Introduction

Trauma is the leading cause of death for the young and productive populations of the world; it is estimated that there are over 5 million deaths yearly from injuries [1]. Over 90% of these occur in resource-challenged, low, and middle-income countries [LMICs] [1].

The temporal death pattern for trauma is classically described as trimodal, and even after a more recent 'transition' to a bimodal model, most preventable trauma deaths still occur during the first peak, within hours of injury. This observation highlights the critical time following the injury, the classical 'golden hour,'' when timely, proven, and effective interventions may mean the difference between survival and certain death.

These early deaths are overwhelmingly due to traumatic exsanguination or uncontrolled bleeding [2]. These fatalities have been significantly reduced in settings with full trauma systems, most found in high-income countries [HICs]. The rapid transport of trauma victims to specialized trauma centers, where immediate hemorrhage control [HC] can be applied, has been identified as one factor that led to this improvement in trauma outcomes [3]. In the prehospital setting or at the scene, it must be noted that only compressible hemorrhage, often found in accessible sites, such as the extremities, can be addressed without sophisticated equipment and highly-trained personnel [4,5,6,7,8,9]. In support, the World Health Organization has identified the creation and/or improvement of prehospital trauma care as a priority for healthcare planners, especially in LMICs [5]. Furthermore, training lay first-person responders [LFPRs] in trauma care, with a focus on bleeding control for compressible hemorrhage, has been a recommended approach [5].

In the USA, the military experience from Iraq and Afghanistan informed recognition of the lifesaving potential of tourniquets to control bleeding immediately at the scene of injury. This practice was adapted and translated into the Tactical Combat Casualty Care (TCCC) course of the US military. The Bleeding Control Basic (B-CON) course, released to the public in 2014, developed and applied a curriculum focused on bleeding control, such as how cardiopulmonary resuscitation (CPR) prepares bystanders for a cardiac emergency. This, and the Hartford Consensus, influenced the creation and widespread implementation of the “STOP THE BLEED” course [STB] starting in October 2015 [8]. STB is the product of a collaborative effort led by the American College of Surgeons Committee on Trauma (ACS COT) to bring knowledge of bleeding control to the public. The ACS Committee on Trauma first publicly introduced bleeding control training courses for its members in October 2016. Since then, thousands of other medical professionals have trained to become course instructors [7]. Today, those instructors are focused on training laypeople from all walks of life to become immediate responders through the “STB” course [7]. In conjunction with these initiatives, a greater emphasis must be placed on evaluating these STB courses and implementing effective strategies for disseminating this crucial information to the public.

STB courses have these basic components: short didactic training followed by demonstrations, return demonstrations, and competency-based end-of-course evaluations. Some versions are conducted face-to-face, and there are online options, too. The rich literature on bystander training in CPR has shown that these courses improve the knowledge, skills, and attitudes of LFPRs and patient outcomes. It is, therefore, of utmost importance to create a similar evidence base upon which recommendations for the future implementation, widespread dissemination, and continued evaluation of STB courses can be built [6,7,8,9].

This systematic review analyzes the effect of the “STOP THE BLEED” training course on the knowledge, skill, and attitudes of lay first-person responders. We hypothesized that STB training courses are needed to improve the awareness, willingness, and skills in the community, which could subsequently reduce the burden of trauma.

Methods

PubMed and Google Scholar databases were used to identify relevant peer-reviewed research articles describing evaluations of the STB courses for laypersons. In addition, a hand search of article references was undertaken. Studies were included if it implemented the STB course; trainees were laypersons without advanced medical, emergency medicine, or surgical training or experience in bleeding control, including but not limited to prehospital providers, community health workers, drivers, police, medical students, or laypersons; the study included some type of outcome measures such as knowledge, skill, confidence gained, willingness to provide or utilization of care provided to and outcomes of trauma patients. Studies were excluded if the training course was not the STB course; trainees were trained medical personnel with previous experience or training in trauma care; provided no details of training methods or details of the structure of the education; or if a subjective course evaluation or nontechnical skill evaluation (such as teamwork) was the only measurement tool used.

We developed, registered, and published a systematic review protocol (PROSPERO; CRD 42022302973) based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Statement (PRISMA).

Information sources and searches

PubMed/MEDLINE database was queried to identify relevant peer-reviewed studies describing or evaluating the training of laypersons in [traumatic] hemorrhage control or simply trauma education/training programs from December 1, 2013 to October 31, 2022. Search terms used for PubMed/MEDLINE search were Stop the Bleed AND (Trauma) OR (Emergency) AND (Education) OR (Training) AND (Community) OR (layman/Layperson) OR Lay First Responder Trauma AND bleeding AND course OR training AND Skill OR (knowledge) OR (outcome) AND (non-specialist/layperson) OR Lay first responder. There were 123 results, 26 were reviewed, and 14 studies were selected.

A Google Scholar search was performed as a secondary search using the same search terms. There were 2,770 results, 27 were reviewed 16 were selected, and six were identified as redundant studies that had been previously chosen.

Only English-language articles were included for analysis. In addition, bibliographies of reviewed publications were crosschecked for additional relevant studies; this yielded 11 more studies for a total of 35 studies included in this systematic review.

Eligibility criteria

Inclusion

Population

Laypersons in the present review include the following but are not limited to,

  • Community members.

  • Teachers and other school employees.

  • School or college students, including medical and nursing students.

  • Law enforcement officers and security professionals.

  • Commercial vehicle drivers.

Setting

  • War or conflict.

  • 'Daily' or routine trauma.

  • Mass Casualty Incident.

Intervention

  • Stop The Bleed education/training programs for laypersons.

Control

  • Not required.

Outcome

  • Acquisition of new knowledge and retention of existing knowledge [measured through test scores].

  • Adequacy and retention of hemorrhage control skills [assessed by timing, proper application of tourniquets, or wound packing].

  • Affective outcomes, including confidence, comfort, and/or willingness to perform hemorrhage control.

Study types

  • Observational studies with pre/post design.

  • Observational studies.

  • Follow-up surveys.

  • Randomized control trials.

Year of publication

  • Published in the duration between January 1, 2013 and October 31, 2022.

Language

  • English.

Exclusion

  • The study population includes only military persons.

  • The study population comprises only healthcare professionals (physicians, nurses, EMS, pharmacists).

  • Not original studies (books and documents, reviews, commentaries, letters, news articles, personal narratives, patient education handouts, case reports, legislation, and retracted publications).

  • Studies evaluating specific equipment or teaching /educational techniques only.

  • Studies reporting only the epidemiology of trauma victims.

  • Psychological studies.

  • Pilot studies.

  • Non-English articles.

  • Articles without full texts.

Study selection

Two independent reviewers screened the titles and abstracts for inclusion in the full-text screening phase following the completion of the initial searches. Subsequently, in-depth evaluations of each full-text article were performed by two independent reviewers for inclusion in the synthesis and review. In the event of a disagreement, a third reviewer independently assessed all titles, abstracts, and full-text articles and served as a decision-maker.

Quality assessment: Due to the wide variations and heterogeneity of the available studies, we opted for the consensus of the four reviewers on the appropriateness and inclusion of the studies.

Data extraction

For each included paper, two investigators independently extracted information on the study objective, study design, population, details about the intervention and control groups (mode and duration of education; emergency health conditions treated; and role of the layperson), outcomes (type of health outcome; description of health outcome; kind of emergency care provided; and effect size and confidence interval) and key conclusions. Where multiple publications were reported on the same dataset, we extracted data from all related papers and reported results from the most definitive paper.

We performed independent and duplicate assessments of study quality, including internal and external validity, selection and measurement biases, and confounding factors. We resolved discrepancies through consensus among the lead investigators.

Data collection process

Data were extracted utilizing standardized forms with preset variables. This process was duplicated, with the authors mitigating any discrepancies for quality assurance.

Data items

Data items included: first author, year published, country, study population, study objective, evaluation method, study design, sample size, and key findings.

Synthesis

We prepared a summative and tabular synthesis of this review (Fig. 1). We tabulated each study's year of publication, location of study, study population, population size, study objective/s, study design, and outcome/s measured, including but not limited to knowledge, skill, willingness to perform bleeding control, confidence, retention of knowledge/skill and patient-related outcome/s.

Fig. 1
figure 1

Flow chart on selection of articles for review

Full size image

Results

The database searches yielded 2,893 unique papers. We retained 33 papers for full-text review, resulting in 24 eligible papers. Gray literature and manual searches yielded 11 additional publications, for a total of 35 articles in this systematic review.

Study characteristics and STB course evaluations

Table 1 summarizes the studies that met the inclusion criteria and classifies the main findings of each of the studies based on the described outcome. There were 35 studies that evaluated the outcomes of the STB training course for laypersons [10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44]. Twelve were published in 2020 and 11 in 2019, 5 in 2021, 4 in 2018, and 3 in 2022. Thirty-one studies were conducted in the USA [89%] and 1 each in Colombia, Japan, Kuwait, and Sierra Leone. The target population of the courses was laypersons in 26 studies, medical students in 6, and stadium personnel in 3. Sample sizes ranged from 10 laypersons to 4,324 LFRs; the total study population, from 36 studies, was 15,406. The most commonly used evaluation tool was the pre and post-test in 33 studies; 4 added a retention evaluation, while 1 added a cost analysis to a post-course survey. There were two randomized controlled trials, one of which also added a retention evaluation. Ten studies evaluated willingness, confidence, comfort, and likelihood [WCCL] to respond to a bleeding patient as their primary objective. Thirteen aimed to assess knowledge acquisition, and 8 assessed tourniquet application skills after the course. Four declared the evaluation of knowledge retention as their primary aim. One sought to examine the frequency and effectiveness of STB interventions and reported the effect of the STB course on patient-related outcomes, i.e., encounters with bleeding patients and their survival after an STB intervention.

Table 1 Studies evaluating the stop the bleed (STB) programs in different population and settings
Full size table

The most commonly reported finding was a statistically significant increase in hemorrhage control knowledge or tourniquet application skill in 26 studies. Twenty-two studies reported statistically significant improvements in WCCL to respond to a bleeding patient, and 6 studies reported on significant reductions in the retention of bleeding control knowledge or skills from 1–9 months after the course.

Discussion

This systematic review of the literature found that the STB training course could improve hemorrhage control knowledge skills, confidence, comfort, and willingness to apply hemorrhagic techniques or equipment to a bleeding patient. These improvements are seen in locations in the USA and selected middle- to high-income countries. Another significant finding is that there is considerable decay in the knowledge and skills acquired between 1 and 9 months after these courses. A thorough evaluation of these courses' impact on patient-centered outcomes and in low-income countries must be conducted in the course of more widespread implementation of STB across the globe.

We applied a standard systematic review methodology for the significant period to assess four important outcomes from hemorrhage control training: the acquisition of knowledge and skill, the retention of both, and patient outcomes. This study built on earlier work by Callese et al. [45] focusing solely on training that only included the recently implemented STB courses and was limited to 'trauma-naïve' layperson first responder populations.

We acknowledge that we only reviewed published studies and that there is a clear publication bias inherent to our study design. We cannot dispute that few publish their failed experiments, but not all successes are trumpeted either. All lessons learned from this review are based on reports from 35 hemorrhage control papers with a total of 15,406 STB participants in various settings.

A further selection bias will be in the student selection for these courses. This bias will inevitably lead to response bias, especially for the affective outcomes. Despite this, there were still sub-populations of students who found the content would have been more helpful to them, i.e., first responders [20]. We considered the inter-study heterogeneity as “very high” in many ways, like the setting, faculty, students, methods, and evaluation tools, but thought of it as further proof of the consistency of the effect of the courses. It almost did not matter who the target population of these courses was, nor did it matter who composed the faculty [19, 29, 37]. The consistent and uniform effect was a significant improvement in skills and knowledge, as well as the willingness to provide a hemorrhage control intervention after the course was taken.

Callese et al. conducted a systematic review that examined existing educational initiatives for layperson first responders in LMICs to inform the design of prehospital trauma care systems in resource-poor settings [45]. The study period of this review was from 1965 to November 2013, and they included 13 manuscripts. Four themes emerged from this review:

  1. 1.

    An initial needs assessment of a region's existing trauma system of care and laypersons' baseline emergency care knowledge focuses on subsequent educational interventions.

  2. 2.

    Effective programs adapt to and leverage existing resources.

  3. 3.

    Training methods should anticipate participants with low levels of education and literacy.

  4. 4.

    Postimplementation evaluation allows for curriculum improvement. Technology, such as online and remote learning platforms, can be used to operationalize each theme [44, 46].

Furthermore, they concluded that for layperson first responders in LMICs, successful training programs identify and maximize existing resources that are adaptable to learners with little formal education and are responsive to post-implementation evaluation.

This review analyzed the effect of hemorrhagic control training on the knowledge, skills, and attitudes of lay first-person responders and the outcomes of patients to whom their hemostatic interventions were applied. Its study period began when Callese et al.[45] ended in December 2013, and it included studies from all of the locations where the STB course was implemented. We focused on the training or education of lay first responders because this is the target population of the STB course. The choice of knowledge, skills, and Willingness, Confidence Comfort towards hemorrhage control, as our primary outcomes, were based on the epidemiology of preventable prehospital or early trauma deaths; the majority expire from exsanguination and low levels of willingness amongst the general public, to intervene to control bleeding in emergency settings [46,47,48,49,50].

We acknowledge that most of the STB studies were more recent; the STB was only implemented in 2015, and 90% were performed in the USA. These limitations are inherent to the course's history, origins, and evolution. We excluded any equipment or device specific evaluation as we were more focused on an evaluation of bleeding control through cognitive, psychomotor, and affective elements, rather than on new tourniquet design [47]. In this same vein, we acknowledge that pre and post-test results are process evaluations that cannot replace objective measurements of bleeding control.This review may have overlooked some non-US-based STB evaluations as it did not review non-English publications and did not query additional, more internationally-focused, databases such as Embase, Cochrane Web-of-Science, and BIOSIS search engines. Furthermore, vital manuscripts could have been overlooked if only a title/abstract review was utilized. Finally, the authors did not follow a well-established grading score for the assessment of the study's quality apart from their consensus.

The fact that the STB course material is being made available, without charge or costs, by the ACS-COT makes this analysis even more compelling as it can serve as a basis for comparison to other non-STB bleeding control courses not only using traditional measures but also cost-effectiveness. However, the affordability of tourniquets or equivalent bleeding control equipment per se will undoubtedly influence the acquisition of such. In the post-course setting, developing strategies that enhance or incentivize access to these materials is imperative. These will favor better implementation of the of the program exactly as it is taught in the STB courses [48, 49].

Almost all studies reported an increase in the bleeding control knowledge of students, measured by the post-tests. However, in Massachusetts, the gain in willingness and comfort to apply bleeding control did not readily translate to improvements in proper tourniquet application [24]. Multiple studies reported that certain sub-populations had a higher 'yield,' as measured by the percentage increase in correct responses to post-test questions. These sub-populations included individuals with prior training or experience in hemorrhage control, those with a shorter time to successful tourniquet placement, and security personnel [32, 44]. Of the six studies that measured bleeding control knowledge retention, the range of knowledge retention was 39–72%; the tests were performed from 1 to 9 months after the initial training [10, 11, 22, 34, 38, 39].

Of the studies that evaluated skill acquisition, it was found that the course significantly improved post-course skill evaluation scores in nine [9,10,11, 22, 32, 34, 37, 38, 40]. Incorporating a hands-on component simulation [18] or a bleeding model [31] resulted in not only better skill at bleeding control but also reduced time to achieve correct tourniquet application [36].

While the merits of knowledge, skill, or attitude as measures of the effectiveness of a bleeding control course have been described and discussed elsewhere [51], in the end, an HC course must demonstrate that it can reduce the number of deaths from exsanguinating trauma patients. The lone study that showed the lifesaving impact of the STB course was not even conducted in the USA. Parvin-Nejad and co-authors described the experience of STB-trained nursing students in Sierra Leone, 98% of whom had an encounter with a bleeding patient at 12 months. Although only 20% used a tourniquet, almost all patients [97%] survived [43].

Given the lack of evidence to support the positive effect of the 'alphabet' courses on trauma outcomes, we thought it would be most pragmatic to include patient outcomes in the performance indicators of these HC courses. And this is why we recommend that all HC course evaluations include specific, clinically significant patient outcome measures.

Four studies evaluated the effect of instructor/faculty characteristics, and they did not find any significant differences in the post-test results of students trained by faculty from different backgrounds [19, 21, 29, 37]. From a task-shifting or force multiplier standpoint, this supports more 'train the trainer' possibilities and options that utilize lay, non-medical faculty to further spread valuable bleeding control knowledge and skills within various communities.

Five studies evaluated the effect of participant/student characteristics on the acquisition of HC knowledge and utilization of HC skills. They found that younger students, from 18 to 55 years, retained HC skills significantly better than more senior students aged > 55 years [10]. First responders who had previous exposure to situations needing HC felt substantially more prepared when compared to students and public workers [20, 23]. Trauma-naïve students, without prior experience or training in HC, had more improvement in post-test scores than other students [31]. In contrast, another paper identified law enforcement and civilian participants with better post-test scores than firefighters [33] and security personnel with reduced time to successful tourniquet placement [43].

Only one study addressed the cost-effectiveness of teaching HC courses to lay persons. The average cost to host a class of 25 trainees was $ 729.00 ( $ 29.16 per student) to achieve significant improvements in feeling prepared to apply a tourniquet and to pack a bleeding wound [20].

Geographically, this review reveals that there are marked regional gaps in the locations of published evaluations of HC courses. For this review, no studies were included from the South-East Asian region (SEAR) and the European region (EUR).

Meaning of the study and mechanisms and implications for policymakers

There is a clear message from 35 studies that evaluated the STB courses for laypersons that trained over 15,000 students. The message is that STB courses can improve students' knowledge, skill, WCCL and the key patients’ outcomes when they implement newly acquired lessons and skills learned. The broader implementation of these courses must be recommended. Still, there must be consensus on evaluation tools, process and outcome indicators, and the priority regions/areas where this must happen.

Many previous authors have enumerated recommendations to improve the Stop The Bleed courses [52,53,54]. While it is beyond the scope of this paper to list and discuss each of these suggestions, we will mention the domains that warrant closer focus as the global HC community moves forward with the STB course:

  1. a.

    To inform the frequency and format of refresher courses, well-designed studies to assess the retention of knowledge and skills must be performed [47, 48].

  2. b.

    With the initiative for public education on tourniquet use, instructions should support victims or first-responder laypeople assuming no education has been received. Given these courses' low penetration, consider using Just In Time [JiT] instructions for tourniquet application [46, 48].

  3. c.

    At a minimum, all STB education programs should achieve certain objectives [55, 56].

    These objectives are strategically structured, commencing with a focus on the affective domain to motivate learners to take prompt actions in response to hemorrhagic emergencies. Subsequently, the programs should be designed to target the cognitive domain, imparting knowledge to learners for distinguishing between life-threatening and non-life-threatening bleeding. Finally, STB education programs must provide comprehensive instructions on the practical application of pressure, combining both cognitive and psychomotor elements.

  4. d.

    While learner reactions inform how training programs are designed, programs must collect data at all levels of the Kirkpatrick model. Behavioral and results outcomes through follow-up data collection with trainees will tell the community whether or not the lay public is utilizing STB training to implement potentially lifesaving interventions [57].

  5. e.

    Just as there has been a consensus among many groups through The Hartford Consensus and the more than 60 organizations that support Stop The Bleed, is it also time to make the curriculum and training more standardized? [58].

  6. f.

    The STB program overwhelmingly improves short-term confidence, but gaps in skill retention, data collection on patient outcomes, and settings that would benefit are identified [51].

Unanswered questions and future research

At this stage, is there certainly enough evidence to make this recommendation for the more widespread implementation of these STB courses? All things considered, any bleeding control course must demonstrate that it reduces the death toll from preventable deaths due to uncontrolled traumatic exsanguination. In the interim, while we await the definitive data demonstrating the survival benefit of the STB courses, the best evidence from this review should suffice to inform the more targeted and focused STB course implementation and consistent evaluation [59]. The proper implementation of such training courses would be expected to improve the potential morbidity and mortality of the casualties’ victims. However, most of the published studies did not specify how to measure these outcomes, and therefore the current systematic review could not assess them. Like the CPR courses, the learning curves and guidelines will improve with time once STB training courses are implemented in the right place and time [60, 61].

Conclusions

Hemorrhage control courses for laypersons have demonstrated significant improvements in knowledge, skill, confidence, and willingness to intervene to stop traumatic exsanguination. The implementation of these courses needs be accompanied by more universal, consistent, and objective evaluations of learning objectives and their effect on desired clinical outcomes that apply the numerous published consensus recommendations. The evaluation of clinically relevant patient outcomes, specifically their effect on preventable deaths from compressible hemorrhage, is needed to strengthen further the evidence behind the recommendations for the more widespread teaching of the STB courses.