Immersive technologies for resuscitation education (EIT 6405) TF SR

Conflict of Interest (COI) 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 recused as no COI declared.

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 a COI.

CoSTR Citation

Lin Y, Lockey A, Greif R, Abelairas Gomez C, Gosak L, Fijacko N, Cheng A on behalf of the International Liaison Committee on Resuscitation Education, Implementation and Teams Task Force (EIT). Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2023 November 30. Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic literature search of virtual and augmented reality in resuscitation training as opposed to other approaches to life support course delivery conducted by an information specialist with involvement of clinical content experts. Evidence collected from the literature was reviewed and considered by the EIT Task Force. These data were taken into account when formulating the Treatment Recommendations.

Systematic Review

Webmaster to insert the Systematic Review citation and link to Pubmed using this format when it is available if published

Publication in progress

PICOST

Prospero Registration: CRD42023376751

Consensus on Science

A total of 17 studies^1-17 were identified to be included in the review (Figure 1). Three studies examined the use of augmented reality (AR) in Basic Life Support (BLS) training^1-3. Two of these studies used augmented reality to provide real-time CPR feedback^{1, 3}, while the other study used augmented reality to provide clinical guidance during training² (Table 1).

A total of 11 studies explored the use of virtual reality for basic life support, with eight studies assessing use amongst lay people^4-11 (Table 2) and three studies evaluating VR use in healthcare providers^12-14 (Table 3). Amongst these studies, the intervention groups all featured virtual reality as the primary instructional methodology, either alone^{4-6, 8-11} or in combination with other features such as a provider’s guide or training module^{7, 13, 14}, or gamification¹². Control groups in the basic life support studies were variable and included: instructor-led training^{5, 6, 10, 11, 13}, video or web-based training^{7-9, 14}, mobile-app based training⁴, or a tablet-based serious game¹².

An additional three studies described VR use for ALS training in healthcare providers^15-17 (Table 3). One study compared virtual reality-based training to traditional instructor-led ALS training¹⁵, another compared virtual reality supplemented by a provider’s guide to standard training and video-based training with the provider’s guide¹⁶, and the last study compared gamified virtual reality training to instructor led neonatal resuscitation program training using high fidelity simulation¹⁷.

We did not conduct a meta-analysis due to significant heterogeneity in the design of the interventions, control groups, participant types, and outcome measures. Evidence is described below in a narrative fashion. Risk of bias assessment for randomized controlled trials (Table 4) and non-randomized studies (Table 5) is summarized in tabular format.

Augmented Reality Studies (Table 6) – CPR Skills

CPR Skills

CPR Depth

Two studies comprising 127 participants reported CPR depth performance with and without use of augmented reality during training^{1, 2}Both studies demonstrated no significant difference in CPR depth performance between control and intervention groups^{1, 2}.

CPR Depth Compliance

Only one study of 34 participants assessed CPR depth compliance after training. This study found that participants in the augmented reality group had significantly better CPR depth compliance compared to those who received traditional training without augmented reality³.

CPR Rate

Two studies with a total of 127 participants evaluated CPR rate immediate after training. Amongst these two studies, there was no significant difference in CPR rate performance between control and intervention groups^{1, 2}.

CPR Rate Compliance

One study found no significant difference in CPR rate compliance after training when compared participants trained with and without augmented reality-assisted feedback³.

Overall CPR Performance

Two studies with a total of 134 participants assessed overall CPR performance with mixed results. One study of 34 participants found significantly improved overall CPR performance in the augmented reality group³, while the other study comprised of 100 participants found significantly better overall CPR performance in the control group (CPR manikin with regular audiovisual feedback system)¹.

Virtual Reality Studies – Knowledge and CPR Skills

BLS Knowledge (Table 7)

Knowledge Acquisition

Five studies with a total of 431 participants assessed participant knowledge after training. One study assessed healthcare providers¹² and four studies recruited laypeople as participants^7-10. In three studies there were significantly higher knowledge scores with virtual reality training compared to other forms of non-VR training, such as a PC-tablet based serious game¹², an e-learning module with video⁷ and video-based training⁸. Two studies showed no difference in participant knowledge when comparing VR training to traditional training¹⁰ or video-based training⁹.

Knowledge Retention

Retention of knowledge was evaluated in three studies with a total of 358 participants. One study with kindergarten teachers demonstrated improved knowledge retention at 5 weeks post-training in the virtual reality group compared to conventional video-based training⁸. Two other studies showed no difference in knowledge retention at 6 months between control and intervention groups^{5, 10}.

Skills Outcomes for BLS Studies (Table 8)

No Flow Time / Chest Compression Fraction

Three studies with a total of 600 participants assessed no flow time or chest compression fraction at the end of training^{6, 13, 14}. In one study, adult lay people in the instructor-led training group had significantly greater chest compression fraction during assessment compared to those trained with virtual reality⁶. For the outcome of no flow time, results were mixed, with one study favoring virtual reality over web-based BLS training¹⁴, and the other study favoring conventional BLS training over VR-based training¹³.

CPR Depth

Four studies comprising 724 participants reported CPR depth performance after training^{4, 6, 10, 11}. Two of the studies who recruited adult lay people demonstrated significantly better CPR depth in the control group compared to those who received virtual reality training^{4, 6}. The other two studies demonstrated no significant difference in CPR depth performance between groups^{10, 11}.

CPR Depth Compliance

Only one study of 352 adult lay people as participants assessed CPR depth compliance after training. This study found that participants in the instructor-led CPR training group has significantly better CPR depth compliance compared to those who received virtual reality training⁶.

CPR Rate

Three studies with a total of 483 participants evaluated CPR rate immediate after training. One study demonstrated higher CPR rate in the intervention group, however both control and intervention groups were within the suggested guideline range for CPR rate⁶; the other two studies found no difference in CPR rate performance between control and intervention groups^{4, 11}.

CPR Rate Compliance

For the outcome of CPR rate compliance, two studies (593 participants) reported mixed results, with one study showing significantly improved rate compliance in the control group (instructor-led training)⁶, and the other study showing no difference between groups¹⁰.

Chest Recoil Compliance

Three studies evaluated chest recoil compliance after training. Two studies demonstrated no difference between groups^{10, 11}, and one study reported better chest recoil compliance amongst those who received virtual reality training compared to the control group⁶.

Overall CPR Performance

For the outcome of overall CPR performance (i.e. CPR scores) after training, two studies found no difference in scores when comparing virtual reality training to instructor-led training with lectures¹¹, and when compared to video-based training⁹.

Skill Retention at 6 months

CPR Depth, Rate and Chest Recoil

One study with 120 participants measured retention of CPR skills 6 months after training. Amongst university students, there was no difference in CPR depth, rate, or chest recoil performance at 6 months between those who received traditional training and those trained using virtual reality¹⁰.

Virtual Reality Studies - Willingness to perform CPR (Table 9)

One study with 188 participants recruited adult lay people to instructor-led CPR training or VR-based CPR training, and found that those who received instructor-led CPR training were more willing to perform CPR at 6 months post-training⁵.

Virtual Reality Studies - Outcomes for ALS studies (Table 10)

Knowledge

One study with nursing students as participants compared neonatal resuscitation program with a high fidelity simulator to NRP training with virtual reality and showed no significant difference in knowledge scores between groups immediately post-training¹⁷.

Adherence to Guidelines

In a study of ACLS certified clinicians, participants were randomized to receive traditional ACLS training (control), VR training with comprehensive feedback, or VR training with limited feedback¹⁵. This study found significantly improved adherence to guidelines amongst participants who received traditional training compared to those who received VR training with limited feedback. There was no significant difference in adherence to guideline when comparing the control group to VR training with comprehensive feedback.

Clinical Performance

One study recruited nurses and midwives and compared standard HBB training to VR-based HBB training, and assessed clinical performance using a standardized OSCE test. They found no significant difference in OSCE scores between groups immediately post training and at 6 months post training¹⁶.

Treatment Recommendations

We suggest either the use of augmented reality or traditional methods for basic life support training of lay people and healthcare providers (weak recommendation, very low quality of evidence).

We suggest against the use of virtual reality for basic and advanced life support training of lay people and healthcare providers (weak recommendation, very low quality of evidence).

Justification and Evidence to Decision Framework Highlights

In making this recommendation, the EIT taskforce considered the following:

Augmented reality

• the evidence was equivocal and very low quality
• only a few studies were identified with a low number of participants
• two studies used augmented reality-based feedback^{1, 3}, and one for clinical guidance² (i.e. different applications of the technology) and the control groups were different across these 3 studies (some included CPR feedback, others did not)
• the costs associated with implementing augmented reality need to be described and explored further

Virtual Reality

• the evidence was predominantly in favor of non-VR based training and of very low quality
• studies were very heterogeneous with respect to type of intervention, type of control, outcome measures
• the cost effectiveness of implementing virtual reality was not reported

Knowledge Gaps

We identified several knowledge gaps in the literature:

• The relative and synergistic effect of immersive technologies when combined with other educational strategies (e.g. video, gamification, feedback etc) is unclear.
• Both augmented reality and virtual reality can be used in many different ways (e.g. real-time feedback, gamification, knowledge delivery); the effects of these different applications should be described and explored further.
• The impact of immersive technology on the acquisition and retention of knowledge and skills is poorly described and need to be further elucidated.
• The effect of immersive technology-based training on team-based skill performance and process measures (e.g. time to epinephrine, time to defibrillation) needs to be explored further.
• The role of the instructor when immersive technology is being used needs to be clarified - for example, when is it beneficial for the instructor to provide feedback, and what type of training does the instructor require when using immersive technology in resuscitation courses?
• The costs associated with implementing and maintaining augmented and virtual reality devices, as well as cost effectiveness of these training modalities, needs to be explored further.

Attachments: EIT 6405 Et D, EIT 6405 PRISMA

References

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2. Hou L, Dong X, Li K, Yang C, Yu Y, Jin X, et al. Comparison of Augmented Reality-assisted and Instructor-assisted Cardiopulmonary Resuscitation: A Simulated Randomized Controlled Pilot Trial. Clin Simul Nurs. 2022;68:9-18.

3. Jeffers JM, Schreurs BA, Dean JL, Scott B, Canares T, Tackett S, et al. Paediatric chest compression performance improves via novel augmented-reality cardiopulmonary resuscitation feedback system: A mixed-methods pilot study in a simulation-based setting. Resusc Plus. 2022;11:100273.

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12. Aksoy E. Comparing the Effects on Learning Outcomes of Tablet-Based and Virtual Reality-Based Serious Gaming Modules for Basic Life Support Training: Randomized Trial. JMIR Serious Games. 2019;7(2):e13442.

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16. Umoren R, Bucher S, Hippe DS, Ezenwa BN, Fajolu IB, Okwako FM, et al. eHBB: a randomised controlled trial of virtual reality or video for neonatal resuscitation refresher training in healthcare workers in resource-scarce settings. BMJ Open. 2021;11(8):e048506.

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