j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 2 0 ( 2 4 5 ) 6 3 6 e6 4 2

Available online at www.sciencedirect.com

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journal homepage: www.JournalofSurgicalResearch.com

Stop the Bleed Training: Rescuer Skills, Knowledge,

and Attitudes of Hemorrhage Control Techniques

Rebecca Schroll, MD,a Alison Smith, MD, PhD,a,* Morgan S. Martin, MD,a
Tyler Zeoli, BA,a Marcus Hoof, BS,a Juan Duchesne, MD,a
Patrick Greiffenstein, MD,b and Jennifer Avegno, MDb
a
Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
b
Section of Emergency Medicine, Louisiana State University School of Medicine, New Orleans, Louisiana

article info abstract

Article history: Background: Bystanders play a significant role in the immediate management of life-
Received 15 April 2019 threatening hemorrhage. The Stop the Bleed (STB) program was designed to train lay
Received in revised form rescuers (LRs) to identify and control life-threatening bleeding. The aim of this study was to
7 August 2019 evaluate the efficacy of STB training for rescuers from different backgrounds. We hy-
Accepted 15 August 2019 pothesized that STB training would be appropriate to increase skills and knowledge of
Available online 13 September 2019 bleeding control techniques for all providers, regardless of level of medical training.
Study design: Course participants anonymously self-reported confidence in six major areas.
Keywords: A five-point Likert scale was used to quantitate participant’s self-reported performance.
Hemorrhage control Results were stratified into medical rescuers (MR) and LRs. Students’ ability to perform STB
Education skills were objectively assessed using an internally validated 15-point objective assessment
Mass shootings tool. Data were pooled and analyzed using Student’s t-test and chi-Squared test with
Mass casualty P < 0.05 considered significant. Results are presented as average with standard deviation
Lay rescuers (SD) unless otherwise stated.
Results: A total of 1974 participants were included in the study. Precourse confidence was
lowest for both groups in management of active severe bleeding and ability to pack a
bleeding wound. Postcourse confidence improved significantly for both groups in all 6 core
areas measured (P < 0.001). The most significant increases were reported in the two pre-
vious areas of lowest precourse confidence-management of active severe bleedingdLRs 2.0
(SD 1.2) versus 4.2 (SD 0.9) and MRs 2.6 (SD 1.4) versus 4.6 (SD 0.6), P < 0.001dand ability to
pack a bleeding wounddLR 2.1 (SD 1.3) versus 4.4 (SD 0.8) and MR 2.7 (SD 1.3) versus 4.7 (SD
0.05), P < 0.001. Objective assessment of LR skills at the end of the course demonstrated
combined 99.3% proficiency on postcourse objective assessments.
Conclusions: This study provides quantitative evidence that Stop the Bleed training is
effective, with both LRs and MRs demonstrating improved confidence and skill proficiency
after a 1-h course. Future program development should focus on building a pool of in-
structors, continued training of LRs, and determining how often skills should be recertified.
ª 2019 Elsevier Inc. All rights reserved.

Meeting presentation: This research was presented at the American College of Surgeons Clinical Congress on October 21-25, 2018, in
Boston, MA.
* Corresponding author. Department of Surgery, Tulane School of Medicine, 1430 Tulane Ave, SL-22 New Orleans, LA, 70112. Tel.: þ412
607-3047; fax: þ504-988-1882.
E-mail address: alison.annette.smith@gmail.com (A. Smith).
0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jss.2019.08.011
 s c h r o l l e t a l  e f fi c a c y o f “ s t o p t h e b l e e d ” t r a i n i n g
Background
Mass shootings in public spaces are occurring with increasing
frequency in the United States.1 This unfortunate rise in
deadly shootings and also ongoing military campaigns in Iraq
and Afghanistan2 resulted in the creation of the Hartford
Consensus.3,4 The goal of the Hartford Consensus was to in-
crease education of lay rescuers (LRs) in the management of
traumatic hemorrhage. Several recent mass casualty in-
cidents (MCIs), including the Boston Marathon bombing and
Pulse Nightclub shooting, demonstrated the need for on-scene
hemorrhage control to decrease preventable deaths during
MCIs.5,6 Furthermore, the emerging role of tourniquets to
manage civilian extremity trauma7 was demonstrated in
several retrospective studies.8-13 As a result, these significant
events led to increased interest from both medical pro-
fessionals and the general public in bleeding control tech-
niques.14,15 In conjunction with the American College of
Surgeons, Stop the Bleed (STB) course was designed to teach
early hemorrhage control techniques to nonmedical by-
standers in order to provide critical life-saving interventions
before the arrival of first responders.16-18
STB training includes the recognition of life-threatening
hemorrhage, hemorrhage control, and alerting of emergency
services using techniques that can be mastered by both LRs
and medical rescuers (MRs). Medical professionals including
emergency medical services, nurses, medical students, resi-
dents, and staff physicians volunteer to become instructors
for this course. For hemorrhage control, trainees receive
hands-on training via trained instructors on appropriate
tourniquet application and proper dressing use. Similar to the
American Heart Association’s widespread educational
campaign of LRs in cardiopulmonary resuscitation and avail-
ability of automated external defibrillators has led to
improved survival after out-of-hospital cardiac arrest, STB has
the potential to increase survival due to hemorrhage before
emergency medical services arrival.
Since the STB campaign was launched in 2017, several
studies have sought to investigate the efficacy of STB training.19-
23
However, no study to date has provided objective evidence on
the performance of STB skills by both LRs and MRs. Thus, the
primary objective of this study was to perform a critical sys-
tematic evaluation of STB course participant knowledge, atti-
tude, and skills with the goal to provide valuable feedback to
continue to enhance the participation in STB courses. We hy-
pothesized that STB training would be appropriate to increase
skills and knowledge of bleeding control techniques for all
providers, regardless of level of medical training.
Methods
Participants in STB courses from July 2017 to November 2018
were included in the study. Individuals were recruited using
institution-wide email from two participating US medical
schools, outreach to physicians and resident at participating
institutions, and printed materials distributed within the
community. Furthermore, STB course was incorporated into
the medical school curriculum for senior medical students at
637
both schools. Courses were taught at routine intervals at the
two participating medical schools, at schools within the
community, and many other public locations within the
community. Institutional Review Board approval was ob-
tained from Tulane University before initiating the study. A
waiver of informed consent was obtained from the Institu-
tional Review Board.
This survey identified individuals based on their level of
medical training. MRs included attending physicians, resi-
dents, medical students, nurses, nursing students, emergency
medical technicians, and self-reported “other” designation if
none of these categories applied. Individuals with no medical
training were designated as LRs. Participants who did not
indicate their level of medical training were classified as
“unknown.” Surveys that could not be linked to participant
type were excluded from the analysis.
Before STB training, all trainees were given an anonymous
survey to self-report knowledge about bleeding control and
confidence in skills within six major areas (the recognition of
life-threatening hemorrhage, proper application of a tourni-
quet, holding pressure on an actively bleeding wound, packing
of a deep open wound, management of active severe bleeding
during a mass casualty event, and confidence to teach the
techniques learned) using a 5-point Likert scale. Trainees were
given the same survey after the completion of the one-hour
STB course to reassess their knowledge and confidence. At
the end of the course, all trainees were assessed for their
ability to adequately perform STB skills by the course
instructor using an internally validated 15-point objective
assessment tool (Table 1). A binary scoring system was used
with “1” for the participant performing the skill and “0” for the
participant not performing the skills or performing it incor-
rectly. This scoring system was employed to help ease the
process for instructors grading students during the course.
Data collected included the ability to assess scene safety
before proceeding, the use of both hands when packing gauze
into open wounds, and tightening of the windlass of the
tourniquet until bleeding stops. These data were collected
using a binary scale, which discerned whether the task was
completed correctly (1) or not (0). Participant satisfaction with
STB was also recorded (GraphPad Prism, version 5; GraphPad
Software Inc, La Jolla, CA). Results are presented as mean
(standard deviation) unless otherwise noted. Unpaired t-test
for other analyses of continuous variables and Fisher’s exact
test for categorical variables were used to make comparisons
between groups. Unpaired t-test was chosen as the method to
analyze the difference between the presurvey and postsurvey
data, instead of the obvious paired t-test, as the individual
surveys could not be linked because they were completed
anonymously. A P-value of 0.05 was considered significant.
Results
Study participants and demographics
During the study period, 165 STB courses were taught to 2348
participants. A total of 84.1% of these participants (n ¼ 1974/
2348) provided information to identify their level of medical
638 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 2 0 ( 2 4 5 ) 6 3 6 e6 4 2

Table 1 e 15-point objective assessment of bleeding

control techniques administered to participants of STB.
Item Not done or Done
incorrect correctly
Ensures scene is safe before 0 1
proceeding
Puts on gloves before beginning 0 1
Calls 911 or asks someone else 0 1
to call 911
Identifies life-threatening bleeding 0 1
Asks for a trauma first aid kit 0 1
Direct pressure
Uses 2 hands 0 1
Applies firm and continuous 0 1
pressure
Packs gauze into open wound 0 1
Tourniquet 0 1
Applies above bleeding site 0 1
Avoids placing tourniquet over 0 1
knee or elbow joint
Removes slack from tourniquet 0 1
before twisting windlass
Locks rod in place in windlass clip 0 1
Adheres remaining strap around 0 1
extremity Fig e Number of surveys and study participants taking STB
Secures windlass strap 0 1 courses during the study period.

Maximum total score: 15.

training. Participant level of medical training was not reported
for 15.9% (n ¼ 374/2348). The overall response rate for partic-
ipants who completed both precourse and postcourse surveys
was 76.6% (MR 89.6%, n ¼ 1004/1120; and LR 63.6%, n ¼ 524/
854). Unknown responses for precourse surveys was 18.5%
(n ¼ 374/2018) and 7.1% (n ¼ 142/2000) for postcourse surveys.
The breakdown of course participants is presented in Figure.
MRs represented 56.7% (n ¼ 1120/1974) of course partici-
pants who completed surveys with the largest group repre-
sented by medical students (22.4%, n ¼ 443/1974). Surgeons
represented 32.1% (n ¼ 18/56) of attending physicians, and
general surgery residents made up 63.5% of residents (n ¼ 66/
104). Average age of course participants was 32 y (range, 7-
88 y), and 60.0% were female.
Precourse and postcourse knowledge
Knowledge of the Hartford Consensus (LR: 4.4% [n ¼ 22/504]
versus 63.9% [n ¼ 484/758], P < 0.001; and MR: 6.6% [n ¼ 72/1098]
versus 77.9% [n ¼ 725/933], P < 0.001) and the STB campaign
(LR: 27.8% [n ¼ 141/508] versus 95.6% [n ¼ 757/792], P < 0.001;
and MR: 40.3% [n ¼ 443/1100] versus 97.9% [n ¼ 941/963],
P < 0.001) improved significantly for both groups following the
course. Participants also expressed increased knowledge of
what to do in the event of an active shooter (LR: 35.7% [n ¼ 178/
499] versus 88.5% [n ¼ 682/771], P < 0.001; and MR: 44.6%
[n ¼ 481/1078] versus 89.4% [n ¼ 839/940], P < 0.001). Finally,
participants were able to more accurately identify the “ABC’s”
of bleeding control following the course. This increase in
postcourse ability to identify the basics of bleeding control
was significantly increased for both LRs (A: 65.5% [n ¼ 130/198]
versus 95.8% [n ¼ 799/834]; B: 77.5% [n ¼ 142/183] versus 98.3%
[n ¼ 819/833]; and C: 68.9% [n ¼ 125/181] versus 96.7% [n ¼ 803/
830]) and MRs (A: 40.7% [n ¼ 230/564] versus 93.8% [n ¼ 915/975];
B: 53.6% [n ¼ 282/527] versus 99.0% [n ¼ 959/969]; and C: 49.0%
[n ¼ 281/574] versus 94.0% [n ¼ 914/972]) with P < 0.001 for all
three areas in both groups.
Precourse and postcourse confidence
MRs had significantly higher precourse confidence compared
with LRs in all six areas measured (P < 0.001). In both groups,
the areas of lowest precourse confidence significantly
improved after course, including management of active se-
vere bleedingdLRs 2.0 (SD 1.2) versus 4.2 (SD 0.9) and MRs 2.6
(SD 1.4) versus 4.6 (SD 0.02), P < 0.001dand ability to pack a
bleeding wounddLRs 2.1 (SD 1.3) versus 4.2 (SD 0.9) and MRs
2.7 (SD 1.3) versus 4.7 (SD 0.5), P < 0.001. Overall, MRs achieved
significantly higher postcourse confidence than LRs
(P < 0.001). These results are presented in Table 2.
Objective skills assessment
A total of 493 (n ¼ 493/1974, 25.0%) objective skills assessments
were completed by instructors for 313 LRs and 180 MRs. All
forms completed by instructors could be linked to either MRs or
LRs. From the LR group, 121 incomplete forms were excluded
from the final analysis. The majority of providers achieved
high scores on the final objective skills assessment. Assess-
ment of LR skills at the end of the course demonstrated a
 s c h r o l l e t a l  e f fi c a c y o f “ s t o p t h e b l e e d ” t r a i n i n g 639

Table 2 e Self-reported confidence of lay rescuers, medical rescuers, and unknown rescuer level to manage severe
hemorrhage before and after STB training.
Lay rescuers Precourse, n ¼ 524 Postcourse, n ¼ 854 P value
Identification of life-threatening bleeding 2.7 (1.3) 4.4 (0.8) <0.001
Appropriate tourniquet use 2.3 (1.3) 4.4 (0.7) <0.001
Ability to apply direct pressure 2.7 (1.3) 4.5 (0.7) <0.001
Ability to pack a wound 2.1 (1.3) 4.4 (0.8) <0.001
Treat severe active bleeding 2.0 (1.2) 4.2 (0.9) <0.001
Teach bleeding control techniques to others 2.4 (1.3) 4.3 (0.9) <0.001

Medical rescuers Precourse, n ¼ 1120 Postcourse, n ¼ 1004 P value

Identification of life-threatening bleeding 3.2 (1.2) 4.7 (0.5) <0.001

Appropriate tourniquet use 2.9 (1.3) 4.7 (0.5) <0.001
Ability to apply direct pressure 3.4 (1.3) 4.8 (0.5) <0.001
Ability to pack a wound 2.7 (1.3) 4.7 (0.5) <0.001
Treat severe active bleeding 2.6 (1.4) 4.6 (0.6) <0.001
Teach bleeding control techniques to others 2.9 (1.4) 4.7 (0.6) <0.001

Confidence level was reported on a 5-point Likert scale with 1 ¼ not confident at all and 5 ¼ very confident. Average values are presented with
the standard deviation in parentheses.

combined 99.3% proficiency on postcourse objective assess-
ments compared with MRs who had 98.0% proficiency. Average
total scores for LRs and MRs were 14.9 (SD 0.9) and 14.7 (SD 0.7),
respectively. MRs did receive perfect scores in 6 categories
(identifies life-threatening bleeding; uses 2 hands for direct
pressure; firm and continuous pressure; packs gauze into an
open wound; tighten windlass to stop bleeding or until pulse
disappears; locks rod in place in windlass clip), whereas LRs did
not receive perfect scores in any of the categories tested.
However, LRs demonstrated significantly better performance
in asking for a trauma first aid kit (LR: n ¼ 191/192 [99.5%] and
MR: n ¼ 173/180 [96.1%], P ¼ 0.03) and securing the windlass
strap of a tourniquet (LR: n ¼ 191/192 [99.5%] and MR n ¼ 144/180
[80.0%], P < 0.001). These data are shown in Table 3.

Table 3 e Comparison of average objective assessment scores of STB Skills for lay rescuers, medical rescuers, and
unknown rescuer level.
Skill assessed, n (%) Lay rescuers, n ¼ 192 Medical rescuers, n ¼ 180 P value
Personal safety/active response
Ensure scene safety 192 (99.5) 177 (98.3) 0.11
Put on gloves 191 (99.0) 174 (96.7) 0.06
Call 911 or ask someone to call 191 (99.0) 178 (98.1) 0.61
Identifies life-threatening bleeding 191 (99.0) 180 (100.0) 1.0
Asks for a trauma first-aid kit 191 (99.0) 173 (96.1) 0.03
Holding direct pressure
Uses 2 hands for direct pressure 191 (99.0) 180 (100.0) 1.0
Applies firm and continuous pressure 191 (99.0) 180 (100.0) 1.0
Packs gauze into open wound 191 (99.0) 180 (100.0) 1.0
Tourniquet application
Applies above bleeding site 191 (99.0) 180 (100.0) 1.0
Avoids placing over knee or elbow joint 190 (98.4) 180 (100.0) 0.50
Removes slack before twisting windlass 191 (99.0) 174 (96.7) 0.06
Tighten windlass until bleeding stops or pulses disappears 191 (99.0) 180 (100.0) 1.0
Locks rod in place in windlass clip 191 (99.0) 180 (100.0) 1.0
Adheres remaining strap around extremity 191 (99.0) 179 (99.0) 1.0
Secures windlass strap 191 (99.0) 144 (80.0) <0.001

Score of “1” if the skill was performed correctly, and a score of “0” if it was not performed correctly. Results are presented as the number of
participants who performed the skill correctly for lay rescuers and medical rescuers with the percentage in parentheses.
640 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 2 0 ( 2 4 5 ) 6 3 6 e6 4 2

Comparison of LRs and medical students
A subgroup analysis of LRs and medical students were per-
formed to determine if there was any difference between LRs
and MRs with the least amount of clinical experience. On the
precourse assessment, the medical students only had signif-
icantly higher confidence in the ability to allow direct pressure
to a wound than the LR group: 2.7 (1.3) versus 3.1 (1.1), P < 0.001.
On the postcourse assessment, medical students demon-
strated significantly higher confidence in all 6 areas evaluated
(P < 0.001) than the LR group (Table 4).
training videos as important to improving the course. In
addition, several participants reported that the Hartford
Consensus was not explained well. Seven participants (3 LRs
and 4 MRs) wanted the course to include more information on
how to deal with mass shootings. Interestingly, 7 MR partici-
pants suggested to teach how to make tourniquets if a com-
mercial device is not available.
Discussion

The STB campaign plays a pivotal role in the public pre-

Course level of difficulty
MRs more frequently than LRs reported that the STB course
was easy (n ¼ 773/1004 [77.0%] versus n ¼ 404/854 [47.3%],
P < 0.001) and less frequently reported that the course was
difficult (n ¼ 10/1004 [1.0%] versus n ¼ 50/854 [5.9%], P < 0.001).
A total of 31% of LRs (n ¼ 135/854) and 20.9% of MRs (n ¼ 210/
1004) deemed that the course level of difficulty was appro-
priate (P < 0.001).
Participant satisfaction
Nearly all participants in both groups (99.6%) reported that
they felt STB course is important for both MRs and LRs to take.
A higher percentage of MRs reported that no changes were
needed to the current course format compared with LRs (9.1%
versus 4.3%, P < 0.001).
Areas for improvement
When asked to identify one area to improve the STB course,
MRs most commonly reported that the course should include
more “hands-on” practice time, whereas LRs identified more
paredness for MCIs. However, no study has critically investi-
gated efficacy of the STB course in both LRs and MRs by
objectively assessing their knowledge and skills learned and
obtaining their feedback on the course itself.19-23 Our study
demonstrates that STB course participants from different
baseline levels of medical training not only had increased
confidence after a 1-h STB course but were also able to
demonstrate both 1) gains in knowledge of bleeding control
techniques and 2) proficiency of critical bleeding control skills.
The largest experience to date of STB training for LRs was
provided by Neal et al., in which an impressive almost 20,000
LRs received STB training during the 21-mo study period.21
However, this descriptive study did not provide any objec-
tive evidence of the knowledge and skills performance of the
participants. A study by Fridling et al. provided a descriptive
experience of training medical students as course participants
and instructors.22 Lei et al. objectively assessed participant
knowledge and willingness to participate in bleeding control
before and after STB courses.23 However, no information was
provided on the ability of course participants, in particular
LRs, to master STB skills. In addition, only 77 nonmedical
providers were included. As STB is a relatively new course, it is
important to continue to assess its efficacy, in particular,

Table 4 e Comparison of precourse knowledge and confidence in bleeding control techniques for lay rescuers versus
medical students.
Precourse assessment Lay rescuers, n ¼ 524 Medical students, n ¼ 152 P value
Identification of life-threatening bleeding 2.7 (1.3) 2.7 (1.0) 1.0
Appropriate tourniquet use 2.3 (1.3) 2.4 (1.0) 0.4
Ability to apply direct pressure 2.7 (1.3) 3.1 (1.1) <0.001
Ability to pack a wound 2.1 (1.3) 2.2 (1.1) 0.4
Treat severe active bleeding 2.0 (1.2) 2.0 (1.0) 1.0
Teach bleeding control techniques to others 2.4 (1.3) 2.5 (1.2) 0.4

Postcourse assessment Lay rescuers, n ¼ 854 Medical students, n ¼ 423 P value

Identification of life-threatening bleeding 4.4 (0.8) 4.7 (0.5) <0.001

Appropriate tourniquet use 4.4 (0.7) 4.7 (0.5) <0.001
Ability to apply direct pressure 4.5 (0.7) 4.8 (0.4) <0.001
Ability to pack a wound 4.4 (0.8) 4.7 (0.5) <0.001
Treat severe active bleeding 4.2 (0.9) 4.6 (0.6) <0.001
Teach bleeding control techniques to others 4.3 (0.9) 4.7 (0.5) <0.001

Confidence level was reported on a 5-point Likert scale with 1 ¼ not confident at all and 5 ¼ very confident. Average values are presented with
the standard deviation in parentheses.
 s c h r o l l e t a l  e f fi c a c y o f “ s t o p t h e b l e e d ” t r a i n i n g
among course participants with no medical knowledge or
baseline skills.
Our study identified that, while less than half of LRs re-
ported that the course was too easy, the majority of MRs
thought the STB course was too basic for their level of training.
Interestingly, although both MRs and LRs were able to
demonstrate skill with overall high proficiency at the end of
the course, there were a few areas in which the MRs per-
formed less proficiently on average than the LRs. We suspect
that this may be due to overconfidence of some MRs. This
finding, as well as the significant increases in knowledge and
confidence in STB course skills in MRs, underscores the need
for STB training even in MRs. Much like the training of MRs on
cardiopulmonary resuscitation (CPR) skills, this course is
likely necessary to ensure that MRs adhere to certain stan-
dards when managing bleeding outside of the workplace.24-26
A subgroup analysis of medical students compared with
LRs showed that medical students had a more significant
improvement in postcourse confidence of skills than the LRs.
This observation shows that medical students, who have less
clinical experience compared with other MRs in our study,
were able to proficiently achieve the confidence for mastering
STB skills.
The STB campaign also seeks to distribute bleeding control
kits to the public. As demonstrated in a recent study of
American College of Surgeons Bleeding Control Basic (B-Con)
class participants, LRs may have interest in performing
bleeding control techniques. However, they failed to obtain
the necessary supplies to perform.20 This indicates that bar-
riers remain in the implanting of techniques to the lay public.
We found similar evidence as multiple course participants,
both LRs and MRs, expressed a desire to have tourniquets and
wound packing materials available. The likely solution to this
issue will require legislative changes that require vulnerable
public spaces to make these tools available to use during MCIs.
Neal et al. reported the vital support of the Pennsylvania State
Senate of STB and making training opportunities and bleeding
kits available.21
In our study, both LRs and MRs were able to achieve high
scores on the objective assessment for the performance of
bleeding control techniques. A statistically higher percentage
of MRs reported that increasing hands-on practice time, case
scenarios, and bleeding simulation were important to the STB
course. We believe that this observation likely highlights that
MRs recognize the need for simulation and practice when
learning and maintaining skills. A recent study by Zwislewski
et al. also confirmed this observation.27 LRs who performed
hands-on training of wound packing and tourniquet place-
ment outperformed rescuers who only listened to the lecture.
This study demonstrated what we observed regarding the
importance of hands-on practice.
Minimal data are available on the retention of rescuer skills
and confidence to apply skills. We completed the assessment
of rescuer skills and confidence immediately after the course.
It is likely that rescuers provided high scores due to the timing
of their responses. A study by Pasley et al. evaluated STB skills
1 mo after the course.28 The authors found significant deteri-
oration of confidence in skills. An analogy of STB training
could be made to CPR/automated external defibrillator
training. The American Heart Association recommends
641
recertification of CPR/automated external defibrillator skills at
a minimum of every 2 y.29 Currently, there are no recom-
mendations regarding the length of time after which STB
training should be recertified. We propose that the ACS should
recommend recertification at a minimum of every 1-2 y for
rescuers depending on their experience and level of comfort
with bleeding control techniques. This recertification could
take place during an abbreviated course for appropriately
enrolled rescuers. Recertification of skills may have to be
approached in a different manner for LRs and MRs. Further
studies are needed to determine the optimal timing of STB
skill recertification.
Several other interesting suggestions for the course
included the possibility of LRs serving as instructors. Recently,
medical students have been allowed to serve as assistant in-
structors for the course. Several of our study participants
suggested that members of the lay public be allowed to serve
as assistant instructors; we agree with this suggestion, as we
showed that LRs were able to master STB skills after a 1-hr STB
course, and adding to our pool of potential instructors would
significantly increase our ability to widely disseminate cour-
ses and educate our community. Numerous LRs requested
additional videos or visual aids to help emphasize teaching
points. Such supplemental materials may indeed be beneficial
particularly to LRs who do not have clinical acumen or expe-
rience to draw from to help them recognize life-threatening
bleeding and injury patterns. Finally, an additional common
suggestion was to have STB courses available in other lan-
guages to help reach additional non-English-speaking res-
cuers. Although we are aware that this has been done
sporadically, it may be beneficial for the American College of
Surgeons to make standardized translated materials widely
available.
Our study has several limitations to discuss. First, we were
not able to obtain responses for both the precourse and
postcourse surveys for all participants. In addition, unfortu-
nately, we were unable to link many of the objective skills
assessments by level of medical training. This lack of com-
plete responses may have impacted our results, although we
suspect that the trends we observed do indeed reflect the
larger population of STB participants as this was the case for
the unknown rescuer-level group. An improved methodology
to ensure more complete information for all participants will
be necessary in future studies to minimize this limitation.
Another potential limitation is that we only assessed the
initial training of course participants. It remains critical to
perform a follow-up analysis of knowledge and skill retention
between both LRs and MRs at various intervals.
Conclusion
This study demonstrates that both MRs and LRs have signifi-
cantly increased knowledge of bleeding control techniques
and confidence in their skills after completing a 1-h STB
course. Both groups were able to demonstrate proficiency in
performing bleeding control skills. In addition, we provide the
largest critical assessment of course participants’ perceptions
and attitudes surrounding STB and identify important di-
rections for future course development. Future initiatives
642 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 2 0 ( 2 4 5 ) 6 3 6 e6 4 2
should focus on continued education through STB courses,
wide distribution of bleeding control kits, and researching the
necessity of recertification; participants’ continued retention
of knowledge and skills over time; and LR participants’ ability
to become course instructors.
Acknowledgment
This study was partially funded by the Spirit of Charity
Foundation.
Authors’ contributions: R.S. contributed to study design
and critical revision of manuscript. A.S. contributed to study
design, data analysis, and writing of the manuscript. M.S.M.
contributed to writing of the manuscript. T.Z. contributed to
data analysis and writing of the manuscript. M.H. contributed
to data analysis. J.D. contributed to study design and critical
revision of manuscript. P.G. contributed to study design and
critical revision of manuscript. J.A. contributed to study design
and critical revision of manuscript.
Disclosure
R.S., A.S., M.S.M., T.Z., M.H., J.D., and J.A. have no financial
disclosure or conflicts of interest to disclose. Dr Greiffenstein
has worked as a paid technical consultant for Zimmer Biomet,
KLS Martin, and DePuy Synthes and leads surgical skills labs
for Zimmer Biomet.
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