Medical Correctness and User Friendliness of Available Apps for Cardiopulmonary Resuscitation: Systematic Search Combined With Guideline Adherence and Usability Evaluation

The Effects of Serious Games on Cardiopulmonary Resuscitation Training and Education: Systematic Review With Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Serious games have emerged as an innovative educational strategy with the potential to significantly enhance the quality and effectiveness of cardiopulmonary resuscitation (CPR) training. Despite their promise, there remains a degree of controversy when comparing the advantages of serious games with traditional CPR training methods. This study seeks to provide a comprehensive assessment of the impact of serious games on CPR training and education by systematically analyzing the results of previous research.

OBJECTIVE

This study aimed to assess the effect of serious games on CPR training and education by summarizing and pooling the results of previous studies.

METHODS

We conducted a thorough and systematic search across 9 prominent web-based databases, encompassing the period from the inception of these databases until April 1, 2023. The databases included in our search were PubMed, Cochrane Library, Wiley Online Library, EBSCO (PsycInfo), SpringerLink, Chinese Biology Medicine Disc, Vip Journal Integration Platform, Wanfang Database, and Chinese National Knowledge Infrastructure. The studies selected adhered to the following criteria: (1) being a randomized controlled trial comparing serious games and traditional methods for CPR training; (2) having participants aged 12 years or older in CPR; (3) having an experimental group using serious games and a control group using nongame methods for CPR instruction; and (4) having outcomes including theoretical and skill assessments, compression depth, and rate. The Cochrane risk of bias assessment tool was used to evaluate the risk of bias. Data analysis was performed using RevMan (version 5.3; Cochrane Training), and mean differences (MDs) and standardized mean differences (SMDs) with 95% CIs were used to calculate continuous variables.

RESULTS

A total of 9 articles were included, involving 791 study participants, of whom 395 in the experimental group taught CPR training using serious games and 396 in the control group taught CPR training using traditional methods. The results of our meta-analysis indicate that the use of serious games in CPR training yields outcomes that are comparable in effectiveness to traditional training methods across several key areas. Specifically, serious games demonstrated equivalence to traditional formats in theory assessment (SMD -0.22, 95% CI - 0.96 to 0.51; P=.55), skill assessment (SMD -0.49, 95% CI -1.52 to 0.55; P=.36), compression depth (MD -3.17, 95% CI -0.18 to 6.53; P=.06), and compression rate (MD -0.20, 95% CI -7.29 to 6.89; P=.96).

CONCLUSIONS

In summary, serious games offer a viable and effective CPR education approach, yielding results comparable to traditional formats. This modality is a valuable addition to CPR training methodologies. However, caution is warranted in interpreting these findings due to limited controlled trials, small sample sizes, and low-quality meta-analyzed evidence.

Large Language Model-based Chatbot as a Source of Advice on First Aid in Heart Attack

The ability of the cutting-edge large language model-powered chatbots to generate human-like answers to user questions hypothetically could be utilized for providing real-time advice on first aid for witnesses of cardiovascular emergencies. This study aimed to evaluate quality of the chatbot responses to inquiries on help in heart attack. The study simulated interrogation of the new Bing chatbot (Microsoft Corporation, USA) with the "heart attack what to do" prompt coming from 3 countries, the Gambia, India and the USA. The chatbot responses (20 per country) were evaluated for congruence with the International First Aid, Resuscitation, and Education Guidelines 2020 using a checklist. For all user inquiries, the chatbot provided answers containing some guidance on first aid. However, the responses commonly left out some potentially life-saving instructions, for instance to encourage the person to stop physical activity, to take antianginal medication, or to start cardiopulmonary resuscitation for unresponsive abnormally breathing person. Mean percentage of the responses having full congruence with the checklist criteria varied from 7.3 for India to 16.8 for the USA. A quarter of responses for the Gambia and the USA, and 45.0% for India contained superfluous guidelines-inconsistent directives. The chatbot advice on help in heart attack has omissions, inaccuracies and misleading instructions, and therefore the chatbot cannot be recommended as a credible source of information on first aid. Active research and organizational efforts are needed to mitigate the risk of uncontrolled misinformation and establish measures for guaranteeing trustworthiness of the chatbot-mediated counseling.

An expert consensus–based checklist for quality appraisal of educational resources on adult basic life support: a Delphi study

Objective

Given the lack of a unified tool for appraising the quality of educational resources for lay-rescuer delivery of adult basic life support (BLS), this study aimed to develop an appropriate evaluation checklist based on a consensus of international experts.

Methods

In a two-round Delphi study, participating experts completed questionnaires to rate each item of a predeveloped 72-item checklist indicating agreement that an item should be utilized to evaluate the conformance of an adult BLS educational resource with resuscitation guidelines. Consensus on item inclusion was defined as a rating of ≥7 points from ≥75% of experts. Experts were encouraged to add anonymous suggestions for modifying or adding new items.

Results

Of the 46 participants, 42 (91.3%) completed the first round (representatives of 25 countries with a median of 16 years of professional experience in resuscitation) and 40 (87.0%) completed the second round. Thirteen of 72 baseline items were excluded, 55 were included unchanged, four were included after modification, and four new items were added. The final checklist comprises 63 items under the subsections “safety” (one item), “recognition” (nine items), “call for help” (four items), “chest compressions” (12 items), “rescue breathing” (12 items), “defibrillation” (nine items), “continuation of CPR” (two items), “choking” (10 items) and “miscellaneous” (four items).

Conclusions

The produced checklist is a ready-to-use expert consensus–based tool for appraising the quality of educational content on lay-rescuer provision of adult BLS. The checklist gives content developers a tool to ensure educational resources comply with current resuscitation knowledge, and may serve as a component of a prospective standardized international framework for quality assurance in resuscitation education.

Large Language Model (LLM)-Powered Chatbots Fail to Generate Guideline-Consistent Content on Resuscitation and May Provide Potentially Harmful Advice

INTRODUCTION

Innovative large language model (LLM)-powered chatbots, which are extremely popular nowadays, represent potential sources of information on resuscitation for the general public. For instance, the chatbot-generated advice could be used for purposes of community resuscitation education or for just-in-time informational support of untrained lay rescuers in a real-life emergency.

STUDY OBJECTIVE

This study focused on assessing performance of two prominent LLM-based chatbots, particularly in terms of quality of the chatbot-generated advice on how to give help to a non-breathing victim.

METHODS

In May 2023, the new Bing (Microsoft Corporation, USA) and Bard (Google LLC, USA) chatbots were inquired (n = 20 each): "What to do if someone is not breathing?" Content of the chatbots' responses was evaluated for compliance with the 2021 Resuscitation Council United Kingdom guidelines using a pre-developed checklist.

RESULTS

Both chatbots provided context-dependent textual responses to the query. However, coverage of the guideline-consistent instructions on help to a non-breathing victim within the responses was poor: mean percentage of the responses completely satisfying the checklist criteria was 9.5% for Bing and 11.4% for Bard (P >.05). Essential elements of the bystander action, including early start and uninterrupted performance of chest compressions with adequate depth, rate, and chest recoil, as well as request for and use of an automated external defibrillator (AED), were missing as a rule. Moreover, 55.0% of Bard's responses contained plausible sounding, but nonsensical guidance, called artificial hallucinations, that create risk for inadequate care and harm to a victim.

CONCLUSION

The LLM-powered chatbots' advice on help to a non-breathing victim omits essential details of resuscitation technique and occasionally contains deceptive, potentially harmful directives. Further research and regulatory measures are required to mitigate risks related to the chatbot-generated misinformation of public on resuscitation.

"ChatGPT, Can You Help Me Save My Child's Life?" - Diagnostic Accuracy and Supportive Capabilities to Lay Rescuers by ChatGPT in Prehospital Basic Life Support and Paediatric Advanced Life Support Cases - An In-silico Analysis

BACKGROUND

Paediatric emergencies are challenging for healthcare workers, first aiders, and parents waiting for emergency medical services to arrive. With the expected rise of virtual assistants, people will likely seek help from such digital AI tools, especially in regions lacking emergency medical services. Large Language Models like ChatGPT proved effective in providing health-related information and are competent in medical exams but are questioned regarding patient safety. Currently, there is no information on ChatGPT's performance in supporting parents in paediatric emergencies requiring help from emergency medical services. This study aimed to test 20 paediatric and two basic life support case vignettes for ChatGPT and GPT-4 performance and safety in children.

METHODS

We provided the cases three times each to two models, ChatGPT and GPT-4, and assessed the diagnostic accuracy, emergency call advice, and the validity of advice given to parents.

RESULTS

Both models recognized the emergency in the cases, except for septic shock and pulmonary embolism, and identified the correct diagnosis in 94%. However, ChatGPT/GPT-4 reliably advised to call emergency services only in 12 of 22 cases (54%), gave correct first aid instructions in 9 cases (45%) and incorrectly advised advanced life support techniques to parents in 3 of 22 cases (13.6%).

CONCLUSION

Considering these results of the recent ChatGPT versions, the validity, reliability and thus safety of ChatGPT/GPT-4 as an emergency support tool is questionable. However, whether humans would perform better in the same situation is uncertain. Moreover, other studies have shown that human emergency call operators are also inaccurate, partly with worse performance than ChatGPT/GPT-4 in our study. However, one of the main limitations of the study is that we used prototypical cases, and the management may differ from urban to rural areas and between different countries, indicating the need for further evaluation of the context sensitivity and adaptability of the model. Nevertheless, ChatGPT and the new versions under development may be promising tools for assisting lay first responders, operators, and professionals in diagnosing a paediatric emergency.

TRIAL REGISTRATION

Not applicable.

The impact of a smartphone-based cognitive aid on clinical performance during cardiac arrest simulations: A randomized controlled trial

Objectives

In-hospital cardiac arrests are common and associated with high mortality. Smartphone applications offer quick access to algorithms and timers but often lack real-time guidance. This study assesses the impact of the Code Blue Leader application on the performance of providers leading cardiac arrest simulations.

Methods

This open-label randomized controlled trial included Advanced Cardiac Life Support (ACLS)-trained medical doctors (MD) and registered nurses (RN). Participants were randomized to lead the same ACLS simulation with or without the app. The primary outcome, "performance score," was assessed by a trained rater using a validated ACLS scoring system. Secondary outcomes included percentage of critical actions performed, number of incorrect actions, and chest compression fraction (percentage of time spent performing chest compressions). A sample size of 30 participants was calculated to detect a difference of 20% at the 0.05 alpha level with 90% power.

Results

Fifteen MDs and 15 RNs underwent stratified randomization. The median (interquartile range) performance score in the app group was 95.3% (93.0%-100.0%) compared to 81.4% (60.5%-88.4%) in the control group, demonstrating an effect size of r = 0.69 (Z = -3.78, r = 0.69, p = 0.0002). The percentage of critical actions performed in the app group was 100% (96.2%-100.0%) compared to 85.0% (74.1%-92.4%) in the control group. The number of incorrect actions performed in the app group was 1 (1) compared to 4 (3-5) in the control group. Chest compression fraction in the app group was 75.5% (73.0%-84.0%) compared to 75.0% (72.0%-85.0%) in the control group.

Conclusions

The Code Blue Leader smartphone app significantly improved the performance of ACLS-trained providers in cardiac arrest simulations.

The Development of a Hypertension Prevention and Financial Incentive Mobile Health Program Using a “No-Code” Mobile App Builder: A Development and Usability Study (Preprint)

BACKGROUND

Regular physical activity (PA) is a key lifestyle component for hypertension prevention. Previous studies have shown that mobile health (mHealth) apps can be an effective tool for improving PA behaviors. However, adherence to and poor engagement with these apps is a challenge. A potential solution to overcome this challenge may be to combine financial incentives with innovative behavior theory, such as the Multiprocess Action Control (M-PAC) framework. Currently, there is a lack of PA financial incentive-driven M-PAC mHealth programs aimed at hypertension prevention.

OBJECTIVE

We aimed to describe the process of developing an 8-week mHealth PA and financial-incentive hypertension education program (Healthy Hearts) and to evaluate usability of the Healthy Hearts program.

METHODS

The first 2 stages of the Integrate, Design, Assess, and Share framework were used to guide the development of the Healthy Hearts program. The development process consisted of 2 phases. In phase 1, the research team met to discuss implementing the M-PAC framework to adopt an existing web-based hypertension prevention program to a mobile app. The app was developed using a no-code app development platform, Pathverse (Pathverse Inc), to help decrease overall development time. In phase 2, we created a prototype and conducted usability testing to evaluate lesson 1 of the Healthy Hearts program to further enhance the user experience. We used semistructured interviews and the mHealth App Usability Questionnaire to evaluate program acceptability and usability.

RESULTS

Intervention development among the research team successfully created an 8-week financial-incentive hypertension education program for adults aged 40-65 years who did not currently meet the Canadian Physical Activity Guidelines (<150 minutes of moderate to vigorous PA per week). This program lasted 8 weeks and comprised 25 lessons guided by the M-PAC framework. The program used various behavior change techniques to further support PA adherence. Usability testing of the first lesson was successful, with 6 participants recruited for 2 rounds of testing. Feedback was gathered to enhance the content, layout, and design of the Healthy Hearts program to prepare the mHealth program for feasibility testing. Results of round 1 of usability testing suggested that the content delivered in the lessons was long. Therefore, the content was divided into multiple lessons before round 2 of usability testing, where feedback was only on design preferences. A minimum viable product was created with these results.

CONCLUSIONS

The iterative development process and the usability assessments suggested by the Integrate, Design, Assess, and Share framework enabled participants to provide valuable feedback on the content, design, and layout of the program before advancing to feasibility testing. Furthermore, the use of the "no-code" app development tool enabled our team to rapidly make changes to the app based on user feedback during the iterative design process.

The impact of cognitive aids on resuscitation performance in in-hospital cardiac arrest scenarios: a systematic review and meta-analysis

Different cognitive aids have been recently developed to support the management of cardiac arrest, however, their effectiveness remains barely investigated. We aimed to assess whether clinicians using any cognitive aids compared to no or alternative cognitive aids for in-hospital cardiac arrest (IHCA) scenarios achieve improved resuscitation performance. PubMed, EMBASE, the Cochrane Library, CINAHL and ClinicalTrials.gov were systematically searched to identify studies comparing the management of adult/paediatric IHCA simulated scenarios by health professionals using different or no cognitive aids. Our primary outcomes were adherence to guideline recommendations (overall team performance) and time to critical resuscitation actions. Random-effects model meta-analyses were performed. Of the 4.830 screened studies, 16 (14 adult, 2 paediatric) met inclusion criteria. Meta-analyses of eight eligible adult studies indicated that the use of electronic/paper-based cognitive aids, in comparison with no aid, was significantly associated with better overall resuscitation performance [standard mean difference (SMD) 1.16; 95% confidence interval (CI) 0.64; 1.69; I² = 79%]. Meta-analyses of the two paediatric studies, showed non-significant improvement of critical actions for resuscitation (adherence to guideline recommended sequence of actions, time to defibrillation, rate of errors in defibrillation, time to start chest compressions), except for significant shorter time to amiodarone administration (SMD - 0.78; 95% CI - 1.39; - 0.18; I² = 0). To conclude, the use of cognitive aids appears to have benefits in improving the management of simulated adult IHCA scenarios, with potential positive impact on clinical practice. Further paediatric studies are necessary to better assess the impact of cognitive aids on the management of IHCA scenarios.

System Usability Scale Benchmarking for Digital Health Apps: Meta-analysis

Background

The System Usability Scale (SUS) is a widely used scale that has been used to quantify the usability of many software and hardware products. However, the SUS was not specifically designed to evaluate mobile apps, or in particular digital health apps (DHAs).

Objective

The aim of this study was to examine whether the widely used SUS distribution for benchmarking (mean 68, SD 12.5) can be used to reliably assess the usability of DHAs.

Methods

A search of the literature was performed using the ACM Digital Library, IEEE Xplore, CORE, PubMed, and Google Scholar databases to identify SUS scores related to the usability of DHAs for meta-analysis. This study included papers that published the SUS scores of the evaluated DHAs from 2011 to 2021 to get a 10-year representation. In total, 117 SUS scores for 114 DHAs were identified. R Studio and the R programming language were used to model the DHA SUS distribution, with a 1-sample, 2-tailed t test used to compare this distribution with the standard SUS distribution.

Results

The mean SUS score when all the collected apps were included was 76.64 (SD 15.12); however, this distribution exhibited asymmetrical skewness (–0.52) and was not normally distributed according to Shapiro-Wilk test (P=.002). The mean SUS score for “physical activity” apps was 83.28 (SD 12.39) and drove the skewness. Hence, the mean SUS score for all collected apps excluding “physical activity” apps was 68.05 (SD 14.05). A 1-sample, 2-tailed t test indicated that this health app SUS distribution was not statistically significantly different from the standard SUS distribution (P=.98).

Conclusions

This study concludes that the SUS and the widely accepted benchmark of a mean SUS score of 68 (SD 12.5) are suitable for evaluating the usability of DHAs. We speculate as to why physical activity apps received higher SUS scores than expected. A template for reporting mean SUS scores to facilitate meta-analysis is proposed, together with future work that could be done to further examine the SUS benchmark scores for DHAs.

Usability Testing and Technology Acceptance of an mHealth App at the Point of Care During Simulated Pediatric In- and Out-of-Hospital Cardiopulmonary Resuscitations: Study Nested Within 2 Multicenter Randomized Controlled Trials

BACKGROUND

Mobile apps are increasingly being used in various domains of medicine. Few are evidence-based, and their benefits can only be achieved if end users intend to adopt and use them. To date, only a small fraction of mobile apps have published data on their field usability and end user acceptance results, especially in emergency medicine.

OBJECTIVE

This study aims to determine the usability and acceptance of an evidence-based mobile app while safely preparing emergency drugs at the point of care during pediatric in- and out-of-hospital cardiopulmonary resuscitations by frontline caregivers.

METHODS

In 2 multicenter randomized controlled parent trials conducted at 6 pediatric emergency departments from March 1 to December 31, 2017, and 14 emergency medical services from September 3, 2019, to January 21, 2020, the usability and technology acceptance of the PedAMINES (Pediatric Accurate Medication in Emergency Situations) app were evaluated among skilled pediatric emergency nurses and advanced paramedics when preparing continuous infusions of vasoactive drugs and direct intravenous emergency drugs at pediatric dosages during standardized, simulation-based, pediatric in- and out-of-hospital cardiac arrest scenarios, respectively. Usability was measured using the 10-item System Usability Scale. A 26-item technology acceptance self-administered survey (5-point Likert-type scales), adapted from the Unified Theory of Acceptance and Use of Technology model, was used to measure app acceptance and intention to use.

RESULTS

All 100% (128/128) of nurses (crossover trial) and 49.3% (74/150) of paramedics (parallel trial) were assigned to the mobile app. Mean total scores on the System Usability Scale were excellent and reached 89.5 (SD 8.8; 95% CI 88.0-91.1) for nurses and 89.7 (SD 8.7; 95% CI 87.7-91.7) for paramedics. Acceptance of the technology was very good and rated on average >4.5/5 for 5 of the 8 independent constructs evaluated. Only the image construct scored between 3.2 and 3.5 by both participant populations.

CONCLUSIONS

The results provide evidence that dedicated mobile apps can be easy to use and highly accepted at the point of care during in- and out-of-hospital cardiopulmonary resuscitations by frontline emergency caregivers. These findings can contribute to the implementation and valorization of studies aimed at evaluating the usability and acceptance of mobile apps in the field by caregivers, even in critical situations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03021122; https://clinicaltrials.gov/ct2/show/NCT03021122. ClinicalTrials.gov NCT03921346; https://clinicaltrials.gov/ct2/show/NCT03921346.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-019-3726-4.

The good, the bad, and the poorly designed: The mobile app stores are not a user-friendly experience for health and medical purposes

The utilization of mobile health applications to help manage health conditions have grown in utilization within the past decade. However, the application stores (i.e. Google and Apple) are not designed in a user-friendly manner that allows consumers to identify high-quality health and medical-related mobile applications. Researchers have been interested in identifying applications that may be recommended for patient care but have found the ability to quantify and assess these applications to be difficult due to the current layout and organization of applications. We explain here in this brief communication our own research experience in the identification of mobile health applications on the application stores, along with trends noted in other mobile health research, and make suggestions on how the application store experience could be improved for both patients and health professionals. These include collaboration between developers, medical professionals and organizations, and technology companies to facilitate a better means of categorizing health applications for patient use, alongside other current endeavors being pursued such as application review organizations and the creation of digital health formulary databases.

Responding to Cardiac Arrest in the Community in the Digital Age

Sudden cardiac arrest (SCA) is a common event, affecting almost 400,000 individuals annually in North America. Initiation of cardiopulmonary resuscitation (CPR) and early defibrillation using an automated external defibrillator (AED) are critical for survival, yet many bystanders are reluctant to intervene. Digital technologies, including mobile devices, social media and crowdsourcing may help play a role to improve survival from SCA. In this article we review the current digital tools and strategies available to increase rates of bystander recognition of SCA, prompt immediate activation of Emergency Medical Services (EMS), initiate high quality CPR and to locate, retrieve and operate AEDs. Smartphones can help to both educate and connect bystanders with EMS dispatchers, through text messaging or video-calling, to encourage the initiation of CPR and retrieval of the closest AED. Wearable devices and household smartspeakers could play a future role in continuous vital signs monitoring in individuals at-risk of lethal arrhythmias and send an alert to either chosen contacts or EMS. Machine learning algorithms and mathematical modeling may aid EMS dispatchers with better recognition of SCA as well as policymakers with where to best place AEDs for optimal accessibility. There are challenges with the use of digital tech, including the need for government regulation and issues with data ownership, accessibility and interoperability. Future research will include smart cities, e-linkages, new technologies and using social media for mass education. Together or in combination, these emerging digital technologies may represent the next leap forward in SCA survival.

PediAppRREST: effectiveness of an interactive cognitive support tablet app in reducing deviations from guidelines in the management of paediatric cardiac arrest: protocol for a simulation-based randomised controlled trial

INTRODUCTION

Paediatric cardiac arrest (PCA), despite its low incidence, has a high mortality. Its management is complex and deviations from guideline recommendations occur frequently. We developed a new interactive tablet app, named PediAppRREST, to support the management of PCA. The app received a good usability evaluation in a previous pilot trial. The aim of the study is to evaluate the effectiveness of the PediAppRREST app in reducing deviations from guideline recommendations in PCA management.

METHODS AND ANALYSIS

This is a multicentre, simulation-based, randomised controlled, three-parallel-arm study. Participants are residents in Paediatric, Emergency Medicine, and Anaesthesiology programmes in Italy. All 105 teams (315 participants) manage the same scenario of in-hospital PCA. Teams are randomised by the study statistician into one of three study arms for the management of the PCA scenario: (1) an intervention group using the PediAppRREST app or (2) a control group Paediatric Advanced Life Support (CtrlPALS+) using the PALS pocket reference card; or (3) a control group (CtrlPALS-) not allowed to use any PALS-related cognitive aid. The primary outcome of the study is the number of deviations (delays and errors) in PCA management from PALS guideline recommendations, according to a novel checklist, named c-DEV15plus. The c-DEV15plus scores will be compared between groups with a one-way analysis of variance model, followed by the Tukey-Kramer multiple comparisons adjustment procedure in case of statistical significance.

ETHICS AND DISSEMINATION

The Ethics Committee of the University Hospital of Padova, coordinating centre of the trial, deemed the project to be a negligible risk study and approved it through an expedited review process. The results of the study will be disseminated in peer-reviewed journals, and at national and international scientific conferences. Based on the study results, the PediAppRREST app will be further refined and will be available for download by institutions/healthcare professionals.

TRIAL REGISTRATION NUMBER

NCT04619498; Pre-results.

Evaluating Quality, Usability, Evidence-Based Content, and Gamification Features in Mobile Learning Apps Designed to Teach Children Basic Life Support: Systematic Search in App Stores and Content Analysis

BACKGROUND

Globally, 3.7 million people die of sudden cardiac death annually. Following the World Health Organization endorsement of the Kids Save Lives statements, initiatives to train school-age children in basic life support (BLS) have been widespread. Mobile phone apps, combined with gamification, represent an opportunity for including mobile learning (m-learning) in teaching schoolchildren BLS as an additional teaching method; however, the quality of these apps is questionable.

OBJECTIVE

This study aims to systematically evaluate the quality, usability, evidence-based content, and gamification features (GFs) of commercially available m-learning apps for teaching guideline-directed BLS knowledge and skills to school-aged children.

METHODS

We searched the Google Play Store and Apple iOS App Store using multiple terms (eg, cardiopulmonary resuscitation [CPR] or BLS). Apps meeting the inclusion criteria were evaluated by 15 emergency health care professionals using the user version of the Mobile Application Rating Scale and System Usability Scale. We modified a five-finger mnemonic for teaching schoolchildren BLS and reviewed the apps' BLS content using standardized criteria based on three CPR guidelines. GFs in the apps were evaluated using a gamification taxonomy.

RESULTS

Of the 1207 potentially relevant apps, only 6 (0.49%) met the inclusion criteria. Most apps were excluded because the content was not related to teaching schoolchildren BLS. The mean total scores for the user version of the Mobile Application Rating Scale and System Usability Scale score were 3.2/5 points (95% CI 3.0-3.4) and 47.1/100 points (95% CI 42.1-52.1), respectively. Half of the apps taught hands-only CPR, whereas the other half also included ventilation. All the apps indicated when to start chest compressions, and only 1 app taught BLS using an automated external defibrillator. Gamification was well integrated into the m-learning apps for teaching schoolchildren BLS, whereas the personal and fictional, educational, and performance gamification groups represented most GFs.

CONCLUSIONS

Improving the quality and usability of BLS content in apps and combining them with GFs can offer educators novel m-learning tools to teach schoolchildren BLS skills.

Smartphone apps to support laypersons in bystander CPR are of ambivalent benefit: a controlled trial using medical simulation

Background

Bystander-initiated resuscitation is essential for surviving out-of-hospital cardiac arrest. Smartphone apps can provide real-time guidance for medical laypersons in these situations. Are these apps a beneficial addition to traditional resuscitation training?

Methods

In this controlled trial, we assessed the impact of app use on the quality of resuscitation (hands-off time, assessment of the patient’s condition, quality of chest compression, body and arm positioning). Pupils who have previously undergone a standardised resuscitation training, encountered a simulated cardiac arrest either (i) without an app (control group); (ii) with facultative app usage; or (iii) with mandatory app usage. Measurements were compared using generalised linear regression.

Results

200 pupils attended this study with 74 pupils in control group, 65 in facultative group and 61 in mandatory group. Participants who had to use the app significantly delayed the check for breathing, call for help, and first compression, leading to longer total hands-off time. Hands-off time during chest compression did not differ significantly. The percentage of correct compression rate and correct compression depth was significantly higher when app use was mandatory. Assessment of the patient’s condition, and body and arm positioning did not differ.

Conclusions

Smartphone apps offering real-time guidance in resuscitation can improve the quality of chest compression but may also delay the start of resuscitation. Provided that the app gives easy-to-implement, guideline-compliant instructions and that the user is familiar with its operation, we recommend smartphone-guidance as an additional tool to hands-on CPR-training to increase the prevalence and quality of bystander-initiated CPR.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00893-3.

[Education for resuscitation]

Diese Leitlinien des European Resuscitation Council basieren auf dem internationalen wissenschaftlichen Konsens 2020 zur kardiopulmonalen Reanimation mit Behandlungsempfehlungen (International Liaison Committee on Resuscitation 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations [ILCOR] 2020 CoSTR). Dieser Abschnitt bietet Bürgern und Angehörigen der Gesundheitsberufe Anleitungen zum Lehren und Lernen der Kenntnisse, der Fertigkeiten und der Einstellungen zur Reanimation mit dem Ziel, das Überleben von Patienten nach Kreislaufstillstand zu verbessern.

Is there a doctor on the plane? A review of in-flight emergencies for the on-board radiologist

In-flight medical emergencies (IFME) are the acute on-service events involving illness or injury to a passenger with the potential for long-term health compromise. With the continuously rising number of flights available, both domestically and internationally, it is conceivable that the number of IFMEs will similarly continue to rise. Although most of these instances are relatively self-limited, the rare instance of a severe occurrence justifies preparation, both from in-flight staff and healthcare providers traveling on these flights. Given these events' sporadic nature and the variable availability of medical support, all physicians need to understand their in-flight ethical and legal capabilities, the available medical supplies, and the most likely etiologies to manage such situations successfully. Most radiologists rarely utilize the hands-on, clinical skills developed in medical school or internship for emergencies beyond allergic contrast reactions. Therefore, they may not be adept in caring for patients during an IFME. As such, we present a thorough overview and literature review for the radiologist regarding the management of various acute IFMEs, with consideration for ethical and legal precedence and a review of medical equipment available on-board.

European Resuscitation Council Guidelines 2021: Education for resuscitation

These European Resuscitation Council education guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidance to citizens and healthcare professionals with regard to teaching and learning the knowledge, skills and attitudes of resuscitation with the ultimate aim of improving patient survival after cardiac arrest.

Mobile App Support for Cardiopulmonary Resuscitation: Development and Usability Study

Background

The user requirements for in-hospital cardiopulmonary resuscitation (CPR) support apps are understudied. To study usability, functionality, and design based on user requirements, we applied a mixed methods research design using interviews, observations, and a Kano questionnaire to survey perspectives of both physicians and nurses.

Objective

This study aims to identify what an in-hospital CPR support app should include to meet the requirements and expectations of health care professionals by evaluating the CprPrototype app.

Methods

We used a mixed methods research design. The qualitative methods consisted of semistructured interviews and observations from an advanced life support (ALS) course; both provided input to the subsequent questionnaire development. The quantitative method is a questionnaire based on the Kano model classifying user requirements as must-be, one-dimensional (attributes causing satisfaction when present and dissatisfaction when absent), attractive, indifferent, and reverse (attributes causing dissatisfaction when present and satisfaction when absent). The questionnaire was supplemented with comment fields. All respondents were physicians and nurses providing ALS at hospitals in the Central Denmark Region.

Results

A total of 83 physicians and nurses responded to the questionnaire, 15 physicians and nurses were observed during ALS training, and 5 physicians were interviewed. On the basis of the Kano questionnaire, 53% (9/17) of requirements were classified as indifferent, 29% (5/17) as attractive, and 18% (3/17) as one-dimensional. The comments revealed 7 different categories of user requirements with noticeable differences between those of physicians and nurses: technological challenges, keep track of time, documentation and history, disturbing element, improvement areas: functions, improvement areas: design, and better guidance.

Conclusions

The study provides recommendations to developers on the user requirements that need to be addressed when developing CPR support apps. Three features (one-dimensional attributes) must be incorporated in an in-hospital CPR support app: reminder of rhythm check, reminder of resuscitation drugs, and differentiate between adults and children. In addition, 5 features (attractive attributes) would result in higher user satisfaction: all functions on one side, access to the patient journal in the app, automatic time recording when cardiac arrest is called, sound to guide the chest compression rate (metronome), and send CPR history to the DANARREST(Danish in-hospital cardiac arrest registry) database.

Development and Usability of a Novel Interactive Tablet App (PediAppRREST) to Support the Management of Pediatric Cardiac Arrest: Pilot High-Fidelity Simulation-Based Study

Background

Pediatric cardiac arrest (PCA), although rare, is associated with high mortality. Deviations from international management guidelines are frequent and associated with poorer outcomes. Different strategies/devices have been developed to improve the management of cardiac arrest, including cognitive aids. However, there is very limited experience on the usefulness of interactive cognitive aids in the format of an app in PCA. No app has so far been tested for its usability and effectiveness in guiding the management of PCA.

Objective

To develop a new audiovisual interactive app for tablets, named PediAppRREST, to support the management of PCA and to test its usability in a high-fidelity simulation-based setting.

Methods

A research team at the University of Padova (Italy) and human–machine interface designers, as well as app developers, from an Italian company (RE:Lab S.r.l.) developed the app between March and October 2019, by applying an iterative design approach (ie, design–prototyping–evaluation iterative loops). In October–November 2019, a single-center nonrandomized controlled simulation–based pilot study was conducted including 48 pediatric residents divided into teams of 3. The same nonshockable PCA scenario was managed by 11 teams with and 5 without the app. The app user’s experience and interaction patterns were documented through video recording of scenarios, debriefing sessions, and questionnaires. App usability was evaluated with the User Experience Questionnaire (UEQ) (scores range from –3 to +3 for each scale) and open-ended questions, whereas participants’ workload was measured using the NASA Raw-Task Load Index (NASA RTLX).

Results

Users’ difficulties in interacting with the app during the simulations were identified using a structured framework. The app usability, in terms of mean UEQ scores, was as follows: attractiveness 1.71 (SD 1.43), perspicuity 1.75 (SD 0.88), efficiency 1.93 (SD 0.93), dependability 1.57 (SD 1.10), stimulation 1.60 (SD 1.33), and novelty 2.21 (SD 0.74). Team leaders’ perceived workload was comparable (P=.57) between the 2 groups; median NASA RTLX score was 67.5 (interquartile range [IQR] 65.0-81.7) for the control group and 66.7 (IQR 54.2-76.7) for the intervention group. A preliminary evaluation of the effectiveness of the app in reducing deviations from guidelines showed that median time to epinephrine administration was significantly longer in the group that used the app compared with the control group (254 seconds versus 165 seconds; P=.015).

Conclusions

The PediAppRREST app received a good usability evaluation and did not appear to increase team leaders’ workload. Based on the feedback collected from the participants and the preliminary results of the evaluation of its effects on the management of the simulated scenario, the app has been further refined. The effectiveness of the new version of the app in reducing deviations from guidelines recommendations in the management of PCA and its impact on time to critical actions will be evaluated in an upcoming multicenter simulation-based randomized controlled trial.

Mobile application-based guidelines to enhance patient care and provider education in trauma and acute care surgery

Introduction

Providing up-to-date, universally accessible care guidelines and education within a quaternary care center is challenging. At our institution, trauma and acute care surgery guidelines have historically been published using a paper-based format. Mobile application-based guidelines were developed to address the shortcomings of paper-based guidelines.

Methods

We assessed the utility, usability, and satisfaction of healthcare providers towards paper-based versus mobile application-based guidelines. A survey was administered to providers within the emergency department and intensive care unit.

Results

Fifty of 137 providers responded (36.5% response rate). Nearly half (47.4%, 9 of 19) of those who received a copy of the paper-based guidelines lost the guidelines at least once. Regarding usage of the mobile application-based guidelines, 92.6% (25 of 27) were aware of the application; 92.6% (25 of 27) considered the application comprehensive, 85.2% (23 of 27) thought the application was organized, and 66.7% (18 of 27) thought the application was easy to use. Additionally, 88.9% (24 of 27) found the application moderately, very, or extremely helpful and 85.2% (23 of 27) judged the application moderately, very, or extremely necessary. Overall, 88.9% (24 of 27) were satisfied with the application and indicated likeliness to recommend to a colleague. Seventeen of 27 (63.0%) agreed or strongly agreed that the application improved their provision of trauma and acute care.

Conclusion

This survey demonstrates positive usability, utility, and satisfaction among trauma healthcare providers with the mobile application-based guidelines. Additionally, this quality improvement initiative highlights the importance of having comprehensive, organized, and easy-to-use trauma and acute care surgery guidelines and targeted educational materials available on demand. The successful transition from paper to mobile application-based guidelines serves as a model for other institutions to modernize and improve patient care and provider education.

Level of evidence

IV.

Evaluating Online Consumer Medication Information Systems: Comparative Online Usability Study

BACKGROUND

Medication is the most common intervention in health care, and the number of online consumer information systems within the pharmaceutical sector is increasing. However, online consumer information systems can be a barrier for users, imposing information asymmetries between stakeholders.

OBJECTIVE

The objective of this study was to quantify and compare the usability of an online consumer medication information system (OCMIS) against a reference implementation based on an interoperable information model for patients, physicians, and pharmacists.

METHODS

Quantitative and qualitative data were acquired from patients, physicians, and pharmacists in this online usability study. We administered 3 use cases and a post hoc questionnaire per user. Quantitative usability data including effectiveness (task success), efficiency (task time), and user satisfaction (system usability scale [SUS]) was complemented by qualitative and demographic data. Users evaluated 6 existing systems and 1 reference implementation of an OCMIS.

RESULTS

A total of 137 patients, 81 physicians, and 68 pharmacists participated in this study. Task success varied from 84% to 92% in patients, 66% to 100% in physicians, and 50% to 91% in pharmacists. Task completion time decreased over the course of the study for all but 2 OCMIS within the patient group. Due to an assumed nonnormal distribution of SUS scores, within-group comparison was done using the Kruskal-Wallis test. Patients showed differences in SUS scores (P=.02) and task time (P=.03), while physicians did not have significant differences in SUS scores (P=.83) and task time (P=.72). For pharmacists, a significant difference in SUS scores (P<.001) and task time (P=.007) was detected.

CONCLUSIONS

The vendor-neutral reference implementation based on an interoperable information model was proven to be a promising approach that was not inferior to existing solutions for patients and physicians. For pharmacists, it exceeded user satisfaction scores compared to other OCMIS. This data-driven approach based on an interoperable information model enables the development of more user-tailored features to increase usability. This fosters data democratization and empowers stakeholders within the pharmaceutical sector.

Evaluation of mHealth Applications Related to Cardiovascular Diseases: a Systematic Review

Introduction:

Currently, with the widespread penetration of mobile devices with Internet access, including smartphones, they can allow specific and/or complementary activities in the health field as well as in other commercial sectors.

Aim:

This systematic review examined the impact of mHealth-based for cardiovascular research. The specific aims of the systematic review are to (1) classification of the studies according to the type of research (scientific articles and master’s and doctoral theses) and (2) relationship of studies with topics associated with cardiovascular diseases.

Results:

This review corresponds to information in scientific journals of high impact. This review intends to respond to the following question: How these research works have evaluated the performance of health mobile applications, with a special interest in cardiac issues? This review of these searches corresponds to an analysis by 14 categories, being these: 1) Scientific paper; 2) Doctoral Thesis; 3) Master thesis; 4) Telemedicine; 5) m-sssshealth, e-health; 6) cardiovascular, coronary diseases, heart failures, cardiopulmonary, cardiac rehabilitation; 7) rural health; 8) prevention and control, protection; 9) wearables; 10) mobile, web applications, app, smartphone, software, platform; 11) mhealth education, training, promotion, formative process; 12) self-management; 13) Multiple Vital Sign Monitoring, medical device, heart rate measurement, health care information systems; 14) health regulatory. It provides evidence of how some apps have been evaluated, and in some cases, the effectiveness of the estimated accuracy is not in line with the real situation.

Conclusion:

The analysis of these studies allows us to locate the sources of the development of mobile health projects. It also guides us to discover some needs that require new technology implementations.

Tracker-Based Personal Advice to Support the Baby's Healthy Development in a Novel Parenting App: Data-Driven Innovation

BACKGROUND

The current generation of millennial parents prefers digital communications and makes use of apps on a daily basis to find information about child-rearing topics. Given this, an increasing amount of parenting apps have become available. These apps also allow parents to track their baby's development with increasing completeness and precision. The large amounts of data collected in this process provide ample opportunity for data-driven innovation (DDI). Subsequently, apps are increasingly personalized by offering information that is based on the data tracked in the app. In line with this, Philips Avent has developed the uGrow app, a medical-grade app dedicated to new parents for tracking their baby's development. Through so-called insights, the uGrow app seeks to provide a data-driven solution by offering parents personal advice that is sourced from user-tracked behavioral and contextual data.

OBJECTIVE

The aim of this study was twofold. First, it aimed to give a description of the development process of the insights for the uGrow app. Second, it aimed to present results from a study about parents' experiences with the insights.

METHODS

The development process comprised 3 phases: a formative phase, development phase, and summative phase. In the formative phase, 3 substudies were executed in series to understand and identify parents' and health care professionals' (HCPs) needs for insights, using qualitative and quantitative methods. After the formative phase, insights were created during the development phase. Subsequently, in the summative phase, these insights were validated against parents' experience using a quantitative approach.

RESULTS

As part of the formative phase, parents indicated having a need for smart information based on a data analysis of the data they track in an app. HCPs supported the general concept of insights for the uGrow app, although specific types of insights were considered irrelevant or even risky. After implementing a preliminary set of insights in a prototype version of the uGrow app and testing it with parents, the majority of parents (87%) reported being satisfied with the insights. From these outcomes, a total of 89 insights were implemented in a final version of the uGrow app. In the summative phase, the majority of parents reported experiencing these insights as reassuring and useful (94%), as adding enjoyment (85%), and as motivating for continuing tracking for a longer period of time (77%).

CONCLUSIONS

Parents experienced the insights in the uGrow app as useful and reassuring and as adding enjoyment to their use of the uGrow app and tracking their baby's development. The insights development process we followed showed how the quality of insights can be guaranteed by ensuring that insights are relevant, appropriate, and evidence based. In this way, insights are an example of meaningful DDI.

The Iterative Convergent Design for Mobile Health Usability Testing: Mixed Methods Approach

Although patients express an interest in using mobile health (mHealth) interventions to manage their health and chronic conditions, many current mHealth interventions are difficult to use. Usability testing is critical for the success of novel mHealth interventions. Researchers recognize the utility of using qualitative and quantitative approaches for usability testing, but many mHealth researchers lack the awareness of integration approaches from advances in mixed methods research that can add value to mHealth technology. As efficient usability testing proceeds iteratively, we introduce a novel mixed methods design developed specifically for mHealth researchers. The iterative convergent mixed methods design involves simultaneous qualitative and quantitative data collection and analysis that continues cyclically through multiple rounds of mixed methods data collection and analysis until the mHealth technology under evaluation is found to work to the satisfaction of the researcher. In cyclical iterations, early development is more qualitatively driven but progressively becomes more quantitatively driven. Using this design, mHealth researchers can leverage mixed methods integration procedures in the research question, data collection, data analysis, interpretation, and dissemination dimensions. This study demonstrates how the iterative convergent mixed methods design provides a novel framework for generating unique insights into multifaceted phenomena impacting mHealth usability. Understanding these practices can help developers and researchers leverage the strengths of an integrated mixed methods design.