Cognitive Aids and Technology

Manikin Fidelity in Resuscitation Education

Last Full Review: ILCOR 2025
Last Update: 2015

High-fidelity manikins have become an important component of life support training, offering healthcare professionals and lay persons a realistic and immersive simulation-based learning experience. Some manikins are designed to replicate human physiology and responses with a high degree of accuracy, enabling learners to engage in hands-on practice within a controlled environment without risk to real patients. A new ILCOR review explores the role, benefits, limitations and current evidence surrounding the use of high-fidelity manikins in basic life support (BLS) and advanced life support (ALS) training, with particular attention to educational outcomes and implementation considerations.

 

Evidence Summary

A 2025 International Liaison Committee on Resuscitation (ILCOR) systematic review and Consensus on Science with Treatment Recommendations (CoSTR) (Donoghue et al. 2024; Greif et al. 2025) sought evidence for the use of high-fidelity manikins compared with low-fidelity manikins on patient outcomes, skill performance in actual resuscitations, skill and knowledge retention, learner outcomes, and cost and resource utilization for participants undertaking basic and advanced life support training in any education setting. An ILCOR systematic review (Cheng et al. 2015, 142) published in 2015 was used, with extraction of data from the 14 studies included in that review. Additional studies published between 2015 and 2024 identified by the literature search were also included in the review. Healthcare providers and/or trainees were participants in all studies.

Meta-analysis of data from eight randomized controlled trials (RCTs) that assessed performance in scenarios with manikins (adults, child and neonate) favored the use of high-fidelity manikins, while a second meta-analysis of data (seven RCTs) did not find a significant effect with use of high-fidelity manikins on knowledge at course completion (Donoghue et al. 2024; Greif et al. 2025, S205).

For other outcomes, meta-analysis of findings was not possible, and results were reported narratively. Findings varied between studies but mostly favored the use of high-fidelity manikins for outcomes of time-to-task completion (EMS activation), time-to-intervention and assessment, improved teamwork behaviors, better cardiopulmonary resuscitation (CPR) parameters such as compression depth and compression fraction, greater improvement in CPR skills, higher reported (subjective) effectiveness of training and improved knowledge retention at 3 months after BLS training and 6 months after pediatric advanced life support (PALS) training (Donoghue et al. 2024; Greif et al. 2025).

A weak recommendation by ILCOR, based on low-certainty evidence, suggests the use of high-fidelity manikins when training centers or organizations have the infrastructure, trained personnel and resources to use them. If high-fidelity manikins are not available, it is suggested that the use of low-fidelity manikins is acceptable for life support training in an educational setting (Donoghue et al. 2024; Greif et al. 2025, S205).

Insights and Implications

The recommendation for the use of high-fidelity mannikins considers the mostly positive benefits identified with their use for life support training and the lack of negative or harmful effects on educational outcomes. The ILCOR CoSTR notes that studies found improved performance in post-training versus pre-training assessment in all groups irrespective of level of manikin fidelity, supporting the recommendation for the use of low-fidelity manikins when high-fidelity manikins are not available (Donoghue et al. 2024; Greif et al. 2025,S205).

This review did not address cost effectiveness and implementation needs for high-fidelity manikin use in training, and it is unclear if the benefits shown translate to clinical care and patient outcomes. The 2025 Internet cost of a low-fidelity manikin ranges from $100 to $800, while the cost of a high-fidelity manikin for use in BLS courses ranges from $1,000 to $3,000. More advanced models using integrated software and cloud data and providing detailed feedback range from $3,000 to $6,000. High-fidelity manikins for ALS training that are fully featured (e.g., wireless capabilities, airway management, drug administration simulation, electrocardiogram interpretation, physiological changes) can cost $20,000 to over $100,000. The significant cost of high-fidelity manikins and other resources required to operate and maintain this equipment will likely be a limiting factor for smaller training sites.

Cognitive Aids During Resuscitation Education

Last Full Review: ILCOR 2020
Last Update: 2024

Cognitive aids are used extensively in the real-world and training contexts to enhance the effectiveness and quality of resuscitation efforts. They range from simple printed or digital checklists and flowcharts to interactive algorithms and advanced systems integrated into defibrillators. A systematic review by the International Liaison Committee on Resuscitation (ILCOR) in 2020 (Greif et al. 2020, S222) was unable to demonstrate if cognitive aids are effective in improving patient outcomes or provider performance during resuscitation. In addition, there was evidence that there are potentially clinically important delays in lay provider initiation of cardiopulmonary resuscitation (CPR) when using cognitive aids. New evidence published since the 2020 review has led to an updated ILCOR systematic review (Nabecker et al. 2024, 100675) of cognitive aids during simulated resuscitation.

 

Evidence Summary 

An updated systematic review (Nabecker et al. 2024a, 100675) and Consensus on Science with Treatment Recommendations (Nabecker et al. 2023b; Greif et al. 2024) identified and analyzed 29 randomized controlled trials (RCTs) and observational studies that evaluated the use of cognitive aids in resuscitation simulations. Various types of cognitive aids—such as checklists, flowcharts and algorithms—were included in the analysis. 

The outcomes that were measured included:

• Adherence to resuscitation protocols
• Team performance
• Time to critical interventions
• Overall effectiveness of the resuscitation efforts 

 

Studies investigated the effects of cognitive aids for:

• Neonatal, pediatric and adult resuscitation scenarios
• The management of other emergencies, such as hypoglycemic coma
• Lay rescuers providing CPR and using an automated external defibrillator (AED) 

 

Heterogeneity between studies prevented any meta-analysis.

Key findings from the review included improved adherence to resuscitation protocols or processes by teams, and reduced time to perform critical interventions such as defibrillation and medication administration. While different types of cognitive aids, including static aids (e.g., printed checklists) and dynamic aids (e.g., interactive software), were found to be beneficial, the degree of effectiveness varied. 

Mixed findings were reported in studies investigating the effects of cognitive aids used by lay rescuers during simulated resuscitation. Three out of four RCTs reported improved adherence to clinical processes with the use of mobile phone applications (Choa et al. 2009, 680; Hawkes et al. 2015, 1084; Paal et al. 2012, 472). Beneficial outcomes were also reported in RCTs investigating the use of instruction cards (Zhou et al. 2023, 265), a voice-activated visual and auditory-assisted decision device (Hunt et al. 2015, 189) and a flowchart. However, an increase in time to starting chest compressions was reported in two RCTs (Hunt et al. 2015, 189; Rössler et al. 2013, 982), while one RCT reported delays in calling emergency services (Paal et al. 2012, 472).

The additional new studies of cognitive aid use by healthcare professionals provided very low-certainty evidence for a new weak recommendation by ILCOR that suggests the use of cognitive aids by healthcare professionals in resuscitation. Because some simulation studies of cognitive aid use by lay rescuers provided low certainty evidence for delays in starting CPR, a weak recommendation was made against their use when initiating CPR.

The ILCOR systematic review of the use of cognitive aids for resuscitation was appraised in a separate review by the American Red Cross Scientific Advisory Council (American Red Cross Scientific Advisory Council 2024a). While no critical areas of weakness were identified in the review using the Assessment of Multiple Systematic Reviews-2 (AMSTAR-2) criteria (Shea et al. 2017, 358), the American Red Cross Scientific Advisory Council reviewers identified other concerns in the evidence-to-decision process related to the use of cognitive aids by lay providers in resuscitation. Delays in starting CPR and activating emergency response compared with control groups were recognized: 

• Hunt et al. (Hunt et al. 2015, 189)​ identified a delay to first compression of 81 seconds when compared with a control group.
• Paal et al. (Paal et al. 2012, 472)​ similarly found a delay in starting compressions of 78 seconds and a delay in calling emergency services of 59 seconds. 
• Rössler et al. (Rössler et al. 2013, 982)​ captured this delay at 27 seconds.

 

However, these findings do not consider other factors in bystander action, including the inherent delays in dispatcher-assisted/telecommunicator CPR (DA-CPR/TCPR) that follows a guideline or goal of initiating firm compressions in less than 150 seconds, as well as the limited availability of DA-CPR/TCPR—with just over half of Public Safety Answering Points providing guidance to callers. Despite factors associated with these identified delays, research did find improvements in CPR performance while using cognitive aids that may have a greater impact on survivability:

• Hunt et al. (Hunt et al. 2015, 189)​ noted responders using cognitive aids were more likely to apply appropriate compression-to-ventilation ratios (94% versus 27%), as well as similar CPR fraction (0.72 versus 0.75) despite an 80 second delay in starting CPR in a 5-minute study.
• Paal et al. (Paal et al. 2012, 472) looked at a composite of actions and found that cognitive aids improved:  
  • Checking (64% versus 27%) and protecting themselves (70% versus 39%) from risk
  • Calling for more for help (56% versus 27%)
  • Opening the airway (78% versus 16%)
  • Providing the correct rate of chest compressions (44% versus 14%)
• Rössler et al. (Rössler et al. 2013, 982)​ found similar improved performance in key actions when using a cognitive aid including:
  • Checking the patient (88% versus 17%)
  • Shouting for help (93% versus 0%)
  • Opening the airway (81% versus 22%)
  • Checking breathing (74% versus 37%) 
  • Making an emergency call and getting an AED (92% versus 5%)

 

For lay responders initiating CPR, while there were delays in initiating CPR and activating emergency response when cognitive aids were used, this was balanced by lay responders’ improved performance in several key CPR measures. Despite the potential delays from using aids, this aligns with the response goals of providing CPR instructions over the phone via DA-CPR/TCPR, as well as the Red Cross’s mantra of CHECK–CALL–CARE. Because there is a lack of universal availability of DA-CPR/TCPR in the United States, the use of cognitive aids is seen by the American Red Cross Scientific Advisory Council (American Red Cross Scientific Advisory Council 2024a) as an augmenting element for areas without this service. In further discussion, it was surmised that cognitive aids or phone applications could increase the likelihood of bystanders initiating CPR by reducing hesitation, increasing confidence and/or by activating local mobile phone dispatch systems (an alternate access point to DA-CPR/TCPR). 

Finally, it was noted that cognitive aids are already used in established layperson rescue processes and devices in the public domain, such as AEDs. Many AEDs come with built-in audio and visual instructions that guide users through the process of CPR and defibrillation. Given that the goal is to have bystanders respond to a cardiac emergency, it is imperative to reduce their anxiety and hesitancy to act and use all available tools to encourage quick responses. Prohibition of cognitive aid use may do more harm by impeding actions if a layperson does not have current training or the CPR process committed to memory.

The American Red Cross Scientific Advisory Council (American Red Cross Scientific Advisory Council 2024) recommendation for the use of cognitive aids by laypersons is designated as conditional, or intended for situations where a layperson does not have access to DA-CPR/TCPR instructions, is untrained or has not committed the process to memory, and with the caveat that any delay is to be minimized as much as possible.

Insights and Implications 

Cognitive aids are a valuable tool in studies of simulated resuscitation with enhanced protocol adherence, team performance and timeliness of critical interventions. Further research is recommended to evaluate the effectiveness of cognitive aids in real-world clinical settings and to explore the impact of different types of aids on resuscitation outcomes. For untrained bystanders and those with difficulty remembering CPR processes, the use of cognitive aids may be considered, particularly in regions where DA-CPR/TCPR is not available. Efforts should be made to limit any delay in starting CPR.

 

Scripted Debriefing in Resuscitation Training

Last Full Review: ILCOR 2024

Data-driven, performance-focused debriefing of rescuers after in-hospital and out-of-hospital adult and pediatric cardiac arrest is recommended to improve performance during resuscitation. Current Red Cross guidelines recommend that debriefing should be performed after resuscitation of adults, children and infants. The debriefing should be focused on performance improvement and at a minimum should include:

• Review of the resuscitation etiology, assessment and interventions
• Reinforcement of correct assessment, decisions, actions and communication
• Discussion of areas for improvement and with whom to communicate these
• Allowing all participants in the resuscitation to participate and have an opportunity to provide input

 

For debriefing during resuscitation training, there are different approaches that vary by institution or organization. Debriefing during simulation-based training can potentially improve a provider’s knowledge, clinical performance and nontechnical skills. Debriefing scripts and tools are one approach to standardizing debriefing during resuscitation training, and were the subject of a recent International Liaison Committee on Resuscitation (ILCOR) review.

 

Evidence Summary 

A 2023 scoping review (Lin et al. 2024, 100581) by ILCOR (Lin et al. 2023a; Lin et al. 2024, 100581; Greif et al. 2024) sought published studies that evaluated debriefings for healthcare professionals receiving resuscitation training and instructors teaching resuscitation courses. The debriefings included those that used cognitive aids, checklists, scripts or tools. Of the six studies included in the review, none evaluated patient outcomes or care provider performance with actual patients. Half of the studies involved adult resuscitation scenarios, and half were pediatric scenarios. 

A debriefing script, which included a framework, topics for discussion and suggested phrasing, was used in five studies. The person doing the debriefing was trained in the use of the script in three studies; the Promoting Excellence and Reflective Learning in Simulation (PEARLS) tool (Eppich et al. 2015, 106) was used most often. One study (Cheng et al. 2023, 100401) using PEARLS-scripted debriefing for a simulated pediatric resuscitation reported improved cardiopulmonary resuscitation (CPR) quality parameters. A multicenter randomized controlled trial found improved team leadership skills and knowledge acquisition in healthcare providers with the use of scripted debriefing. 

A good practice statement was provided by ILCOR to consider using debriefing scripts to support instructors during debriefing in resuscitation programs because their use may improve learning and performance. In addition, instructors need to ensure they have a complete understanding of how the debriefing script should be used.

Insights and Implications 

Use of a script for debriefing may facilitate the process for the debriefer. However, in this review, only a single study was found that described improved CPR performance, and only a single study reported improved team leader performance and knowledge acquisition. Further research is needed to confirm these findings and to help determine if scripted debriefing impacts clinically relevant patient or process outcomes in actual resuscitations. The Red Cross guideline (good practice statement) is informed by this ILCOR scoping review.

First Responder Engaged by Technology

Last Full Review: ILCOR 2020

A 2020 International Liaison Committee on Resuscitation (ILCOR) systematic review and Consensus on Science with Treatment Recommendations (Greif et al. 2020, S222) evaluated the role of citizens as first responders, defined as all individuals who were engaged/notified by a smartphone’s app with mobile positioning system or text message alert system to respond to out-of-hospital cardiac arrest and begin early cardiopulmonary resuscitation (CPR) and defibrillation.

 

Evidence Summary

The ILCOR review (Greif et al. 2020, S222) identified two observational studies provided low-certainty evidence from 2,149 out-of-hospital cardiac arrests showing no association between citizen CPR responder notification of the event by technology or social media and survival with favorable neurological outcome at discharge (Lee et al. 2019, 198; Stroop et al. 2020, 57). Meta-analysis of adjusted data from one randomized controlled trial (RCT) (Ringh et al. 2015, 2316) and four observational studies (Lee et al. 2019, 198; Stroop et al. 2020, 57; Caputo et al. 2017, 73; Pijs et al. 2018, 397) that included 2,905 out-of-hospital cardiac arrests showed higher rates of survival to discharge with event notification to citizen CPR responder via smartphone app with mobile positioning system or text message alert systems compared with no alert notifications (aRR, 1.70; 95% CI, 1.16–2.48; 98/1000 more patients benefited with the intervention; 95% CI, 22 more patients/1000 to 208 more patients/1000) (Greif et al. 2020, S222). One RCT (Ringh et al. 2015, 2316) with 667 out-of-hospital cardiac arrests and three observational cohort studies (Lee et al. 2019, 198; Stroop et al. 2020, 57; Pijs et al. 2018, 397)  with 2,571 out-of-hospital cardiac arrests were reported to show no difference in rates of return of spontaneous circulation with citizen responder notification via technology or social media compared with no such notification (Greif et al. 2020, S222). High-certainty evidence from one RCT (Ringh et al. 2015, 2316) with 667 out-of-hospital cardiac arrests and one before-after study (Lee et al. 2019, 198) with 1,696 out-of-hospital cardiac arrests was reported to show higher rates of bystander CPR with smartphone app mobile positioning system or text message alert notification of citizen responders compared with no such notification (aRR, 1.27; 95% CI, 1.10–1.46 for the RCT; aRR, 1.20; 95% CI, 1.20–1.37 for the observational study) (Greif et al. 2020, S222). Very low-certainty evidence from four observational studies with 1,833 out-of-hospital cardiac arrests (Stroop et al. 2020, 57; Caputo et al. 2017, 73; Berglund et al. 2018, 160; Zijlstra et al. 2014, 1444) showed lower (i.e., faster) median response times with citizen responder event notification via technology or social media compared with no such notification (Greif et al. 2020, S222). A strong recommendation is made by ILCOR that citizens/individuals who are in close proximity to a suspected out-of-hospital cardiac arrest and willing to be engaged/notified by a smartphone app with mobile positioning system or text message alert system should be notified (very low-certainty evidence) (Greif et al. 2020, S222).

Insights and Implications

The ILCOR review evaluated programs in cities where citizen responders are located within a certain radius, such as 55 meters, from an out-of-hospital cardiac arrest, with findings of improved outcomes with first responder notification by smartphone mobile positioning system or text message alert for an out-of-hospital cardiac arrest (Greif et al. 2020, S222). Additional well-designed prospective studies are needed to evaluate long-term survival. The use of mobile phone technology and alert systems has potential associated costs and may result in reduced health equity. The Red Cross has used mobile apps for several years to facilitate just-in-time instructions in first aid, swimming safety, pet first aid, as well as apps to alert citizens of impending severe weather, tornadoes, hurricanes, earthquakes and floods (https://www.redcross.org/get-help/how-to-prepare-for-emergencies/mobile-apps.html).

 

Augmented and Virtual Reality for Resuscitation Training

Last Full Review: ILCOR 2024

Resuscitation training scenarios for healthcare professionals, such as those in basic life support (BLS) and advanced life support (ALS) courses, have been shown to improve knowledge and skill acquisition. However, the translation of these skills from simulation scenarios to real-life resuscitations is more challenging. Different and novel techniques exist for teaching and training healthcare professionals, as well as lay persons. Recently, immersive technology has emerged as a potential strategy to enhance the effectiveness of resuscitation training. Immersive technologies create or extend reality by immersing users in a digital environment, and include virtual reality (VR), augmented reality (AR) and mixed reality (MR):

• Virtual reality creates a completely virtual three-dimensional environment that replaces the real world. Users typically wear headsets that provide visual and auditory experiences.
• Augmented reality overlays digital information, such as a computer-generated holographic image, on a real-world or clinical environment, thus enhancing the user’s perception of their environment and permitting the user to interact with the hologram and objects in their environment. This can be experienced through devices such as smartphones, tablets or wearable AR glasses.
• Mixed reality combines elements of both VR and AR, allowing real and virtual objects to interact in real-time, typically with the use of advanced headsets. Recent studies have explored the use of AR and VR during training of technical skills, such as cardiopulmonary resuscitation (CPR), or interactive scenarios that allow users to engage with simulated patients.

 

 

Evidence Summary

A 2023 International Liaison Committee on Resuscitation (ILCOR) systematic review (Cheng 2024, 100643) and Consensus on Science with Treatment Recommendations (CoSTR) (Lin et al. 2023b; Greif et al. 2024) looked at the use of immersive technologies as part of the instructional design for training healthcare professionals and trainees and laypersons in neonatal, pediatric and adult BLS/ALS, compared with other methods of training such as traditional manikin/simulation training. The review selected 19 studies for the final analysis, including 17 randomized controlled trials.

For VR, most studies assessed its use for BLS training in laypersons versus healthcare professionals. Virtual reality was the primary instructional methodology alone or combined with training modules/guides or gamification. Comparison groups varied and included instructor-led training, video or web-based training, mobile app-based training or other strategies. Studies investigating VR for ALS training showed no difference in knowledge immediately after training in neonatal resuscitation compared with high-fidelity simulations, while mixed results were reported for adherence to guidelines when comparing traditional training with VR training (Lin et al. 2023b). 

For acquisition of BLS knowledge using VR, findings were mixed and the comparison of instructional strategies varied. Studies of adult laypersons showed mixed results for CPR depth and recoil. Compression rate compliance was not better with VR. There was no difference in overall CPR performance after training with VR and no difference in compression depth, rate or chest recoil. For BLS skills outcomes with VR training, adult laypersons demonstrated greater chest compression fraction with instructor-led training than with VR. For AR, only three studies were included, with few participants, and each with different control groups. Two of these studies found no difference in compression depth with and without AR during training, while one reported better compression depth with AR during training. No difference was shown with AR during training for CPR-quality parameters and compression rate. Mixed results were reported for overall CPR performance as assessed in two studies (Lin et al. 2023b).

The authors summarized the evidence to be either equivocal or in support of AR, while acknowledging the limited number of studies and participants. For VR, the evidence was predominantly in favor of non-VR training or its relative equivalent for the more important outcomes, such as skills, adherence to guidelines and clinical performance—although some studies reported improved knowledge acquisition with VR training. A weak recommendation was made by ILCOR suggesting the use of either AR or traditional methods for BLS training of laypersons and healthcare professionals. A second weak recommendation suggests against the use of virtual reality only for BLS and ALS training of laypersons and healthcare professionals (Lin et al. 2023b; Greif et al. 2024).

Insights and Implications

The recommendation for the use of either AR or traditional methods for BLS training of laypersons and healthcare professionals seems at first glance to be at odds with the limited evidence (i.e., evidence based on only three studies and limited participants)—with findings that were equivocal or in support of AR. In addition, the initial draft of the ILCOR CoSTR on this topic recommended against the use of VR in BLS or ALS training (Lin et al. 2023b). Following the public comment period and reconsideration of additional studies and evidence, the treatment recommendation was revised to suggest against the use of VR “only” for BLS and ALS training. 

This revision has been interpreted by the American Red Cross Scientific Advisory Council to mean that the use of VR is not recommended as a stand-alone technique for BLS and ALS training. There are several reasons for considering the use of either AR or VR as part of a training strategy for resuscitation courses. Immersive technologies are rapidly evolving, with new studies underway or published almost daily showing beneficial uses in different domains of healthcare education and training. Both VR and AR should be viewed as complementary techniques used in an overall educational and training strategy, rather than as stand-alone tools. The strengths of each platform potentially contribute to an exceptional blended learning approach for resuscitation training. While immersive and interactive experiences may benefit learners with diverse styles, cost and accessibility to this technology are major limitations to widescale implementation.

 

Gamified Learning

Last Full Review: ILCOR 2024

Gamification of learning in healthcare education involves integrating game design elements, such as competition, point scores and leaderboards, and gaming principles into educational activities—with the goal of increased engagement, motivation and improved effectiveness of learning. This approach uses the fun and interactive aspects of games to make learning more appealing and thus improve knowledge retention and skill acquisition. Examples of gamification in learning include simulation training using virtual or augmented reality for clinical scenarios, “serious” games and interactive case studies involving the management of virtual patients. Gamified learning has been used for cardiopulmonary resuscitation (CPR) training, both as a stand-alone and as preliminary training for a standard life support course.

 

Evidence Summary

A 2024 International Liaison Committee on Resuscitation (ILCOR) systematic review (Donoghue et al. 2024, 100640) and Consensus of Science on Resuscitation with Treatment Recommendations (Donoghue et al. 2023; Greif et al. 2024) compared instruction using gamified learning with traditional instruction or other non-gamified forms of learning for students in basic or advanced life support training. Educational, clinical and process outcomes were sought. The review included 13 studies (six randomized controlled trials [RCTs], seven observational), using mostly digital (e.g., online or smartphone app) platforms. Heterogeneity between studies was significant. Study participants and learners ranged from high school students to healthcare providers, as individual learners or within teams. The studies used scenarios with six adults, three pediatric subjects and four neonates. 

In most RCTs, gaming was associated with better overall CPR performance by healthcare professionals and laypersons (Boada et al. 2015, 282; MacKinnon et al. 2015, 71; Otero-Agra et al. 2019, 653). One observational study of laypersons reported improved performance 6 months after training with gaming (Toft et al. 2022, 2251). A screen-based, gamified learning interface used to train high school students in basic life support (BLS) reported improved chest compression depth and rate immediately after training and at 3 months (Semeraro et al. 2017, 27). For neonatal resuscitation programs, gamified learning reported improved knowledge scores immediately after learning, and improved skill scores in a neonatal scenario. Knowledge and self-reported confidence improvement was shown in healthcare professionals with smartphone-based games for advanced life support (ALS), but no difference was shown for skills during scenarios (Donoghue et al. 2023; Greif et al. 2024)

The ILCOR review led to a weak recommendation that gamified learning should be considered as a component of resuscitation training for all types of BLS and ALS courses. 

Insights and Implications

The Red Cross guideline is informed by this ILCOR review. This systematic review has been assessed by the American Red Cross Scientific Advisory Council (American Red Cross Scientific Advisory Council 2024b) using the Assessment of Multiple Systematic Reviews-2 (AMSTAR-2) criteria (Shea et al. 2017, 358), and the ILCOR recommendations aligned with current Red Cross training methodologies. Gamified learning has been successfully incorporated into Red Cross safety skills education and training for children, such as WHALE Tales. Gamified first aid training applications have been developed for children and teenagers (Borgund et al. 2019, 126; Global First Aid Reference Centre 2024). While gamified learning has been shown to have beneficial educational outcomes for BLS and ALS training, studies showing clinical outcomes are lacking. In addition, there are several potential disadvantages when considering the use of gamification for learning, including:

• Risk of distracting learners from the core content, leading to superficial learning
• Oversimplification or dramatization of scenarios, creating unrealistic expectations or perceptions of real-life situations
• High development costs and limited access to required technology
• Lack of standardized metrics to gauge proficiency within gamified platforms
• Increased stress and performance anxiety from the competitive elements, negatively impacting students’ ability to learn
• Overconfidence, which might not translate to actual competence in real-life emergency situations

 

As for the use of immersive technology in resuscitation education, training should ideally integrate gamified elements with traditional (i.e., hands-on) practice to provide a well-rounded educational experience.

 

Rapid Cycle Deliberate Practice Design

Last Full Review: ILCOR 2024

Rapid Cycle Deliberate Practice (RCDP) is a training method designed for simulation-based resuscitation training (Hunt et al. 2014, 945). With RCDP, a training scenario is stopped at certain points to provide immediate feedback to the learner on the task performed, helping them to understand what they did right and where they need improvement. There is ample time for repetition to reinforce correct technique and procedure. The scenario may initially be simple and become progressively more challenging as learners demonstrate competence. By focusing on specific skills in short bursts, learners may be able to master each component of basic life support (BLS) and advanced life support (ALS) more effectively, and correct errors before they become ingrained. The rapid pace and immediate feedback can help learners stay engaged and avoid cognitive overload and fatigue that can occur in longer, traditional training sessions. The use of RCDP has not been previously reviewed systematically by the International Liaison Committee on Resuscitation (ILCOR) to determine its impact on education, clinical or patient-centered outcomes.

 

Evidence Summary

A 2024 ILCOR systematic review (Abelairas-Gómez et al. 2024, 100648) and Consensus on Science with Treatment Recommendations  (Abelairas-Gómez et al. 2023; Greif et al. 2024) aimed to evaluate the effectiveness of RCDP compared with traditional instruction or other forms of learning on resuscitation training outcomes and survival. Nine simulation studies (eight randomized controlled trials [RCTs], one non-RCT) were included in the review. Study participants varied from respiratory therapists and medical students to nurses and physicians. Simulations included adult, pediatric and neonatal scenarios. Meta-analyses were completed for outcomes of time to chest compressions, time to defibrillation and time to first epinephrine (Abelairas-Gómez et al. 2024, 100648; Abelairas-Gómez et al. 2023; Greif et al. 2024). The findings are as follows:

• For time to chest compressions, no benefit was shown from the use of RCDP compared with after-event debriefing. 

• For time to defibrillation, significantly less time between recognition of the rhythm and defibrillation was shown with RCDP in three RCTs included in the meta-analysis, while one RCT and the observational study both reported reduced time to recognize the rhythm and to defibrillate. 
• For time to the administration of the first epinephrine, meta-analysis of three RCTs showed that RCDP participants had significantly shorter time to administration compared with controls. 
• Other RCTs and non-RCTs not included in this meta-analysis reported a benefit for other outcomes, such as shorter pre-shock pause direction, time to ventilation and compression fraction. 
• There was no difference found in single studies for retention of skills at 4 months after training, time to recognition of cardiac arrest and time to positive-pressure ventilation within a minute. 

 

In summary, the ILCOR review authors noted that although meta-analysis did not show a benefit with RCDP for time to chest compressions, RCDP was favored as a teaching modality because no harmful outcomes were reported and most outcomes showed a benefit from RCDP, including shorter times to critical task performance (Abelairas-Gómez et al. 2023; Greif et al. 2024). A weak recommendation was made based on very low-certainty evidence, suggesting that it may be reasonable to include RCDP as an instructional design feature of BLS and ALS training.

Insights and Implications

This review was limited due to the heterogeneity across studies, including how RCDP was defined. Implementing RCDP in BLS and ALS training requires:

• Using simulation-based training
• Incorporating structured debriefing sessions after each practice cycle to provide feedback 
• Using scenarios that are incrementally complex 
• Training instructors in RCDP techniques to provide effective guidance and feedback

 

Additional studies are needed to confirm beneficial outcomes in resuscitation education for different levels of healthcare professionals and laypersons.