(Appendix D). Rosswurm and Larrabee’s (1999) model provided a systematic approach for the
implementation process of evidenced-based change from assessing the need for change, linking
problems to interventions, synthesis of evidence, designing a practice change, implementing and
evaluating change, to the integration and maintenance of change (Appendix D). This
implementation framework was well suited for this project in its inherent structure and utilization
of both quantitative and qualitative data, and contextual evidence which supports the current
body of evidence on this topic. Incorporation of both the SLT and the Rosswurm and Larrabee
implementation model provided continuity during the translation of evidence to practice process
in a systematic well-organized manner.
Applying Evidence to Practice
Implications for this practice change have the potential for a profound effect on the
survivability of those involved in a mass casualty or serious bleeding event by implementing an
educational hemorrhage control training course. Evidence shows one-day hemorrhage control
training sessions have a positive effect on not only skill acquisition of hemorrhage control
techniques, but increase knowledge, confidence, and willingness of participants to react during a
bleeding event. Stop the Bleed (STB) training is a national initiative from the United States

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Department of Homeland Security (DHS). This one-day training course was developed to teach
laypeople hemorrhage control techniques until the arrival of emergency personnel. This course
focuses on identification of severe bleeding, immediate application of manual pressure,
tourniquet application, and wound packing techniques. Currently, STB training consists of a
brief slide show presentation, discussion of hemorrhage control techniques, and hands-on
practice. Success among adult layperson populations has been seen throughout the literature
however, little research on STB training in the adolescent population has been performed to date.
With more than half the current evidence utilizing this nationally recognized teaching program,
the likelihood of its success in a local high school with an adolescent population remains high.
Methods
Overall Study Design
The overall study design of this evidenced-based needs assessment was completed in five
phases. The recruitment phase initially consisted of identification of students participating in
HOSA programs and was followed by, phase two, a recruitment speech to students in the HOSA
medical professions and sports medicine programs. Determination of eligibility to sit for the
student survey and dissemination and collection of parental informed consents marked phase
three. Next students and staff completed an online survey which was directed at evaluating
values and beliefs towards hemorrhage control training. Finally, data analysis was performed on
both the student and faculty surveys.
Ethics
Permission to conduct this evidenced-based needs assessment was granted by expedited
review from the Arizona State University Institutional Review Board on October 12, 2020
lasting one year from approval date. To protect participant privacy, no personal identifying

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information was collected during the survey dissemination process. All survey responses were
collected via QuestionPro software utilizing anonymously generated identification numbers to
preserve anonymity of responses. All participating faculty, staff, and students 18 years of age
and older were required to consent electronically prior to the start of the survey. All minor
students, ages 14-17, were required to provide written parental consent along with school issued
identification badge to verify written consent matched the student present prior to admittance to
sit and take the survey. All minor students were also required to electronically assent to the
survey prior to survey start. Students’ faculty remained present throughout the entirety of the
intervention process.
Recruitment
Upon receiving IRB approval, recruitment initially consisted of identification of students
participating in HOSA programs, as these students have an expressed interest in healthcare
directed programs. Due to faculty turnover midsemester, students in the HOSA JROTC program
were unable to participate in this intervention and recruitment was limited to the medical
professions and sports medicine programs. Recruitment was performed via speech to students
utilizing a Zoom session during class time. Between these two programs, 133 students were
recruited by a short speech discussing project specifics and goals. Recruitment for all 93 faculty
members was performed via email. Inclusion criteria for students in this project consisted of
enrollment in either the medical professions or sports medicine program at the project site and
furnishing a signed parental consent with school issued identification for all minors aged 14-17
years. Inclusion criteria for faculty consisted of being 18 years or older and employed at project
site. Exclusion criteria for students included not being enrolled in either the medical professions

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or sports medicine program and no signed parental consent for minor students. Exclusion criteria
for faculty included any faculty member who was not directly employed at the project site.
Setting
This evidence-based project took place at a local high school in a rural community in the
Southwestern US. This high school is currently hosting an annual mass casualty (MASCAL)
event with participation from both the medical professions and sports medicine programs. These
students were targeted in their ability to utilize hemorrhage control training in this annual event.
All 100 students currently enrolled in the sports medicine program and the 33 medical
professions students were invited to participate in this needs assessment.
Intervention
Layperson hemorrhage control training has shown to be a successful grassroots effort to
improve survivability of a serious bleeding event. The project aimed to utilize surveys to
understand faculty and students’ attitudes, values, and beliefs toward hemorrhage control
training as well as faculty perceived preparedness for a serious bleeding event. This evidencedbased needs assessment took place over a 4-week period in which the faculty survey was sent via
email to all faculty members and remained open for one week before closing in which 49 (53%)
faculty members participated. The student survey took place during a one-day session in an oncampus computer lab with site champion and student faculty present where 80 (60%) students
participated.
Measures
The primary outcome variable for this project included understanding student and faculty
perceived attitudes, values, and beliefs, toward receiving hemorrhage control training. This data
was gathered using two originally created surveys due to the lack of hemorrhage control self-

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efficacy measurement tools. The student survey created was five questions, three dichotomous
and two five-point Likert scale, to evaluate student willingness to participate in and utilize
hemorrhage control training as well as understand their perceived value toward hemorrhage
control training. The faculty survey created was seven questions, five dichotomous and two fivepoint Likert scale, to evaluate perceived school preparedness, value of hemorrhage control
training, and likelihood of utilizing the training if needed. Both surveys are non-standardized
measures that have not been tested for validity or reliability but were created from previous
research and theory utilizing combination dichotomous and Likert style questions to evaluate
willingness, value, and comfort level (Ali et al., 2019; Ross et al., 2018).
Data Analysis
The primary analysis for the student and faculty survey was to understand perceived
value, willingness, and desire to receive hemorrhage control training. Secondarily, faculty
perceived school preparedness to respond to a serious bleeding was also evaluated to better
understand and quantify the need for hemorrhage control training implementation. Statistical
data was collected via QuestionPro software and exported to Intellectus software where it was
stored and analyzed using descriptive statistics to describe the outcome variable.
Results
Statistical analysis was conducted utilizing descriptive statistics to determine student and
faculty perceived value, willingness, and need for hemorrhage control training. The results of the
student survey (Figure C1) found 96% of students believe hemorrhage control training would be
beneficial, 81% feel unprepared to handle a serious bleeding event, 85% want training. However,
only 38% said they would be very likely to utilize received training. These results suggest
students do want and value hemorrhage control training and do feel unprepared to handle a

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serious bleeding event. While only 38% of students reported feeling very likely to utilize
hemorrhage control training, this may be, in part, due to a lack of understanding of what skills
they would be deploying and perceived self-efficacy of skill utilization after educational
intervention.
The results of the faculty survey (Figure C2) found only 20% of faculty have received
hemorrhage control training, only 2.4% were aware that their school offered hemorrhage control
training to faculty, 54% felt the school was unprepared to handle a serious bleeding event and
44% reported feeling very likely to assist with a serious bleeding event with the proper training.
The faculty survey also suggests that while only 2.4% of faculty have received hemorrhage
control training, 63% currently feel comfortable providing interventions for a serious bleeding
event.
Discussion
Evidence strongly supports the implementation of hemorrhage control training among
laypersons and implementing training programs that specifically target adolescents are essential
as the majority of school shooting events occur in high schools. The findings from this needs
assessment strongly depicts the desire and value seen in hemorrhage control training by students
and faculty. The findings from both surveys also suggest an overall feeling of unpreparedness
personally and in relation to the school’s ability to appropriately handle and respond to a lifethreatening bleeding event. Layperson hemorrhage control training can provide students and
faculty with not only the skills to stop a serious bleed but also the confidence to utilize learned
skills and techniques.
Limitations

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Limitations of this project consist of the use of originally made self-report surveys and
inability to perform hands-on in-person training due to the COVID-19 pandemic. Additionally,
the student survey was only open to HOSA students who already have a direct interest in
healthcare and did not capture the attitudes, values, and beliefs of the general student population.
Future Implications
Future studies targeting the adolescent population with more representative student
populations are required to broaden and support the growing body of evidence surrounding
hemorrhage control training for high school adolescents. Future research should include
implementing hands-on in-person training with pre- and post-surveys to evaluate self-efficacy of
learned skills and skill acquisition. Additionally, future studies should also examine the
adolescent learner’s ability to retain learned skills by providing a post evaluation sometime after
initial implementation.
Conclusion
Layperson hemorrhage control training is a novel approach aimed to improve survival
from life-threatening bleeding events. The aim of this evaluation assessment was to better
understand student and faculty values and beliefs toward receiving hemorrhage control training
to support and direct future implementation of a hemorrhage control educational intervention.
Current evidence surrounding layperson hemorrhage control training strongly supports its value
and effectiveness among adult learners. This project adds insight into adolescent attitudes,
values, and beliefs towards hemorrhage control training for this growing body of evidence.
Implementation of hemorrhage control training among high school students has the potential to
increase the likelihood of student survival should an active shooter or serious bleeding event
occur. Another potential outcome of this project is the transference of learned lifesaving skills to

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other everyday scenarios such as accidental injuries, falls, and vehicle collisions. Effectively
delivering hemorrhage control training to high school adolescents has the potential to give our
most at-risk population the greatest chance for survival.

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The Journal of Trauma, 64(2), 38-49. https://doi.org/10.1097/TA.0b013e31816086b1
Lei, R., Swartz, M. D., Harvin, J. A., Cotton, B. A., Holcomb, J. B., Wade, C. E., & Adams, S.
D. (2019). Stop the bleed training empowers learners to act to prevent unnecessary
hemorrhagic death. American Journal of Surgery, 217(2), 368–372.
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McCarty, J. C., Hashmi, Z. G., Herrera-Escobar, J. P., de Jager, E., Chaudhary, M. A., Lipsitz, S.
R., Jarman, M., Caterson, E. J., & Goralnick, E. (2019). Effectiveness of the American
College of Surgeons Bleeding Control Basic Training Among Laypeople Applying
Different Tourniquet Types: A Randomized Clinical Trial. JAMA Surgery, 154(10), 923.
https://doi.org/10.1001/jamasurg.2019.2275
Pasley, A. M., Parker, B. M., Levy, M. J., Christiani, A., Dubose, J., Brenner, M. L., Scalea, T.,
& Pasley, J. D. (2018). Stop the bleed: Does the training work one month out? The
American Surgeon, 84(10), 1635–1638. https://pubmed.ncbi.nlm.nih.gov/30747685/
Ross, E. M., Redman, T. T., Mapp, J. G., Brown, D. J., Tanaka, K., Cooley, C. W., Kharod, C.
U., & Wampler, D. A. (2018). Stop the Bleed: The effect of hemorrhage control
education on laypersons’ willingness to respond during a traumatic medical emergency.
Prehospital and Disaster Medicine, 33(2), 127–132.
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hemorrhage control techniques. The Journal of Surgical Research, 245, 636–642.
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USDHS. (2018). School-Age Trauma Training. https://www.grants.gov/web/grants/viewopportunity.html?oppId=307563
Weinman, S. (2019). Retention of tourniquet application skills following participation in a
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Emergency Department Nurses Association. https://doi.org/10.1016/j.jen.2019.10.020
Zhao, K. L., Herrenkohl, M., Paulsen, M., Bulger, E. M., Vavilala, M. S., Moore, M., & Pham,
T. N. (2019). Learners’ perspectives on stop the bleed: A course to improve survival
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Zwislewski, A., Nanassy, A. D., Meyer, L. K., Scantling, D., Jankowski, M. A., Blinstrub, G., &
Grewal, H. (2019). Practice makes perfect: The impact of stop the bleed training on
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workplace. Injury, 50(4), 864–868. https://doi.org/10.1016/j.injury.2019.03.025

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING

24

Appendix A
Evaluation and Synthesis Tables
Table A1
Evaluation Table Quantitative Studies
Citation

Ali et al.,
2019
Teaching
how to stop
the bleed:
Does it
work? A
prospective
evaluation
of tourniquet
application
in law
enforcement
officers and
private
security
personnel.
Country:
U.S.A.
Funding:
Not
disclosed.

Theory/
Conceptual
Framework
Adult
Learning
Theory

Design/
Method

Design:
Mixed
methods
NRNCT
(pre-&posttest)
Purpose:
To assess
correct
tourniquet
knowledge
and
comfort
level of
tourniquet
application
after 7
didactic
and
practical
sessions.

Sample/ Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data Analysis

N: 151

IV: Correct
tourniquet
placement in a
simulated
scenario

DO of skills
DV1, DV2

Likert Scale
for pre/post
questionnaire

Site:
Recreational
site in
community.
Demographics:
118 (78%)
male, 28
(18.5%) female,
5 (3.5%) otherno answer
provided
Inclusion:
Police officers
and security
personnel from
secondary
schools,
universities,
hospitals, and

DV1: Correct
tourniquet
placement
DV2: Time to
tourniquet
application
DV3: Increased
Comfort
applying
tourniquet
DV4: Familiarity
with anatomy
and bleeding
control

Selfassessment,
DV3, DV4

Fisher’s exact
tests or
Wilcoxon
matched-pairs
signed-ranked
tests to
compare prepost
measurements

Findings/
Results

DV1: Pre17.2%
(26/151);
post-92.7%
(140/151)
DV2:
Mean times
were pre
29.8 ±18.5
to post 18.7
± 6.7
(p<0.001)
DV3: 5.1 ±
3.3 to 8.8 ±
2.2,
(p<0.001)
DV4: 9.2 ±
1.9 (95%
CI 8.9-9.5)

Level/Quality of
Evidence; Decision for
practice/ application to
practice
LOE: III
Strengths: Mixed
methodology supports
a well-rounded view
of B-Con intervention.
Appropriate analysis
for quantitative and
qualitative data.
Study subjects had no
previous tourniquet
knowledge, quantified
by Likert results.
Structured course
based on STB
guidelines.
Weaknesses: Level III
evidence. Small study
group. Some
participants were
allowed to practice
multiple times. Only
evaluation of skills

Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Citation

Theory/
Conceptual
Framework

Design/
Method

Bias:
None
noted.

Baruch et
al., 2016

Sample/ Setting

Major Variables
& Definitions

25
Measurement/
Instrumentation

Data Analysis

Findings/
Results

commercial
businesses.

was immediately post
training. Did not focus
on civilian population,
may not be
generalizable to
general population.

Attrition:
No participants
lost.

Inferred
Adult
Learning
Model

Design:
Prospective
Educational
study.
Mixed
methods
NRNCT
(pre-&posttest).

N: 156
n: 87 (TAP)
n: 69 (SAP)

Level/Quality of
Evidence; Decision for
practice/ application to
practice

IV: Effective
application of
tourniquet after
either SAP or
TAP.

Direct
observation and
evaluation of no
distal pulse
from tourniquet
site.

Intragroup
comparisons
of continuous
data, a paired t
test was used.

DV1: No
significant
difference
(P =0.6)
between
SAP and
TAP
groups
ability to
apply
pressure.

Conclusions: STB
course has immediate
and reproducible on
tourniquet application
and skill acquisition.
LOE: III

Strengths:
Does
Appropriate analysis
practice
Site: Israeli
for quantitative data.
make
military
Participants had not
DV1:
A χ2 test was
perfect?
platoon.
previous tourniquet
Participants able
used for
Prospectivel
training. Study was
categorical
y comparing
Demographics: to apply pressure
conducted in the field
data.
effects of 2
All new male
under real combat
amounts of
Purpose:
recruits age 18- DV2:
situations.
Participants
practice on
To
20, median age
The Student t
DV2:
application time.
tourniquet
compare to 18, from a
Weaknesses:
test was
Significant Population not
DV3:
use
amounts of single infantry
performed, all
difference
performance
practice of
brigade enlisted Participants
generalizable. High
t tests were 2
was
seen
in
unable to apply
Country:
tourniquet
for active duty.
dropout rate. Lower
tailed.
TAP
Israel
training.
Inclusion: Had pressure.
level of evidence. Not
A Cochranparticipants
Funding:
to be a qualified
generalizable to the
Mantelapplication general public.
No funding
“Life Saver”,
Haenszel test
time (p
from
42 recruits were
was used
<0.001).
commercial,
excluded
Conclusion: The TAP
between
not-forbecause they
was more effective
groups and
Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Citation

Theory/
Conceptual
Framework

Design/
Method

profit, or
private
section
utilized.
Bias: None
declared.

Goolsby et
al., 2016
Analysis of
layperson
tourniquet
application
using a
novel colorcoded
device

Sample/ Setting

Major Variables
& Definitions

26
Measurement/
Instrumentation

were not
qualified “Life
Savers.
Attrition: 108
dropped out of
the study during
initial
assessment and
43 were not
available for
final
assessment.

Inferred
Trial
Design
Model

Design:
Prospective
RCT

N: 157
n: 72 (ColorCoded)
n: 85 (All
black)

Data Analysis

Findings/
Results

across
assessments
for those
unable to
apply pressure.

DV3: TAP
group
improved
more than
the SAP
group in
their ability
to improve
those who
could not
apply any
pressure
18%
reduction
verses an
8%
reduction;
P = .009

than SAP, this
knowledge can be
applied to other
organizations and BCon classes.

DV1:
51.38% (n
= 37)
applied the
device
correctly.

LOE: II

Significance
set as P ≤ .05
for all tests.

IV: Correct
application of the
tourniquet

Direct
observation of
tourniquet
application by
medically
trained staff.

Chi-squared or
Fisher’s exact
tests for
proportions.

Level/Quality of
Evidence; Decision for
practice/ application to
practice

Strengths: RCT level
design, inherently
high-level evidence.
Statistical analysis
used was appropriate
for this study.
Findings of this study
are generalizable to
the general population.

Purpose:
DV1:
to evaluate
Color-coded
Mann-Whitney
the lay
Site: University tourniquet
testing was
person
in midwestern
DV2:
done for
ability to
DV2: All black
U.S.A.
44.71% (n
comfort level
use a colortourniquet
= 38)
and time to
coded
Demographics:
applied the
successful
Color-coded
tourniquet
device
application.
Weaknesses:
31% male, All
designed
Country:
correctly.
Occurred in a
black 38%
for lay
U.S.A.
person
male.
controlled
Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Citation

Theory/
Conceptual
Framework

Funding:
Funded by
the USU
Office of
Research
and the
Office of the
Dean
through the
Capstone
Student
Research
Program
Bias: None
noted.

Goralnick
et al., 2018
Effectivenes
s of
instructional
intervention
s for
hemorrhage
control

Design/
Method

rather than
a combat
application
tourniquet.

Inferred
Trial
Design
Model

Design:
RCT
Purpose:
To
determine
the
effectivene
ss of
different

Sample/ Setting

Major Variables
& Definitions

27
Measurement/
Instrumentation

Data Analysis

Mean age 35.5
color-coded,
32.5 all black.
Exclusion:
Less than 18,
having military
experience in
that last 15
years, prior
tourniquet
training, being a
licensed
healthcare
provider, or
medical training
beyond high
school CPR.
Attrition:
None lost.

N: 464
laypersons
n: 232 (CG)
n: 232 (IG)
Participants
divided equally
among the
study arms.

IV: Correct
tourniquet
application in a
simulated
scenario
DV1:
Instructional
Flash cards

Observer
recorded
whether or not
tourniquet was
applied
properly in
simulated
scenario.

Wilcoxon rank
sum test to
compare time
with correct
tourniquet
placement
across arms.

Findings/
Results

Level/Quality of
Evidence; Decision for
practice/ application to
practice

6.67%
difference
between
tourniquets
not
statistically
significant,
(risk ratio
[RR]: 1.15;
95%
confidence
interval
[CI]: 0.831.59; P =
0.404, chisquare
test).

environment.
Soliciting with poster
could induce a
selection bias. Small
population. Only
assessed laypeople
ability to apply
tourniquet but not
when to actually use
one.

DV3:
highest
proportion
of correct
tourniquet
application
s (87.7%;
95% CI,
81.8-93.6)
compared

LOE: Level II

Conclusions:
Laypeople are capable
of applying
tourniquets
successfully. Their
application time is
likely fast enough to
save lives.

Strengths: RCT level
design. Detailed
discussion of
interventions. Findings
of this study are
generalizable to the
general population.

Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Citation

readiness for
laypersons
in the public
access and
tourniquet
training
study
(PATTS): A
randomized
clinical trial.
Country:
U.S.A.
Funding:
Partially
supported by
the Gillian
Reny
Stepping
Strong
Center for
Trauma
Innovation.
Bias:
None noted.

Theory/
Conceptual
Framework

Design/
Method

instructiona
l
interventio
ns and inperson HC
training
compared
to no
interventio
n and
assess skill
retention 39 months
after
training.

28

Sample/ Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Site: Sports
stadium in
Massachusetts

DV2: audio kits
with embedded
flashcards
DV3: B-con
course

Observers were
medically
trained
professionals.

Demographics:
Of the 464
participants 189
were female
leaving a higher
proportion of
men.
Highest level of
education: 111
(21.7%)
reported high
school or less;
189 (40.7%)
had some
college; 128
(27.5%) had a
bachelor’s
degree; 36
(7.7%) had an
advanced
degree.
Exclusion:
Anyone with
previous
hemorrhage
control training
Attrition: Of
the 464

Data Analysis

2-sided Fisher
exact tests for
categorical
variables with
logistic
regression
analysis to
identify any
demographic
associations
with correct
tourniquet
placement.

Findings/
Results

Level/Quality of
Evidence; Decision for
practice/ application to
practice

with
control
group
(16.3%;
95%CI,
9.1-23.6;
P<.001).
No
difference
in
successful
tourniquet
placement
between
DV1 or
DV2
compared
to control
arm.

Weaknesses: B-con
technique is hard to
evaluate in a
simulation setting.
Scenario does not
mimic stress and chaos
of a true emergency.
Evaluators were not
blinded, although
given the wide range
of differences seen
potential for bias is
minimal. 35% of the
sample was lost to
follow-up.

DV1:
19.7%;
95% CI,
12.3-27.0
DV2:
23.0%;
95% CI;
15.4-30.5)

Conclusions: B-con in
person training is the
superior to audio kits,
flashcards, and no
prior training. B-con is
an effective way to
train bystanders thus
supporting the call to
train laypeople in
bleeding control
programs.

compared
with
control arm
(16.3%;95
% CI; 9.1Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Citation

Jones et al.,
2019

Theory/
Conceptual
Framework

Design/
Method

Design:
Crosssectional
observation
al study
with a
convenienc
e, nonprobability
sampling
technique

Sample/ Setting

participants 303
(65%) were
assessed for
retention. At
retention
testing, no
statistically
significant
(P>0.05)
between
demographics
of those in
control group
and those who
were
reassessed.
N: 466 full-time
personnel
utilizing
convivence,
non-probability
sampling
technique

Major Variables
& Definitions

29
Measurement/
Instrumentation

Data Analysis

Findings/
Results

Level/Quality of
Evidence; Decision for
practice/ application to
practice

23.6;
P>.05)

IV: To assess
perceived
readiness and
willingness to
train other
faculty members
STB methods.
DV: Trauma
outreach
personnel
completed STB
training with
faculty and staff.

136 survey LOE: V
responses
received
Strengths:
Evaluation
with a
This study found great
of "stop the
response
implications for
bleed"
rate of
implementation at
training
29%.
other schools.
After HC
among k-12
The findings are
Site: Public city
training:
faculty and
logical and were not
school system
reports of
staff in
surprising. This study
in Alabama.
increased
Alabama
confirms the use of
knowledge STB training with
Purpose:
Demographics:
of HC
Country:
laypersons is effective.
To evaluate Largely
methods/te
U.SA.
Funding:
Wilcoxon
Weaknesses: Being
STB
Caucasian
chniques P
Funding
signed rank
the lowest level of
training
(67%) females
<.001;
through the
test prior to
evidence is inherently
among K12 (80%) between
increased
Community
personnel
and after
comfort
a weakness. The
Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha
Data was
collected using
an anonymous
online survey.

5-point Likert
Scale with
logistic
regression to
evaluate
association
among post
training
feelings and
perceived
preparedness
to train others
in STB.

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Citation

Health
Scholars
Program at
the
University
of Alabama
at
Birmingham
School of
Public
Health.
Bias: None
noted.

Theory/
Conceptual
Framework

Design/
Method

and to
assess
participants
’ perceived
readiness to
train peers
in STB
methods.

Sample/ Setting

the ages of 1885.
Exclusion: Had
to be at least 18
years old, speak
English, and
held full time
positions at the
school system.
Attrition: Not
discussed.

Major Variables
& Definitions

30
Measurement/
Instrumentation

Data Analysis

completing
training.

Findings/
Results

Level/Quality of
Evidence; Decision for
practice/ application to
practice

with
providing
HC to
injured
persons P
<.001;
empowered
to organize
STB
training
their home
institution
p < .001

population is not
generalizable.
Convenience sample
utilized. No simulated
events were utilized to
demonstrate effective
application of HC
measures.

72%
(n=91) of
participants
reported
the HC
training
they
received
adequately
prepared
them to
tech others.

Conclusions:
After a single STB
training course faculty
felt comfortable and
willing to apply HC
techniques to injured
persons. This study
confirms the success
of this course in other
schools is likely.

Logistic
regression
results
found
participants
eight times
more likely
Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Citation

Lei et al.,
2018
Stop the
bleed
training
empowers
learners to
act to
prevent
unnecessary
hemorrhagic
death

Theory/
Conceptual
Framework

Inferred
Adult
Learning
Theory

Design/
Method

Design:
Mixed
methods
NRNCT
(pre-&posttest)
Purpose:
Develop
and test an
educational
B-con
program
for
increased
willingness
,
preparedne
ss, and
knowledge.

Sample/ Setting

N: 555
Site: Medical
School
Demographics:
287 SN, 123
MS3, 68 ID, 77
CM
Exclusion:
Incomplete
surveys (19),
lack of
anonymous
identifier (30),
and those who
choose to opt
out (0).

Major Variables
& Definitions

IV: Increase
willingness and
preparedness to
intervene and
preform
tourniquet
application.
DV1: Increase
willingness
DV2: Increase
preparedness
DV3: Correct
knowledge about
tourniquet
placement and
HC.

31
Measurement/
Instrumentation

Self-assessment
of DV1, DV2,
& DV3.

Data Analysis

Likert Scale
for pre/post
questionnaire;
pre α 0.38,
post α 0.72.
Pre/posttraining data
was analyzed
using T-test
and Wilcoxonsigned ranked
test, with
significance
defined as p <
0.05

Findings/
Results

than their
peer to
teach
others STB
techniques
[OR] 7.65,
95% [CI]
2.41-24.25.
DV1: pre:
SN 92%,
MS3 93%,
ID 88%
CM 96%
Post:
SN 99%,
MS3 99%,
ID 99%,
CM 99%
DV2: Pre:
SN 80%
MS3 19%
ID 34%
CM 48%
responded
positively
(p < 0.05).
Post:
SN 100%,
MS3 98%,
ID 99%,
CM 99%
DV3:

Level/Quality of
Evidence; Decision for
practice/ application to
practice

LOE: III
Strengths: Mixed
methodology supports
a well-rounded view
of B-Con intervention.
Appropriate analysis
for quantitative and
qualitative data.
Intervention was well
described. This study
had an adequate
population size.
Population was
diverse making the
result generalizable to
the general population.

Country:
U.S.A.
Funding:
Projected
Weaknesses: Lower
funded by
level of evidence. This
the Center
study is limited by
for
Attrition:
lack of long-term
Translationa
No participants
follow-up with the
l Injury
lost.
participants as well as
Research
Bias: None
training on real life
noted.
bleeding situations.
Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

Major Variables
& Definitions

32
Measurement/
Instrumentation

Data Analysis

Findings/
Results

Passing set
at >60%
Pre:
SN 63%
MS3 76%
ID 66%
CM 48%
Post:
SN 89%
MS3 100%
ID 85%
CM 86%

McCarty et
al. 2019
Effectivenes
s of the
American
College of
Surgeons
bleeding
control basic
training
among
laypeople
applying
different
tourniquet
types: A

Inferred
Adult
Learning
Theory

Design:
RCT
nonblinded,
crossover

N: 102
Site: Sports
stadium

IV: Correct
tourniquet
application
defined by ≥250
mm Hg with a 2minute time cap,
after an
educational
intervention
during a
simulated event
utilizing three
different
tourniquets

Direct
observation by
trained
personnel.

Correct CAT
application
was used as an
internal
control
utilizing 4
pairwise
Bonferronicorrected
comparisons
with the
McNemar test.

DV1: CAT
was applied
correctly at
a
significantl
y higher
rate 92.2%
of
participants

Level/Quality of
Evidence; Decision for
practice/ application to
practice
Conclusion: B-Con
training is effective at
increasing participants
preparedness and
willingness to
intervene during a
bleeding event with a
stranger.

LOE: II
Strengths: RCT level
design. One of the fist
studies to evaluate
laypersons ability to
apply tourniquet other
than the one they were
trained on. Detailed
discussion of
interventions. Findings
of this study are
generalizable to the
general population.

Demographics:
Purpose:
50 [49.0%]
To evaluate male,
the
Median
effectivene [interquartile
DV2:
ss of
range] age, 37.5
68.6%
laypersons
[27.0-53.0]
applied this
ability to
years
tourniquet
apply a
correctly
tourniquet
Exclusion:
Weaknesses: This
DV1: CAT
other than
Persons with
DV3:
was a non-randomized
DV2: SOFTT
the one
previous
they were
11.8%
non-controlled trial
Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Citation

Theory/
Conceptual
Framework

randomized
clinical trial

Design/
Method

trained on
in a B-Con
course.

Country:
U.S.A.
Funding:
Not
disclosed.
Bias: None
noted.

Sample/ Setting

Major Variables
& Definitions

medical
training.

DV3: StretchWrap-and-Tuck
Tourniquet
DV4: Rapid
Application
Tourniquet
System
DV5:
improvised
tourniquet

Attrition: Oneday course no
participants
lost.

33
Measurement/
Instrumentation

Data Analysis

Findings/
Results

Level/Quality of
Evidence; Decision for
practice/ application to
practice

applied
tourniquet
correctly

although it likely had
little impact on the
overall results. The
educational level of
the population was not
discussed in the
demographics.
Evaluation staff was
not well discussed in
there won training and
ability to assess
laypersons
applications.

DV3:
11.8%
applied
tourniquet
correctly
DV4:
32.4%
applied
correctly
P<0.001
for each
pairwise
comparison

Ross et al.,
2018

Conclusions: This
study found there is a
disconnect between BCon course and the
layperson ability to
apply a tourniquet
other than one
traditionally used in BCon training.
Laypersons may not
be prepared to assist in
bleeding emergencies
as tourniquet designs
evolve and change.
LOE: III

Design:
N: 218
IV: To evaluate
Self-assessment Likert Scale
DV1:
Crossperceived
of DV1, DV2,
for pre/post
72.5%
Strengths: One of the
sectional
Site: A
readiness and
& direct
questionnaire,
(158/218)
Stop the
first to examine
observation university in
willingness of
observation of
significance
felt they
Bleed: The
barriers to B-Con
al study
western USA
laypersons to
DV3.
p<0.05 and CI were safe,
effect of
with a
intervene in a
95%
2.3%
training. Mixed
Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha
Inferred
Adult
Learning
Theory

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Citation

hemorrhage
control
education on
laypersons’
willingness
to respond
during a
traumatic
medical
emergency
Country:
U.S.A
Funding:
Not
disclosed.
Bias: None
noted.

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

Major Variables
& Definitions

convenienc
e, nonprobability
sampling
technique

Demographics:
All volunteers
31.9% Male
(69) 68.1%
Female (147);
30.0% (65)
College, 2.8%
(6) Grade
School, 10.1%
(22) high
school, 8.3%
(18) post Grad,
48.8% (106)
some college.

bleeding event
after an
educational
intervention.

Purpose:
The
purpose of
this article
was to
create and
educational
program to
evaluate
the type
and
duration of
instruction
needed to
meet STB
requiremen
ts.

Inclusion: 18
people were
excluded
because they
had previous
medical
training.
Attrition:
14 participants
did not fill out a
post-course
questionnaire.

DV1:
Participants
belief of
tourniquets being
safe
DV2:
Participants
willingness to
use a tourniquet
in real life after
training session
DV3: Correct
tourniquet
placement after
learning
intervention

34
Measurement/
Instrumentation

Data Analysis

Fisher’s exact
tests and
Wilcoxon
signed-ranked
paired tests to
compare prepost
measurements
McNemarBowker test of
symmetry
utilized for
DV1 and DV2.

Findings/
Results

Level/Quality of
Evidence; Decision for
practice/ application to
practice

(5/218) felt
they were
unsafe,
post
training
97.5%
(199/204)
felt they
were safe,
0.5%
(1/218) still
felt they
were
unsafe.

methodology supports
a well-rounded view
of B-Con intervention.
Appropriate analysis
for quantitative and
qualitative data.
Study subjects had no
previous tourniquet
knowledge, making
this generalizable to
the general population.

DV2: Preinterventio
n 64.2%
(140/218)
responded
“Yes”,
postinterventio
n 95.6%
(19/203)
responded
“Yes”.
DV3: pretraining
knowledge
4.1/5
increased
to 4.7/5

Weaknesses:
This study was part of
a larger study looking
at different
commercial
tourniquets. Highschool and middle
school students who
attended the classes
were excluded from
the results. This was a
convenience sample
gathered from one
community that
volunteered to take BCon classes.
Conclusion: This
study was able to
demonstrate a short
educational

Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Citation

Tsur et al.,
2019
High
tourniquet
failure rates
among nonmedical
personnel do
not improve
with
tourniquet
training,
including
combat
stress
inoculation:
A
randomized
controlled
trial.

Theory/
Conceptual
Framework

Trial
Design
Model

Design/
Method

Design:
SingleCenter,
parallelgroup,
randomized
control
open trial
of an
educational
interventio
n.

Sample/ Setting

N: 305
n: 138 (CG)
n: 167 (IG)

Major Variables
& Definitions

Site:
Israel Defense
Forces’
Armored
School

IV:
Improved
competency and
correct
tourniquet
placement in a
combat stress
inoculation
setting.

Exclusion:
No previous
experience with
the tourniquets
used in this
trial.

DV1:
Application of
the tourniquet 12
times on
themselves or on
peers

35
Measurement/
Instrumentation

Observers, who
were similarly
qualified
instructors,
evaluated
correct
placement by
determining
lack of distal
pulse as
palpated by the
instructor.

Data Analysis

Comparison of
categorical
variables
utilized Chisquare.
Quantitative
variables
compared
utilizing
student T-test.

Findings/
Results

Level/Quality of
Evidence; Decision for
practice/ application to
practice

(p<0.001)
posttraining.
Correct
tourniquet
placement
pre-training
3.1/4 and
3.6/4
(p,0.001)
posttraining.
Overall
failure rate
was
80.33%
(81.90% in
the control
group
versus
79.00% in
the CSI
group; P
value =
.565; 95%
CI, 0.677
to 2.122)

intervention was able
to increase laypersons
self-efficacy and their
reported willingness to
intervene in a bleeding
event.

LOE: Level II
Strengths:
RCT level design.
Detailed discussion of
interventions and
results. Data collection
techniques were
appropriate.

Weaknesses:
Not generalizable to
general population.
Purpose:
Participants, assessors,
To examine
and instructors were
if early
not blinded due to the
Differences nature of the
advanced
between
training
educational
Demographics: DV2:
Males between
Application of
time to stop intervention. Another
under
the ages of 18the tourniquet 12
bleeding,
condition
weakness is the
20 enlisted to
times on
or
similar to
platoon-based
combat and active military
themselves or on
placement
randomization.
Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Citation

Country:
Israel
Funding:
None
recognized.
Bias: None
noted.

Theory/
Conceptual
Framework

Design/
Method

provide
stress
inoculation
improve
competenc
y compared
to the
current
educational
program on
nonmedical
personnel.

Sample/ Setting

Major Variables
& Definitions

duty in August
2017.

peers in combat
stress situations
including lowlight conditions,
post-physicalexertion.

Attrition:
Not discussed

36
Measurement/
Instrumentation

Data Analysis

Findings/
Results

Level/Quality of
Evidence; Decision for
practice/ application to
practice

were not
significant
(95%
confidence
intervals,
−17.283 to
23.404,
−1.792 to
6.105, and
0.932 to
2.387. The
difference
in the rate
of those
unable to
apply any
pressure
between
the CSI
group and
the control
group was
not
significant
(18.6%
versus
20.3%,
95%
confidence
interval,
0.507 to
1.583)

Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Citation

Zwislewski
et al., 2019
Practice
makes
perfect: The
impact of
stop the
bleed
training on
hemorrhage
control
knowledge,
wound
packing, and
tourniquet
application
in the
workplace.
Country:
U.S.A.
Funding:
Not
disclosed.
Bias: None
noted.

Theory/
Conceptual
Framework
Inferred
Adult
Learning
Theory

Design/
Method

37

Sample/ Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data Analysis

Findings/
Results

Design:
Mixed
methods
NRNCT
(pre-&posttest)

N: 298
laypersons

IV: Laypersons
pre/post
knowledge of BCon techniques.

Self-assessment
of DV1.

Purpose:
To evaluate
the
effectivene
ss of
various
component
s of the
STB
program.

Tourniquet
Application
n: 70 (IG)
n: 72 (CG)

Independent
sample t-tests
and Wilcoxon
signed-ranked
paired tests to
compare prepost
measurements

DV1:
Scores
were higher
on the
posttest
compared
to the
pretest
(M = 4.63,
SD = 1.32)
than on the
cognitive
pre-test
(M = 3.21,
SD = 1.14

Wound packing
n: 94 (IG)
n: 69 (CG)

Site:
Local
Department of
Transportation
warehouses.
Exclusion:
Participants
who did not
complete the
cognitive
pre/post as
instructed were
removed from
this study
(n=16)
Demographics:
Not discussed.
Attrition: Not
all participants

DV1: Bleeding
control
knowledge
DV2: Ability to
pack a wound
DV3: Ability to
apply a
tourniquet

Direct
observation for
DV2 & DV3 by
qualified STB
instructors.

Level/Quality of
Evidence; Decision for
practice/ application to
practice
LOE: IV
Strengths: Mixed
methodology supports
a well-rounded view
of B-Con intervention.
Appropriate analysis
for quantitative and
qualitative data.

DV2: IG
scored
significantl
y higher
(M = 2.93,
SD = .26)
than the
CG
(M = 1.97,
SD = .77) t
(161) = 11.
21, p ≤ 0.00
01.

Weaknesses:
Lower level of
evidence. No
demographics
collected, although, it
was a predominately
male population. Not
all participants choose
to participate in the
hands-on training or
complete the cognitive
post-test which lead to
attrition. Limited
participant stock in
completing the
assessments.
Warehouse setting not
ideal for training due
to acoustic issues.

DV3:
Scores
were
significantl

Conclusion: STB
training does increase
layperson knowledge
of hemorrhage control

Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/ Setting

agreed to
complete the
cognitive
posttest.

Major Variables
& Definitions

38
Measurement/
Instrumentation

Data Analysis

Findings/
Results

Level/Quality of
Evidence; Decision for
practice/ application to
practice

y higher in
the IG
(M = 7.41,
SD = .91)
compared
to the CG
(M = 5.99,
SD = 1.81)
t (140) = 5.
9
p ≤ 0.0001

techniques and handson training allows for
better performance of
hands-on wound
packing and tourniquet
application skills.

Key: B-con- bleeding control; CG- control group; CM-community member; DO-direct observation; DV-dependent variable; HC- hemorrhage control; IDinterdisciplinary member; IG- intervention group; IV- independent variable; MS3-third year medical student; N-number of studies (if SR) or participants in
study; n- number of participants (if SR) of number of participants in subset; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCTrandomized control trial; SAP-single-application practice; SOFTT- Special Operation Forces Tactical Tourniquet; SN- school nurses; STB- stop the bleed;
TAP-triple-application practice; α-Cronbach’s alpha

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING

39

Table A2
Synthesis Table

Design
Number of
Participants
LOE

Ali et
al.
2019
MM
NRNCT
151

Baruch et
al.
2016
MM
NRNCT
156

Goolsby
et al.
2016
RCT

Goralnick
et al.
2018
RCT

Jones et
al.
2019
CSS

157

464

466

MM
NRNCT
555

III

III

II

II

V

X

X

X

X

Non-medically trained
participants
Independent Variables
Correct tourniquet placement

X

X

Willingness to apply
tourniquet
Dependent Variables
Correct tourniquet placement
with hands-on training

Lei et al.
2019

McCarty
et al.
2019
RCT

Ross et
al.
2018
CSS

Tsur
et al.
2019
RCT

102

218

205

Zwislewski
et al.
2019
MM
NRNCT
298

III

II

III

II

III

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Correct tourniquet placement
after learning intervention

X

X

X

X

X

X

X

X

X

X

Time to tourniquet
application

X

X

Increased
comfort/willingness applying
tourniquet

X

X
X

X

X
X

Key: CSS-Cross-sectional Study-Observational; MM-Mixed Methods; LOE- level of evidence; NRNCT- nonrandomized noncontrolled trial; RCT-randomized
control trial

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Appendix B
Models and Frameworks
Figure 1
Albert Bandura’s Social Learning Theory

Bandura (1986).

40

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING
Figure 2
Rosswurm & Larrabee’s Model

Rosswurm & Larrabee (1999).

41

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING

42

Appendix C
Graphical Data

Figure 1
Student Survey Results

Would you like to obtain training that could
help you, a friend, or a loved one survive a
severe bleeding event?
Do you think receiving training that teaches
you how to stop severe bleeding would be
helpful?

Have you heard of training that can teach
you how to control severe bleeding?
0

20

Yes

No

40

60

80

100 120 140 160

If you obtained bleeding control training,
how likely would you be to use this training
to help a friend, student, or loved one?

How prepared do you currently feel in your
ability to help a fellow student, friend, or
family member survive a serious bleeding
event?

0
Strongly Disagree

Disagree

20
Neutral

40
Agree

60

80

100

Strongly Agree

120

SCHOOL-BASED HEMORRHAGE CONTROL TRAINING

43

Figure 2
Faculty Survey Results
Do you feel comfortable intervening if you
come across a serious bleed?
Do you feel the school is prepared to
respond to a serious bleed?
Does your school currently perform STB
training?
Have you received "Stop the Bleed
Training"?
Have you heard of "Stop the Bleed
Training"?
0

20

Yes

No

40

60

80

100

120

40

60

80

100

120

If you obtained bleeding control training,
how likely would you be to use this training
to help a friend, student, or loved one?

How prepared do you currently feel in your
ability to help a fellow student, friend, or
family member survive a serious bleeding
event?

0
Strongly Disagree

Disagree

20
Neutral

Agree

Strongly Agree