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: Andrew Lockey, Joyce Yeung, and Robert Greif.
CoSTR Citation
Eastwood K, Nabecker S, Breckwoldt J, Lockey A, Greif R, on behalf of the International Liaison Commitee on Resuscitation Education, Implementation and Teams Task Force.
Self-directed digital-based versus instructor-led cardiopulmonary resuscitation (CPR) education and training in adults and Children Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation and Teams Task Force, 2024 November 1. 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 review (Nabecker S, Seneviratne J, Arundale J, Breckwoldt J, Lockey A, Greif R, Bray J, Eastwood K. A systematic review of self-directed digital-based versus instructor-led cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) training. PROSPERO 2020 CRD42020199176) conducted by Sabine Nabecker, Kathryn Eastwood and Janet Bray (now BLS Task Force) with involvement of clinical content experts. Evidence for adult and pediatric literature was sought and considered by the Education, Implementation and Teams Task Force. These data were taken into account when formulating the Treatment Recommendations.
We defined self-directed digital-based CPR training as any form of digital (e.g. video, phone application-based, internet-based, game-based learning, virtual reality, augmented reality) education or training for CPR that can be completed without an instructor.
We defined instructor-led training as education or training (e.g. lecture, skills demonstration, skills feedback) that occurred in the presence of a BLS instructor.
We excluded studies if: they were not a randomized controlled trial (RCT); the self-directed training arm included instructor-led practice or feedback; studies without an instructor-led control group or comparing different methods of self-directed learning; the training was specifically designed for health care professionals (e.g. computer training for nursing students to use over the course of a semester); the intervention was designed for refreshment of CPR skills; was a mass media campaign (e.g. television and social media education); the sample included a high proportion of health care students who were already CPR certified; or training included advanced life support skills. Some of the included studies examined additional interventions; in these studies, we excluded data from these arms (e.g. blended-training or a no training control group).
Systematic Review
In progress
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Adults and children undertaking CPR training.
Intervention: Self-directed digitally-based CPR training.
Comparators: Instructor-led CPR training.
Outcomes: Patient outcomes: Good neurological outcome at hospital discharge/30-days; Survival at hospital discharge/30-days; Return of spontaneous circulation (ROSC); Rates of bystander CPR; Bystander CPR quality during an OHCA (any available CPR metrics); Rates of automated external defibrillator (AED) use. Educational outcomes at the end of training and within 12 months: CPR quality (chest compression depth and rate; chest compression fraction; full chest recoil, hand position, ventilation rate) and AED competency; CPR and AED knowledge; Confidence and willingness to perform CPR.
Study Designs: Randomized controlled trials (RCTs) were eligible for inclusion. Non-randomized studies, unpublished studies (e.g., conference abstracts, trial protocols), commentary and editorial papers, reviews and animal studies were excluded.
Timeframe: All years and all languages were included as long as there was an English abstract; Literature search updated to March 28, 2024.
PROSPERO Registration CRD42020199176
Consensus on Science
For the critical patient outcomes of good neurological outcome at hospital discharge/30-days, survival at hospital discharge/30-days, return of spontaneous circulation (ROSC), rates of bystander CPR, bystander CPR quality during an OHCA (any available CPR metrics), rates of automated external defibrillator (AED) use there were no studies identified.
For the important educational outcomes of CPR quality, automated external defibrillator (AED) use, knowledge, confidence and willingness we identified 29 RCTs.(1-29) For CPR quality there was 27 studies (1-4, 6-19, 21-29), AED use (10 studies (2, 5, 6, 9, 18, 20-22, 24, 25)), knowledge (7 studies(7, 12, 17, 23, 24, 26, 27)), confidence (10 studies(1, 10, 12-14, 16, 18, 20, 22, 29)) and willingness (6 studies(4, 14, 16, 18-20)). 25 studies tested participants immediately to <1 month(1, 3-13, 15-25, 28, 29) and 15 studies tested, or repeated testing between 1-12 months of training (2, 3, 5, 8, 11, 12, 14, 20, 22-24, 26-29). Overall, the overall quality of evidence was rated as very low for the CPR quality outcomes of compression depth for serious risk of bias, inconsistency, and indirectness (16 studies(1, 3, 4, 6, 8, 9, 11, 14, 15, 18, 21, 22, 24, 27-29)); for chest recoil for serious risk of bias, indirectness and imprecision and very serious inconsistency (6 studies(1, 9, 18, 21, 22, 26)); and for hand position for very serious risk of bias, and serious indirectness and imprecision (16 studies(1, 2, 4, 6, 8, 9, 11, 15, 18, 19, 22, 24-28)). The quality of evidence was rates as low for the CPR quality outcomes of compression rate for serious risk of bias and indirectness (17 studies(1-4, 6, 9, 11, 13, 18, 19, 21, 22, 25-29)); for chest compression fraction for serious indirectness and imprecision (4 studies(1, 3, 21, 29)); and for ventilation rate for serious risk of bias and imprecision (8 studies(4, 6, 8, 9, 13, 14, 22, 26, 27)). For AED use, the quality of evidence was rated as very low for serious risk of bias, indirectness and imprecision (9 studies(2, 5, 6, 9, 20-22, 24, 25)). Finally, the quality of evidence was rated as very low for knowledge for very serious risk of bias and inconsistency, and serious indirectness and imprecision (7 studies(7, 12, 17, 23, 24, 26, 27)); for confidence to provide CPR for very serious risk of bias, indirectness and imprecision (10 studies(1, 10, 12-14, 16, 18, 20, 22, 29)), and for willingness to provide CPR for very serious indirectness and serious risk of bias and imprecision (6 studies(4, 14, 16, 18-20)). Because of this and a high degree of heterogeneity in the interventions, comparators and in the measurements of outcomes, no meta-analysis could be performed. Instead, we have performed a narrative synthesis of the findings for each educational outcome. EIT 6406 Certainty of Evidence
Study characteristics
Populations and sample sizes
Sample sizes ranged from 52(29) to 826 participants,(16) and 14 of the 29 studies had sample sizes under 140 participants.(1-3, 12-15, 17-19, 23, 25-27, 29) Populations included children, high-school students,(3, 6, 24, 28, 29) university students(1, 17-19) including specific cohorts such as medical(2, 22, 25, 26) and nursing students,(9, 14) and adults,(4, 5, 8, 10, 11, 15, 16, 21, 23, 27) again including specific cohorts such as those over 60 years,(20) parents/carers for children,(13) parents of children at high risk for sudden cardiopulmonary arrest,(7) university staff and their spouses,(18) and carers of family members with cardiac histories.(12)
Interventions
Eight studies used video-only to provide the self-directed education.(1-3, 5, 9, 11, 12, 23) These ranged from a 1-minute video(11) to a 20-minute video(2) (although many studies did not state the video length). Sixteen studies used a video + manikin practice approach,(4, 5, 7, 8, 11, 13-17, 19, 20, 22, 26-28) which ranged in length from 4 minutes(11) to 35 minutes(19) (again, some studies did not state their video length). Other interventions that were used included an app-based self-training intervention,(6) virtual reality,(21) video + manikin + scenario self-training,(5) computer programme/online tutorial + video + manikin,(10, 18, 25) interactive computer session,(24) and game-in-film(29).
Comparators
Like the interventions, the comparators varied widely. Some cited formal certified courses,(15, 16, 18, 20, 25-27) while many didn’t. The length of the course varied in those that reported it from 9 minutes(1) up to 5 hours(25).
Educational outcomes immediately after training (up to 1 month)
Compression rate
Low certainty of evidence (downgraded for serious risk of bias and indirectness) was reported in 16 studies for either compression rate/minute (12 studies(1, 3, 9, 13, 18, 19, 21, 22, 25, 27-29) and/or proportion of compressions at the correct rate (4 studies(4, 6, 11, 28)). For compression rate/minute nine studies showed no difference between the groups,(1, 3, 9, 13, 19, 21, 22, 28, 29) two favored the instructor-led group(18, 25) and one favored self-directed group.(27) For proportion of compressions at the correct rate, three studies did not favor either group(4, 6, 28), and one study with two varying intervention arms (a video-only arm and a video + manikin arm) favored instructor training for the video arm,(11) and self-directed training for the video + manikin arm.(11)
For compression rate, the two studies that favored self-directed training used video + manikin training as their intervention.(11, 27) However, this intervention was also used in five of the studies that showed no difference between the groups.(4, 13, 19, 22, 28) Two different interventions were used in the studies that favored instructor-led training, including video only training,(11) and online tutorial + video + manikin training(18, 25). The remaining six studies that did not favor either self-directed or instructor-led training used video only,(1, 3, 9) app-based self-training,(6) game-in-film,(29) and virtual reality(21).
Compression depth
Very low certainty of evidence (downgraded for serious risk of bias, inconsistency, and indirectness) was reported across 15 studies for either compression depth (distance) (9 studies(1, 3, 9, 11, 21, 22, 27-29)) or proportion of compressions at the correct depth (10 studies(4, 6, 8, 9, 11, 15, 18, 22, 24, 28)). For compression depth (distance), three studies favored instructor training,(11, 21, 29) including both intervention arms of the study by Heard (2019),(11) and six studies showed no difference between the groups.(1, 3, 9, 22, 27, 28) For proportion of compressions at the correct depth, three studies favored instructor training,(4, 18, 24) one study favored self-directed training,(9) and six studies showed no difference between the groups.(6, 8, 11, 15, 22, 28)
For compression depth, only one study favored self-directed learning for proportion of compressions at the correct depth, and this study used video-only self-directed training.(9) However, when this study measured depth in terms of distance, this intervention was no different to the instructor-led training.(9) Across the studies that favored instructor-led training, video-only self-directed training was used in one study,(11) video + manikin self-directed training was used in two studies,(4, 11) and one study each used online + video + manikin training,(18) virtual reality,(21) an interactive computer session(24) or game-in-film(29). Finally, in the studies that identified no difference between the training arms, video-only training was used in four studies,(1, 3, 9, 11) video + manikin training was used in six studies,(8, 11, 15, 22, 27, 28) and app-based self-training was used in one study.(6)
Compression fraction
Low certainty of evidence (downgraded for serious indirectness and imprecision) was reported in 4 studies (1, 3, 21, 29). One study using virtual reality favored instructor training(21) and the remaining three found no difference between the groups.(1, 3, 29) These three studies used video-only(1, 3) and game-in-film self-directed training(29).
Chest recoil
Very low certainty of evidence (downgraded for very serious inconsistency and serious risk of bias, indirectness and imprecision) was reported across five studies(1, 9, 18, 21, 22). Two studies using video-only(9) and online + video + manikin training(18) favored the self-directed training interventions, one study using virtual reality favored the instructor training(21) and two studies found no difference.(1, 22) One of these studies used a video-only self-training arm(1) and the other used video + manikin self-training.(22)
Hand position
Very low certainty of evidence (downgraded for very serious risk of bias, and serious indirectness and imprecision) was reported across 14 studies(1, 4, 6, 8, 9, 11, 15, 18, 19, 22, 24, 25, 27, 28). Two studies favored the self-directed interventions using video + manikin training,(11, 15) four studies favored instructor training,(4, 8, 19, 24) with three using video + manikin training(4, 8, 19) and one using an interactive computer session.(24) The remaining nine studies that found no difference between the groups used video-only,(1, 9, 11) video + manikin,(22, 27, 28) online + video + manikin,(18, 25) or app-based self-directed learning.(6)
Ventilation rate
Low certainty of evidence (downgraded for serious risk of bias and imprecision) was reported for ventilation rate in seven studies(4, 6, 8, 9, 13, 22, 27). All seven studies found no difference for ventilation rate between the self-directed and instructor led groups. Five of these studies used video + manikin,(4, 8, 13, 22, 27) and one each used video-only(9) or app-based self-directed training(6).
AED use
Very low certainty of evidence (downgraded for very low for serious risk of bias, indirectness and imprecision) for AED use in eight studies.(5, 6, 9, 20-22, 24, 25) Three studies favored instructor training,(5, 6, 21) and five studies found no difference between the groups.(9, 20, 22, 24, 25) One study that favored instructor-led training had three intervention arms, consisting of video-only, video + manikin, and video + manikin + self-directed scenario self-training.(5) The remaining two studies that favored instructor-led training used virtual reality(21) and app-based self-directed training(6). One of the studies that did not favor either group used video-only training,(9) two used video + manikin,(20, 22) and one each used online + video + manikin(25) or an interactive computer session(24).
Knowledge
Very low certainty of evidence (downgraded for very serious risk of bias and inconsistency, and serious indirectness and imprecision) was reported for knowledge in six studies.(7, 12, 17, 23, 24, 27) Two studies favored instructor-led training when using video + manikin(7) or video-only self-directed training(12) one study using an interactive computer session favored self-directed training,(24) and three studies found no difference between the groups.(17, 23, 27) Amongst these three studies, two used video + manikin(17, 27) and one used video-only self-directed training(23).
Confidence
Very low certainty of evidence (downgraded for very serious risk of bias, indirectness and imprecision) was reported for confidence in nine studies.(1, 10, 12, 13, 16, 18, 20, 22, 29) One study using video-only self-directed training favored the self-directed intervention.(1) Three studies using a computer programme tutorial + video + manikin(10), video + manikin,(22) and video-only self-directed training(12) favored the instructor training, and five studies found no difference between the groups.(13, 16, 18, 20, 29) Three of these studies used video + manikin self-directed training,(13, 16, 20) one used online tutorial + video + manikin,(18) and one used game-in-film.(29)
Willingness
Very low certainty of evidence (downgraded for very serious indirectness and serious risk of bias and imprecision) was reported for willingness to provide CPR five studies.(4, 16, 18-20) All five studies found no difference between the two groups. Four of these studies used video + manikin self-directed training(4, 16, 19, 20) and one used online + video + manikin self-directed training.(18)
Educational outcomes from greater than 1 month to 12 months after training
15 studies tested, or repeated testing between 1-12 months of training (2, 3, 5, 8, 11, 12, 14, 20, 22-24, 26-29). Three of these studies conducted their first assessment of CPR skills at 4 months,(14) 6 months(2) and between 2-6 months after training.(26) Across these studies all the outcomes except for chest compression fraction were measured and two used a video + manikin intervention(14, 26) and one used a video only self-directed intervention.(2) No difference between the self-directed versus instructor-led groups were found for any of the outcomes.
The remaining 11 studies conducted follow-up testing between one to six months after the training,(3, 5, 8, 11, 12, 20, 22-24, 28, 29) and almost all studies reported a loss to follow up.(3, 5, 8, 11, 20, 22-24, 28, 29) Across the outcomes measured, many continued to reflect the findings from the immediate testing. For compression depth, very low certainty of evidence (downgraded for serious risk of bias, inconsistency, and indirectness) was reported across seven studies for either compression depth (distance) (5 studies(3, 11, 22, 28, 29)) or proportion of compressions at the correct depth (5 studies(8, 11, 22, 24, 28)). Three of the studies had a shift in their findings for compression depth, where two studies that had previously favored instructor-led training now identified no difference between the groups,(24, 29) and another study had a marked drop in proportion of compressions performed to the correct depth in the instructor-led group at 3 months, and an increase in the proportion in the self-directed group. This resulted in the findings now favoring the self-directed intervention.(22) This study also reported a change in confidence with this shifting from favoring the instructor-led group, to no difference between the groups.(22)
While there was limited changes in the direction of the outcomes, it is important to note that many of these studies reported a reduction in the quality of the skills being performed (compression rate: 2 studies(11, 28) compression depth: 4 studies(11, 22, 24, 28); chest compression fraction: 1 study(29); chest recoil: 1 study(22); hand position: 4 studies(11, 22, 24, 28); ventilation rate: 1 study(8); AED: 1 study(20); knowledge: 1 study(12); confidence: 1 study(22)). The opposite of this was seen in the paper by DeVries where both the groups were significantly more likely to pass the AED testing at 2 months than immediately after the education.(5)
Intervention training mediums
The only self-directed training interventions with sufficient numbers for comparison at immediate testing were the video + manikin and the video-only self-directed training intervention.
The video + manikin intervention was the most popular self-directed intervention used in 15 studies(4, 7, 8, 11, 13-17, 19, 20, 22, 26-28) across all outcomes except chest compression fraction. Outcomes using this intervention arm were measured 54 times and 43 of these demonstrated no difference between self-directed training using a video + manikin intervention and an instructor-led group. It was favored only four times for compression rate,(27) proportion of compressions at the correct rate,(11) and hand position.(11, 15) The instructor-led training was favored over video + manikin self-directed training seven times, for chest compression depth,(11) proportion of chest compressions at the correct depth,(4) hand position,(4, 8, 19) knowledge,(7) and confidence.(22)
Video-only self-directed training was used in seven studies(1-3, 9, 11, 12, 23) measuring all of the outcomes except willingness. It was the intervention arm in 26 outcome measurements across the studies, and was the favored arm in only three instances for proportion of compressions at the correct depth,(9) chest recoil,(9) and confidence.(1) When video-only was the intervention arm, instructor-led training was favored in five times for proportion of compressions done at the correct rate(11) or depth(3, 11), knowledge,(12) and confidence.(12) The remaining 18 instances where video-only was the intervention arm, it was no different to the instructor-led comparator groups.
Treatment Recommendations
We suggest the use of either instructor-led training or self-directed digital training with for the acquisition of CPR or AED skills in lay-adults and high school aged (>10 years) children (weak recommendation, very low quality of evidence).
We suggest self-directed digital training be used when instructor-led training is not accessible, or when quantity over quality of CPR training is needed in adults and children (weak recommendation, very low quality of evidence).
There was insufficient evidence to make a recommendation on game-in-film, virtual reality, computer programmes, online tutorials or app-based training as a CPR or AED training method.
There was insufficient evidence to suggest a treatment effect on bystander CPR rates or patient outcomes.
Justification and Evidence to Decision Framework Highlights
In making these recommendations the Education, Implementation and Teams (EIT) considered the following:
- Significant variation in all aspects of the study methodologies exists and therefore limits definitive recommendations.
- That any form of CPR/AED training is likely improve knowledge, confidence and willingness in simulated settings, however, this may not translate to real-life situations.
- Cost-effectiveness analysis performed typically favored digital-training(10, 28). Instructor-led classes require human resources, organization, location and equipment.
- Acquisition of different CPR skills may vary across different mediums and age groups.
- The known barriers that exist to attend instructor-led CPR classes (e.g. time, costs, and accessibility) and the need to make CPR training available to everyone.
- The need and ease for updating digital and instructor-led materials to ensure training complies with CPR recommendations.
- Digital training allows skills to be refreshed at any time, and at no additional cost, and provide the opportunity to teach others.
- Digital training enables more people to be educated in periods of need (e.g. pandemics).
Knowledge Gaps
- Future research should focus on standardised outcome measures (educational and CPR performance outcomes) to allowing for pooling of data.
- Comparator groups should be aligned using standardised, accepted instructor-led training programmes to reduce inconsistency and uncertainty.
- Future research should also investigate the ability of these interventions and comparators to produce findings that meet accepted standards for adequate CPR that are maintained at defined time intervals.
- Regarding specific self-directed digital interventions, further research is required for methods such as game-in-film, virtual reality, computer programmes, online tutorials or app-based training to determine their effectiveness.
- Finally, the treatment effect on bystander CPR rates and patient outcomes needs to be included in future research.
ETD summary table: EIT 6406 Et D table
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