Discussion
In July 2016, the HMC Trauma Program implemented the STB program with the goal to educate and train the public as well as to promote bleeding control kit placement in schools, public venues, and private businesses in our State. To date, this STB program has instructed almost 3000 people in hemorrhage control in Western Washington. By continuing to share the curriculum and mentor new instructors, the reach of STB can be expanded to include other healthcare facilities and school districts in Washington State. Many other organizations are taking action and creating programs to educate students, staff, and the general public to recognize and control bleeding.
Qualitative analysis of broad, open-ended comments in the survey responses from learners who attended the STB courses during a 9-month period revealed themes that fell within known categories of adult learning theory (see table 1), which posits that active participation is important for adult students. Malcolm Knowles developed this theoretical and practical approach to adult education with the following principles: adults should have a say in the content of their learning and should be involved in evaluating their instruction, learning should be based on experiences and have practical and relevant implications, learning should involve problem solving rather than content memorization, and finally, learning can be enhanced if it is driven by internal, rather than external motivation.9 It is a framework widely adopted within the medical community to create courses for the education of patients and healthcare providers alike.11 12
With respect to hemorrhage control, prior research indicates formal hands-on training in a small group environment is the most effective method to teach laypersons to use a tourniquet.13 Learners should also feel prepared to use these skills during an emergency. Studies have demonstrated that a short hands-on course on bleeding control technique use improved laypersons’ self-efficacy and willingness to use a tourniquet during emergency situations.14 15 Many ‘Stop the Bleed’ participants felt empowered and more comfortable with their ability to respond during emergency situations. Indeed, learners reported that the STB course was immediately useful and practical. Additionally, participants generally felt that they were engaged in the hands-on component and were given opportunities to provide feedback about the course. An overwhelming majority of participants responded they would recommend the course to others; learners found the course content and experience to be positive.
The most common suggestion for improvement was a request for take-home reference materials. Creating a handout emphasizing essential takeaways from the course is an actionable item that could improve learner experiences after future courses. The next most common theme for improvement pertained to course logistics. A number of participants noted long wait times to take the STB courses from time of signing up. Over the course of the study period, the program has since made an effort to expand course times and locations; in addition to public classes offered monthly at HMC, STB has now been taught at Safeco Field in Seattle, the Washington State Capitol, the Woodland Park Zoo, and a number of other public venues. Additionally, the STB program has expanded to other hospitals and community organizations. With regard to the timing of the course, it is possible that certain groups of learners are being excluded due to limited course times. As community course offerings continue to grow, we expect that STB training will extend to a larger, more diverse learner population.
Based on collected participant feedback from HMC, course interest is high within the greater Washington State community. A national survey from 2016 confirmed that a there is a need for STB training; a majority of respondents—over 90%—stated they were physically able and willing to provide first aid for someone they did not know after a mass shooting or car crash and over 80% of respondents indicated they would be interested in attending a class to learn bleeding control techniques.16 Geographically expanding course offerings to Central and Eastern Washington could increase the number of laypeople with the skills and confidence to assist others during mass casualty events, leading to a potential to save more lives.
Training in hemorrhage control has been researched in military and hospital settings before the need to educate the public became clear. There exist strong similarities with the modern cardiopulmonary resuscitation (CPR) program, developed in the 1960s and first taught to healthcare workers.17 CPR training is now widely available to the general public and is required education for first responders, health professionals, and even high school graduates in 38 states and Washington, DC.5 18 There is growing support for legislation that requires Bcon education for Washington State students as well.19 As the number of mass shootings continues to rise, so, too, does the importance of educating the public regarding hemorrhage control. Just like a bystander with CPR training, a layperson with STB training can save a life during an emergency situation. In 2018, the Netter School of Medicine at Quinnipiac University (New Haven, CT) established itself as the first Hartford Consensus-Complaint Medical School in the USA.20 During a recent mass shooting in Pittsburgh, PA, STB graduates were able to access public bleeding kits and properly place tourniquets for wounded victims. Georgia recently became the first state to offer hemorrhage control kits and training to every public school.21 The impact of the STB course itself, advocacy for educational programs, and public access to bleeding control equipment is already apparent.
The study has some limitations. First, we did not collect demographic data, and course completion surveys were optional. This limits our ability to examine more granular data (gender, age, occupation, and so on) may indeed allow for tailored improvements to the ‘Stop the Bleed’ course specific to certain groups of learners. Including close-ended questions that address specific course content in the future may provide more quantifiable feedback that can be compared across courses taught at different sites. Finally, since qualitative analysis spanned only 9 months of our STB course taught in Western Washington, findings may not be generalizable to other geographic areas.
We cannot comment on STB skill retention.22–24 This is important because the PATTS trial demonstrated that retention of proper tourniquet application 3–9 months after hemorrhage control training was approximately 55%.13 However, there is no clear consensus on the frequency or content required to retain this knowledge. In the future, hemorrhage control training may become a course that requires refresher courses to ensure retention of skills.