A pragmatic randomized trial of cardiopulmonary resuscitation training for families of cardiac patients before hospital discharge using a mobile application.

AIM OF THE STUDY: Since over 80% of sudden cardiac arrests occur in the home, cardiopulmonary resuscitation (CPR) training for family members of high-risk cardiac patients represents a promising intervention. The use of mobile application-based (mApp) CPR training may facilitate this approach, but evidence regarding its efficacy is lacking. METHODS: We conducted a multicenter, pragmatic, cluster-randomized trial assessing CPR training for family members of cardiac patients. The interventions were mApp (video, no manikin) and VSI (video + manikin). CPR skills were evaluated 6-months post-training. We hypothesized that chest compression (CC) rate from training with an mApp would be no worse than 5 compressions per minute (CPM) lower compared to VSI. RESULTS: From 01/2016 to 01/2018, we enrolled 1325 eligible participants (mean age 51.6 years, 68.2% female and 59.4% white). CPR skills were evaluated 6-months post-training in 541 participants (275 VSI, 266 mApp). Mean rate was 84.6 CPM (95% CI: 80.4, 88.6) in VSI, compared to 82.7 CPM (95% CI: 76.2, 89.1) in the mApp, and mean depth was 42.1 mm (95% CI: 40.3, 43.8) in VSI, compared to 38.9 mm (95% CI: 36.2, 41.6) in the mApp. After adjustment, the mean difference in CC rate was -2.3 CPM (95% CI -9.4, 4.8, p = 0.25, non-inferiority) and CC depth was -3.2 mm (95% CI -5.9, 0.1, p = 0.056). CONCLUSION: In this large prospective trial of CPR skill retention for family members of cardiac patients, mApp training was associated with lower CC quality. Future work is required to understand additional approaches to improve CPR skill retention. CLINICAL TRIAL REGISTRATION: URL: ClinicalTrials.gov, Identifier: NCT02548793.

A Pilot Study of CPR Quality Comparing an Augmented Reality Application vs. a Standard Audio-Visual Feedback Manikin.

Background: Guidelines-based cardiopulmonary resuscitation (CPR) during in-hospital cardiac arrest is a significant predictor of survival, yet the quality of healthcare provider (HCP) CPR (e.g., nurses, physicians etc.) has been shown to be poor. Studies have found that providing HCPs with simulated CPR refresher trainings can improve their CPR quality, however, no studies have compared the use of an augmented reality (AR) CPR refresher training with a standard audio-visual (AV) feedback manikin to improve HCP training. Objectives: In our pilot study, HCPs were randomized to a refresher CPR simulation training with either our AR CPR training application (CPReality) or a standard AV feedback manikin. All subjects completed 2 min of CPR on their respective CPR training modalities, followed by an additional 2 min post-simulation CPR evaluation with no feedback. We hypothesized that the AR CPR training application would confer improved CPR quality defined as chest compression rate and depth compared with the standard AV feedback training. Results: Between January 2019 and May 2019, 100 HCPs were enrolled (50 in the CPReality cohort and 50 in the standard AV manikin cohort). The mean chest compression (CC) rate for all subjects during the intervention was 118 ± 15 cpm, and CC depth was 50 ± 8; post-intervention the CC rate was 120 ± 13 and CC depth was 51 ± 8. The mean CC rate for those trained with CPReality was 121 ± 3 compared with the standard CPR manikin training which was 114 ± 1 cpm (p < 0.006); CC depth was 48 ± 1 mm vs. 52 ± 1 (p = 0.007), respectively. Post-simulation CPR quality with no feedback showed a mean CC rate for the CPReality application at 122 ± 15 cpm compared with the standard CPR manikin at 117 ± 11 cpm (p = 0.09); depth was 49 ± 8 mm vs. 52 ± 8 (p = 0.095), respectively. In the post-survey, 79% of CPReality subjects agreed that the AR application provided a realistic patient presence compared with 59% (p = 0.07) of subjects in the standard CPR manikin cohort. Conclusions: In a randomized trial of an AR CPR training application compared with a standard CPR manikin training, the AR CPR application did not improve the quality of CPR performed during a CPR refresher training compared with the standard training in HCPs. Future studies should investigate the use of this and other digital technologies for CPR training and education.

Feasibility of an augmented reality cardiopulmonary resuscitation training system for health care providers.

AIM OF THE STUDY: Augmented reality (AR) has the potential to offer a novel approach to CPR training that supplements conventional training methods with gamification and a more interactive learning experience. This is done through computer-generated imagery superimposed on users' view of the real environment to simulate interactive training scenarios. We sought to test the feasibility of an AR CPR training system (CPReality) for health care providers (HCPs). METHODS: In this feasibility trial, a CPR training manikin was integrated with a commercial AR device (Microsoft HoloLens) to provide participants with real-time audio-visual feedback via a holographic overlay of blood flow to vital organs dependent on CC quality. In this system, higher quality CC visually improved virtual blood circulation. HCPs performed a 2-minute cycle of hands-only CPR using only the AR system, and CC parameters were recorded. Descriptive data on participants' demographics, CC quality, and satisfaction with the training environment were reported using quantitative and qualitative analysis. RESULTS: Between 10/2018-11/2018, we enrolled a convenience sample of 51 HCPs. The median age of participants was 31 years (IQR 27-41), 71% (36/51) were female, and 67% (34/51) were registered nurses. CC rates (mean 126 ± 12.9 cpm), depths (median 53 mm, IQR 46-58), and percent with complete recoil (median 80%, IQR 12-100) were consistent with guideline recommendations for good quality CPR. Participants were predominantly satisfied with the system, with 82% perceiving the experience as realistic, 98% recognizing the visualizations as helpful for training, and 94% willing to use the application in future CPR training. CONCLUSIONS: As AR is increasingly applied in the healthcare setting, integration in CPR training offers a novel and promising educational approach. In this convenience sample of trained HCPs, high quality CC delivery was feasible using the AR CPR training system which was received favorably by most participants.

Association of state-level CPR training initiatives with layperson CPR knowledge in the United States.

STUDY AIM: Recent work has demonstrated low rates of layperson CPR training across the US. In an attempt to increase rates, some states passed legislation that requires CPR training before high school graduation. We hypothesized laypeople in states with required training would exhibit a greater likelihood of being currently trained in CPR when compared with laypeople in states without required CPR training. METHODS: We used a previously conducted nationwide cross-sectional random-digit dial survey of the US adult population (09/2015-11/2015). Survey weighted descriptive statistics and logistic regression were used to assess the primary association of likelihood of CPR training and required CPR training by graduation. RESULTS: Of the 9022 participants, 677 healthcare workers were excluded. Among those living in states with required training, 17% of laypersons were currently trained, while 14% of laypersons in states without required training were currently trained (p < 0.01). Amongst younger individuals (18-24), 29% were currently trained in states with required CPR training compared with 19% currently trained in states without required training (p < 0.01). Those in required training states were 34% more likely to be currently trained than individuals in states without required training (OR: 1.34, 95%CI: 1.20-1.50, p < 0.01). In a secondary analysis, younger laypersons in required training states were almost two times more likely to be currently trained (OR: 1.81, 95% CI: 1.18-2.78, p = 0.01). CONCLUSIONS: Individuals were more likely to be currently trained in CPR in states with mandatory CPR training for high school graduation, suggesting a need for additional research on this public policy.

Comparing bystander response to a sudden cardiac arrest using a virtual reality CPR training mobile app versus a standard CPR training mobile app.

BACKGROUND: Using a mobile virtual reality (VR) platform to heighten realism for cardiopulmonary resuscitation (CPR) training has the potential to improve bystander response. OBJECTIVES: We examined whether using a VR mobile application (mApp) for CPR training would improve bystander response compared with a standard mApp CPR training. METHODS: We randomized lay bystanders to either our intervention arm (VR mApp) or our control arm (mApp). During a post-intervention skills test, we collected bystander response data (call 911, perform CPR, ask for an automated external defibrillator (AED)), along with CPR quality (chest compression (CC) rate and depth). Wilcox rank sum was used to analyze CC rate and CC depth as they were not normally distributed; Pearson's Chi-square was used to analyze Chain of Survival variables. RESULTS: Between 3/2018 and 9/2018, 105 subjects were enrolled: 52 VR mApp and 53 mApp. Mean age was 46 ± 16 years, 34% were female, 59% were Black, and 17% were currently CPR trained (≤2 years). Bystander response was significantly higher in the VR mApp arm: called 911 (82% vs 58%, p = 0.007) and asked for an AED (57% vs 28%, p = 0.003). However there was no difference in CPR performed (98% vs 98%, p = NS) and the application of the AED (90% vs 93%, p = NS). When comparing the VR mApp to the mApp, mean CC rate was 104 ± 42 cpm vs 112 ± 30 cpm (p = NS), and mean CC depth was 38 ± 15 mm vs 44 ± 13 mm (p = 0.05). CONCLUSION: The use of the VR mApp significantly increased the likelihood of calling 911 and asking for an AED, however, CC depth was decreased.

Gender Disparities Among Adult Recipients of Bystander Cardiopulmonary Resuscitation in the Public.

BACKGROUND: Bystander cardiopulmonary resuscitation (BCPR) improves survival from out-of-hospital cardiac arrest (OHCA), yet BCPR rates remain low. It is unknown whether BCPR delivery disparities exist based on victim gender. We measured BCPR rates by gender in private and public environments, hypothesizing that females would be less likely than males to receive BCPR in public settings, with an associated difference in survival to hospital discharge. METHODS AND RESULTS: We analyzed data from adult, nontraumatic OHCA events within the Resuscitation Outcomes Consortium registry (2011-2015). Using logistic regression, we modeled the likelihood of receiving BCPR by gender, including patient-level variables, stratified by location. A cohort of 19 331 OHCAs was assessed. Mean age was 64±17 years, and 63% (12 225/19 331) were male. Overall, 37% of OHCA victims received bystander CPR. In public locations, 39% (272/694) of females and 45% (1170/2600) of males received BCPR ( P<0.01), whereas in private settings, 35% (2198/6328) of females and 36% (3364/9449) of males received BCPR ( P=NS). Among public OHCAs, males had significantly increased odds of receiving BCPR compared with females (odds ratio, 1.27; 95% CI, 1.05-1.53; P=0.01); this was not the case in the private setting (odds ratio, 0.93; 95% CI, 0.87-1.01; P=NS). Controlling for site, age, and race, BCPR was significantly associated with survival to hospital discharge (odds ratio, 1.69; 95% CI, 1.54-1.85; P<0.01); in this model, males had 29% increased odds of survival compared with females (odds ratio, 1.29; 95% CI, 1.17-1.42; P<0.01). CONCLUSIONS: Males had an increased likelihood of receiving BCPR compared with females in public. BCPR improved survival to discharge, with greater survival among males compared with females.

Association of race and socioeconomic status with automatic external defibrillator training prevalence in the United States.

AIM OF THE STUDY: Automated external defibrillators (AEDs) improve survival from out-of-hospital cardiac arrest (OHCA), however bystander use remains low. Limited AED training may contribute to infrequent use of these devices, yet no studies have assessed AED training nationally. Given previously documented racial disparities among Latinos in CPR provision and OHCA outcomes, we hypothesized that racial and socioeconomic differences exist in AED training, with Whites having increased training compared to Latinos and higher socioeconomic status being associated with increased training. METHODS: We administered a random digit dial survey to a nationally-representative adult sample. Using survey-weighted logistic regression adjusted for location, we assessed race and socioeconomic status of individuals trained in AEDs compared to never-trained individuals. RESULTS: From 09/2015-11/2015, 9022 individuals completed the survey. Of those, 68% had never been AED trained. Self-identified Whites and Blacks were more likely to have AED training compared to Latinos (OR: 1.90, 95% CI: 1.43-2.53 and OR: 1.73, 95% CI: 1.39-2.15, respectively). Higher educational attainment was associated with an increased likelihood of training, with an OR of 4.36 (95% CI: 2.57-7.40) for graduate school compared to less than high school education. Increased household income was not associated with an increase in AED training (p = .08). CONCLUSIONS: The minority of respondents reported AED training. Whites and Blacks were more likely to be trained than Latinos. Higher educational attainment was associated with an increased likelihood of training. These findings highlight an important opportunity to improve training disparities and layperson response to OHCA.

Characterizing barriers to CPR training attainment using Twitter.

STUDY AIM: Recent investigations have suggested that CPR training rates are low within the U.S and barriers to CPR training are poorly understood. Social media holds great potential for large scale capture of the public's CPR training experiences and may illuminate barriers to CPR training. While studies have examined Twitter data for behaviors associated with cardiovascular health, no investigation has evaluated Twitter data to understand public perception of CPR training. We characterized Tweet content about CPR training and associated sentiment to better understand barriers associated with CPR training. We hypothesized that negative CPR training impressions would be identifiable as barriers to CPR training attainment. METHODS: We extracted Tweets from 2011 to 2015 originating in Pennsylvania including the keyword CPR (n = 8419). A random subset of 1000 tweets was independently coded by two authors using grounded theory (mean kappa = 0.74). CPR training Tweets were analyzed for subtopic and sentiment ("positive" or "negative"). Descriptive statistics were used; a chi squared test was used to examine differences in positive and negative responses. RESULTS: Of 8419 Tweets, CPR training was the most frequent queried result (16%). Within the coded 1000 subset, 18% referenced a CPR training experience. Upcoming CPR training (22%), CPR training curriculum (17%), job-related training (12%), and duration of training (10%) were the most discussed topics regarding CPR training experiences. Of those, the majority of CPR training experiences were negative (53% vs. 47%, p < 0.01) and barriers to CPR training emerged as the primary source of negative experiences. CONCLUSIONS: CPR training is the most referenced theme in CPR Tweets from Pennsylvania, and tweets were predominately negative, particularly referencing barriers such as time, location, and duration. Social media is useful for tracking barriers to CPR training attainment and future CPR education modalities.