EIT 6420 Alternative Objects for CPR Training - ScR

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: (none applicable)

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 applicable)

Task Force Synthesis Citation

Donoghue A, Abelairas-Gomez C, Carballo Fazanes A, Cortegiani A, Pardo Rios M, Ko Y, Greif R, Lauridsen K, Finn, J, Cheng A on behalf of the International Liaison Committee on Resuscitation Education, Implementation, and Teams Task Force.  Alternative Objects For CPR Training: Task Force Synthesis of a Scoping Review. International Liaison Committee on Resuscitation (ILCOR) Education, Implementation, and Teams Task Force, 2026 October7.  Available from: http://ilcor.org

Methodological Preamble

The continuous evidence evaluation process started with a scoping review of the use of alternative objects for CPR training conducted by members of the ILCOR EIT Task Force.

Scoping Review

To be updated.

PCC

The PCC (Population, Concept, Context)

Registered in Open Science Framework July 29, 2026

Search Strategies

The search strategy was developed and run by Julie Reed at the Children’s Hospital of Philadelphia.

PubMed 188 4/22/2026

(Heart Arrest[Mesh] OR resuscitation[mesh] OR ventricular fibrillation[mesh] OR Return of Spontaneous Circulation[mesh] OR "heart arrest"[tiab] OR "cardiac arrest"[tiab] OR "ventricular fibrillation*"[tiab] OR "pulseless electrical activity"[tiab] OR flat-lin*[tiab] OR flatlin*[tiab] OR "heart stop"[tiab] OR "cardiac stop"[tiab] OR "cardiac standstill"[tiab] OR asystole[tiab] OR "cardiopulmonary arrest"[tiab] OR "Cardiopulmonary Resuscitation"[tiab] OR OHCA[tiab] OR IHCA[tiab] OR CPR[tiab] OR resuscitation*[tiab] OR "advanced life support*"[tiab] OR "advanced cardiac life support*"[tiab] OR ROSC[tiab] OR "chest compression*"[tiab] OR "return spontaneous"[Title/Abstract:~3]) AND (low-cost[tiab] OR lowcost[tiab] OR home-made[tiab] OR homemade[tiab] OR "do it yourself"[tiab] OR DIY[tiab] OR makeshift[tiab] OR hand-made[tiab] OR handmade[tiab] OR pillow*[tiab] OR bottle*[tiab] OR "low fidelity"[tiab]) AND (train*[tiab] OR teach*[tiab] OR learn*[tiab] OR instruct*[tiab]) AND (2000:2024[pdat])

Embase 365 4/22/2026

('heart arrest'/exp OR 'resuscitation'/exp OR 'heart ventricle fibrillation'/exp OR 'return of spontaneous circulation'/exp OR 'heart arrest':ti,ab,kw OR 'cardiac arrest':ti,ab,kw OR 'ventricular fibrillation*':ti,ab,kw OR 'pulseless electrical activity':ti,ab,kw OR 'flat-lin*':ti,ab,kw OR 'flatlin*':ti,ab,kw OR 'heart stop':ti,ab,kw OR 'cardiac stop':ti,ab,kw OR 'cardiac standstill':ti,ab,kw OR 'asystole':ti,ab,kw OR 'cardiopulmonary arrest':ti,ab,kw OR 'cardiopulmonary resuscitation':ti,ab,kw OR 'ohca':ti,ab,kw OR 'ihca':ti,ab,kw OR 'cpr':ti,ab,kw OR 'resuscitation*':ti,ab,kw OR 'advanced life support*':ti,ab,kw OR 'advanced cardiac life support*':ti,ab,kw OR 'rosc':ti,ab,kw OR 'chest compression*':ti,ab,kw OR ((return NEXT/4 spontaneous):ti,ab,kw)) AND ('low-cost':ti,ab,kw OR 'lowcost':ti,ab,kw OR 'home-made':ti,ab,kw OR 'homemade':ti,ab,kw OR 'do it yourself':ti,ab,kw OR 'diy':ti,ab,kw OR 'makeshift':ti,ab,kw OR 'hand-made':ti,ab,kw OR 'handmade':ti,ab,kw OR 'pillow*':ti,ab,kw OR 'bottle*':ti,ab,kw OR 'low fidelity':ti,ab,kw) AND ('train*':ti,ab,kw OR 'teach*':ti,ab,kw OR 'learn*':ti,ab,kw OR 'instruct*':ti,ab,kw) AND [2000-2024]/py

Cinahl 89 4/22/2026

S11 S7 AND S8 AND S9 2000-2026

Database - CINAHL 89

S10 S7 AND S8 AND S9

Database - CINAHL 91

S9 train* OR teach* OR learn* OR instruct*

Database - CINAHL 646,399

S8 low-cost OR lowcost OR home-made OR homemade OR "do it yourself" OR DIY OR makeshift OR hand-made OR handmade OR pillow* OR bottle* OR "low fidelity"

Database - CINAHL 20,969

S7 S1 OR S2 OR S3 OR S4 OR S5 OR S6

Database - CINAHL 117,356

S6 return ADJ3 spontaneous

Database - CINAHL 26

S5 "heart arrest" OR "cardiac arrest" OR "ventricular fibrillation*" OR "pulseless electrical activity" OR flat-lin* OR flatlin* OR "heart stop" OR "cardiac stop" OR "cardiac standstill" OR asystole OR "cardiopulmonary arrest" OR "Cardiopulmonary Resuscitation" OR OHCA OR IHCA OR CPR OR resuscitation* OR "advanced life support*" OR "advanced cardiac life support*" OR ROSC OR "chest compression*"

Database - CINAHL 86,433

S4 (MH "Resuscitation+")

Database - CINAHL 54,441

S3 (MH "Return of Spontaneous Circulation")

Database - CINAHL 113

S2 (MH "Ventricular Fibrillation")

Database - CINAHL 4,330

S1 (MH "Heart Arrest+")

Database - CINAHL 22,723

Inclusion and Exclusion Criteria

Inclusion Criteria: all studies describing chest compression +/- assisted ventilation training using alternative devices (household objects or non-manikin commercial objects)

Exclusion Criteria: Neonatal Resuscitation Program training (delivery room), training not inclusive of chest compressions (e.g. Helping Babies Breathe)

No grey literature was searched.

Data Table

EIT 6420 DATA TABLE Authors November2026

Task Force Insights

1. Why this topic was reviewed

This topic was chosen for an ILCOR review based on inclusion of similar reviews in the Education chapters of both the American Heart Association and European Resuscitation Council’s 2025 Guidelines.19,20

Widespread population-level CPR training is a desirable outcome but challenging to implement; one obstacle for disseminating such training is the incomplete availability of manikins and task trainers traditionally used in CPR training courses. In low resource settings, the lack of access to and/or availability of manikins and task trainers, whether due to economic or infrastructural limitations, is a barrier to CPR training of sufficient quality and adequate scope. Small descriptive studies have reported the use of a variety of household objects such as pillows, plastic bottles, rolls of toilet paper, etc. being used as simple alternative to manikins. Additionally, simple and low-cost devices are made and/or marketed by companies to allow CPR skill training without the need for a manikin (e.g. foam blocks such as PushHeart, etc.) It is not known whether training using such objects can achieve comparable levels of skill and knowledge acquisition or maintenance when compared with standard training devices such as manikins and simulators. A more detailed understanding of the educational outcomes from training with these objects would allow instructors and investigators to tailor their implementation and optimize their use to a greater extent, particularly with studies providing a head-to-head comparison of alternative objects with standard training devices.

2. Narrative summary of evidence identified

After screening of 6931 records and duplicate removal, 25 full texts were assessed. 18 studies were included. There were 8 RCTs4,7,9,10,12,13,15,16 and 10 observational studies1-3,5,6,8,11,14,17,18; seven RCTs involved a comparison of alternative object versus manikin training4,9,10,12,13,15,16 and one RCT compared alternative object training to blended learning without skill practice.7 Five studies were conducted with healthcare students (nursing, medical, dental)3,7-9,14; the remaining studies were conducted with lay rescuers only. Seven studies excluded subjects with prior CPR training4,8,9,12,14,17,18; three studies did not exclude based on prior CPR training2,5,10; eight studies did not specify whether prior CPR training was assessed or not.1,3,6,7,11,13,15,16

Several different alternative objects were studied. Six studies involved use of a pillow with superimposed landmarks.2,4-7,17 Four studies used a plastic bottle1,3,12,13; one of these studies included a balloon for assisted ventilation training.1 Two studies used rolls of toilet paper.10,18 One study each used the following: foam blocks (dice) with a plastic bag for ventilation training16, plastic tubes filled with liquid to simulate blood flow11, and a combination of a pillow plus a plastic bottle.9

Three additional studies involved the use of low-cost simplified models made by life support training equipment companies.8,14,15 All three studies used a compressible foam block; two studies used a foam block with an audible click for feedback on depth.8,14

Outcome measures were very heterogeneous across studies. 17 studies assessed learner performance immediately post-training1-6,8-18; 1 study reported on an additional assessment at 6 months post training16; 1 study reported on assessments at 15 days and 6 months post training.7 13 studies assessed specific CPR parameters4,7-18; 5 studies assessed overall CPR performance1,4,9-11; two studies assessed ventilation skill.1,16 Four studies assessed knowledge via post-training questions.3,5,7,9 Seven studies assessed learner attitudes (confidence, willingness to perform CPR, perceived effectiveness of objects).2,5,6,8,9,14,15 Cost was reported in one study.1

Results for studies with manikin training as a comparator were heterogenous. Three studies reported overall CPR score and found no significant differences between alternative objects and manikin-based training4,9,10. Six studies reported on chest compression depth and found no significant differences between groups.4,7,10,12,15,16 Eight studies reported on chest compression rate; five studies found no difference9,10,12,13,15 and three studies found that manikin training was associated with better guideline compliance with CC rate.4,11,16 Three studies reported on chest wall recoil; one study found no difference11; one study found that alternative object training (pillow) was associated with a greater proportion of CC with appropriate recoil; one study found that manikin-based training was associated with improved recoil10. Two studies reported that manikin-based training was associated with greater percentage of adequate CC depth.11,15 Two studies reported on percentage of adequate CC rate and found no difference.11,15 Two studies reported on knowledge post-training and found no difference between groups.7,9 One study found that learners trained on manikins felt better prepared to perform CPR than learners trained on an alternative object (PushHeart device (foam block)).15

3. Narrative Reporting of the task force discussions

The task force concluded that the high degree of heterogeneity in the objects used, the influence of concomitant instructional design elements used, the variability in subject groups, and the differing outcome measures made it difficult to make a uniform statement about the usefulness of alternative objects for CPR training. Only three studies (one with a pillow, one with a plastic bottle, and one with a combination of pillow and plastic bottle) had the simultaneous features of a randomized design, exclusion of subjects with prior CPR training, and a summative assessment on a feedback-enabled manikin as the outcome of interest.4,9,12 Most of the studies that compared an object to another form of training seemed to demonstrate comparability without proving non-inferiority; only one study was designed for non-inferiority.10

The task force also concluded that alternative objects may be used for training when standard manikins or task trainers were not accessible. In reaching this conclusion, the task force considered that, when such objects are all that is available, training on alternative objects is preferable to no training at all. However, despite the fact that this review does not include studies that suggest that manikins lead to superior outcomes when compared with alternative objects, the task force consensus was that standard manikins as task trainers should be preferentially used when possible.

Knowledge Gaps

• For learners receiving training in basic life support, does any alternative object (e.g. pillow, plastic bottle, etc.), when compared to another alternative object, lead to improved CPR skill acquisition?

• For learners with prior CPR training, does additional training (maintenance, spaced, or refresher training) with alternative objects lead to improved skill maintenance?

• Amongst all learner types, is the use of alternative objects cost-effective in comparison to standard training courses without sacrificing educational outcomes?

• During CPR training with alternative objects, do any specific additional instructional design elements lead to better educational outcomes?

• For all learners in basic life support, can alternative objects be used to train the simultaneous coordinated delivery of chest compressions and assisted ventilations?

• For patients receiving basic life support, does the presence of BLS providers trained on alternative objects have any effect on clinical outcomes?

References

1. Barcala-Furelos R, Martínez-Isasi S, Sanmartín-Montes M, Aranda-Garcia S, Peixoto-Pino L, Rodríguez-Núñez A. DIY LoCo-Baby: a ultra-low-cost infant CPR manikin for universal training access. Resusc Plus. 2026;28:101217. doi: 10.1016/j.resplu.2026.101217

2. Barry M, Dixon M, Armstrong C, Keane F. The Pillow Project, Infant Choking, and Basic Life Support Training for Prospective Parents: A Low-Cost Intervention for Widespread Application. J Perinat Neonatal Nurs. 2019;33:260–267. doi: 10.1097/JPN.0000000000000397

3. Bonizzio CR, Nagao CK, Polho GB, Paes VR. Basic Life Support: an accessible tool in layperson training. Rev Assoc Med Bras (1992). 2019;65:1300–1307. doi: 10.1590/1806-9282.65.10.1300

4. Goldstein M, Goldstein B, Novograd J, Carden K, Kirwan M. Comparison of a low and high resource model to effectively train college students in compression only cardiopulmonary resuscitation. Circulation. 2018;138.

5. Goldstein M, Goldstein B, Novograd J, Wallace I, Goldstein L, Carden K. Use of a Low Resource Model for Group Cardiopulmonary Resuscitation Training: Knowledge Gains and Attitude Changes. Circulation. 2019;140. doi: 10.1161/circ.140.suppl_2.392

6. Goldstein B, Clark EL, Goldstein MM, Novograd J, Silverman AJ, Uhley V. USING A LOW RESOURCE METHOD TO TEACH HANDS-ONLY CPR TO ADOLESCENTS IN A COMMUNITY SETTING. In; 2025:2757.

7. Koyuncu A, Pehlivan K, Yava A, Çetindaş K, Karacan H, Ulaşli Z. New method for autonomous learning of BLS psychomotor skills: Pillow mannequin: Randomized controlled study. Nurse Educ Today. 2024;140:106273. doi: 10.1016/j.nedt.2024.106273

8. Leiton-Espinoza ZE, López-González Á, Villanueva-Benites ME, Urbina-Rojas YE, Rabanales-Sotos J, Hoyos-Álvarez Y, Gómez-Lujan MDP. Suitability of a Low-Fidelity and Low-Cost Simulator for Teaching Basic Cardiopulmonary Resuscitation-"Hands-Only CPR"-To Nursing Students. Nurs Rep. 2025;15. doi: 10.3390/nursrep15050162

9. Nehra A, Ravindra P, Bhat R, Nagesh SK, Alok Y, Nisarg S, Shanmukhappa Maddani S, Balakrishnan JM. Comparison between a low-cost model (CPR Pillow) and a mannequin in training hands only cardiopulmonary resuscitation (CPR): A randomised trial. Resusc Plus. 2024;17:100518. doi: 10.1016/j.resplu.2023.100518

10. Ohle R, Moskalyk M, Boissonneault E, Bilgasem A, Tissot E, McIsaac S. Is a homemade cardiopulmonary resuscitation (CPR) trainer non-inferior to a commercially available CPR mannequin in teaching high-quality CPR? A non-inferiority randomized control trial. Resusc Plus. 2021;6:100134. doi: 10.1016/j.resplu.2021.100134

11. Peixoto-Pino L, Isasi SM, Agra MO, Van Duijn T, Rico-Díaz J, Núñez AR, Furelos RB. Assessing the quality of chest compressions with a DIY low-cost manikin (LoCoMan) versus a standard manikin: a quasi-experimental study in primary education. Eur J Pediatr. 2024;183:3337–3346. doi: 10.1007/s00431-024-05601-8

12. Piscopo A, Piscopo IC, Fonseca FA, Pinto IM, Saraiva FK, Avezum A. Cardiopulmonary Resuscitation (CPR) Mass Training for High School Children in Public Schools in São Paulo - Brazil - Using PET Bottle Mannequins and Recycled Material. Global Heart. 2018;13:458–459. doi: 10.1016/j.gheart.2018.09.293

13. Piscopo A, Piscopo IC, Fonseca FA, Pinto IM, Saraiva FK, Avezum A. A New Mannequin Made by Recyclable PET Bottle for Training Thoracic Compressions at Schools. Global Heart. 2018;13:458. doi: 10.1016/j.gheart.2018.09.292

14. Rabanales-Sotos J, Guisado-Requena IM, Leiton-Espinoza ZE, Guerrero-Agenjo CM, López-Torres-Hidalgo J, Martín-Conty JL, Martín-Rodriguez F, López-Tendero J, López-González A. Development and Validation of a Novel Ultra-Compact and Cost-Effective Device for Basic Hands-On CPR Training: A Randomized, Sham-Controlled, Blinded Trial. Int J Environ Res Public Health. 2022;19. doi: 10.3390/ijerph192215228

15. Tanaka S, White AE, Sagisaka R, Chong G, Ng E, Seow J, Mj NA, Tanaka H, Ong MEH. Comparison of quality of chest compressions during training of laypersons using Push Heart and Little Anne manikins using blinded CPRcards. Int J Emerg Med. 2017;10:20. doi: 10.1186/s12245-017-0147-6

16. Van Raemdonck V, Monsieurs KG, Aerenhouts D, De Martelaer K. Teaching basic life support: a prospective randomized study on low-cost training strategies in secondary schools. Eur J Emerg Med. 2014;21:284–290. doi: 10.1097/MEJ.0000000000000071

17. Wahid A, Isfandiari AM, Aridamayanti BG, Wardani SA, Mahadani M, Salsabila NI, Syarif M, Wiguna AR, Maulidah M. Enhancing cardiopulmonary resuscitation training for the community with foam pillows: A promising approach. Afr J Reprod Health. 2024;28:160–167. doi: 10.29063/ajrh2024/v28i10s.19

18. Wanner GK, Osborne A, Greene CH. Brief compression-only cardiopulmonary resuscitation training video and simulation with homemade mannequin improves CPR skills. BMC Emerg Med. 2016;16:45. doi: 10.1186/s12873-016-0110-5

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20. Nabecker S, de Raad T, Abelairas-Gomez C, Breckwoldt J, Chakroun-Walha O, Farquharson B, Hunyadi-Anticevic S, Lott C, Schnaubelt S, Yeung J, et al. European Resuscitation Council Guidelines 2025 Education for Resuscitation. Resuscitation. 2025;215 Suppl 1:110739. doi: 10.1016/j.resuscitation.2025.110739