The goal of the Stop the Bleed (STB) campaign is to save lives by giving people the tools to control life-threatening hemorrhage, whether it is caused by unintentional injury, crash, violence or natural disaster. Trauma centers can take a leading role in disseminating bleeding control information and skills — and it makes sense that these efforts should be part of a center’s formal injury prevention program (IPP).
Recently, the trauma team at Kaiser Permanente Vacaville Medical Center in Vacaville, California, partnered with Cascade Training Centers and Solano County EMS Agency to offer Bleeding Control Basic (BCon) to the community. Kaiser Permanente Vacaville is a Level II trauma center approximately 55 miles northeast of San Francisco. Our hospital is a primary trauma facility for two counties and more than 650,000 people.
Our goal was to save lives and build resiliency in our community by educating the public on how to identify and stop major bleeding. Since this program offers significant potential to reduce the burden of injury, we structured it as an injury prevention program as recommended by the American College of Surgeons (ACS).
In designing this IPP, we learned many lessons on how to plan, structure and roll out a bleeding control program to diverse audiences. The first priority is to create a three-step implementation plan.
Three-step implementation plan
1. Train the trainers. Our first step was to create an instructor pool. We invited and encouraged several RNs, physicians, surgeons and EMS staff to participate in the initial instructor training. This training took place during two separate Train the Trainer (TTT) classes held at Kaiser Permanente Vacaville in December 2016 and January 2017. The two classes produced a total of 28 trained BCon instructors.
Both of the TTT courses were led by staff from Cascade Training, a healthcare training and education company. Cascade provided the required supplies, including practice tourniquets, dressings, wound molds and simulated blood.
2. Host pilot courses. When implementing a new IPP, it is a good idea to do an initial test run with controls in place. This allows you to evaluate and improve your approach before you introduce the program to the general public.
In March 2017, we conducted four BCon pilot courses at Kaiser Permanente Vacaville. Each of the 28 newly trained BCon instructors was encouraged to sign up to teach at least one pilot course. A seasoned BCon instructor was available at each pilot session to assist and facilitate the new instructors as needed.
The pilot courses were free to registrants and were scheduled strategically around end of shift times for instructors and staff. The courses were advertised as an optional educational opportunity and not a mandatory training.
The project team sent invitations to participate in the pilot classes to a select sample of potential students. We targeted three groups for this pilot project:
- “Internal” staff members and associates, which included paid, volunteer, contracted, clinical, ancillary and support staff from both Kaiser Permanente Vacaville and Kaiser Permanente Vallejo Medical Center (there was additional emphasis on recruiting non-clinical support staff).
- Family members of internal staff and associates.
- Students from the health sciences departments of two community colleges, which included students in the RN, RT, paramedic and EMT programs.
Each pilot course received a formal evaluation from both the Kaiser Permanente Vacaville trauma educator and the Cascade Training instructor. We also conducted informal peer evaluations. In addition, we held a 30-minute instructor debriefing after each pilot session to discuss findings and recommendations.
Changes were implemented after each pilot course, which resulted in each course being somewhat different. Although this process was labor-intensive, each set of changes produced dramatic improvements in the fluency and flow of the course.
3. Train the community. After the BCon pilots were complete and the identified opportunities for improvement were implemented, we began rolling the course out to the community.
A tri-fold advertising flyer was created and made available for distribution by the three cooperating organizations. Our initial outreach was to organizations and businesses in or around areas at higher risk for a multiple-victim incident as a result of dense population, violent crimes or terrorism — for example, shopping malls, government buildings, event centers and schools. We also targeted groups that share a common interest in community safety, such as churches, scouting groups, security patrol agencies, and public health and safety groups.
Once the three-step implementation process was complete, we re-grouped to discuss the experience and identify the lessons learned. Here are our recommendations to trauma program leaders who are considering implementing a community hemorrhage control course as an IPP under the STB campaign:
Partner with other organizations
Because of the resource demands of offering this class, a partnership with at least one other agency is imperative. Potential collaborators include other hospitals, local EMS agencies, healthcare training centers, community colleges, fire departments and law enforcement agencies.
The right partner can provide needed support in terms of instructors and supplies. Partnerships can also extend your ability to promote the course to the community.
Reach out for funding
Some trauma centers may be able to fund a community BCon course through an existing IPP budget. However, to meet the aims of the STB campaign completely, it will be necessary to provide the community with the tools needed to control bleeding. In this case, the primary tool is a tourniquet. Even if your center has a healthy IPP budget, supplying tourniquets to the community will likely require you to consider alternate funding sources.
In California, potential funding sources include Hospital Emergency Preparedness grants, private grants, and county, state or federal Homeland Security grants. Other states offer similar opportunities. Another way to fund a BCon implementation is to share costs with the agencies you are partnering with. Private philanthropy can also be a promising avenue for funding this kind of program.
Whichever sources of money you pursue, we recommend that you begin seeking funding one full year before program implementation.
Promote and remind
Our pilot course experience suggests that most people have never heard of Stop the Bleed. So, before launching a community BCon course, it will be helpful to educate the community on the existence of the STB campaign and its importance to public safety.
Advertise to the populations who are likely eager to participate. Our pilot course findings indicate that community college health science programs are an excellent source for recruiting students. Nearly 30% of attendees at our pilot sessions were from the nursing and EMT programs at a local community college.
According to the ACS, one element of an effective injury prevention program is leveraging the media to disseminate program information. IPP leaders can do this by distributing press releases about the BCon program to media outlets and inviting members of the media to attend a class.
To facilitate attendance, offer online registration. There are a variety of free, web-based event registration programs that are extremely efficient. Online registration also allows for easy tracking and simple data collection.
We recommended establishing a reminder system for registered students. Based on our experience in the pilot phase, as many as half of people who register for a free class do not ultimately attend. A simple email reminder may help reduce no-shows.
In addition, put a process in place for on-site registration. For our pilot courses, as many as one-third of attendees were “walk ups” who had not pre-registered. This had an adverse effect on data collection since much of the student demographic data was captured through our online registration process.
Structure the class for optimal results
The minimum class ratio for the BCon course is 1 instructor per 8 students. We found that the ideal class size for us was 24 students, which requires 3 instructors.
With 24 students per session, the class can divide into 2 groups of 12 for the skills portion of the course. At each skill station, the students further divide into pairs. This puts 6 pairs of students at the tourniquet application station with one lead instructor and 6 pairs of students at the wound packing station with another lead instructor. The third instructor is best utilized to monitor time and assist as needed. When signaled to rotate, students wrap up at one station and move to the other.
Plan for a 1.5-hour class, which includes:
- 1 hour for the lecture
- 5 minutes for a break
- 10 minutes for skill station #1
- 10 minutes for skill station #2
- 5 minutes for student evaluations and distribution of participation certificates
Consider providing additional practice teaching opportunities
As noted above, after an instructor is trained, he or she teaches the BCon course alongside an experienced trainer. In our surveys, we found that about half of newly trained instructors felt the need for more than one practice teach.
Track data to show effectiveness
According to the ACS, trauma centers should track data on their injury prevention initiatives. After each of the BCon pilot courses, we administered a student evaluation tool to gauge the effectiveness of the program. We also administered an evaluation tool to the instructors to evaluate the need for program changes prior to community implementation. We recommend that formative evaluations be administered to both students and instructors at the end of each class for ongoing assessment.
Improve your program and share it with others
Data tracking will identify opportunities for improving a bleeding control program. As just one example, our pilot course evaluations showed that students felt there could have been better advertising for the course and a more detailed description of class content. As a result, a new and enhanced tri-fold advertising flyer was created with detailed information regarding the STB campaign and course content.
Once you understand how to launch a BCon IPP and have implemented it within the community, the next step is to share your knowledge with others. One program’s data and findings will help another program at a neighboring trauma center or community hospital. Better yet, share the knowledge by partnering with each other. Take the initiative to lead and support other agencies in an effort to build resilient communities.
Paula Green, RN, BSN, MS, CCRN, CFRN was formerly the trauma educator, injury prevention and outreach coordinator at Kaiser Permanente Vacaville Medical Center and is now an assistant professor at Samuel Merritt University in Sacramento, California. Amy Brammer, RN, BSN, TNS, CEN, CAISS, CSTR is the trauma program director at Kaiser Permanente Vacaville. Lori Gallian, BS, EMT-P is the director of strategic relationships at Cascade Training Center in Roseville, California. Jessica Pemberton, MSN, RN, CEN, TCRN is the trauma performance improvement coordinator at Kaiser Permanente Vacaville.