Rationale and design of the Lowlands Saves Lives trial: a randomised trial to compare CPR quality and long-term attitude towards CPR performance between face-to-face and virtual reality training with the Lifesaver VR app

Redesign of a virtual reality basic life support module for medical training - a feasibility study

BACKGROUND

Healthcare providers, including medical students, should maintain their basic life support (BLS) skills and be able to perform BLS in case of cardiac arrest. Research shows that the use of virtual reality (VR) has advantages such as improved accessibility, practice with lifelike situations, and real-time feedback during individual training sessions. A VR BLS module incorporating these advantages, called Virtual Life Support, has been developed especially for the medical domain. Virtual Life Support was collaboratively developed by software developers and stakeholders within the field of medical education. For this study, we explored whether the first version of this module capitalised on the advantages of VR and aimed to develop an understanding of barriers to feasibility of use.

METHODS

This study was conducted to assess the feasibility of employing Virtual Life Support for medical training and pinpoint potential obstacles. Four groups of stakeholders were included through purposive sampling: physicians, BLS instructors, educational experts, and medical students. Participants performed BLS on a BLS mannequin while using Virtual Life Support and were interviewed directly afterwards using semi-structured questions. The data was coded and analysed using thematic analysis.

RESULTS

Thematic saturation was reached after seventeen interviews were conducted. The codes were categorised into four themes: introduction, content, applicability, and acceptability/tolerability. Sixteen barriers for the use of Virtual Life Support were found and subsequently categorised into must-have (restraining function, i.e. necessary to address) and nice to have features (non-essential elements to consider addressing).

CONCLUSION

The study offers valuable insights into redesigning Virtual Life Support for Basic Life Support training, specifically tailored for medical students and healthcare providers, using a primarily qualitative approach. The findings suggest that the benefits of virtual reality, such as enhanced realism and immersive learning, can be effectively integrated into a single training module. Further development and validation of VR BLS modules, such as the one evaluated in this study, have the potential to revolutionise BLS training. This could significantly improve both the quality of skills and the accessibility of training, ultimately enhancing preparedness for real-life emergency scenarios.

Development and evaluation of a virtual reality basic life support for undergraduate students in Thailand: a project by Mae Fah Luang University (MFU BLiS VR)

BACKGROUND

In traditional basic life support training for university students or the public, trainees practice simulations only once or twice during the course, potentially limiting their competence. In contrast, virtual reality allows trainees to independently study and practice as often as needed, enhancing their skills. This research and development project aimed to develop and evaluate a novel learning device, virtual reality basic life support for undergraduate students of Mae Fah Luang University (MFU BLiS VR).

METHODS

This study employed a two-group, pre- and post-test design, involving seventy students (n = 35 in each group) from Mae Fah Luang University, Thailand. Data were collected from March 2022 to January 2023. The experimental group received the MFU BLiS VR, in addition to traditional teaching, while the control group received only traditional teaching. Data analysis employed descriptive statistics, Chi-square, Mann-Whitney U test, and Wilcoxon signed ranks test.

RESULTS

"MFU BLiS VR" provided a learning experience in out-of-hospital basic life support for adult patients in four scenarios: (1) a person who was not breathing but had a pulse; (2) a person who was not breathing, had no pulse, and required defibrillation; (3) a person who was not breathing, had no pulse, and did not require defibrillation; and (4) a person with normal breathing and pulse but was unconscious. Each scenario was presented sequentially from scenario one to scenario four. The scenarios encompassed common and complex situations requiring prompt and effective bystander responses to save lives. The results revealed that the experimental group had a significantly shorter no-flow time compared to the control group (Z = -5.02, p < .001) and achieved significantly higher knowledge scores than the control group (Z = -3.39, p < .01) as well as superior practical skills (Z = -7.26, p < .001). Both groups reported the highest satisfaction levels in all aspects, with no significant differences.

CONCLUSION

MFU BLiS VR is an effective training approach for teaching and learning basic life support and the use of an automated electronic defibrillator. It captures students' attention and enhances their understanding of these essential life support skills, which are crucial for everyone.

Efficacy of Virtual Reality Simulation in Teaching Basic Life Support and Its Retention at 6 Months

Educational efficiency is the predetermining factor for increasing the survival rate of patients with cardiac arrest. Virtual reality (VR) simulation could help to improve the skills of those undergoing basic life support-automated external defibrillation (BLS-AED) training. Our purpose was to evaluate whether BLS-AED with virtual reality improves the skills and satisfaction of students enrolled in in-person training after completing the course and their retention of those skills 6 months later. This was an experimental study of first-year university students from a school of health sciences. We compared traditional training (control group-CG) with virtual reality simulation (experimental group-EG). The students were evaluated using a simulated case with three validated instruments after the completion of training and at 6 months. A total of 241 students participated in the study. After the training period, there were no statistically significant differences in knowledge evaluation or in practical skills when assessed using a feedback mannequin. Statistically significant results on defibrillation were poorer in the EG evaluated by the instructor. Retention at 6 months decreased significantly in both groups. The results of the teaching methodology using VR were similar to those obtained through traditional methodology: there was an increase in skills after training, and their retention decreased over time. Defibrillation results were better after traditional learning.

Viewpoint: Virtual and Augmented Reality in Basic and Advanced Life Support Training

The use of augmented reality (AR) and virtual reality (VR) for life support training is increasing. These technologies provide an immersive experience that supports learning in a safe and controlled environment. This review focuses on the use of AR and VR for emergency care training for health care providers, medical students, and nonprofessionals. In particular, we analyzed (1) serious games, nonimmersive games, both single-player and multiplayer; (2) VR tools ranging from semi-immersive to immersive virtual and mixed reality; and (3) AR applications. All the toolkits have been investigated in terms of application goals (training, assessment, or both), simulated procedures, and skills. The main goal of this work is to summarize and organize the findings of studies coming from multiple research areas in order to make them accessible to all the professionals involved in medical simulation. The analysis of the state-of-the-art technologies reveals that tools and studies related to the multiplayer experience, haptic feedback, and evaluation of user's manual skills in the foregoing health care-related environments are still limited and require further investigation. Also, there is an additional need to conduct studies aimed at assessing whether AR/VR-based systems are superior or, at the minimum, comparable to traditional training methods.

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

Introduction

Technology has been a major contributor to recent changes in education, where simulation plays a huge role by providing a unique safe environment, especially with the recent incorporation of immersive virtual reality (VR) training. Cardiopulmonary Resuscitation (CPR) is said to double, even triple survival from cardiac arrest, and hence it is crucial to ensure optimal acquisition and retention of these skills. In this study, we aim to compare a VR CPR teaching program to current teaching methods with content validation of the VR course.

Methods

A randomized single-blinded simulation-based pilot study where 26 participants underwent baseline assessment of their CPR skills using a validated checklist and Laerdal QCPR®. Participants were randomly allocated and underwent their respective courses. This was followed by a final assessment and a questionnaire for content validation, knowledge and confidence. The data was analysed using STATA 16.2 to determine the standardized mean difference using paired and unpaired t-test.

Results

Subjective assessment using the checklist showed statistically significant improvement in the overall scores of both groups (traditional group mean improved from 6.92 to 9.61 p-value 0.0005, VR group from 6.61 to 8.53 p-value 0.0016). However, no statistically significant difference was noted between the final scores in both the subjective and objective assessments. As for the questionnaire, knowledge and confidence seemed to improve equally. Finally, the content validation showed statistically significant improvement in ease of use (mean score 3 to 4.23 p-value of 0.0144), while for content, positivity of experience, usefulness and appropriateness participants showed similar satisfaction before and after use.

Conclusion

This pilot study suggests that VR teaching could deliver CPR skills in an attractive manner, with no inferiority in acquisition of these skills compared to traditional methods. To corroborate these findings, we suggest a follow-up study with a larger sample size after adding ventilation and Automated External Defibrillator (AED) skills to the VR course with re-examination after 3–6 months to test retention of the skills.

Efficacy and knowledge of conducting CPR through online learning during the COVID-19 pandemic: A literature review

The COVID-19 pandemic has made it difficult to carry out face-to-face training activities in various higher institutions. This has led to a negative impact on the skills and abilities of nursing students in performing cardiopulmonary resuscitation (CPR) and the cessation of their clinical practice programs in hospitals. Therefore, the aim of this study is to determine the efficacy and knowledge of nursing students in performing CPR by implementing a blended learning program, through online learning platforms. The search for full-text articles was carried out in May 2020 and were reviewed to know whether they fit the theme using the ProQuest, ScienceDirect and PubMed databases with the keywords "BLS", "CPR", "Blended learning", "Knowledge" and "Self-efficacy". In addition, there were 15 articles that matched the criteria. The application of a blended learning program that integrates video and face-to-face lectures through online learning platforms in conducting effective CPR, increases the efficacy and knowledge of nursing students. The effectiveness of online learning greatly affects the efficacy and knowledge of nursing students in conducting CPR. Therefore, it was highly recommended during the COVID-19 pandemic.

VirtualCPR: Virtual Reality Mobile Application for Training in Cardiopulmonary Resuscitation Techniques

Deaths due to heart diseases are a leading cause of death in Mexico. Cardiovascular diseases are considered a public health problem because they produce cardiorespiratory arrests. During an arrest, cardiac and/or respiratory activity stops. A cardiorespiratory arrest is rapidly fatal without a quick and efficient intervention. As a response to this problem, the VirtualCPR system was designed in the present work. VirtualCPR is a mobile virtual reality application to support learning and practicing of basic techniques of cardiopulmonary resuscitation (CPR) for experts or non-experts in CPR. VirtualCPR implements an interactive virtual scenario with the user, which is visible by means of employment of virtual reality lenses. User’s interactions, with our proposal, are by a portable force sensor for integration with training mannequins, whose development is based on an application for the Android platform. Furthermore, this proposal integrates medical knowledge in first aid, related to the basic CPR for adults using only the hands, as well as technological knowledge, related to development of simulations on a mobile virtual reality platform by three main processes: (i) force measurement and conversion, (ii) data transmission and (iii) simulation of a virtual scenario. An experiment by means of a multifactorial analysis of variance was designed considering four factors for a CPR session: (i) previous training in CPR, (ii) frequency of compressions, (iii) presence of auditory suggestions and (iv) presence of color indicator. Our findings point out that the more previous training in CPR a user of the VirtualCPR system has, the greater the percentage of correct compressions obtained from a virtual CPR session. Setting the rate to 100 or 150 compressions per minute, turning on or off the auditory suggestions and turning the color indicator on or off during the session have no significant effect on the results obtained by the user.

Optimal Combination of Chest Compression Depth and Rate in Virtual Reality Resuscitation Training: A Post Hoc Analysis of the Randomized Lowlands Saves Lives Trial

Background Dissemination of cardiopulmonary resuscitation (CPR) skills is essential for cardiac arrest survival. Virtual reality (VR)-training methods are low cost and easily available, but to meet depth requirements adaptations are required, as confirmed in a recent randomized study on currently prevailing CPR quality criteria. Recently, the promising clinical performance of new CPR quality criteria was demonstrated, based on the optimal combination of compression depth and rate. We now study compliance with these newly proposed CPR quality criteria. Methods and Results Post hoc analysis of a randomized trial compared standardized 20-minute face-to-face CPR training with VR training using the Lifesaver VR smartphone application. During a posttraining test, compression depth and rate were measured using CPR mannequins. We assessed compliance with the newly proposed CPR criteria, that is, compression rate within ±20% of 107/minute and depth within ±20% of 47 mm. We studied 352 participants, age 26 (22-31) years, 56% female, and 15% with CPR training ≤2 years. Among VR-trained participants, there was a statistically significant difference between the proportions complying with newly proposed versus the currently prevailing quality criteria (52% versus 23%, P<0.001). The difference in proportions complying with rate requirements was statistically significant (96% for the new versus 50% for current criteria, P<0.001), whereas there was no significant difference with regard to the depth requirements (55% versus 51%, P=0.45). Conclusions Lifesaver VR training, although previously found to be inferior to face-to-face training, may lead to CPR quality compliant with recently proposed, new quality criteria. If the prognostic importance of these new criteria is confirmed in additional studies, Lifesaver VR in its current form would be an easily available vector to disseminate CPR skills.

Effect of Face-to-Face vs Virtual Reality Training on Cardiopulmonary Resuscitation Quality: A Randomized Clinical Trial

Importance

Bystander cardiopulmonary resuscitation (CPR) is crucial for survival after cardiac arrest but not performed in most cases. New, low-cost, and easily accessible training methods, such as virtual reality (VR), may reach broader target populations, but data on achieved CPR skills are lacking.

Objective

To compare CPR quality between VR and face-to-face CPR training.

Design, Setting, and Participants

Randomized noninferiority trial with a prospective randomized open blinded end point design. Participants were adult attendees from the science section of the Lowlands Music Festival (August 16 to 18, 2019) in the Netherlands. Analysis began September 2019.

Interventions

Two standardized 20-minute protocols on CPR and automated external defibrillator use: instructor-led face-to-face training or VR training using a smartphone app endorsed by the Resuscitation Council (United Kingdom).

Main Outcomes and Measures

During a standardized CPR scenario following the training, we assessed the primary outcome CPR quality, measured as chest compression depth and rate using CPR manikins. Overall CPR performance was assessed by examiners, blinded for study groups, using a European Resuscitation Council-endorsed checklist (maximum score, 13). Additional secondary outcomes were chest compression fraction, proportions of participants with mean depth (50 mm-60 mm) or rate (100 min-1-120 min-1) within guideline ranges, and proportions compressions with full release.

Results

A total of 381 participants were randomized: 216 women (57%); median (interquartile range [IQR]) age, 26 (22-31) years. The VR app (n = 190 [49.9%]) was inferior to face-to-face training (n = 191 [50.1%]) for chest compression depth (mean [SD], VR: 49 [10] mm vs face to face: 57 [5] mm; mean [95% CI] difference, -8 [-9 to -6] mm), and noninferior for chest compression rate (mean [SD]: VR: 114 [12] min-1 vs face to face: 109 [12] min-1; mean [95% CI] difference, 6 [3 to 8] min-1). The VR group had lower overall CPR performance scores (median [IQR], 10 [8-12] vs 12 [12-13]; P < .001). Chest compression fraction (median [IQR], 61% [52%-66%] vs 67% [62%-71%]; P < .001) and proportions of participants fulfilling depth (51% [n = 89] vs 75% [n = 133], P < .001) and rate (50% [n = 87] vs 63% [n = 111], P = .01) requirements were also lower in the VR group. The proportion of compressions with full release was higher in the VR group (median [IQR], 98% [59%-100%] vs 88% [55%-99%]; P = .002).

Conclusions and Relevance

In this randomized noninferiority trial, VR training resulted in comparable chest compression rate but inferior compression depth compared with face-to-face training. Given the potential of VR training to reach a larger target population, further development is needed to achieve the compression depth and overall CPR skills acquired by face-to-face training.

Trial Registration

ClinicalTrials.gov identifier: NCT04013633.

Chest compressions quality during sudden cardiac arrest scenario performed in virtual reality: A crossover study in a training environment

Potential attributes of virtual reality (VR) can be a breakthrough in the improvement of sudden cardiac arrest (SCA) training. However, interference with the virtual world is associated with the need of placing additional equipment on the trainee's body. The primary aim of the study was to evaluate if it does not affect the quality of chest compressions (CCs).91 voluntarily included in the study medical students participated twice in the scenario of SCA - Traditional Scenario (TS) and Virtual Reality Scenario (VRS). In both cases two minutes of resuscitation was performed.If VRS was the first scenario there were significant differences in CCs depth (VRS - Me = 47 mm [IQR 43 - 52] vs TS - Me = 48 mm [IQR 43 - 55]; P = .02) and chest relaxation (VRS - Me = 37% [IQR 5 - 91] vs TS - Me = 97% [IQR 87 - 100]; P < .001). 97.8% of respondents believe that training with the use of VR is more effective than a traditional method (P < .01). Most of the study group (91%, P < .01) denied any negative symptoms during the VR scenario.Virtual reality can be a safe and highly valued by medical students, method of hands-on CPR training. However additional VR equipment placed on the trainee's body may cause chest compressions harder to provide. If it is not preceded by traditional training, the use of VR may have an adverse impact on depth and full chest relaxation during the training. To make the best use of all the potential that virtual reality offers, future studies should focus on finding the most effective way to combine VR with traditional skill training in CPR courses curriculum.