Immersive technologies for resuscitation education (EIT 6405) TF SR

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ILCOR staff

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This CoSTR is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final COSTR will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

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:

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

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Publication in progress



Description (with recommended text)


All laypersons and healthcare providers in any educational setting.


Immersive technologies (virtual reality, augmented reality, mixed reality, extended reality) as part of instructional design to train neonatal, pediatric, adult basic and advanced life support.


Other methods of resuscitation training in basic and advanced life support (e.g., traditional manikin-based simulation training, other).


Knowledge acquisition and retention, skills acquisition and retention, skill performance in real CPR, willingness to help, bystander CPR rate, and patients’ survival.

Study Design

Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies and case series where n>5, conference abstracts) and research letters are eligible for inclusion.


All years and all languages were included if there was an English abstract. Literature search updated to January 1, 1990 to April 3, 2023.

Prospero Registration: CRD42023376751

Consensus on Science

A total of 17 studies1-17 were identified to be included in the review (Figure 1). Three studies examined the use of augmented reality (AR) in Basic Life Support (BLS) training1-3. Two of these studies used augmented reality to provide real-time CPR feedback1, 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 people4-11 (Table 2) and three studies evaluating VR use in healthcare providers12-14 (Table 3). Amongst these studies, the intervention groups all featured virtual reality as the primary instructional methodology, either alone4-6, 8-11 or in combination with other features such as a provider’s guide or training module7, 13, 14, or gamification12. Control groups in the basic life support studies were variable and included: instructor-led training5, 6, 10, 11, 13, video or web-based training7-9, 14, mobile-app based training4, or a tablet-based serious game12.

An additional three studies described VR use for ALS training in healthcare providers15-17 (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 training1, 2Both studies demonstrated no significant difference in CPR depth performance between control and intervention groups1, 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 groups1, 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 participants7-10. 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 groups5, 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 training6, 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 training4, 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 training4, 6. The other two studies demonstrated no significant difference in CPR depth performance between groups10, 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 groups4, 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 groups10, 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)


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 feedback1, 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


1. Leary M, McGovern SK, Balian S, Abella BS, Blewer AL. A Pilot Study of CPR Quality Comparing an Augmented Reality Application vs. a Standard Audio-Visual Feedback Manikin. Front Digit Health. 2020;2:1.

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.

4. Leary M, McGovern SK, Chaudhary Z, Patel J, Abella BS, Blewer AL. Comparing bystander response to a sudden cardiac arrest using a virtual reality CPR training mobile app versus a standard CPR training mobile app. Resuscitation. 2019;139:167-73.

5. Nas J, Thannhauser J, Konijnenberg LSF, van Geuns RM, van Royen N, Bonnes JL, et al. Long-term Effect of Face-to-Face vs Virtual Reality Cardiopulmonary Resuscitation (CPR) Training on Willingness to Perform CPR, Retention of Knowledge, and Dissemination of CPR Awareness: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open. 2022;5(5):e2212964.

6. Nas J, Thannhauser J, Vart P, van Geuns R-J, Muijsers HEC, Mol J-Q, et al. Effect of Face-to-Face vs Virtual Reality Training on Cardiopulmonary Resuscitation Quality. JAMA Cardiology. 2020;5(3):328.

7. Barsom EZ, Duijm RD, Dusseljee‐Peute LWP, Landman‐van der Boom EB, van Lieshout EJ, Jaspers MW, et al. Cardiopulmonary resuscitation training for high school students using an immersive 360‐degree virtual reality environment. British Journal of Educational Technology. 2020;51(6):2050-62.

8. Liu ZM, Fan X, Liu Y, Ye Xd. Effects of immersive virtual reality cardiopulmonary resuscitation training on prospective kindergarten teachers' learning achievements, attitudes and self‐efficacy. British Journal of Educational Technology. 2022;53(6):2050-70.

9. Liu Q, Tang Q, Wang Y. The effects of pretraining intervention in immersive embodied virtual reality cardiopulmonary resuscitation training. Behaviour & Information Technology. 2021;40(12):1265-77.

10. Castillo J, Rodriguez-Higueras E, Belmonte R, Rodriguez C, Lopez A, Gallart A. Efficacy of Virtual Reality Simulation in Teaching Basic Life Support and Its Retention at 6 Months. Int J Environ Res Public Health. 2023;20(5).

11. Hubail D, Mondal A, Al Jabir A, Patel B. Comparison of a virtual reality compression-only Cardiopulmonary Resuscitation (CPR) course to the traditional course with content validation of the VR course - A randomized control pilot study. Ann Med Surg (Lond). 2022;73:103241.

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.

13. Issleib M, Kromer A, Pinnschmidt HO, Suss-Havemann C, Kubitz JC. Virtual reality as a teaching method for resuscitation training in undergraduate first year medical students: a randomized controlled trial. Scand J Trauma Resusc Emerg Med. 2021;29(1):27.

14. Moll-Khosrawi P, Falb A, Pinnschmidt H, Zollner C, Issleib M. Virtual reality as a teaching method for resuscitation training in undergraduate first year medical students during COVID-19 pandemic: a randomised controlled trial. BMC Med Educ. 2022;22(1):483.

15. Khanal P, Vankipuram A, Ashby A, Vankipuram M, Gupta A, Drumm-Gurnee D, et al. Collaborative virtual reality based advanced cardiac life support training simulator using virtual reality principles. J Biomed Inform. 2014;51:49-59.

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.

17. Yang SY, Oh YH. The effects of neonatal resuscitation gamification program using immersive virtual reality: A quasi-experimental study. Nurse Educ Today. 2022;117:105464.


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ILCOR staff

Dear all,

Congratulations on your systematic review. Your analysis provides a comprehensive overview of the current evidence regarding immersive technologies in resuscitation education. However, considering some additional points and recent evidence before drawing a definitive conclusion might be beneficial.

Recent Advancements in VR/AR Technologies: The VR and AR fields are rapidly evolving. Newer studies may have incorporated more advanced technologies, potentially addressing some limitations identified in earlier research.

Variability in Study Design and Implementation: The significant heterogeneity in study designs, control groups, and interventions, as noted in your analysis, suggests that some observed limitations might stem from these variables rather than the VR/AR technologies themselves.

Different Learning Styles and Environments: VR and AR cater to diverse learning styles, providing immersive and interactive experiences that could be more effective for certain learners.

Long-term Skill Retention and Transferability: While immediate knowledge acquisition and skill performance are important, the long-term retention of these skills and their transferability to real-world scenarios are crucial.

Cost-Effectiveness and Accessibility: The cost and accessibility of VR/AR technologies are significant factors in their adoption. With technological advancements, these modalities might become more affordable and accessible, making them viable options for a broader range of training environments.

Complementary Role of VR/AR in Training: Viewing VR/AR as complementary to traditional methods, rather than standalone training tools, might be more appropriate. This blended approach could leverage the strengths of each modality.

Participant Feedback and Engagement: Participant feedback, particularly regarding engagement and motivation during training, is an important consideration. Recent studies focusing on these subjective aspects could provide a more holistic view of the effectiveness of VR/AR training.

In light of these considerations, suggesting against the use of VR/AR in life support training might be premature.

I have sent another comment with some references not included in your review, based on personal experience, which could be potentially useful for your consideration.

Thank you in advance for further evaluating this additional content.

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ILCOR staff

Dear all,

Some references to take into account to review the second part of the Treatment Recommendations
We suggest against the use of virtual reality for basic and advanced life support training of laypeople and healthcare providers.

In particular these two:
Semeraro F, Imbriaco G, Del Giudice D, Antognoli M, Celin D, Cuttitta M, Lo Guasto V, Giulini G, Gnudi T, Monesi A, Nava E, Tucci R, Carenzio A, Lo Jacono S, Gordini G, Gamberini L; Collaborators. Empowering the next Generation: An innovative "Kids Save Lives" blended learning programme for schoolchildren training. Resuscitation. 2023 Dec 13;194:110088. doi: 10.1016/j.resuscitation.2023.110088.

Chang YT, Wu KC, Yang HW, Lin CY, Huang TF, Yu YC, Hu YJ. Effects of different cardiopulmonary resuscitation education interventions among university students: A randomized controlled trial. PLoS One. 2023 Mar 14;18(3):e0283099. doi: 10.1371/journal.pone.0283099.

1. Jaskiewicz F, Kowalewski D, Starosta K, Cierniak M, Timler D. Chest compressions quality during sudden cardiac arrest scenario performed in virtual reality: A crossover study in a training environment. Medicine (Baltimore). 2020 Nov 25;99(48):e23374. doi: 10.1097/MD.0000000000023374.
2. Sadeghi AH, Peek JJ, Max SA, Smit LL, Martina BG, Rosalia RA, Bakhuis W, Bogers AJ, Mahtab EA. Virtual Reality Simulation Training for Cardiopulmonary Resuscitation After Cardiac Surgery: Face and Content Validity Study. JMIR Serious Games. 2022 Mar 2;10(1):e30456. doi: 10.2196/30456.
3. Buttussi F, Chittaro L, Valent F. A virtual reality methodology for cardiopulmonary resuscitation training with and without a physical mannequin. J Biomed Inform. 2020 Nov;111:103590. doi: 10.1016/j.jbi.2020.103590.
3. Semeraro F, Ristagno G, Giulini G, Gnudi T, Kayal JS, Monesi A, Tucci R, Scapigliati A. Virtual reality cardiopulmonary resuscitation (CPR): Comparison with a standard CPR training mannequin. Resuscitation. 2019 Feb;135:234-235. doi: 10.1016/j.resuscitation.2018.12.016.
4. Semeraro F, Ristagno G, Giulini G, Kayal JS, Cavallo P, Farabegoli L, Tucci R, Scelsi S, Grieco NB, Scapigliati A. Back to reality: A new blended pilot course of Basic Life Support with Virtual Reality. Resuscitation. 2019 May;138:18-19. doi: 10.1016/j.resuscitation.2019.02.034.

5. Semeraro F, Frisoli A, Bergamasco M, Cerchiari EL. Virtual reality enhanced mannequin (VREM) that is well received by resuscitation experts. Resuscitation. 2009 Apr;80(4):489-92. doi: 10.1016/j.resuscitation.2008.12.016.

Fabio Stroppa

This is a very limited point of view. The opportunities in terms of research and development with VR are enormous, and many different types of applications can be made to serve the purpose of helping people. Specifically on CPR, it can be used to recreate immersive environments for serious games and training, which is helpful and scientifically validated by many studies in healthcare and rehabilitation. These devices are also very accurate: studies have shown that the tracking error of Oculus Quest 2 HMD over static measurement is 0.06 mm (Holzwarth, V., Gisler, J., Hirt, C., & Kunz, A. (2021, March). Comparing the accuracy and precision of steamvr tracking 2.0 and oculus quest 2 in a room scale setup. In 2021 the 5th International conference on virtual and Augmented Reality Simulations (pp. 42-46)). Although these devices cannot replace the performance of a mechanical/compliant manikin, they are less expensive (100$ vs 2000$ on average); therefore, it is easy to share technology with people at home that have a limited budget and still want to learn proper CPR.

Federico Semeraro

Dear all,

I apologize for the multiple comments. I wasn’t recognized as the author in my first two comments.

Here are some additional references for your evaluation, specifically for the second part of the TR:

Alcázar Artero PM, Greif R, Cerón Madrigal JJ, Escribano D, Pérez Rubio MT, Alcázar Artero ME, López Guardiola P, Mendoza López M, Melendreras Ruiz R, Pardo Ríos M. Teaching cardiopulmonary resuscitation using virtual reality: A randomized study. Australas Emerg Care. 2023 Sep 2:S2588-994X(23)00055-6. doi: 10.1016/j.auec.2023.08.002. Epub ahead of print. PMID: 37666723.

Alcázar Artero PM, Pardo Rios M, Greif R, Ocampo Cervantes AB, Gijón-Nogueron G, Barcala-Furelos R, Aranda-García S, Ramos Petersen L. Efficiency of virtual reality for cardiopulmonary resuscitation training of adult laypersons: A systematic review. Medicine (Baltimore). 2023 Jan 27;102(4):e32736. doi: 10.1097/MD.0000000000032736. PMID: 36705392; PMCID: PMC9875948.

Best wishes

Federico Semeraro


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