Conflict of Interest Declaration
The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: Kevin Nation, Robert Greif. Kevin Nation is the Chief Executive of the New Zealand and Australian Resuscitation Councils – both Councils produce resuscitation guidelines that may include algorithms, flowcharts and infographics. RG has served as the recent Director of Guidelines for the 2025 Resuscitation Guidelines from the European Resuscitation Council, and SN was a lead member of the Guideline writing group for the 2025 Education for Resuscitation Guideline. RG was involved in the development of algorithms, flowcharts and infographics. SN was only involved in development of the education for resuscitation guidelines and not involved in development of algorithms, flowcharts and infographics for the resuscitation course participants, she co-developed 2 infographics targeted at the resuscitation training instructor.
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none declared.
CoSTR Citation
Nabecker S, Cheng A, Abelairas-Gomez C, Greif R, Viggers S, Chowdhury D, Alghaith A, Faraq AJ, Lennertz J, Brenna L, Lauridsen K, Finn J, Nation K on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force (EIT). Cognitive Aids in Resuscitation Education., Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation and Teams Task Force, 31 October 2026.
Background
Cognitive aids are intended to decrease the cognitive load of the resuscitation team, standardize communication and allow for a shared mental model among resuscitation team members. Unfortunately, some cognitive aids may promote fixation errors and potentially impair communication amongst team members. Poorly designed cognitive aids may negatively influence resuscitation team performance or patient outcomes.
EIT 6400 (former EIT 629) examined cognitive aid use during simulated cardiac arrest resuscitations. This review, published in 2024, demonstrated that cognitive aids used during simulated resuscitations were effective when used by health care professionals (very low certainty evidence). However, the use of cognitive aids by laypersons delayed certain critical actions and was not recommended (low certainty evidence).1 The use of cognitive aids during the training of healthcare professionals or lay rescuers was not examined at that time, and this was prioritized by the EIT taskforce as a knowledge gap warranting a new CoSTR. This CoSTR was conducted to guide resuscitation councils and their educational processes for development of cognitive aids as part of their teaching materials.
Definitions:
We defined cognitive aid as the “presentation of prompts aimed to encourage recall of information to increase the likelihood of desired behaviours, decisions, and outcomes”.2 Interactive cognitive aids were defined as cognitive aids that provide the user with the opportunity to interact with it in different ways. Data flows bidirectionally from user to cognitive aid and back. Examples of interactive cognitive aids include tablet apps, smartphone apps, audio voice guidance applications, computer-based clinical decision display systems, personal digital assistant apps, augmented reality decision support tools, or a Chatbot.1 Non-interactive cognitive aids were defined as being static with no possibility to interact. Examples of non-interactive cognitive aids include posters, checklists, smartphone apps, flowcharts, instruction cards, and tablets with auditory and visual prompts.1
Checklists were defined as “a list of action items or criteria arranged systematically, allowing the user to record the presence or absence of the individual items listed, thereby ensuring that all have been considered or completed”.3 A passive learner was defined as a person watching during a simulation training or a person watching someone else train. In resuscitation studies, these persons are often called observers. An active learner is a person actively participating in a simulation training. The person performing CPR and treating a simulated patient, rather than watching the scenario from the sidelines. Studies evaluating feedback devices without additional cognitive aid use, and studies evaluating cognitive aid use during debriefing were excluded, as both of these topics are evaluated in separate ILCOR EIT systematic reviews.
The continuous evidence evaluation process to produce Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic literature search of the use of cognitive aids in resuscitation education conducted by an information specialist (Brenna Leslie, Toronto) with involvement of clinical content experts. Evidence collected from the literature was reviewed and considered by the EIT Task Force. These data were considered when formulating the Treatment Recommendations.
Review Citation
Nabecker S, Cheng A, Abelairas-Gomez C, Greif R, Viggers S, Chowdhury D, Alghaith A, Faraq AJ, Lennertz J, Brenna L, Lauridsen K, Finn J, Nation K on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force (EIT). Cognitive Aids in Resuscitation Education: A Systematic Review. In draft.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: All learners during resuscitation training in any setting (adult, paediatric, neonatal).
Intervention: Use of a cognitive aid
Comparators: No use of cognitive aid
Outcomes: Patient survival, survival with good neurological outcome and return of spontaneous circulation (critical outcomes). Quality of performance in actual resuscitations as measured by CPR quality parameters such as chest compression rate, chest compression depth and chest compression pauses (important outcomes). Simulation-based measures including: overall excellent CPR, skills acquisition as measured by CPR quality parameters such as chest compression rate, chest compression depth and chest compression pauses/ventilation/compliance with depth and/or rate (end of course, <3mo, 3-6 mo, >6mo); time to starting CPR, time to epinephrine, time to ventilation, and time to secure airway (end of course, <3mo, 3-6 mo, >6mo); teamwork, cognitive load, and workload (end of course, <3mo, 3-6 mo, >6mo); adherence to guidelines as measured by end of course test scores (end of course, <3mo, 3-6 mo, >6mo) (important outcomes). Knowledge acquisition and implementation outcomes (cost, cost-effectiveness, time needed) (not important).
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. All languages are included as long as there is an English abstract available. Non-peer-reviewed studies and unpublished studies (e.g., conference abstracts, trial protocols) are excluded. Review articles will be searched for additional citations.
Timeframe: All years from inception to 16 June 2026.
PROSPERO Registration CRD420251140982.
Consensus on Science
The search identified 5072 records from five databases (Web of Science, PubMed, Medline, Embase and Cochrane). After removal of 1028 duplicates, 4044 were screened and 3917 were excluded upon review of titles and abstracts. 126 records were retrieved and assessed in full text; of these, 120 were excluded (38 abstracts only, 64 wrong intervention, 8 wrong study design, 5 trial protocols or registrations, 3 wrong outcomes, 2 wrong context). We found 6 studies investigating the effects of cognitive aid use during resuscitation training.4-9 Five of these studies were randomized controlled trials4-7,9, and one was a non-randomized, comparative study.8 Four studies involved medical students as participants5-8, one study recruited middle or high school students, and one study had healthcare professionals as participants.4 Interactive, smartphone-based cognitive aids4,9 or paper-based checklists8 were used by active learners in three studies, while the other three studies evaluated checklists utilized by passive learners (observers) who were not actively participating in the learning session or simulated event.5-7 No studies reported on any patient survival outcomes (critical), performance outcomes in actual clinical resuscitations (important) or implementation outcomes (not important).
CPR Skills
For the important outcome of overall excellent CPR (composite measure of global performance in CPR and CPR depth and rate) in simulated cardiac arrest, we identified very low quality evidence (downgraded for serious risk of bias, indirectness, and imprecision) from one study.7 This randomized trial with 200 medical student participants found that use of a checklist by passive learners significantly improved chest compression depth and rate (Intervention: 96%; comparator: 91%, p=0.032) compared to passive learners who did not use the checklist.7
For the important outcome of chest compression rate in simulated cardiac arrest, we identified low quality evidence (downgraded for serious risk of bias and imprecision) from one randomized trial.9 They recruited school-aged children (n=1426) and investigated the use of an interactive smartphone-based mobile app during training. The study found that app use resulted in reduced compliance with CPR rate compared to DVD training, both immediately after training (28% compliance with app vs. 43% compliance with DVD training, p<0.001) and at 6 months after training (30% compliance with app vs. 38% with DVD training, p=0.008).9 Chest compression rates fell within guideline targets (i.e. 100-120 / min) immediately after training and 6 months post-training in both groups.9
For the important outcome of chest compression (CC) depth performance in simulated cardiac arrest, we identified low quality evidence (downgraded for serious risk of bias and imprecision) from the same study as above.9 The study found no difference in mean CC depth when comparing app use to DVD training immediate after training, with both groups having a CC depth below guideline targets (i.e. 5-6 cm).9 The same study found the mean CC depth in both study groups fell below guideline targets (i.e. 5-6 cm) at 6 months post-training.9
For the important outcome of hands-off time during simulated cardiac arrest, we identified low quality evidence (downgraded for serious risk of bias and serious risk of imprecision) from the same study as above.9 The study found shorter hands-off time in the cognitive aid group compared to the DVD training group immediately after training (73 s hands-off time with app vs. 81s with DVD training, p<0.001), but no difference 6 months post-training.9
Time to Critical Interventions
For the important outcome of time to initiation of CPR in simulated cardiac arrest, we identified very low quality evidence (downgraded for serious risk of bias, indirectness and imprecision) from one randomized trial.5 The study investigated the use of a skills-based checklist by medical student passive learners (n=232) and found no significant difference in the time to CPR between those observing with or without a checklist (18s time to CPR with checklist vs. 24 s without checklist, p=0.15).5
For the important outcome of time to defibrillation in simulated cardiac arrest, we identified very low quality evidence (downgraded for serious risk of bias, indirectness and imprecision) from one study.5 This study found no significant difference in the time to defibrillation between those observing the simulated cardiac arrest event with or without a checklist (94s time to defibrillation with checklist vs. 92s without checklist, p=0.84).5
Adherence to Guidelines
For the important outcome of adherence to guidelines in simulated cardiac arrest, we identified very low quality evidence (downgraded for serious risk of bias, indirectness and imprecision) from three randomized trials.6,7,9 One study investigating use of an app-based cognitive aid amongst 1426 grade school students found that those trained using a DVD performed significantly better on the modified Cardiff test than those using the app-based cognitive aid both immediately after training (p<0.001) and at 6 months post-training (p>0.001).9 The two other studies explored use of a checklist amongst medical student passive learners (n=362), with one study reporting no difference in a global performance score (25-item checklist) (Intervention 24 vs control 23, p = 0.052)6 and the other demonstrating improved performance in the checklist group in the global performance score (checklist score) (Intervention: 25.2 vs. comparator: 24.6, p=0.001)7.
Teamwork
For the important outcome of Teamwork in simulated cardiac arrest, we identified low quality evidence (downgraded for serious risk of bias and indirectness) from two randomized trials using the Anesthesia Non-technical Skills score (ANTS) and the Non-Technical Skills (NTS) score to assess teamwork6,7. Both studies investigated the use of an observer (passive learner) checklist amongst medical students (n=362), and found no significant difference in teamwork scores between passive learners using a checklist vs. those observing without a checklist (ANTS score: checklist use median 24 vs 33 without checklist, p=0.606; and NTS score: checklist use 8.9 vs. 8.7 without checklist, p=0.22).7
Knowledge
For the not important outcome of knowledge, we identified very low quality evidence (downgraded for very serious risk of bias and indirectness) from four studies.4,6-8 One study investigating the use of a smartphone-based app amongst healthcare professionals (n=30) showed no difference in knowledge acquisition immediately after training (intervention 42.7 vs. control 43.5, p=0.45), but improved knowledge retention at 2 months in the intervention group (intervention 43.6 vs. control 39.27, p<0.001). The numbers represent a score on an MCQ test, however the maximum achievable number was not specified in the publication.4 A second study investigating checklist use during training amongst medical students (n=28) showed no significant difference in knowledge after training (92 % in intervention vs. 91.9% in control, p=0.71, 50-item Multiple Choice Test).8 Two other studies investigating checklist use amongst passive learners reported significantly improved knowledge acquisition in those participants using a checklist while observing (Intervention 8.0 vs Control 6.7, p = 0.05, 10-item Multiple Choice Test6; Intervention: 19.2 vs. control 17, p=0.003, 20-item Multiple Choice Test7).
Treatment Recommendations or Good Practice Statement
There is insufficient evidence in lay persons or healthcare professionals to make a recommendation for or against the use of cognitive aids during resuscitation education across adult, pediatric and neonatal settings. (very low certainty evidence)
Justification and Evidence to Decision Framework Highlights
In making this recommendation, the EIT task force considered the following:
- The EIT Task Force continues to prioritise this topic because international resuscitation councils commonly provide cognitive aids to resuscitation course participants and health care organizations (algorithms, pocket cards, flowcharts, infographics, apps etc.). However, it has not been determined if they are effective in improving patient outcomes or CPR knowledge or performance when introduced during resuscitation education.
- The available evidence evaluating the use of cognitive aids during resuscitation education is heterogenous with respect to methods and findings, and of very low certainty. Although some studies suggest improvements in selected performance outcomes, these findings are inconsistent across studies and outcomes. Patient outcomes and clinical process outcomes in real cardiac arrests were not reported. The task force determined that the current evidence does not establish a sufficiently clear balance of desirable vs. undesirable effects to support a recommendation for or against the intervention.
- All included studies targeted adult resuscitation training, there was no study identified for the use of a cognitive aid during pediatric- or neonatal resuscitation education.
- Studies included healthcare professionals and laypersons, and focused on basic life support training. There is insufficient evidence for advanced life support training.
- The studies included showed significant methodological heterogeneity, and half of the studies targeted mainly passive learners.
- Most of the outcomes were only reported in one included study, except teamwork skills, adherence to guidelines and knowledge acquisition.
- EIT Task Force members state that cognitive aids are currently being used frequently in advanced life support courses, whereas many basic life support courses are not using cognitive aids at the moment, yielding some expected costs related to a general implementation.
- Use and effect of cognitive aids during resuscitation education might be highly dependent on the learner and instructor population and circumstances, therefore, the current level of evidence is insufficient to recommend for or against the use of cognitive aids during resuscitation education.
Knowledge Gaps
We identified several knowledge gaps in the literature:
- Amongst resuscitation learners in any setting, it is unknown whether cognitive aid use during resuscitation education, compared to no cognitive aid use, improves patient outcomes, CPR skills during clinical resuscitation, or cost-effectiveness.
- Amongst resuscitation learners in neonatal- or pediatric life support, it is unknown whether cognitive aid use during resuscitation education, compared to no cognitive aid use, improves any resuscitation-specific outcomes.
- Amongst resuscitation learners in any setting, it is unknown whether cognitive aids enhanced with virtual/augmented reality, compared to no cognitive aid use, improve any resuscitation-specific outcome.
- Amongst resuscitation learners in any setting, it is unknown whether cognitive aids enhanced with artificial Intelligence, compared to no cognitive aid use, improve any resuscitation-specific outcome.
Data Tables
EIT 6418 Evidence to Decision Table (EtD)_October2026
EIT 6418 Evidence Table October2026
EIT 6418 Risk of Bias Table October 2026
References
1. Nabecker S, Nation K, Gilfoyle E, Abelairas-Gomez C, Koota E, Lin Y, Greif R, Education Implementation Team Task Force of the International Liaison Committee on R: Cognitive aids used in simulated resuscitation: A systematic review. Resusc Plus 2024; 19: 100675
2. Fletcher KBW: Cognitive aids: design suggestions for the medical field. Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care 2014; 3
3. St. Pierre MH, G; Simon, R; Buershaper, C.: Crisis Management in Acute Care Settings Human Factors, Team Psychology, and Patient Safety in a High Stakes Environment. 2011
4. Ahmad N, Musa M, Kadir F, Sharizman S, Hidrus A, Hassan H, Mamat R, Baddiri B: Exploring the Functionality of Technology-driven CPR Training Methodologies Among Healthcare Practitioners: A Randomized Control Pilot Study. J Saudi Heart Assoc 2024; 36: 99-105
5. Dilley SJ, Weiland TJ, O’Brien R, Cunningham NJ, Van Dijk JE, Mahoney RM, Williams MJ: Use of a Checklist During Observation of a Simulated Cardiac Arrest Scenario Does Not Improve Time to CPR and Defibrillation Over Observation Alone for Subsequent Scenarios. Teaching and Learning in Medicine 2015; 27: 71-79
6. Goulamhoussen A, Havard C, Gille B, François B, Benhamou D, Blanié A: An observer tool to enhance learning of medical students during simulation training of cardiopulmonary resuscitation: a randomised controlled trial. BMC Medical Education 2024; 24: 719
7. Khan M NK, Jadoon M, Siddique U, Aman F, Durrani M.: N OBSERVER TOOL TO ENHANCE LEARNING OF MEDICAL STUDENTS DURING SIMULATION TRAINING OF CARDIOPULMONARY RESUSCITATION: A RANDOMIZED CONTROLLED TRIAL. A Journal of Population Therapeutics and Clinical Pharmacology 2024: 2552-2558.
8. McSwain C, Mahan JM, Herrin TJ: The use of a criterion performance checklist to improve efficiency and effectiveness in a CPR self-teaching program. Academic Medicine 1979; 54
9. Nord A, Svensson L, Hult H, Kreitz-Sandberg S, Nilsson L: Effect of mobile application-based versus DVD-based CPR training on students’ practical CPR skills and willingness to act: a cluster randomised study. BMJ Open 2016; 6: e010717