Technological innovations in layperson CPR education – A scoping review

Abstract

Background

Rapid initiation of CPR is key for survival in out-of-hospital cardiac arrests, making bystander CPR education a key part of the cardiac chain-of-survival. CPR classes continue to include new technologies that enable more widespread and high-fidelity training. We aimed to examine the landscape of technological innovations in layperson CPR training since the onset of the COVID-19 pandemic.

Methods

We searched Cochrane, Medline, PubMed, and Web of Science from database inception to July 2024 for studies. We included articles with layperson CPR classes that included a technological advance, either in the equipment or mode of delivery of education. We focused on studies published after the start of 2020.

Results

Out of 1070 studies screened, 50 met the selection criteria. The primary groups of technology found were extended reality (20), feedback devices (11), asynchronous video instruction (10), tele-education (5), and low-cost CPR manikins (4). These technologies show promise to offer comparable or improved effectiveness compared to traditional options. Several topics may warrant further investigation, such as cognitive load associated with extended reality, the practicality of student-created CPR training devices, and possible interactive effects between technologies.

Conclusion

Future systematic reviews should evaluate the specific learning contexts for which these individual technologies, or combinations of these technologies, may be best suited to guide regulating bodies and CPR instructors in their pedagogical decisions.

Introduction

Bystander cardiopulmonary resuscitation (CPR) is a critical intervention for out-of-hospital cardiac arrests (OHCA) that can drastically increase the victim’s chance of survival.1, 2 Public health interventions, such as CPR education, make it more likely that bystanders will intervene and perform CPR.3, 4 Yet, out-of-hospital CPR prior to professional intervention only occurs about 40% of the time in the U.S., with global OHCA CPR rates ranging from 1.3% to 72%.5, 6

A study conducted in high- and middle-income countries found that a median of 40% of people are trained in CPR, and there are stark disparities between income brackets and limited data on CPR training in low-income countries.⁷ When surveyed, respondents listed time constraints, high cost, and a lack of accessible classes as the top reasons that they had not learned CPR.⁷ For instance, current standard CPR classes in the U.S. are 2–6 hours with an in-person instructor, where students watch instructional videos and practice CPR with a CPR manikin and a training automated external defibrillator. Innovations in CPR educational equipment have continued since CPR’s modern inception to make training more accessible to laypeople and better prepare trainees. CPR manikins and trainer AEDs, once considered novel technological innovations, are now common in CPR training worldwide.

The COVID-19 pandemic put distinct pressure on CPR educators to find new techniques to safely teach trainees.⁸ Previous reviews have examined the effect of the COVID-19 pandemic on CPR classes for nursing students or focused solely on tele-education.9, 10 Due to the importance of public CPR education, this review paper examines a wider swath of technological innovations in layperson CPR education since the onset of the COVID-19 pandemic. By evaluating recent studies on these varied technologies, we seek to outline their potential benefits and limitations and discuss how these innovations could contribute to a more resilient, widely-trained responder base for future cardiac emergencies.

Practitioner Notes

What is already known about this topic

• •Previous studies have highlighted potential roles for several emerging technologies in CPR education as alternatives to traditional methodologies.

What this paper adds

• •Contextualize the push for technological innovations specifically in layperson CPR education since the onset of the COVID-19 pandemic.
• •Provide an integrated review of the use of extended reality, feedback devices, tele-education, and low-fidelity manikins in CPR education.

Implications for practice and/or policy

• •Guide training sites in balancing the cost and complexity of technological innovations with efficacy in training and accessibility.

Methods

Scoping review

We chose the scoping review as compared to the systematic review format to perform a comprehensive overview of CPR training education. With a scoping review, we can provide an unbiased understanding of the trends of innovations in the field. This is as an alternative compared to a systematic review, which would require a critique or synthesis of the works referenced. We have designed this review to follow the PRISMA Extension for Scoping Reviews, the checklist for which can be found in Appendix 1.¹¹

Search method

We sourced articles by searching on Cochrane, Medline, PubMed, and Web of Science from database inception to July 2024. The key terms “CPR,” “cardiopulmonary resuscitation,” “bystander,” “layperson,” “virtual,” “hands-only,” “teaching,” “training,” and “class” were used to search these databases. The full search strategy can be found in Appendix 2. The references of the resultant articles were also searched to find relevant articles that did not appear in the initial search. A larger grey literature search was not performed.

Selection

The ‘PICOST’ (Population, Intervention, Comparison, Outcome, Study Design, Timeframe) format was used to define the study objectives below:

Population: Non-medical professionals learning to perform cardiopulmonary resuscitation.

Intervention: Use of technology outside of what is required by traditional certifying agencies, such as the American Heart Association (AHA) or European Resuscitation Council (ERC) for layperson CPR certification classes.

Comparison: CPR classes that do not use the relevant technological innovations.

Outcome: The quality of CPR performed by trainees in a skill test after taking a CPR class, defined by the AHA’s definition of high-quality CPR. This includes chest compression rate, chest compression depth, chest compression fraction, chest recoil, and ventilation rate. Secondary outcomes include hand position, accuracy of patient assessment, knowledge of CPR parameters (rate, depth, step sequence), execution of CPR steps in the correct order, self-efficacy around CPR, and questionnaires on the user satisfaction with the intervention.

Study Design: Randomized-Control Trials, Quasi-Experimental, or Technological Feasibility Studies.

Timeframe: Post-2020.

For the purpose of this analysis, technology was defined as a material good, such as a manikin, or software, such as a video, that aids CPR education. We took a broad interpretation of technology in order to include important advancements that can make CPR education more affordable and accessible. We also chose to consider outcomes measured beyond the components of high-quality CPR, such as student’s self-efficacy, as these extra components can be valuable measures of whether a student will intervene in a real emergency or keep their CPR skills up to date. We consider these outcomes both immediately after the intervention is applied and, where applicable, when assessing skill retention.

Once duplicates were merged, 1070 papers remained. We conducted a title and abstract review to select papers where a CPR class was taught to laypeople. The title and abstract review were conducted by two independent reviewers (AS and CS), with disagreements resolved by a third review (RK). A final full-text review was conducted by three reviewers (AS, CS, LS), with disagreements resolved by majority opinion. Papers were eligible for final selection if they examined the effect of a technical innovation, either physical or digital, on the quality of CPR education. Fig. 1 presents a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for paper selection.

Fig. 1.

Paper inclusion flow chart.

Data extraction

Data extraction was independently performed on the remaining 50 articles by two reviewers (AS and CS) and verified by a third (LS). Data was extracted into a spreadsheet in the following domains: study type, reported outcomes, participant demographic, study geographical region, and technological innovation intervention category.

Results

Of the 50 studies extracted for review, 20 tested extended reality interventions,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 11 tested CPR feedback devices,32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42 10 tested asynchronous video education programs,43, 44, 45, 46, 47, 48, 49, 50, 51, 52 5 tested tele-education programs,53, 54, 55, 56, 57 and 4 tested low-cost manikins,58, 59, 60, 61 as shown in Table 1. Fig. 2 shows the outcomes that the studies reported, with compression depth being the most common, followed by compression recoil and qualitative survey results. Though approximately half of the studies included general adult participants, 13 targeted students in their initial years studying a health field,12, 13, 29, 48, 53, 54, 60, 61, 32, 33, 34 and 8 studied high school students or other minors.14, 26, 27, 36, 39, 55, 58, 59 Fig. 3 shows a geographical breakdown of the location where the studies took place, with the majority taking place in Asia.

Table 1.

Summary of study characteristics.

Technological Innovation Intervention Category	n
Extended Reality	20
Feedback Devices	11
Asynchronous Video Education	10
Tele-education	5
Low-cost Manikins	4
Class Populations	n
Other Lay People	19
Health Students	12
Other University Students	9
High Schoolers and Minors	8
Lifeguards	2
Study Type	n
Randomize Control	38
Quasi-Experimental	10
Usability Study	1
Crossover	1
Total Number of Studies	50

Fig. 2.

Distribution of Measured Outcomes Across Studies. The bar graph shows the number of studies that assess various components of CPR performance. The most frequently measured were compression depth, compression rate, and chest recoil.

Fig. 3.

Geographic Distribution of Studies Included in the Review. This map shows the global distribution of the studies reviewed with a color-coded gradient from dark teal, indicating fewer studies, to dark orange, indicating a higer number of studies. Countries presented with grey shading were not represented in the studies.

Table 2 provides a summary of the control, interventions, and outcomes of each study. This table highlights the diversity in types of interventions, even within each technological category. There is also considerable variation in the control groups, which may be partly due to the varying standards for CPR educations across different countries, making it difficult to make direct comparisons across the findings in the studies.

Table 2.

Summary of Studies Included in the Scoping Review.

Primary Author and Publication Year	Control	Intervention	Outcome
Alcázar Artero et al. (2023)	Students underwent a standard 15-minute training with an instructor, which included a theoretical presentation, training by a Basic Life Support Instructor, and a clinical case.	Students participated in a 15-minute serious game through VR goggles and haptic controls.	The group that trained with VR had better chest compression quality, rhythm and depth than the control group. There was also a greater increase in the biochemical stress marker in the VR group than the control.
Aranda-García et al. (2024)	Students were given conventional face-to-face training.	Students were training with a distance learning program that involved a video call with an instructor on smart glasses.	The smart glasses had comparable CPR training outcomes for all metrics of high-quality CPR.
Barsom et al. (2020)	Students in the standard group were given an online e-learning module with 2D videos.	Students trained using a 360-degree VR resuscitation training in place of the 2D videos in the standard e-learning.	Students in the VR group had a significantly higher increase in the number of correct answers between the pre- and posttest of theoretical CPR knowledge, and reported higher self-confidence.
Breindahl et al. (2020)	Students received a 2-minute verbal lecture on agonal breathing from the ERC BLS materials.	Students were shown a 2-minute video on agonal breathing.	Students taught with the video were more able to identify agonal breathing (90% accurate) than the lecture group (83% accurate).
Castillo García et al. (2020)	Students received a 4-hour in-person CPR class based on the ERC curriculum.	Students received the first 2-hours of the curriculum online and the second 2-hours in-person.	The groups performed the same at practical CPR skills (compression rate, depth, recoil, fraction), but the control group performed significantly better on the knowledge assessment.
Chang et al. (2023)	Students underwent a pretest, followed by a face-to-face lecture and practice, and then two posttests.	Students underwent a pretest, followed by a lecture and practice with either a web-based video playlist or VR platform and goggles.	Face-to-face, video-based, and VR-based training were equally effective in improving attitude toward CPR, intention to perform CPR, CPR knowledge, and CPR skills.
Chien et al. (2020)	Students were given conventional in-person training.	Students were training with a blended learning program that involved both e-learning and in-person instruction.	The training program outcome was comparable in both groups for all metrics of high-quality CPR.
Chong et al. (2023)	Students watched videos on BLS skills independently then practiced the hands-on skills with an instructor.	Students watched videos on BLS skills independently then were given a manikin, AED, and BLS course materials to practice the hands-on skills independently.	Students in the control group achieved significantly better chest recoil. All other metrics (compression rate, depth, fraction, and willingness to perform CPR) were the same.
Fierros et al. (2021)	None reported.	Students used VirtualCPR, a VR mobile application that displays an interactive virtual scenario and a portable sensor embedded inside training manikins.	Students who had more training using VirtualCPR had a greater number of correct compressions during evaluation.
Giacomini et al. (2023)	Students completed a practical skills evaluation and questionnaire, and then participated in a two-hour, instructor-led lesson with practice on a training manikin. Finally, they completed two post-training questionnaires and practical skill evaluations.	Students first completed a practical skills evaluation and a questionnaire, and then they either participated in a two-hour, instructor-led lesson with VR or received a Basic Life Support manual for independent study. Finally, all students completed two post-training questionnaires and evaluations.	The MR group had the greatest improvement in the median correct answers, while the self-directed learning was most limited. The MR group's CPR skills, BLS checklist acquisition and retention, and satisfaction rates were significantly higher than the mass-training and self-directed learning groups.
Goldberg et al. (2023)	Students received an AHA BLS Course.	Students watched a short, just-in-time training video.	Students in the control group achieved significantly better chest compression fraction, compression rate, and requested AEDs more frequently than the intervention group. The two groups were comparable in terms of time to initiate CPR and compression rate.
González-Santano et al. (2020)	Traditional instructor feedback was given to students with no visual feedback.	Feedback mannikins or feedback on an app was utilized as a visual feedback intervention for students.	Compression and ventilation success was increased in feedback mannikins compared to all other groups.
Han et al. (2021)	Students were given conventional instructor feedback in-person.	Students received distant instructor feedback via videoconferencing.	Both feedback forms were comparable in CPR training metrics.
Hou et al. (2022)	Students underwent instructor assisted bystander CPR, simulating dispatcher-assisted CPR in OHCA.	Students in the AR group self-trained with an AR CPR app through which they received holographic real-time feedback in addition to audio feedback.	No statistically significant differences were found between the AR-assisted bystander CPR and simulated traditional dispatcher-assisted bystander CPR.
Hubail et al. (2022)	Students underwent an instructor-led course with a lecture and hands-on skills component.	Students trained with a VR course using VR headsets and hand sensors under the guidance of an instructor.	No statistically significant differences were found between the control and VR groups in terms of CPR skill acquisition, CPR quality, or confidence, suggesting that VR-based CPR education is not inferior to standard training methods.
Ingrassia et al. (2020)	Did not have a control group given the nature of study.	Students took interaction training with the AR system, and then guided through resuscitation using AR tools for CPR training.	Users reported that the AR system was easy to use, comfortable, and overall acceptable for self-instructed CPR training.
Issleib et al. (2021)	Students received a Basic Life Support course with a seminar and basic skill training.	Students received a 35-minute VR Basic Life Support course and basic skill training.	Learning gain was higher with the VR training and 96% of the VR group reported wanting to use the tool more frequently; however, the time between cardiac arrest and CPR initiation was significantly lower in the control group compared to the VR group.
Jang et al. (2020)	CPR training was given to students with no real time feedback.	Real-time feedback was given to students during their training.	Real-time feedback improved short-term retention of skills but did not significantly improve retention after 6 months.
Jaskiewicz et al. (2020)	Students performed the final CPR assessment on a commercial manikin.	Students used a VR headset and gloves for a simulation in the final CPR assessment.	Students in the VR simulation had statistically significantly worse compression depth and chest recoil than the control.
Jiang et al. (2024)	Students were trained without an audiovisual feedback (AVF) device and tested without AVF.	Students were trained with an audiovisual feedback (AVF) device and tested with AVF.	An audiovisual feedback device is more effective during the cardiac arrest event than during the training.
Kim et al. (2020)	Students were trained without a visual feedback device and were assessed on CPR metrics.	A visual feedback device was introduced for training.	The visual feedback increased adequate chest compression depth and full chest recoil.
Kim et al. (2023)	Students watched videos and a slideshow before the class then practiced CPR on a manikin with instructor feedback during the class.	Students practiced CPR on a manikin with feedback from an instructor and a VR tool during the class.	Students in the VR group had statistically significantly better CPR knowledge, compression depth, rate, chest recoil, and AED usage than the flipped classroom group.
Ko et al. (2021)	Students watched a 27-minute long video on CPR then practiced hands-on skills on a manikin with instructor feedback.	Students watched a 27-minute long video on CPR then practiced hands-on skills on a manikin with feedback only from the manikin.	Students in both groups performed comparably on the knowledge test and on compression skills. Students in the intervention group performed significantly worse at checking for scene safety and calling for help.
Kong et al. (2020)	Students received judgement-based instructor feedback.	Students received objective QCPR instructor feedback.	Objective metric measurement for CPR instructor consideration improved CPR training outcomes.
Lee et al. (2023)	Students were given conventional face-to-face training.	Students were training with a distance learning program that involved a smart phone app for feedback and manikin delivery.	The training program outcome was comparable in both groups. Distance learning had higher user satisfaction.
Lin et al. (2021)	Students were trained via a traditional face-to-face method.	Students were trained via synchronous online training with audiovisual feedback.	Both training groups had similar skill acquisition and training capability.
Liu et al. (2021)	Students took a CPR training with either 2D videos or VR-based training without any supplemental information.	Students received supplemental information prior to their training, and then took a CPR training with either 2D videos or VR-based training.	Students in the VR group who received the pre-training intervention had a higher skill transfer level than those who didn't. Students in the video group who received the pre-training intervention had a lower skill transfer level than those who didn't. There were no significant differences in study outcomes based on the levels of immersion (video vs. VR).
Liu et al. (2022)	Students received brief instruction on child CPR, watched a recording of a CPR professional go through a CPR scenario, and then practiced chest compressions on a table.	Students received brief instruction on child CPR and then participated in a CPR scenario with the VR software, using VR controllers to perform compressions on the floor.	A significantly greater increase in self-efficacy and CPR knowledge was seen with the immersive VR group than the video group.
Marcus et al. (2022)	Students received a 4-hour long CPR class based on the AHA 2015 BLS course.	Students received a self-guided 30-minute video with CPR information and guided practice, and were allowed to repeat the video up to 4 times.	Students in the video group were less likely to check for patient responsiveness, place their hands at the correct point during compressions, and provide compressions at the correct rate than the control. Participants reported similar self-efficacy for CPR across both groups.
Misztal-Okońska et al. (2021)	Students were trained with traditional instructor feedback and basic mannikin feedback.	Students were trained on manikins with detailed objective feedback.	Students stated that the detailed feedback made them feel more motivated to learn and judged fairly.
Nakagawa et al. (2021)	Students received a 120-minute CPR class using an intermediate-fidelity manikin.	Students received a 40-minute CPR class using a low-fidelity manikin.	In the 40-minute low-fidelity manikin class, 89% of students achieved appropriate compression rate, depth, and recoil, comparable to the longer, high-fidelity manikin class.
Nas et al. (2020)	Students received a 20-minute face-to-face training with an instructor and practiced with a certified CPR manikin.	Students participated in a 20-minute VR CPR scenario with goggles and headphones, and practiced chest compressions on a pillow.	VR training resulted in noninferior chest compression rate, although compression depth was inferior, when compared to face-to-face training. However, VR training yielded a higher proportion of compressions with full release.
Nas et al. (2021)	Post hoc analysis was conducted on the results of students who participated in a 20-minute face-to-face training session using a certified CPR manikin, following novel guidelines for optimal CPR.	Post hoc analysis was conducted on the results of students who participated in a 20-minute VR CPR scenario with goggles and headphones, and practiced chest compressions on a pillow, following novel guidelines for optimal CPR.	In accordance with the new criteria for optimal chest compression depth and rate, 52% of the VR training group met the standard (previously 23%) and 28% of the face-to-face training group met the standard (previously 49%).
Nas et al. (2022)	Students took a 6-month post-training survey after participating in a 20-minute face-to-face training using a certified CPR manikin.	Students took a 6-month post-training survey after participating in a 20-minute VR CPR scenario with goggles and headphones, and practiced chest compressions on a pillow.	Fewer students who trained with VR were willing to perform CPR; however, theoretical CPR knowledge retention was equal in both groups.
Nehra et al. (2024)	Students were trained on a traditional CPR manikin.	Students were trained on a low-cost CPR pillow.	The low-cost CPR pillow was comparable for all training metrics.
Peixoto-Pino et al. (2024)	Students were trained on a traditional, commercial CPR manikin.	Students made and trained on low-cost CPR manikins with visual feedback.	Both training groups had similar skill acquisition in the metrics of high-quality CPR.
Rabanales-Sotos et al. (2022)	N/A	Students were trained on a low-cost, feedback manikin.	CPR outcome measurement revealed adequate training outcomes utilizing this device.
Ruibal-Lista et al. (2021)	Students received instructor feedback after each training session.	Students received automated feedback from their mannikin.	Short CPR training sessions are effective for retaining skills in the short term with instructor or automated feedback.
Sahu et al. (2023)	Students received instructor feedback.	Students received automated feedback from their mannikin.	Visual feedback improved CPR training outcomes.
Schauwinhold et al. (2022)	Students were given traditional instructor feedback.	Students received tele-instructor peer-feedback.	Tele-instructor peer-feedback was not inferior to traditional instructor feedback.
Semeraro et al. (2024)	Students took a pre-course questionnaire to evaluate knowledge and attitude, and collect demographic information.	Students underwent a three-to-four-hour blended CPR course involving theoretical, practical, and VR components, and then were tasked with a post-training homework assignment. Students then took a post-training questionnaire to evaluate knowledge and attitude.	The Implementation of blended learning with VR technology significantly increased the students' knowledge about CPR and their attitudes towards acting in out-of-hospital cardiac arrests.
Sopka et al. (2021)	Students were trained with traditional instructor feedback.	Peer video feedback was used.	Peer video feedback intervention was non-inferior for training outcomes.
Strada et al. (2021)	An instructor demonstrated CPR skills and provided feedback to the students	Students used an AR tool to self-teach and receive feedback on CPR skills.	The AR technology was able to provide a reliable assessment of the trainees' performance. There were no statistically significant difference in examiner's scores between the control and AR group.
Sungur et al. (2024)	Students received a live presentation from a live trainer, followed by a guided practice with verbal feedback from the instructor and visual feedback from a Bluetooth device, and then concluded with an unguided practice.	After becoming acquainted with the MR device, students watched a prerecorded holographic lesson, followed by an MR guided practice where there was a holographic overlay on a physical manikin, and then ended with an unguided practice.	Mixed reality and traditional training had comparable results in terms of chest compression rate and perceived presence; however, those who trained with the mixed reality outperformed the control group in terms of compression depth and perceived the training as more enjoyable.
Tanaka et al. (2020)	Students were instructed by a trained CPR instructor with practice-while-watching training and feedback.	Students were taught by an untrained CPR instructor with practice-while-watching training and feedback.	Students had improved cognitive understanding of CPR administration with the untrained CPR instructor and PWW.
Xu et al. (2020)	Participants received BLS CPR training, then sent home with a pamphlet about CPR skills and a placebo DVD about coronary disease prevention.	Participants received BLS CPR training, then sent home with a pamphlet about CPR skills and a DVD about CPR. Some participants were called on the telephone and reminded to review the materials. Others were called and specifically instructed to practice CPR with the DVD using a human-shaped pillow.	Both intervention groups performed significantly better than the control in both CPR knowledge and skills. The group that was instructed to practice performed significantly better than those not instructed to practice, but had no difference in CPR knowledge retention.
Yang et al. (2020)	Before intervention, students completed pretest questionnaires and performed CPR simulation on a force-sensitive model.	Students from the control group performed a CPR simulation using a VR-based system, which was used for evaluation. Students then completed a posttest questionnaire.	VR-based training improved CPR learning outcomes for 85% of participants, and most participants were satisfied with the VR CPR learning system used.
Yang et al. (2023)	Students received a standard blended CPR training, with videos and instructors.	Students received a higher instructor to student ratio, braille materials, descriptive video services, and follow up instruction two weeks later.	The intervention group had better retention of CPR skills, such as compression rate, depth, and recoil, after one month.
You et al. (2022)	Students received an initial BLS provider course, then a text message reminder every 3-months with a summary of BLS skills.	In addition to the initial provider course and text messages, students received a 1-minute-long video every three months with a summary of BLS skills.	Students in the video group were significantly better at checking for responsiveness, AED usage, and had better compression rate, depth, and recoil than the control.
Zhou et al. (2020)	Students performed repetition of CPR training.	Students performed repetition of CPR training with audiovisual feedback (AVF).	AVF improved short-term retention of skills but did not significantly improve long term training.

Extended reality

We reviewed 20 studies that investigated the role of extended reality (XR) in CPR training, with each study analyzing varying levels of immersion through different forms of XR. XR, an umbrella term for the varying technologies able to alter the perception of reality, can broadly include virtual reality (VR), augmented reality (AR), and mixed reality (MR). These technologies have the potential to shape the future of medical training by making training simulations more immersive and realistic. Fifteen of the studies used VR, which involved creating artificial environments that trainees could be fully immersed in and interact with digital elements using hand controls and sensors.12, 14, 15, 16, 20, 21, 23, 24, 25, 26, 28, 29, 31, 52 These simulations were primarily in the form of games made to encourage learning in an interactive way. Three studies using AR focused on enhancing the physical world with digital information or visuals, such as overlaying a realistic torso or full body onto a standard CPR manikin to increase visual realism while maintaining the somatosensory experience of providing chest compressions on the manikins13, 17, 22. Finally, the two MR studies enabled participants to interact with and manipulate both the digital and physical.27, 30

Audiovisual feedback, distance, and asynchronous learning

We reviewed 11 studies that examined feedback devices, both in traditional in-person classes and as a replacement for instructors.32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42 Ten studies investigated videos as a tool to asynchronously teach CPR.43, 44, 45, 46, 47, 48, 49, 50, 51, 52 Two of these studies focused on using videos to replace follow-up CPR classes,45, 51 and one study used a video as a short Just-In Time (JIT) training.⁴⁴ Five studies incorporated video instruction into in-person classes to demonstrate skills or provide feedback.33, 43, 46, 47, 52 One of these studies created videos with descriptions specifically tailored for visually impaired students.⁵² Four studies examined tele-education, either through blended classes, where part of the class was online and part was virtual, or through fully virtual classes.53, 54, 56, 57

Low-fidelity manikins

Of the studies reviewed, four studies tested a low-fidelity manikin in a layperson CPR class. Three of these studies developed their own low-cost manikins,58, 60, 61 while the third compared existing commercial high-fidelity and low-fidelity manikins.⁵⁹ The three manikins built for the study all incorporated real-time feedback. To make training equipment more accessible, one study used a disposable water bottle to provide audio feedback and additional resistance to compression,⁶¹ and another used a small plastic bladder that emitted a sound when compressed.⁶⁰ On the other hand, one study focused on showing the physiological response of compressions by using a simulated circulatory system of tubes where the user could see blood pumping as they compressed the chest.⁵⁸ Two of these manikin studies were focused on school children and emphasized the value of school children building manikins to learn about anatomy.58, 59

Discussion

The purpose of this scoping review was to lay out emerging technologies in CPR education. We observed two main directions of the studies: technologies that increased the fidelity of CPR training and others that could make classes more accessible.

Some technological innovations would require increased commercial availability and usability of the technology before they lead to improvements in accessibility. Still, the improvements in fidelity increase the efficacy of CPR education. Because the emergency setting of an OHCA is unfamiliar to most layperson CPR trainees, high-fidelity virtual reality simulations can be a valuable tool for immersing students in a realistic environment, making them better prepared to act should a real emergency occur.

With regard to the quality of CPR provided, the majority of studies found that XR training was an acceptable alternative to standard training, with seven studies having reported comparable outcomes between the control group and XR groups.12, 13, 16, 17, 20, 25, 27 Five of the studies even reported better outcomes in the XR groups.14, 23, 28, 29, 30 Two studies with a pretest–posttest design found improved learning outcomes when participants underwent VR-based training; however, since improvement is expected with any training and these studies do not include a control, they do not provide insight into how outcomes compare with standard training.26, 31 One study demonstrated an increase in the biochemical stress marker salivary alpha-amylase in trainees who underwent VR CPR training, suggesting the use of XR can induce the psycho-physiological responses of an actual emergency.²⁸ Beyond the psychomotor skills, XR trainees reported greater self-confidence, attitude, and willingness to perform CPR than traditional trainees.14, 19 Users in an AR study reported that the AR system was easy to use, comfortable, and overall acceptable for self-instructed CPR training.²² These findings are in line with previous scoping⁶² and systematic63, 64, 65 reviews, notably including a recent systematic review by the International Liaison Committee on Resuscitation (ILCOR),⁶⁶ which have suggested that XR is not an inferior form of training compared to traditional simulation methods.

Still, participants reported some complaints about XR classes, such as the equipment being uncomfortable to perform compressions with, or the repetition of information in the XR simulations being boring.12, 13 Two other studies showed that the XR group had a significantly worse CPR skill outcome, either in chest compression depth or time to initiate CPR.18, 24 Although this may have been specific to the software or equipment used, it underscores a more general concern that trainees experience the added cognitive load from becoming acquainted with the XR technology, in addition to learning the CPR skills. In a post hoc analysis of one of the studies that originally reported inferior chest compression depth with trainees who used VR found that the percent of trainees who met an updated criteria for optimal compression rate and depth was greater in the VR group than in the standard training group.²¹ XR technology is in its early stages and further studies should refine the equipment and curriculum.

Though XR equipment is currently a financial investment, it could still increase the accessibility of CPR classes. During the social distancing restrictions of the COVID-19 pandemic, it could have provided a convenient way to train lay people in CPR. As XR technology becomes increasingly commercially available, it could become a cost-effective way to deliver high-quality CPR education in people’s homes.

Many of the studies centered around questions of the value of in-person education and instructors. We believe that the COVID-19 pandemic motivated many of these questions, as the risk of infection pushed many forms of education to be virtual. Of the three studies that assessed fully virtual CPR training with synchronous instructors, all three showed students’ skills after the class to be non-inferior to traditional in-person classes, with CPR skills such as compression rate and depth equivalence between the groups.53, 54, 57 These synchronous and virtual CPR training options offer an alternative to traditional CPR training without compromising the metrics of high-quality CPR.

Other studies assessed how an in-person instructor could be replaced, which would allow CPR classes to be accessible in places without a developed instructor cadre. In both studies that assessed “Practice-While-Watching,” a teaching method where videos and didactic training are paired, the students had at least equivalent CPR skills as the control group, without the need for a trained instructor.36, 50 Group instruction, where the CPR students used videos to learn and provide feedback to each other, was also shown to be non-inferior in two studies.33, 46 Even fully asynchronous video instruction was sufficient in follow-up training for long-term CPR understanding. This training method reduces the need for multiple follow-up classes.45, 51 However, students in one study that used short just-in-time videos performed worse in a CPR simulation regarding AED-request rates and chest compression fraction, yet showed similar CPR knowledge in a quiz.⁴⁴ These different methods could offer solutions for areas with decreased instructor resources and an avenue for more available training.

One of the primary concerns about virtual CPR classes is that students would not have access to a CPR manikin because manikins are one of the most expensive pieces of CPR education equipment. In 2019, the American Heart Association mandated the use of a directive feedback device, either audio, visual, or both, in all of its adult CPR classes.⁶⁷ Real-time feedback manikins have repeatedly been shown to increase student CPR skills and knowledge retention, an effect that is described in several prominent reviews.68, 69, 70 Even manikin feedback alone, without an instructor, has been suggested not to be an inferior training method to traditional in-person instruction.⁴³ However, high-fidelity feedback manikins are more expensive than their low-fidelity counterparts, making them less accessible. In two of the four studies on low-cost manikins that we reviewed, students who trained on low-cost manikins showed no significant difference in CPR quality compared to those who trained with traditional manikins.58, 61 These studies used simple but effective ways to incorporate feedback, such as the crunching of a water bottle embedded in the manikin’s chest. Some of these manikins are both financially cheaper and allow students to aid in the process of their creation, creating additional pedagogical opportunities, especially for the school-aged audience. So, instructing students to purchase a more frugal manikin or construct their own may help to enhance future virtual education and classes in low-income environments, a possibility that reinforces the need for additional high-quality studies on student-created CPR training devices to validate their efficacy.⁷¹

We have outlined the various categories of innovations; however, multiple studies utilized different interventions synchronously. A common one was the combination of XR training and feedback.13, 29 XR was also used in combination with low-cost compression apparatuses to create more available training without losing quality.18, 20, 21 Though feedback is often associated with high-fidelity, high-cost manikins, the low-cost methods of integrating audio or visual feedback are emerging in low-cost manikins.58, 60 Further investigations into the specific benefits of combining these technologies may likely provide important insights into how CPR curricula can be tailored to different learning settings.

Limitations

Across all of the technologies, the reviewed studies primarily involved relatively young participants, with many classes targeting undergraduate students or school children. This population is not representative of the typical scenario of at-home cardiac arrests, which represent 73.4% of all cardiac arrests, where older adults are more likely to be witnesses.⁷² Additionally, younger individuals often have more prior experience with new technologies, such as video conferencing and XR, which could lead to more favorable responses to new technologies.

We have included no assessment of the quality of the results, nor can we draw statistical conclusions from this initial review. Further research should include systematic reviews and meta-analyses of how these technologies may differ in efficacy across different learning settings and/or student populations. Some studies excluded from the review, such as abstracts or non-English publications, may have held more relevant information that was not included in this review. Additionally, the search procedure would not have reached studies not indexed in the selected databases, meaning some relevant studies may have been excluded.

Conclusion

This scoping review has explored several distinct fields of emerging technology in CPR education. Some seek to increase the accessibility of CPR education by making manikins more affordable or lowering the barrier to accessing CPR information, while others seek to increase the fidelity of CPR training with increasingly immersive extended reality systems. As more studies emerge, future work should include tradespace analyses of these technological interventions to determine what combination could maximize the breadth and depth of CPR training in the population and inform guidance for CPR instructors and training centers.

CRediT authorship contribution statement

Abigail E. Schipper: Visualization, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Charles S.M. Sloane: Writing – original draft, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Lydia B. Shimelis: Writing – original draft, Visualization, Formal analysis, Conceptualization. Ryan T. Kim: Writing – review & editing, Methodology, Formal analysis.

Funding

This research is funded as part of the Massachusetts Institute of Technology Eloranta Research Fellowship.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: “Abigail Schipper reports a relationship with Massachusetts Institute of Technology Heartsafe Program that includes: employment. Charles Sloane reports a relationship with Massachusetts Institute of Technology Heartsafe Program that includes: employment. Lydia Shimelis reports a relationship with Harvard CrimsonEMS CPR Education that includes: funding grants. Ryan Kim reports a relationship with Harvard CrimsonEMS CPR Education that includes: funding grants. Abigail Schipper reports a relationship with Massachusetts Institute of Technology IDEAS Social Innovation Challenge that includes: funding grants. Charles Sloane reports a relationship with Massachusetts Institute of Technology IDEAS Social Innovation Challenge that includes: funding grants. Abigail Schipper reports a relationship with Massachusetts Institute of Technology Eloranta Fellowship that includes: funding grants. Charles Sloane reports a relationship with Massachusetts Institute of Technology Eloranta Fellowship that includes: funding grants. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.”

Glossary

Asynchronous Learning

Learning where the student is not working in real-time with an instructor.

Augmented Reality (AR)

Technology that overlays digital information onto the real world.

Bystander CPR

CPR performed by someone before emergency medical services arrive.

Crossover Study

A study in which participants receive different treatments at different times.

Extended Reality (XR)

An umbrella term encompassing technologies that alter the perception of reality, including augmented reality, mixed reality, virtual reality.

Feedback Device

A tool that provides real-time information on the quality of CPR performance, using various metrics such as compression depth and rate.

Just-In-Time (JIT) Training

Training modules, usually short in length, that teach a skill right before someone needs to perform it.

Layperson

An individual who is not a medical professional.

Low-Fidelity Manikin

A simplified CPR manikin that may lack some features of high-fidelity manikins, such as realistic anatomy or advanced feedback mechanisms.

Mixed Reality (MR)

Technology that combines elements of VR and AR.

Quasi-Experimental

A research design that resembles an experiment but lacks random assignment of participants to groups.

Randomized Controlled Trial (RCT)

A type of clinical trial that randomly assigns participants to different groups to compare the effectiveness of an intervention.

Tele-education

The use of technology to deliver education remotely, such as online courses or video conferencing.

Virtual Reality (VR)

Technology that creates an artificial environment that users can interact with.

Appendix A. Supplementary material

The following are the Supplementary material to this article: