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NTOA. This study specifically examined limb­tourniquet ap­  application videos produced by the tourniquet manufacturer
          plication for bleeding control and measured associated com­  was used. Didactic training content included historical back­
          petence and confidence levels during and after a simulation   ground on bleeding control, indications for limb­tourniquet
          exercise.                                          use, steps for proper limb­tourniquet application, measures
                                                             to check therapeutic efficacy, and how and why to document
                                                             time of application. One­hour, group hands­on practice ses­
          Methods
                                                             sions were conducted using a TCCC instructor who trained
          A bleeding­control training program was implemented and   the participants to apply direct pressure to a wound, place a
          evaluated in a rural police department in Pinehurst, North   tourniquet 2–3 inches above a simulated wound over cloth­
          Carolina, from February to April 2017. A repeated measures   ing using the two­handed method, tighten the tourniquet
          observational study was conducted to evaluate the training   strap, and then turn and secure the tourniquet windlass rod to
          program. Measured were self­efficacy (pre­ and post­test),   eliminate the distal pulse on a hypothetically wounded limb.
          knowledge (pretest, post­test 1 [immediate], post­test 2 [at   Participants then documented the time it took to apply the
          4 weeks]), and limb tourniquet application time (classroom,   tourniquet to the casualty.
          simulation exercise).
                                                             After practicing tourniquet application, an observation and
          Pinehurst is 70 miles from the nearest level I trauma center.   measurement of participant ability to use the two­hand method
          This small, rural village of 15,000 people hosts major sport­  to apply a tourniquet to a simulated wounded lower limb was
          ing events that can attract as many as 350,000 visitors; thus,   conducted. This occurred in the classroom 2 weeks before the
          creating the potential for a significant mass casualty event. Ap­  simulation exercise. The lower limb was chosen over the upper
          proval to implement and evaluate this training program was   limb because it is a larger target with larger blood vessels that
          received from the Pinehurst Police Department. Approval to   have a higher potential for rapid exsanguination during a re­
          conduct this study was provided by the Institutional Review   al­world occurrence. The event was timed and measured to the
          Board at Duke University.                          hundredth of a second using an Ultrak 360 Stopwatch, model
                                                             C­521 (Ultrak, http://www.cei­ultrak.com/). The time inter­
          A convenience sample of sworn police officers volunteered   val between initiating and completing tourniquet application
          and participated in this study. Evaluated and described were   was measured and recorded on a data collection tool. Cor­
          performance and confidence of rural law enforcement person­  rect tourniquet placement was defined as properly applying
          nel in responding to a simulated bleeding­control casualty sce­  the tourniquet 2–3 inches above the simulated wound. Proper
          nario. The study team was blinded to participant identities in   tourniquet application included having the windlass rod tight­
          this pre­ and post­test design project.            ened and secured in accordance with manufacturer guidelines
                                                             and time of tourniquet application documented.
          Prior to training, study participants completed an anony­
          mous demographic survey that included questions on age, sex,   An active­shooter simulation exercise was undertaken in ac­
          length of service as a police officer, length of service with the   cordance with TECC guidelines, which instruct officers to first
          Pinehurst police department, prior military experience, prior   secure the scene and then render aid. The officers were given
          tourniquet training, and prior use of tourniquets. Study par­  the scenario of having to respond to an improvised explosive
          ticipants also completed a pre­event five­question cognitive   device–initiated active­shooter attack at a local youth soccer
          assessment test of bleeding­control knowledge, and a gen­  event.
          eral self­efficacy (GSE) questionnaire to measure confidence.
          Cognitive assessment questions were developed and refined   After officers were briefed on the simulation exercise, they
          to be congruent with TCCC and Tactical Emergency Casu­  were positioned in a stationary vehicle. On cue, they exited the
          alty Care (TECC) course examination questions on bleeding   vehicle and responded to the scenario in accordance with their
          control. The cognitive assessment test and GSE questionnaire   training. The scenario included a casualty drag of a 165­lb
          were both administered again immediately after completion of   low­fidelity adult manikin (Rescue Randy; Simulaids, https://
          training. A third cognitive assessment test was administered 4   www.simulaids.com), as well as two other simulated victims
          weeks after completion of training.                (infant and child manikins). Also used was a shooting target
                                                             that simulated an attacker armed with a handgun. The officers
          The GSE questionnaire is an internationally recognized, 10­   were expected to secure the scene with a laser pistol, move
          question tool that uses a Likert scale.  This tool is valid and   the victims to cover, and then render care. The officers were
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          reliable; individuals with a high degree of self­efficacy and   timed in their ability to successfully apply a tourniquet to a
          confidence in an activity or task have been shown to be more   wounded lower limb of the adult manikin. The time interval
          likely to participate and be successful in that activity. 18,19  between initiating and completing tourniquet application was
                                                             measured and recorded as in the classroom training. Officers
          The Combat Application Tourniquet (C­A­T; Generation 7;   were debriefed after each measurement.
          C­A­T Resources Inc., http://combattourniquet.com/) was used
          during training simulations. This tourniquet is one of the mod­  Demographic variables were analyzed using descriptive statis­
          els recommended by TCCC and TECC courses endorsed by   tics. Paired t tests were used to compare pre­ versus post­ed­
          the NTOA. Funding for initial training, as well as future recur­  ucation self­efficacy questionnaires and classroom versus
          rent training, was allocated and approved by the police depart­  simulation exercise tourniquet­application time. A one­way
          ment. To accommodate various work shifts, didactic training   repeated measures analysis of variance was used to compare
          was provided through the departmental intranet. A narrated,   knowledge scores before, immediately after, and at 4 weeks af­
          15­minute, PowerPoint (Microsoft, www.microsoft.com) pre­  ter training. SPSS, version 24 (IBM, www.ibm.com) was used
          sentation with embedded one­ and two­handed tourniquet   to conduct statistical analyses with α set to .05.


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