Resus Today Autumn 2021

Volume 8 No. 3
Autumn 2021
Resuscitation Today
A Resource for all involved in the Teaching and Practice of Resuscitation
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Key factors when placing your
Key LUCAS factors ® chest when compression placing your systems LUCAS in ® the chest hospital compression systems
in the hospital
Immediate, high-quality CPR is a critical step in the American Heart Association’s (AHA) chain of survival
during a sudden cardiac arrest (SCA). No matter where the emergency takes place teams must respond quickly
Immediate, with AHA high-quality Guidelines-consistent CPR is a critical CPR to step help in improve the American patient outcomes. Heart Association’s (AHA) chain of survival during
a sudden 6 Look ways cardiac around. arrest Where (SCA). could your No matter LUCAS where device be the placed? emergency takes place teams must respond quickly with AHA
Guidelines-consistent CPR to help improve patient outcomes.
to 1. save Incidence rate
4. Team travel route
Look around. Where could your LUCAS device be placed?
Identify highly trafficked locations
Map out routes to possible event locations so
Key factors where when SCAs placing are your common LUCAS ® chest compression systems code/response teams can quickly grab and go
in the hospital
1. Incidence 2. Physical rateplacement
5. 4. EMS Team arrival travel route
Immediate, high-quality CPR is a critical step in the American Heart Association’s (AHA) chain of survival during
Identify a sudden cardiac Confirm highly arrest (SCA). device trafficked No matter storage where locations the is emergency always takes where secure place teams must respond quickly with AHA Station Map the out device routes near to possible EMS entrances, event reducing locations so
Guidelines-consistent CPR to help improve patient outcomes.
SCAs are and common accessible, consider adding it to your
hands-off code/response time during teams transport can quickly and patient grab and go
Look around. Where could your LUCAS device be placed?
code cart/rapid response kit
transfer
2. Physical 1. Incidence rate placement
4. Team travel route
5. EMS arrival
3. Identify Understaffed highly trafficked locations areas where
Map out routes to possible event locations 6. so Response time
Confirm SCAs are common device storage is always secure code/response and teams can quickly grab and go Station the device near EMS entrances,
Target areas with less staff to help maximize
Pinpoint locations where you can quickly
2. Physical placement
5. EMS arrival
accessible,
Confirm resources device storage
consider
is during always secure
adding critical and
it care to your events Station
code
the device near EMS entrances, access reducing and apply hands-off the device time to during deliver immediate transport and
accessible, consider adding it to your code
reducing hands-off time during transport and
cart/rapid response kit
patient transfer
cart/rapid response kit
patient transfer
high-quality CPR
3. Understaffed areas
6. Response time
Pinpoint locations where you can quickly
access and apply the device to deliver
3. Understaffed Target areas with less staff areas to help maximize
resources during critical care events
Target areas with less staff to help maximize
resources during critical care events
Cath lab
Main
entrance
immediate high-quality CPR
Operating
room
ICU
Emergency
department
6. Response time
Pinpoint locations where you can quickly
access and Why apply location the device matters to deliver
immediate high-quality CPR
“Our staff members are always prepared for code
events, even if sudden, because the LUCAS device
is accessible and centrally located. We have two
Operating
room
LUCAS devices in our department, one in the
middle of the unit with easy access for all staff and
an additional unit located in the back
of the department. If the second LUCAS
device is needed, it is clearly marked and
very easy to obtain. The hardcase
backpack also enables quick and easy|
transport to code rooms.”
ICU
~ Samantha Bolduc Brannigan, MSN, RN,
Patient Care Manager at MedStar Washington
Hospital Center Emergency Department
Cath lab
Acute Care
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CONTENTS
CONTENTS
Resuscitation Today
4 EDITORS COMMENT
6 FEATURE The opportunities of BLS self-directed learning
(SDL) in a post Covid world
10 FEATURE Resuscitating Cardiopulmonary Resuscitation
Training in a Virtual Reality: Prospective
Interventional Study
19 NEWS
This issue edited by:
David Halliwell
MSc Paramedic
c/o Media Publishing Company
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RESUSCITATION TODAY - AUTUMN 2021
3

EDITORS COMMENT
EDITORS COMMENT
This copy of the Resuscitation Journal features an original article by the team
behind the innovative Brayden manikin range.
Working closely with Resuscitation officers in the U.K. the team have been developed a platform
for “Remote” and “Self Directed” Resuscitation education strategies.
Classroom time has become a valuable resource, and with the advent of Covid 19 the skills
needing to be trained have been expanded, whilst group sizes have been reduced - for social
distancing reasons.
RESUSCITATION TODAY - AUTUMN 2021
“We are
seeing a
continued
growth in
AR and VR
strategies
being used
to enhance
and
prepare our
learners.”
It’s great to see novel education activities and technologies being developed which support the
post covid world.
We also feature an article from a team in New South Wales which explores the use of Virtual
Reality as a solution for wide scale resuscitation training. We are seeing a continued growth in AR
and VR strategies being used to enhance and prepare our learners.
We are grateful to all who write articles and news features for the journal - please continue to
do so. Our Advertisers are a vital component and key to the success of this journal and we are
always grateful for support from this community.
We have adverts for key aspects of resuscitation equipment -
The Litescope from Intersurgical, the Lucas Chest Compression device from Stryker, the Brayden
manikin team and the EOlife Ventilation monitor from MDT Global Solutions.
Conferences have started to re-open in the U.K. and across Europe and next year sees a few key
dates for your Resuscitation Diary.
European Resuscitation Council congress
16 & 17 June 2022 Antwerp - this will be a Hybrid Conference allowing both Face to Face and
online access to sessions.
Emergency Services Show - Birmingham NEC
21 & 22 September 2022
American Heart Association congress -Chicago USA
5-7 November 2022
David Halliwell
MSc Paramedic
4

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FEATURE
THE OPPORTUNITIES OF BLS
SELF-DIRECTED LEARNING (SDL)
IN A POST COVID WORLD
Brayden Online supporting self-directed learning
RESUSCITATION TODAY - AUTUMN 2021
The recent Covid-19 pandemic and the resulting backlog of
Basic Life Support (BLS) training is reportedly putting increasing
pressure on training departments that are struggling to meet their
BLS certification compliance targets. This article looks at the
Brayden Online system and how through close collaboration with
resuscitation educators and instructors, Self Directed Learning (SDL)
BLS training is now enabling high quality training and assessment for
a high throughput of trainees that is both cost and time efficient.
Self-directed learning is not a new pedagogical approach in healthcare
education having successfully been employed in a wide variety of
training programs across multiple clinical disciplines and related
curricula 1,2 . However, the teaching of Basic Life Support through SDL
has presented some unique challenges to the clinical community 3 . It
has been suggested that theoretical eLearning programs combined
with practical CPR skills training have not yet convincingly proven to be
consistent quality training experiences, whilst subscription costs and
reduced management controls for the instructor in some systems have
also been seen as prohibitive factors.
Commenting on the issues of integrating SDL systems into BLS training,
Kevin Mackie, Lead for Education at Resuscitation Council UK said,
‘We have steered away from SDL training through sole use of eLearning
because the muscle memory of practicing CPR skills on a manikin is
actually much more important than knowing the theory. The approach
we are looking at here is blended learning, which must include a
practical, hands-on component 4,5,6 . Instructors can direct their trainees
to extensive eLearning resources to cover BLS theory; resources which
are now highly engaging and immersive e.g. Healthcare Education
England, E-Learning for Healthcare (eLFH). Once completed, trainees
can then practice on a manikin at a time convenient to them. A good
SDL system gives the student easy to interpret, real-time feedback
on their performance allowing them to make instant improvements to
the quality of their CPR 7,8 . They can then progress to an assessment
that provides full debrief metrics, if successful, this sends a certificate
direct to their email and the organisation’s LMS (Learning Management
System) - all in one simple, streamlined process.’
Objective versus subjective assessment
‘One of the challenges of previous SDL systems has been the averaging
out of metrics, which gave trainees anomalous scores across the
different systems’, continued Mackie. ‘Working with Brayden on this
aspect of the system, we know the metrics have been inputted by UK
and Global professionals, where every single element of CPR has been
looked at and weighted accordingly – it’s the professional standard of
expected performance 9 .’
‘Objective and repeatable assessment is I feel pivotal to ensure
consistent, high standards of CPR from all healthcare staff required to
initiate BLS in cardiac arrests. Recent research 10 found that subjective
assessment has been shown to be inconsistent when compared with
objective assessment. Resuscitation trainers will be all too familiar with
the pressures of progressing large cohorts of BLS trainees in classroom
settings, where time and logistical constraints have meant that some
have been passed as ‘good enough’ rather than attaining the higher
standards we would all wish.
The 24/7, high frequency, low fidelity nature of this system’s set up,
enabling trainees to practice as their own schedules allow to reach the
standards we set, then be assessed and certified accordingly, makes a
compelling case for SDL BLS training, not just as a solution for present
training challenges in Covid times but as the standard training approach
for the future 11 .’
Integration and instructor autonomy within
a hospital’s Learning Management System
(LMS) –
The Genk Experience
Sylvain Haekens, Head of Training and Development at Ziekenhuis
Oost-Limburg, Genk in Belgium looked at SDL BLS training solutions
six years ago with two primary needs in mind; a system that could be
integrated into the hospital’s new LMS and a training program that could
provide objective assessment to ensure high standards of CPR across
the hospital.
‘The hospital has approximately 4,000 employees and my department
is responsible for all education and development programs for
both doctors and nurses. I am constantly looking at opportunities
to maximise both cost and time efficiencies in our programs, while
maintaining the highest standards in both educational delivery and
outcomes,’ said Haekens.
‘The Brayden Online system caught my attention because it had the
6

FEATURE
operational flexibility I needed. The hospital’s LMS system organises
the scheduling of our trainees, who go to our CPR room where they
can learn or refresh their skills on the Brayden manikins (adult and/
or infant), take the assessment and a certificate is automatically sent
to their emails at the same time as updating our LMS system. Our
hospital LMS system also automatically sends staff renewal invites
within the time period we set. This automatic processing of staff records
through the integration of the Brayden Online system has significantly
reduced the administrative workload of our BLS training program saving
the department both time and money. This has allowed us to divert
resources to our more instructor intensive ALS programs. When the
parameters change for CPR performance, we can of course update
those markers on the Brayden system, but otherwise, our BLS program
virtually runs itself and ensures demonstrable high standards of CPR
competence at both an individual and organisational level.’
Introducing SDL has reduced the need for us to do face to face
teaching. The system has been easy to use and the staff like the SDL
method of practicing and taking their test. It has freed my staff up for
other things such as our ILS and ALS courses, which are also down on
compliance.
We are a large NHS Hospital Trust with up to 9,000 staff. Since
introducing Brayden Online, we have recovered our compliance rating
of 85% far quicker than we could have done with our face-to-face
program. At the height of Covid we had dropped down to 62%, so the
Brayden Online system has been really beneficial.’
Catching up to pre-covid levels of BLS
compliance through self-assessment
The St. George’s Teaching Hospital NHS Foundation Trust
experience
Jeannie Walls, Lead Resuscitation Officer at St. George’s Hospital
highlighted the significant impact of the pandemic on BLS compliance
targets in hospitals across the country. ‘We had a huge reduction in
compliance over Covid due to having to stop face-to-face sessions
during the peak wave periods. When we could resume, our class sizes
were reduced drastically in order to enable social distancing and our
training team was reduced by half with staff sent to work in the ITU.
We had to find other solutions. We decided on compression only CPR
to reduce the risk of having two people working so closely together. In
a hospital setting, the most important BLS learning objective is early
hands-on compressions as full resuscitation support will never be
more than three minutes away. We introduced the eLFH Level 2 online
module, so staff could cover the theoretical learning before attending
the practical sessions in our self-assessment pod on the Brayden Online
manikin system. Staff were noticeably more fully prepared prior to their
online self-assessment.
Greater efficiencies in BLS training that go
beyond the classroom
The District General Hospital Experience – Darent Valley Hospital
Rob Morrison, Resuscitation Officer at Darent Valley Hospital cited
similar challenges to St. George’s and comments on how quickly he
has been able to embed SDL into the hospital’s BLS training program.
‘It was the Covid situation that triggered the shift in our training. I was
not convinced about this type of training before, and it took me to use
the system to become convinced. I was told I had to stop mandatory
training for three months, which resulted in a significant backlog. I was
really struggling but Brayden’s SDL system has resolved most of my
problems for BLS. It’s easy- to- use and so the staff have been very
receptive to it. We now use the Brayden Online system for infant and
paediatric CPR certification as well as adult 12 . I can quickly identify
RESUSCITATION TODAY - AUTUMN 2021
7

FEATURE
staff who are struggling to perform correct CPR and so run supervised
sessions for one-to-one instruction as necessary. The training room
is open 24/7 and I have had staff coming here on night shifts at 5am
to practice CPR. Clinical staff who need re-certification for BLS can
optimise their valuable time with patients by accessing refresher training
and assessment convenient to their shifts rather than attending a
scheduled class. This level of flexibility for training such a high number
of clinical staff has been an added benefit of the system.
The data trail the system provides for auditing, compliance and
governance has created much greater efficiencies in our BLS program.’
healthcare professionals and amongst students in Italy. Nurse
Education in Practice 2012 12, 153-158
3. Roppolo L, Heymann R, Pepe P, Wagner J, Commons B, Miller R,
et al. Wainscott M, Idris A. A randomised controlled trial comparing
traditional training in cardiopulmonary resuscitation (CPR) to selfdirected
CPR learning in first year medical students: The two-person
CPR study. Resuscitation 2011 82, 319-325
4. Gagnon M, Gagnon J, Desmartis M, Njoya M. The impact
of blended teaching on knowledge, satisfaction, and selfdirected
learning in nursing
undergraduates: A randomised,
controlled trial. Nursing Education
Perspectives 34(6) 377-382
5. Lotrecchiano G, McDonald
P, Lyons L, Long T, Zajiek-Farber
M. Blended learning: Strengths,
challenges, and lessons learned
in an interprofessional training
program. Matern. Child Health
2013 17 1725-1734
6. Lehmann R, Thiessen C, Frick
B et al. Improving paediatric basic
life support performance through
blended learning with web-based
virtual patients: randomised
controlled trial. J Med Internet
Res 2015 17:e17:e162, doi:http://
dx.doi.org/10.2196/jmir.4141
RESUSCITATION TODAY - AUTUMN 2021
Commenting on the Brayden Online development project, Dr. Jonathan
Smart, Global Product Development Director concluded, ‘It has been
a privilege and as it has turned out, quite fortuitous in these Covid
times to have partnered so closely with key opinion leaders in the
resuscitation community. By listening and applying what we have
learnt to our Brayden Online system and adapting it for use in an SDL
teaching environment, we are proud to be helping restore high levels
of BLS competence amongst hospital staff in such difficult times.
We look forward to further supporting all those who teach or practice
resuscitation by continuing to learn and develop new training solutions,
as we work together towards improving patient outcomes.’
For further information about Brayden Online please contact:
enquiries@innosonian.eu
References:
1. O,Shea E. Self-directed learning in nurse education: a review of the
literature. Journal of Advanced Nursing 2003 43(1), 62-70
2. Cadorin L, Suter N, Dante A, Williamson S, Devetti A, Pales A.
Self-directed learning competence assessment within different
7. Yeung j, Meeks R, Edelsen D,
Gao F, Soar J, Perkins GD et al.
The use of CPR feedback/prompt
devices during training and CPR
performance: A systematic review.
Resuscitation 2009 80 743-751
8. Smart J, Kranz K, Carmona F, Lindner T, Newton A. Does real-time
objective feedback and competition improve performance and
quality in manikin CPR training – a prospective observational study
from several European EMS. Scandinavian Journal of Trauma,
Resuscitation and Emergency Medicine 2015 23:79
9. Smart J. Brayden Pro – lessons learnt to help develop the ideal CPR
training manikin. Resuscitation Today 2017 4(2) 3-4
10. Abelsson A, Gwinnutt C, Greig P, Smart J, Mackie K. Validating
peer-led assessments of CPR performance. Resusc Plus. 2020 3
(100022). Published 2020 Aug 6. doi:10.1016/j.resplu.2020.100022
11. Yeung J, Djarv T, Hsieh M, Sawyer T, Lockey A Finn J, Grief R.
Spaced learning versus massed learning in resuscitation – A
systematic review. Resuscitation 2020 (156) 61-71
12. Abelsson A, Szarpak L, Morrison R, Smart J. Real-time objective
feedback for infant CPR using a novel new infant manikin: A
pilot study with paediatric nurses in the UK. 2021 IMSH Poster
presentation.
8

ADULT, PAEDIATRIC AND INFANT CPR
ONLINE
FEATURE
Compliant
with 2021 ARC,
AHA & ERC
Guidelines
The most complete CPR training system:
• Instructor-led learning
• Self-directed learning
• Remote learning (NEW)
Ensuring high standards
of CPR performance:
• Objective feedback
• Maintaining competence
• Integration with Learning
Management Systems
• Customisable training for
varied curricula and
individual trainee needs
RESUSCITATION TODAY - AUTUMN 2021
Further information: enquiries@innosonian.eu
9

FEATURE
RESUSCITATING CARDIOPULMONARY
RESUSCITATION TRAINING IN A VIRTUAL REALITY:
PROSPECTIVE INTERVENTIONAL STUDY
Janaya Elizabeth Perron 1 , BMed, MD; Michael Jonathon Coffey 1 , BMed, MD, PhD; Andrew Lovell-Simons 2 , BA,
MA; Luis Dominguez 3 ; Mark E King 3 , PhD; Chee Y Ooi 1 , Dip Paeds, MBBS, PhD
The Journal of Medical Internet Research (J Med Internet Res 2021;23(7):e22920) doi: 10.2196/22920 PMID: 34326040
Abstract
Background: Simulation-based technologies are emerging to enhance
medical education in the digital era. However, there is limited data for
the use of virtual reality simulation in pediatric medical education. We
developed Virtual Doc as a highly immersive virtual reality simulation to
teach pediatric cardiopulmonary resuscitation skills to medical students.
Objective: The primary objectives of this study were to evaluate
participant satisfaction and perceived educational efficacy of Virtual
Doc. The secondary aim of this study was to assess the game play
features of Virtual Doc.
Methods: We conducted a prospective closed beta-testing study at the
University of New South Wales (Sydney, Australia) in 2018. All medical
students from the 6-year undergraduate program were eligible to
participate and were recruited through voluntary convenience sampling.
Participants attended a 1-hour testing session and attempted at least
one full resuscitation case using the virtual reality simulator. Following
this, participants were asked to complete an anonymous postsession
questionnaire. Responses were analyzed using descriptive statistics.
Results: A total of 26 participants were recruited, consented to participate
in this study, and attended a 1-hour in-person closed beta-testing
session, and 88% (23/26) of participants completed the anonymous
questionnaire and were included in this study. Regarding participant
satisfaction, Virtual Doc was enjoyed by 91% (21/23) of participants,
with 74% (17/23) intending to recommend the simulation to a colleague
and 66% (15/23) intending to recommend the simulation to a friend.
In assessment of the perceived educational value of Virtual Doc, 70%
(16/23) of participants agreed they had an improved understanding of
cardiopulmonary resuscitation, and 78% (18/23) agreed that Virtual Doc
will help prepare for and deal with real-life clinical scenarios. Furthermore,
91% (21/23) of participants agreed with the development of additional
Virtual Doc cases as beneficial for learning. An evaluation of the game
play features as our secondary objective revealed that 70% (16/23) of
participants agreed with ease in understanding how to use Virtual Doc,
and 74% (17/23) found the game play elements useful in understanding
cardiopulmonary resuscitation. One-third (7/23, 30%) found it easy
to work with the interactive elements. In addition, 74% (17/23) were
interested in interacting with other students within the simulation.
Conclusions: Our study demonstrates a positive response regarding
trainee satisfaction and perceived educational efficacy of Virtual Doc.
The simulation was widely accepted by the majority of users and may
have the potential to improve educational learning objectives.
Keywords
pediatrics (72); cardiopulmonary resuscitation (11); virtual reality (147);
medical education (129)
RESUSCITATION TODAY - AUTUMN 2021
Introduction
Simulation-based education plays a significant role in developing vital
clinical assessment and management skills, especially in emergency
scenarios such as a sudden cardiac arrest (SCA). SCA is an uncommon
but life-threatening condition within the pediatric population [1,2] that
includes the potential catastrophic consequences of mortality and
poor neurological morbidity. An estimated 16,000 [3,4] children in the
United States experience out-of-hospital SCAs and 5800 [4] experience
in-hospital SCAs every year. Overall, survival rates are better for inhospital
arrests compared with out-of-hospital arrests [5], which is
unsurprising considering that the most significant predictor of survival
is early initiation of adequate cardiopulmonary resuscitation (CPR)
[6]. However, junior doctors often have limited real-world learning
experience managing an acutely ill and vulnerable child [7], especially
in emergent scenarios, where active participation is often reserved
for more experienced practitioners. In addition, many pediatric health
care professionals feel inadequately prepared to manage a critically
ill child, increasing the risk of medical errors [8]. Therefore, simulation
training forms the cornerstone of resuscitation education, providing an
opportunity for trainees to prepare for real-world clinical practice without
risking patient safety [9-11]. However, in-person simulation training
sessions are expensive and resource-intensive [12], and, therefore, the
efficacy of alternative modalities should be explored.
The revolutionary development of highly immersive digitized learning
resources such as virtual reality simulators harness the advantages
of simulation while offering a cost-effective and widely accessible
educational platform. Several studies have provided evidence for
the use of virtual reality simulators for procedural skills training in the
surgical field, with improved intraoperative performance [13] and
accuracy [14] and a reduction in operating times [13] and errors [15-
18]. One study investigated the use of virtual reality for CPR education
compared with traditional mannequins and found virtual reality could
be a valid and acceptable training method [19]. Furthermore, in a
study by Wong et al [20], clinical CPR instructors outlined the limits
of traditional education and noted the potential beneficial features of
10
1
Discipline of Paediatrics, School of Women’s and Children’s Health, University of New South Wales, Randwick, Australia
2
Medicine Education Development Unit, Faculty of Medicine, University of New South Wales, Sydney, Australia
3
Educational Delivery Services, Office of the Pro Vice-Chancellor (Education), University of New South Wales, Sydney, Australia

FEATURE
FREE EDUCATIONAL PODCASTS
In the knowledge that conferences and exhibitions may be difficult to attend we are delighted to
offer you the opportunity to listen to the following presentations listed on www.resustoday.com
FREE OF CHARGE with further presentations being added on a regular basis (average Podcast
time is 30 minutes):
Sepsis - Kevin Rooney
Permissive Hypertension - James Hale
Its Good To Talk - Andy Elwood
Damage Control Resuscitation - Pete Davis
Head Injuries - Dr Jonathan Hanson
Drowning and cold water - Paddy Morgan
Post Resuscitation Care - Paul Rees
This unique section on our web site also gives you the opportunity to see the following products being
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• I-view(tm) video laryyngoscope
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We are also seeking further presentation/podcasts to add to this exciting new educational concept
therefore if you have anything to submit that would interest those working in Pre Hospital Care,
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Volume 35 No. 5
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Volume 30 No. 4
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Gastroenterology Today
New Ways of Working
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One of the impacts of Covid-19 is
the way the NHS is accepting and
encouraging new ways of working.
But is this true in endoscopy?
In this edition, we look at insourcing
with 18 Week Support as a solution,
the actual experience of our nurses
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18 Week Support compared to their
day to day jobs in their home trusts.
Volume 7 No. 2
Autumn 2020
Resuscitation Today
A Resource for all involved in the Teaching and Practice of Resuscitation
Volume 2 No. 2
Autumn 2020
SimulationToday
A resource for all involved in the teaching and practice of simulation
RESUSCITATION TODAY - AUTUMN 2021
Blood &
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Sy
ys
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ENHANCE PAEDIATRIC SIMULATION WITH REALITi
Train critical skills required for your most vulnerable patients
FAST | EFFECTIVE | SAFE | INTUITIVE | LIGHTWEIGHT | POWERFUL
EXCLUSIVE TO
See reverse for Simulation Today
See reverse for Resuscitation Today
11

FEATURE
virtual reality as an additional learning tool. The experiential nature of
virtual reality may also be conducive to developing procedural skills
such as CPR, as repetitive hands-on practice permits the development
of muscle memory [21], leading to technical skill competence. CPR
involves the activation of declarative memory to recall the sequential
steps and procedural memory to perform the active steps such as chest
compressions [22], both of which may be developed and reinforced
through the use of virtual reality.
To the best of our knowledge, there are no highly immersive virtual
reality simulators for pediatric CPR training. As such, we developed
Virtual Doc, a highly immersive and experiential 3D multimedia sensory
virtual environment designed to teach pediatric CPR skills to medical
students and junior doctors. We performed a prospective closed betatesting
study on undergraduate medical students with the primary aim
to evaluate participant satisfaction and perceived educational efficacy
of Virtual Doc. The secondary aim of this study was to assess the
gameplay features of our simulation. We hypothesized that Virtual Doc
would be an enjoyable and highly educational learning experience. We
also hypothesized that the gameplay features would be beneficial in the
facilitation of a realistic hands-on clinical learning experience.
Methods
Study Design
We conducted a prospective, uncontrolled, interventional closed betatesting
study in 2018 to assess the usability, acceptability, and perceived
educational effectiveness of Virtual Doc as a method for teaching
pediatric CPR to medical students. All participants provided implied
consent by expressing interest in the study, attending a 1-hour closed
beta-testing session, and completing an anonymous postsession
questionnaire (Multimedia Appendix 1). The study was approved by
the University of New South Wales Human Research Ethics Committee
(HC180484).
Participants
Participants were eligible to partake in this study if they were currently
enrolled in the 6-year undergraduate medical program at the University
of New South Wales, Sydney, Australia. All medical students from the
6-year program were eligible and invited to participate in this study
through an information email sent out by the University of New South
Wales Medical Society administration. Students were instructed to
contact the study investigators with their expression of interest. They
were subsequently allocated to a 1-hour session in which they would
engage with Virtual Doc and complete the postsession questionnaire.
Participants were excluded from the analysis if they did not complete the
questionnaire.
Virtual Doc
Virtual Doc is a virtual reality simulation developed for Oculus VR
(Facebook Technologies LLC; Figure 1). The Virtual Doc app was
developed using Unity3D software (Unity Technologies), and models
were developed using open-source Blender modeling software. The
simulation was conducted using the hardware of the Oculus Rift
system linked to Alienware laptops (Alienware Corp). Virtual Doc is
a first-person active learning experience through immersion within a
multimedia sensory environment. Users wear a headset and use 2 hand
controllers and are able to use these controllers, which are equipped
with haptic technologies, to interact with the virtual environment. This
simulation enables users to perform a series of actions including picking
up objects, pushing buttons, and turning dials. They are also fully
immersed with audiovisual aids such as auscultation of the heart and
lungs.
The scenario in this study involved an SCA in a young child that required
appropriate and timely management. The required cardiac arrest
management was in keeping with the Advanced Pediatric Life Support
Australia guidelines [23]. Students were provided with a brief written
clinical history on the main screen in the virtual environment and were
then instructed to begin CPR. To complete the case, participants were
required to assess the surroundings, check for a response, signal for
senior help by pressing a call button, and then begin resuscitation by
assessing the airway, breathing, and circulation; bagging and masking
the patient (Figure 2); performing adequate chest compressions;
and defibrillating the patient. As this scenario featured a shockable
rhythm, this patient was defibrillated as part of the SCA management
algorithm; however, this step may not be required for all pediatric
SCA presentations. Shortly after the participant signaled for help, a
senior physician arrived in the virtual environment to resume chest
compressions while the user prepared for defibrillation. For successful
completion of the case, all steps must have been completed correctly
within 10 minutes.
RESUSCITATION TODAY - AUTUMN 2021
Figure 1. The Virtual Doc environment.
Outcome Measures
Validating the use of highly immersive and experiential virtual reality
simulators as a form of active learning can be achieved by assessing
various outcomes through the Kirkpatrick model of evaluation [24]. This
4-tiered hierarchy includes a scaffolding evaluation of reaction (level
1), learning (level 2), behavior (level 3), and results (level 4) [24]. As the
levels progress, there is an increase in conclusively defining the efficacy
of the educational activity [25].
The primary outcomes of this study were participant satisfaction
(Kirkpatrick level 1) and the perceived educational value of Virtual Doc
(Kirkpatrick level 2). Participant satisfaction was assessed through 1
Likert-style question and 2 trichotomous questions regarding enjoyment
of the game and whether the participant would recommend the game to
a colleague or friend. The perceived educational efficacy was assessed
through 3 Likert-style questions including whether participants improved
12

FEATURE
Study Population
All 23 of the included participants completed the demographic
characteristics section of the questionnaire. Overall, the median age
of participants was 22.0 (interquartile range 21.5-23.0) years, and 70%
(16/23) of participants were female. In 2018, 61% (14/23) of participants
were in year 4, 13% (3/23) were in year 5, and 26% (6/23) were in year
6. A total of 87% (20/23) of participants were local students, while 13%
(3/23) were international students.
Figure 2. User is ventilating the patient with a bag-valve mask as per
the resuscitation algorithm.
Outcome Measures
Participants responded to 10 Likert-style, trichotomous, or dichotomous
questions regarding their experience with Virtual Doc. The results of
these questions are summarized by question type in the horizontal
stacked bar graphs in Figures 3-5.
their understanding of the simulation objectives, whether engaging with
Virtual Doc prepares students for a similar real-life clinical scenario, and
whether different clinical cases would be beneficial for learning.
The secondary outcome was an evaluation of the gameplay features.
Here, subjects were asked to respond to 3 Likert-style questions and 1
dichotomous question regarding the ease of understanding how to engage
with the simulation, the level of ease to work with the interactive elements,
whether the interactive elements were useful for learning, and whether the
user would like to interact with other students in the virtual world.
Testing Session
All interested participants were allocated to a 1-hour in-person session.
Attendees were invited to attempt at least one full clinical scenario using
the virtual reality simulator. They were offered an unlimited number of
attempts within the 1-hour session. After engaging with Virtual Doc,
participants were invited to complete an anonymous questionnaire that
evaluated the primary and secondary outcomes.
Data Collection and Statistical Analysis
Each postsession questionnaire was assigned a unique identification
number and was completed anonymously by participants. The
responses were collated and outcome measures were analyzed
using descriptive statistics. The 7-point Likert scale responses were
streamlined to 3 categories of agree (included all responses indicating
strongly agree, agree, and mildly agree), neutral, and disagree (included
all responses indicating mildly disagree, disagree, and strongly
disagree) for the data analysis. Trichotomous questions requiring a
response of yes, not sure, or no and dichotomous questions requiring a
response of yes or no were analyzed as such. The data were analyzed
using the statistical software R (version 1.1.423, R Foundation for
Statistical Computing) [26].
Results
A total of 26 participants were recruited and attended 1-hour in-person
closed beta-testing sessions. A total of 88% (23/26) of participants
completed the anonymous questionnaire and were included in the
analysis, and 12% (3/26) attended the testing session but declined
to complete the questionnaire and were therefore excluded from the
analysis. They were not required to provide a reason for declining to
participate.
Participant Satisfaction
Respondents completed 1 Likert-style question and 2 trichotomous
questions to evaluate satisfaction with Virtual Doc as an assessment
of Kirkpatrick level 1. Virtual Doc was enjoyed by 91% (21/23) of
participants. Furthermore, 74% (17/23) would recommend this
simulation to a colleague, and 66% (15/23) would recommend this
simulation to a friend.
Perceived Educational Value
Participants completed 3 Likert-style questions to assess the perceived
educational efficacy of Virtual Doc, evaluating Kirkpatrick level 2, and 70%
(16/23) of participants agreed they had an improved understanding of CPR
following the use of Virtual Doc. In addition, 78% (18/23) agreed that Virtual
Doc will help them prepare for and deal with real-life clinical scenarios.
Furthermore, 91% (21/23) agreed there was a learning benefit to developing
different cases within Virtual Doc, and 9% (2/23) were neutral.
Gameplay Features
Respondents completed 3 Likert-style questions and 1 dichotomous
question evaluating the gameplay features of Virtual Doc. In terms of
usability and gameplay, 70% (16/23) of participants agreed they had
ease in understanding how to use Virtual Doc, and 74% (17/23) found
the gameplay elements useful for understanding CPR. Furthermore,
30% (7/23) of participants found it easy to work with the interactive
elements, which provides a template for future software improvements.
In addition, 74% (17/23) would like the option to interact with other
students within the game.
Discussion
Principal Findings
To the best of our knowledge, a prospective study on the use of a virtual
reality simulator to teach pediatric CPR to medical students has yet
to be conducted. In accordance with the Kirkpatrick model [24], the
results of our study demonstrated high trainee satisfaction (Kirkpatrick
level 1) and a perceived improvement in learning (Kirkpatrick level
2). In evaluating our secondary outcome of assessing the response
to the virtual reality gameplay features, the majority of participants
agreed with the ease in understanding how to use the simulation and
the usefulness of gameplay features in improving their understanding
of CPR and expressed a desire for interacting with others in the virtual
environment. Although some participants found it difficult to work with
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13

FEATURE
Figure 3. Results of the Likert-style questions.
Figure 4. Results of the trichotomous questions.
RESUSCITATION TODAY - AUTUMN 2021
Figure 5. Results of the dichotomous question.
the interactive elements, this closed beta test provided an opportunity Current data on trainee satisfaction, educational efficacy, and gameplay
to identify elements for future improvements, including the refinement of elements of virtual reality simulators for pediatric medical education is
the interactive elements and future considerations such as a multiplayer limited, and the encouraging results of this study will address the gap in
design which may further enhance the learning experience and element the literature and could have an integral role in transforming the culture
of realism given the significant role of teamwork in resuscitation.
of future medical education.
14

FEATURE
Immersive technologies provide users with an engaging and enjoyable
learning platform to train skills to proficiency without risking patient
safety. Our study illustrated high participant satisfaction as Virtual Doc
was enjoyed by almost all participants. This result parallels a study
by Kron et al [27] in which an evaluation of medical student attitudes
toward technology-based education was conducted and revealed that
almost all students liked the idea of using technology to enhance their
educational experience and thought that education should make better
use of new media technologies. Beyond satisfaction, a previous study
reported that experiential simulations offer a high level of interactivity
and engagement, which may increase user motivation to learn [28].
Providing a highly engaging environment, such as that of Virtual Doc,
is important for trainees as increased interest and satisfaction with the
learning modality may result in an increased level of motivation to learn;
one study showed that highly motivated students are more effective
learners [29]. The importance of satisfaction and effective learning
is reinforced by a study evaluating the effectiveness of virtual reality
versus traditional or other forms of digital learning in educating health
care professionals, in which a higher level of interactivity was more
effective for the development of postintervention knowledge and skills
[30]. The level of satisfaction with a learning experience also affects the
probability of a user recommending such an experience to their peers
[31]. The results of our study are congruent with this notion, as indicated
by most students enjoying the simulation and agreeing with the intention
of recommendation.
In this study, Virtual Doc was perceived as educationally efficacious by the
majority of the participants, as indicated by a positive response toward
improved understanding, preparation for real-world clinical scenarios,
and support for designing additional cases. An important component
of effective education in the adult learner involves the psychological
concept of flow. This term is defined as a state in which a learner is “fully
engaged, focused, and committed to the success of the activity” [32],
and this can be achieved through active engagement in an experiential
learning process. The use of highly immersive and interactive virtual
reality simulators can improve flow, which may lead to superior learning
outcomes and performance as echoed by the majority of participants
reporting an improved understanding of CPR. Additionally, engaging
sensory modalities including vision, haptics, and audition also promotes
active learning, which can improve memory retention [33]. Virtual Doc
includes sensory features through auscultation of heart and lung sounds
and palpation of the peripheral pulses, which the user will hopefully be
able to translate into the real-world clinical setting when assessing or
managing a similar patient presentation.
Being immersed in the virtual yet realistic hospital environment of Virtual
Doc provides users with a lifelike clinical experience. This digital-based
environment is an innovative tool with realistic features supporting
the recommendations of adult learning theories such as Knowles’
theory [34,35]. The responses in this study regarding the Virtual Doc
environment and its ability to prepare students for real-life clinical
scenarios showcases a facility in which the elements of adult learning
theories can be included. Active experimentation within a realistic
and immersive learning environment allows users to make clinical
decisions and experience the consequences of their actions in real time,
mimicking a real-world clinical environment. This element of realism is
important in encouraging intrinsic motivation to support the needs of an
adult learner.
Additionally, the Kolb cycle of learning encourages repetition, reflection,
and correction to improve learning outcomes [36]. Virtual Doc supports
this cyclical relationship as learners have the opportunity to engage
in repetitive practice until they achieve educational mastery in a safe
and controlled environment, which is an important benefit of simulation
as this is severely limited in real-world emergency patient encounters,
especially in the pediatric population [5]. The flexible design of virtual
reality may enable health care professionals to have more convenient
and frequent opportunities to practice and refine skills.
Several studies have demonstrated that junior doctors feel inadequately
prepared and lack confidence in their early training years [37-41].
This is further supplemented by less favorable outcomes for neonatal
resuscitation being described in the summer when senior staff
physicians are less likely to be present and the overall volume of
staff members is reduced [42]. Lacking confidence and inadequate
preparation may translate into unsafe practice and poor patient
outcomes and is an especially important consideration when managing
emergency scenarios such as an SCA. Virtual reality simulators such as
Virtual Doc may provide an avenue to bridge the gap between trainee
and doctor through immersive gameplay by enabling users to master
foundational principles and basic management algorithms and apply
this knowledge to challenging simulated cases. In our study, the majority
of respondents expressed that this simulation game would aid in
developing clinical skills and preparing the user for dealing with real-life
clinical scenarios. In addition, almost all participants expressed benefit
in the development of different cases, indicating a positive response
toward the clinical educational value of the simulation.
The gameplay elements involved in virtual reality add entertainment to
the learning process, thereby motivating learners to engage in study.
The triad of immersion, interaction, and imagination, as described
by Burdea and Coiffet [43], are important factors of virtual reality
technology. Coupled with andragogical principles, a highly interactive
game design improves intrinsic motivation and creates a more
enjoyable and engaging learning experience with a consequential
potential to illustrate superior examination scores [44]. In our study,
the vast majority of respondents agreed that the interactive gameplay
elements were useful in understanding how to perform CPR and
found the process of the virtual reality simulation easy to understand.
This was further supplemented by almost all participants enjoying the
experience in the assessment of participant satisfaction. However,
some respondents did not experience ease in using the interactive
elements within the virtual environment. As this was a closed beta test,
the software was able to deliver its intentional value to the participants,
but there were some minor issues reported with ease in fully integrating
into the environment such as accurately picking up a stethoscope or
pushing the assistance button. This feedback is being considered as we
progress toward the final product and acts as identified areas for future
developments.
Finally, nontechnical skills such as teamwork and leadership are
paramount in successful resuscitation. The collegiality of the responding
team directly impacts predictors of postarrest survival as a coordinated
course of action is associated with improved patient outcomes [45].
Technology-based games such as Virtual Doc have the potential to
facilitate an atmosphere of teamwork, and in the digital era, medical
students have agreed with introducing multiplayer simulations if
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15

FEATURE
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16
they were fun and developed clinical skills [27]. Likewise, our study
demonstrated that the majority of participants were interested in
interacting with other players. A multiplayer design within the virtual
environment could afford an opportunity to rotate through different
resuscitation team roles, supporting an active and immersive learning
experience, with the potential to equip learners with the crucial teamwork
skills required for the effective management of a pediatric SCA.
Limitations
Our study was limited by the small sample size and monocentric
design, which limits its generalizability and external validity. However,
participants from all years of study were eligible to participate,
providing a degree of generalizability. This trial is also limited by
voluntary convenience sampling, leading to a potential selection
bias. Furthermore, this study used a single intervention with no active
comparator, and therefore, the participants were not randomized and
were unblinded to the intervention, which may formulate a measurement
bias. However, the questionnaires were anonymized, providing a layer
of security for participants to provide uncoerced feedback. Moreover,
the final version of Virtual Doc will differ from the prototype used in this
study as this was closed beta-testing and we are improving the software
to address the feedback provided by the participants in this study. In
addition, the prototype design of Virtual Doc in this closed beta test did
not assess user hand technique or the quality of chest compressions.
This limitation will guide future software improvements to ensure users
are equipped with real-time visual and haptic feedback regarding the
technique and quality of chest compressions.
Future Research
Given the encouraging results of this study, future research should
include an investigator-blinded randomized controlled trial to objectively
evaluate the educational efficacy of Virtual Doc against traditional
simulation-based education or other digitized modalities such as serious
games or e-learning modules. Furthermore, an evaluation of translation
of knowledge into clinical practice (Kirkpatrick level 3) and the impact
of learned knowledge on changes within the organizational practice to
improve patient outcomes (Kirkpatrick level 4) should be performed,
with emphasis on a reduction in medical errors and improved patient
survival rates and overall health outcomes. This study does not assess
the higher levels of the Kirkpatrick model, and this limitation should be
the focus of future research to contribute to the quality of data for the
efficacy of Virtual Doc.
Conclusion
In summary, our study demonstrates a positive response regarding the
satisfaction and educational efficacy of Virtual Doc. Our findings reveal
that this virtual reality simulation was widely accepted by the majority of
users and has the potential to improve educational learning objectives.
As such, our results provide a promising contribution to the educational
revolution and may encourage the use of this emerging and versatile
technology in the transformation of the 21st century medical curricula.
Acknowledgments
The study team would like to acknowledge the participating medical
students for their involvement in this study, Reece Pahn (University of
New South Wales Medical Society secretary) for facilitating the invitation
of students, and Seiya Takeda and Zheyu Li for assisting with game
development.
Authors’ Contributions
The study was conceived by CYO and MJC. The study design and
analysis were developed by CYO and MJC. CYO, MJC, ALS, and
LD contributed to the conception and design of Virtual Doc. Subject
recruitment and trial coordination were performed by JEP and MJC. LD
sourced and coordinated the required technological equipment for the
testing sessions. Data collection and statistical analysis were performed
by JEP, MJC, and CYO. The paper was first drafted by JEP and revised
in subsequent drafts by MJC, MEK, and CYO. All authors reviewed and
approved the final manuscript.
Conflicts of Interest
None declared.
Multimedia Appendix 1
Questionnaire instrument.
DOC File , 236 KB (https://jmir.org/api/download?alt_name=jmir_
v23i7e22920_app1.doc&filename=2b10c5adf953d3941a41949cdba1a
ad9.doc)
References
1. Ilina MV, Kepron CA, Taylor GP, Perrin DG, Kantor PF, Somers
GR. Undiagnosed heart disease leading to sudden unexpected
death in childhood: a retrospective study. Pediatrics 2011
Sep;128(3):e513-e520. [doi: 10.1542/peds.2010-2307] [Medline:
21824887]
2. Meyer L, Stubbs B, Fahrenbruch C, Maeda C, Harmon K,
Eisenberg M, et al. Incidence, causes, and survival trends
from cardiovascular-related sudden cardiac arrest in children
and young adults 0 to 35 years of age: a 30-year review.
Circulation 2012 Sep 11;126(11):1363-1372. [doi: 10.1161/
CIRCULATIONAHA.111.076810] [Medline: 22887927]
3. Topjian AA, Nadkarni VM, Berg RA. Cardiopulmonary resuscitation
in children. Curr Opin Crit Care 2009 Jun;15(3):203-208. [doi:
10.1097/mcc.0b013e32832931e1] [Medline: 19469022]
4. Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins
DL, American Heart Association Congenital Cardiac Defects
Committee of the Council on Cardiovascular Disease in the Young,
Council on Clinical Cardiology, Council on Cardiovascular and
Stroke Nursing, Council on Cardiovascular Surgery and Anesthesia,
Emergency Cardiovascular Care Committee. Cardiopulmonary
resuscitation in infants and children with cardiac disease: a scientific
statement from the American Heart Association. Circulation 2018
May 29;137(22):e691-e782. [doi: 10.1161/CIR.0000000000000524]
[Medline:29685887]
5. Nadkarni VM, Larkin GL, Peberdy MA, Carey SM, Kaye W, Mancini
ME, et al. First documented rhythm and clinical outcome from inhospital
cardiac arrest among children and adults. JAMA 2006 Jan
4;295(1):50-57. [doi:10.1001/jama.295.1.50] [Medline: 16391216]
6. Goto Y, Maeda T, Goto Y. Impact of dispatcher-assisted bystander
cardiopulmonary resuscitation on neurological outcomes in children
with out-of-hospital cardiac arrests: a prospective, nationwide,
population-based cohort study. J Am Heart Assoc 2014 Apr
30;3(3):e000499 [FREE Full text] [doi: 10.1161/JAHA.113.000499]
[Medline: 24785780]
7. Clerihew L, Rowney D, Ker J. Simulation in paediatric training. Arch
Dis Child Educ Pract Ed 2016 Feb;101(1):8-14 [FREE Full text] [doi:
10.1136/archdischild-2015-309143] [Medline: 26614805]
8. Cheng A, Duff J, Grant E, Kissoon N, Grant VJ. Simulation in
paediatrics: an educational revolution. Paediatr Child Health 2007

FEATURE
Jul;12(6):465-468 [FREE Full text] [doi: 10.1093/pch/12.6.465]
[Medline: 19030409]
9. Ten Eyck RP. Simulation in emergency medicine training.
Pediatr Emerg Care 2011 Apr;27(4):333-341. [doi:10.1097/
PEC.0b013e3182131fe0] [Medline: 21467889]
10. Issenberg SB, McGaghie WC, Petrusa ER, Lee GD, Scalese RJ.
Features and uses of high-fidelity medical simulations that lead
to effective learning: a BEME systematic review. Med Teach 2005
Jan;27(1):10-28. [doi: 10.1080/01421590500046924]
[Medline: 16147767]
11. Gaba DM. The future vision of simulation in health care. Qual
Saf Health Care 2004 Oct;13 Suppl 1:i2-i10 [FREE Full text] [doi:
10.1136/qhc.13.suppl_1.i2] [Medline: 15465951]
12. Drummond D, Arnaud C, Thouvenin G, Guedj R, Grimprel E,
Duguet A, et al. An innovative pedagogic course combining
video and simulation to teach medical students about pediatric
cardiopulmonary arrest: a prospective controlled study. Eur J
Pediatr 2016 Jun;175(6):767-774. [doi: 10.1007/s00431-016-2702-1]
[Medline: 26847430]
13. Larsen CR, Soerensen JL, Grantcharov TP, Dalsgaard T,
Schouenborg L, Ottosen C, et al. Effect of virtual reality training on
laparoscopic surgery: randomised controlled trial. BMJ 2009 May
14;338:b1802 [FREE Full text] [doi: 10.1136/bmj.b1802]
[Medline: 19443914]
14. Gallagher AG, Ritter EM, Champion H, Higgins G, Fried MP,
Moses G, et al. Virtual reality simulation for the operating room:
proficiency-based training as a paradigm shift in surgical skills
training. Ann Surg 2005 Feb;241(2):364-372. [doi:10.1097/01.
sla.0000151982.85062.80] [Medline: 15650649]
15. Munz Y, Kumar BD, Moorthy K, Bann S, Darzi A. Laparoscopic
virtual reality and box trainers: is one superior to the other? Surg
Endosc 2004 Mar;18(3):485-494. [doi: 10.1007/s00464-003-9043-7]
[Medline: 14752633]
16. Grantcharov TP, Kristiansen VB, Bendix J, Bardram L, Rosenberg J,
Funch-Jensen P. Randomized clinical trial of virtual reality simulation
for laparoscopic skills training. Br J Surg 2004 Feb;91(2):146-150.
[doi: 10.1002/bjs.4407] [Medline:14760660]
17. Seymour NE, Gallagher AG, Roman SA, O’Brien MK, Bansal VK,
Andersen DK, et al. Virtual reality training improves operating
room performance: results of a randomized, double-blinded
study. Ann Surg 2002 Oct;236(4):458-463. [doi:10.1097/01.
SLA.0000028969.51489.B4] [Medline: 12368674]
18. McClusky DA, Gallagher AG, Ritter E, Lederman AB, Van Sickle
KR, Baghai M, et al. Virtual reality training improves junior
residents’ operating room performance: results of a prospective,
randomized, double-blinded study of the complete laparoscopic
cholecystectomy. J Am Coll Surg 2004 Sep;199(3):73. [doi:
10.1016/j.jamcollsurg.2004.05.157]
19. Semeraro F, Ristagno G, Giulini G, Gnudi T, Kayal JS, Monesi A, et
al. Virtual reality cardiopulmonary resuscitation (CPR): comparison
with a standard CPR training mannequin. Resuscitation 2019
Feb;135:234-235. [doi:10.1016/j.resuscitation.2018.12.016]
[Medline: 30597133]
20. Wong M, Chue S, Jong M, Benny H, Zary N. Clinical
instructors’ perceptions of virtual reality in health
professionals’ cardiopulmonary resuscitation education.
SAGE Open Med 2018;6:2050312118799602 [FREE Full text]
[doi:10.1177/2050312118799602] [Medline: 30245815]
21. Hunt EA, Duval-Arnould JM, Nelson-McMillan KL, Bradshaw
JH, Diener-West M, Perretta JS, et al. Pediatric resident
resuscitation skills improve after “rapid cycle deliberate practice”
training. Resuscitation 2014 Jul;85(7):945-951. [doi:10.1016/j.
resuscitation.2014.02.025] [Medline: 24607871]
22. Sense F, Maass S, van Rijn H. Interactions of declarative and
procedural memory in real-life tasks: validating CPR as a new
paradigm. 2016 Presented at: Proceedings of the 14th International
Conference on Cognitive Modeling; 2016; University Park.
23. Advanced Life Support Group. Advanced Paediatric Life Support,
Australia and New Zealand: A Practical Approach to Emergencies.
6th edition. West Sussex: John Wiley & Sons; 2017.
24. Kirkpatrick DL, Kirkpatrick J. Evaluating Training Programs: The Four
Levels. 3rd Edition. San Francisco: Berrett-Koehler Publishers, Inc;
2006.
25. Drummond D, Hadchouel A, Tesnière A. Serious games for health:
three steps forwards. Adv Simul (Lond) 2017;2:3 [FREE Full text]
[doi: 10.1186/s41077-017-0036-3] [Medline: 29450004]
26. Hornik K. The R FAQ. URL: https://cran.r-project.org/doc/FAQ/R-
FAQ.html [accessed 2019-09-13]
27. Kron FW, Gjerde CL, Sen A, Fetters MD. Medical student attitudes
toward video games and related new media technologies in medical
education. BMC Med Educ 2010;10:50 [FREE Full text] [doi:
10.1186/1472-6920-10-50] [Medline: 20576125]
28. Limniou M, Roberts D, Papadopoulos N. Full immersive virtual
environment CAVETM in chemistry education. Comput Educ 2008
Sep;51(2):584-593. [doi: 10.1016/j.compedu.2007.06.014]
29. Sutcliffe A. Multimedia and Virtual Reality: Designing Multisensory
User Interfaces. Mahwah: Psychology Press; 2003.
30. Kyaw BM, Saxena N, Posadzki P, Vseteckova J, Nikolaou CK,
George PP, et al. Virtual reality for health professions education:
systematic review and meta-analysis by the digital health education
collaboration. J Med Internet Res 2019 Jan 22;21(1):e12959 [FREE
Full text] [doi: 10.2196/12959] [Medline: 30668519]
31. Hyejin C, Woonhan K, Hwayeol C. Effects of smartphone-based
learning properties on user satisfaction and recommendation
intention. Indian J Sci Technol 2015;8:26. [doi: 10.17485/ijst/2015/
v8i26/80990]
32. Taekman JM, Shelley K. Virtual environments in healthcare:
immersion, disruption, and flow. Int Anesthesiol Clin 2010;48(3):101-
121. [doi: 10.1097/AIA.0b013e3181eace73] [Medline: 20616640]
33. Freeman S, Eddy SL, McDonough M, Smith MK, Okoroafor N,
Jordt H, et al. Active learning increases student performance in
science, engineering, and mathematics. Proc Natl Acad Sci U S
A 2014 Jun 10;111(23):8410-8415 [FREE Full text] [doi: 10.1073/
pnas.1319030111] [Medline: 24821756]
34. Akl EA, Sackett K, Pretorius R, Erdley S, Bhoopathi PS,
Mustafa R, et al. Educational games for health professionals.
Cochrane Database Syst Rev 2008 Jan 23(1):CD006411. [doi:
10.1002/14651858.CD006411.pub2] [Medline: 18254103]
35. Knowles M. The Modern Practice of Adult Education: Andragogy
Verus Pedagogy. New York: Association Press; 1970.
36. Kolb AY, Kolb DA. Learning styles and learning spaces: enhancing
experiential learning in higher education. Acad Manag Learn Educ
2005 Jun;4(2):193-212. [doi: 10.5465/amle.2005.17268566]
37. Tallentire VR, Smith SE, Skinner J, Cameron HS. The preparedness
of UK graduates in acute care: a systematic literature review.
Postgrad Med J 2012 Jul;88(1041):365-371. [doi: 10.1136/
postgradmedj-2011-130232] [Medline: 22167809]
RESUSCITATION TODAY - AUTUMN 2021
17

FEATURE
38. Goldacre MJ, Taylor K, Lambert TW. Views of junior doctors
about whether their medical school prepared them well for work:
questionnaire surveys. BMC Med Educ 2010 Nov 11;10:78 [FREE
Full text] [doi: 10.1186/1472-6920-10-78] [Medline: 21070622]
39. Bligh J. The first year of doctoring: still a survival exercise. Med
Educ 2002 Jan;36(1):2-3. [doi:10.1046/j.1365-2923.2002.01129.x]
[Medline: 11849515]
40. Wall D, Bolshaw A, Carolan J. From undergraduate medical
education to pre-registration house officer year: how
prepared are students? Med Teach 2006 Aug;28(5):435-439.
[doi:10.1080/01421590600625171] [Medline: 16973456]
41. Drummond D, Arnaud C, Thouvenin G, Guedj R, Duguet A, de
Suremain N, et al. [Newly formed French residents in pediatrics
are not well prepared for conducting pediatric resuscitation after
medical school]. Arch Pediatr 2016 Feb;23(2):150-158. [doi:
10.1016/j.arcped.2015.11.012] [Medline: 26774839]
42. Stewart JH, Andrews J, Cartlidge PH. Numbers of deaths related
to intrapartum asphyxia and timing of birth in all Wales perinatal
survey, 1993-1995. BMJ 1998 Feb 28;316(7132):657-660 [FREE Full
text] [doi: 10.1136/bmj.316.7132.657] [Medline: 9522787]
43. Burdea GC, Coiffet P. Virtual Reality Technology. 2nd Edition.
Hoboken: John Wiley & Sons; 2003.
44. Kiili K. Digital game-based learning: towards an experiential gaming
model. Internet Higher Educ 2005 Jan;8(1):13-24.
[doi: 10.1016/j.iheduc.2004.12.001]
45. Hunziker S, Johansson AC, Tschan F, Semmer NK, Rock L, Howell
MD, et al. Teamwork and leadership in cardiopulmonary resuscitation.
J Am Coll Cardiol 2011 Jun 14;57(24):2381-2388 [FREE Full text]
[doi: 10.1016/j.jacc.2011.03.017] [Medline: 21658557]
Abbreviations
CPR: cardiopulmonary resuscitation
SCA: sudden cardiac arrest
Edited by G Eysenbach, R Kukafka; submitted 29.07.20; peer-reviewed
by T Canares, R Lundin, D Drummond; comments to author 18.09.20;
revised version received 16.10.20; accepted 11.03.21; published
29.07.21
Copyright
©Janaya Elizabeth Perron, Michael Jonathon Coffey, Andrew Lovell-
Simons, Luis Dominguez, Mark E King, Chee Y Ooi. Originally published
in the Journal of Medical Internet Research (https://www.jmir.org),
29.07.2021.
Corresponding Author:
Janaya Elizabeth Perron, BMed, MD
Discipline of Paediatrics
School of Women’s and Children’s Health
University of New South Wales
Centre for Child Health Research & Innovation
Level 8, Bright Alliance Building, Corner of Avoca & High Streets
Randwick
Australia
Phone: 61 2 9382 5500
Fax: 61 2 9382 5681
Email: j.perron@unswalumni.com
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NEWS
How to tackle the nursing
crisis
For many people the social restrictions
experienced during lockdowns will
have had long-lasting consequences,
increasing feelings of loneliness, stress
and depression.
But throughout the pandemic those employed
in hospitals and care settings have faced the
same issues, alongside having to deal with the
pressures of working on the front-line.
Covid-19 has stretched medical staff to their limit,
and with cases continuing to rise in some areas
and a growing backlog of patients with other
health problems, they are tired, stressed, underresourced,
and some are simply burning out.
So it is perhaps unsurprising that the sector
has reported a surge in Covid-related staff
shortages.
As of June 2021, National Health Service
(NHS) vacancy statistics for England showed
there were an alarming 38,952 registered
nurse vacancies across the health service.
In a report by the Royal College of Nursing
(RCN), it was revealed that the NHS in
England recorded 73,209 more sick days
among nurses and health visitors in May 2021
compared to May 2019 - a rise of 18%.
The analysis showed that staff are now at
greater risk of mental health problems, chest
and respiratory problems and migraines than
before the pandemic.
The UK government has promised a nursing
recruitment drive – increasing the number
of nurses in the NHS by 50,000 by 2024-25
- and pledged to increase nurse pay by 3%
in recognition of the “extraordinary efforts” of
NHS staff during the pandemic.
But whether these measures have any real
impact on staff recruitment or retention remains
to be seen as nursing shortages are a global
issue and there simply aren’t surpluses of trained
nurses anywhere. Even if they were available,
employing more and more nurses is not a
sustainable solution to an ever-growing problem.
A recent article by the New York Times
headlined ‘Nursing is in crisis: Staff shortages
in US put patients at risk’, quotes an
emergency room nurse who describes her work
environment as being “like a war zone”, with
sick patients waiting to be admitted to hospital
and staff left physically and emotionally drained.
In the piece, Patricia Pittman, Director of the
Health Workforce Research Center at George
Washington University, says: “When hospitals
are understaffed, people die.”
The story paints a troubling picture – and
shows that the situation is not confined to
hospitals in the UK.
That’s why some providers have begun to
explore novel technological solutions to their
staffing challenges.
It’s an approach that has already attracted the
interest of UK government decision makers.
In a keynote speech during London Tech
Week, UK Health and Social Care Secretary,
Sajid Javid, said he hoped the healthcare
progress made during the pandemic under
“incredible strain” would pave the way for a
“long-awaited digital revolution”.
Javid said the building blocks of this revolution
would see out-of-date technology replaced
and the adoption of a “truly integrated system”
where health service employees can easily
access and share patient data.
“It’s only by allowing colleagues to see
patients’ information in one place, regardless
of what part of the system they use, that we
can have a truly integrated system for health
and social care,” he said.
While better and safely shared access to
patient data is essential, it raises the question
of whether even this will make much difference
to ever extending waiting times to see a doctor
or to get booked in for an operation.
What is needed are new connected digital
technologies that automate much of the
basic work in the wards, giving nurses more
time to care for their patients and doctors the
vital information they need to make fast and
accurate decisions about a patient’s treatment.
Systems such as Isansys Lifecare’s Patient
Status Engine (PSE) provide a way of relieving
pressure on staff and freeing up hospital beds.
The PSE is a Class II(a) CE and FDA certified
wireless patient monitoring platform that allows
clinicians to monitor patients in hospital and
at home by automatically collecting realtime
physiological data such as heart rate,
respiration rate, oxygen saturation, blood
pressure and body temperature.
This data is then transmitted via Bluetooth from the
Patient Gateway to a central server, then through
the nurses’ station, or remotely to clinicians.
This data is filtered and analysed at each point
so only the key clinical information is provided.
Smart notifications can alert care teams or
clinicians anywhere, any time on computers,
tablets or phones.
Patients are also free from wires and cables,
and can walk around or even go home, freeing
up much-needed hospital beds for those most
in need.
The technology reduces the amount of nurses’
time spent in mundane tasks and form-filling,
provides a safe way to check in on how those
with Covid-19 or other infectious conditions are
doing, and allows one nurse to safely monitor
several patients at once.
If a patient’s health starts to deteriorate, the
system will provide an early warning to nursing
staff so they can act on it in a timely and proactive
way.
It’s an approach that has already seen
success in the field.
The Sorlandet Hospital in Kristiansand,
Norway, used the PSE to allow clinicians and
nurses to view vital sign measurements and
real-time calculations of patient health direct
from a wireless bedside gateway to their
nursing stations.
The hospital said the technology freed-up
nurses’ time and provided complete and
accurate information to support their care
decisions, allowing them to focus on a proactive
rather than reactive care delivery model.
Birmingham Women’s and Children’s NHS
Foundation Trust took part in the RAPID (Real
Time Adaptive and Predictive Indicator of
Deterioration) project, a ground-breaking study
to detect and respond to clinical deterioration
in sick children.
The Trust used the PSE platform to monitor
and care for children and babies in real-time,
helping staff to identify deterioration more
quickly so timely treatment could be given.
In all these cases the PSE worked in
conjunction with nurses and doctors to free up
time and improve efficiency – key areas when
care providers are trying to balance high patient
numbers with the wellbeing of their staff.
The goal of any care provider is to provide
staff with the right tools and optimal working
conditions to deliver the best possible care for
patients - and ultimately save lives. And that,
after all, is what we all want.
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