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

Abstract

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

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

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

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

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

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

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

Trial registration: ClinicalTrials.gov identifier: NCT04013633.

Conflict of interest statement

Conflict of Interest Disclosures: Dr van Geuns reports grants from Abbott Vascular, Boston Scientific, and Amgen and personal fees from Abbott Vascular outside the submitted work. Dr van Royen received research grants from Abbott, Biotronik, AstraZeneca, and Philips and professional fees from Abbott, MicroPort, Amgen, and Medtronic. No other disclosures were reported.

Figures

Figure 1.. CONSORT Flow Diagram

CPR indicates cardiopulmonary resuscitation; VR, virtual reality. aAll included participants were able to pass the tandem gait test, if applicable.

Figure 2.. Forest Plots of the Mean Difference in Chest Compression Depth and Rate Between Virtual Reality (VR) and Face-to-Face Training

Forest plots for the mean difference (95% CI) in chest compression depth and rate between virtual reality (VR) and face-to-face training. The prespecified noninferiority margins were −5 mm for depth and −17 min−1 for rate. For depth, the P value for noninferiority was .99. For rate, the P value for noninferiority was <.001. Dashed line indicates noninferioirity margin.

Figure 3.. Boxplots of Chest Compression Depth and Rate in Relation to Guideline Recommendations

Boxplots of chest compression rate and depth. Whiskers are 10th and 90th percentiles. Percentages at the side of each graph indicate the proportion of participants with compression depth or rate that is below, within, or above guideline-endorsed ranges respectively. VR indicates virtual reality.

Figure 4.. Subgroup Analyses for Chest Compression Depth and Rate

Forest plot on prespecified subgroup analyses based on sex, age, weight, education, health care professional, previous cardiopulmonary resuscitation (CPR) training (within 2 years), alcohol level, and drug/substance use. Mean differences in compression depth (A) (millimeters) and compression rate (B) (compressions minute−1) between virtual reality (VR) and face-to-face training, with 95% confidence intervals. The P value for interaction is for testing whether the effect of the intervention on compression depth and rate differs between the subgroups.