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Virtual Reality and the Redesign of Sudden Cardiac Arrest Training to Increase Lay Bystander Training and Response

Disruptive Innovations

 Executive Summary

There exists an emotional disconnect between managing an emergency situation in practice versus managing an emergency in real-life. The Center for Resuscitation Science (CRS) at the University of Pennsylvania is exploring ways in which Virtual Reality (VR) can enhance current emergency trainings for Sudden Cardiac Arrest (SCA), while also increasing the dissemination potential of cardiopulmonary resuscitation to communities that are at increased risk of SCA. VR is a computer-programed, 3D environment where users interact with immersive realities, allowing learners to experience, in real-time, their decisions and actions in high-stress, seemingly realistic environments. The CRS is focusing their efforts on adapting traditional VR technologies for mobile devices, allowing greater dissemination of these technologies for social good. The creation of an effective VR SCA mobile training system has the potential to improve both the number of people trained in CPR and the accessibility of trainings. 


Standard cardiopulmonary resuscitation (CPR) classroom trainings have been utilized for more than 50 years, yet in that time survival from cardiac arrest has only incrementally increased.1 A Sudden Cardiac Arrest (SCA) is the abrupt cessation of cardiac function and blood flow in the out-of hospital setting requiring CPR. In the U.S., greater than 350,000 people suffer from an SCA annually, and survival is low, just 12 percent.2-4 Bystander CPR could double to even triple survival rates, however, only 18 percent of the lay public are trained in CPR.5-7 Consequently, most victims of an SCA, roughly 60 percent, often do not receive this life-saving intervention.8-9 Further, large disparities exist within SCA care. Studies have shown that the rate of bystander CPR nationally is significantly lower in low-socioeconomic status (SES) communities, even though the incidence of SCA is two times higher in these communities.10-14 A study published in the New England Journal of Medicine examining 29 U.S. sites found that low-income Blacks were less likely to receive bystander CPR when compared to their high-income White counterparts.11 This study highlighted the increased risk SCA poses to low-income communities. 

One potential reason for the low bystander CPR rates, and the existing disparities in SCA response, can be linked to the current CPR training paradigm. Lay bystander CPR trainings are costly to participants, limited in their locations, and long in duration, thus inhibiting widespread participation. Additionally, lay bystanders are trained in a classroom setting where they watch a training video and then briefly practice CPR skills on a plastic manikin. They complete a CPR skills test and a written exam to determine if their knowledge of resuscitation skills meets the current guideline standards. This type of classroom training does not simulate the stress of a real SCA event or enhance knowledge translation.15-17 Underscoring these issues, the American Heart Association and the National Academy of Medicine both acknowledge that efforts to improve outcomes from cardiac arrest in the U.S. are falling short, and have emphasized the need for innovation, and the integration of technology, into bystander response training.8,18-19 One such innovation that has the potential to better prepare individuals for emergency situations and, if further developed, allow for widespread applicability, is Virtual Reality (VR). 

VR is a computer-programmed, environment where users engage with multi-sensory, immersive 3D realities using VR headsets and haptic sensors.20 These VR systems allow learners to experience, in real-time, their decisions and actions in a seemingly real and high-stress environment. Studies have found that subjects who learned on VR had an increase in learning effectiveness, along with better recall, than those taught with traditional methods. Additionally, clinical trials using virtual reality exposure therapy (VRET) found that patients who underwent VRET had significantly better behavioral assessments post intervention. Such research shows that VR immersion can significantly change behavior in real-life situations. Many healthcare domains that manage high-acuity illnesses and injuries, such as neurosurgery, general surgery, and psychiatry are already using VR technologies for a range of training applications.9, 21-25 An inherent power of VR for lay bystander training is that it can simulate high-stress, rare-occurring events in a dynamic, yet safe environment. This allows trainees to not just be prepared with the knowledge and skills to save a life, but to be emotionally and mentally prepared to respond if needed.

Our team at the Center for Resuscitation Science (CRS) at the University of Pennsylvania is exploring ways in which VR can enhance current CPR trainings for SCA. Supported by grant funding from the Medtronic Foundation and the Laerdal Foundation, the CRS created and studied a three-minute long VR SCA system to determine the effectiveness of using this technology to improve bystander response.26-27 Subjects were equipped with traditional VR goggles, integrated with a CPR feedback manikin, and “transported” to an urban city street. In the simulation, an avatar collapsed, and subjects had to decide how to respond. The subjects could communicate with other avatars, and if they chose to perform CPR, a real-life manikin was placed where the avatar fell to provide tactile feedback. The team held a debriefing with subjects to discuss how they could have improved their response had the simulation been a “real” SCA event. The CRS feels VR SCA trainings hold great promise in improving the quality of bystander response; however, they recognize that traditional VR technologies, which are cumbersome and costly, must be developed further to allow for more widespread applicability.

Therefore, the CRS is currently focusing its efforts on adapting the VR SCA technology into a mobile application, which will allow for greater dissemination of trainings for social good. As over three-quarters of Americans, including more than half of low-income individuals, own smartphones, mobile training applications serve as an ideal platform for cost-effective, widespread community CPR trainings. Mobile VR applications work in conjunction with low cost, standalone, VR “devices, ” which are currently available from companies such as Google for around $15. The devices combine with a mobile phone to create VR immersion, allowing a higher dissemination training modality with the increased realism of VR. The CRS recently created a mobile VR SCA training application to be used with the low-cost cardboard VR devices; this work was supported by a grant from the Astrazeneca Foundation to begin a community-wide campaign to disseminate the free VR SCA training application in low-SES communities throughout Philadelphia. The creation of an effective mobile VR SCA training application could greatly improve the quality of bystander CPR and increase the percentage of the lay public prepared to respond to an SCA. 

VR technologies have the potential to change the paradigm of CPR training and could have broad applications in preparing lay bystanders for rare-occurring, time-sensitive, emergencies. Further, VR mobile applications are able to offer immediate, widespread access to immersive, multisensory emergency trainings. If these types of trainings prove to be more effective than current classroom trainings, it could revolutionize emergency response training models and increase survival rates. Such a potential for social good warrants continued exploration and development of these technologies. 

Author bios

Ariel Karwat holds a B.S in Psychobiology from the University of California, Los Angeles and is currently an accelerated BSN/MSN candidate at the University of Pennsylvania’s School of Nursing. Prior to attending nursing school, she worked as a Clinical Research Coordinator in Breast Oncology for the University of California, San Francisco. This past year she joined the team at the University of Pennsylvania’s Center for Resuscitation Science to explore more innovative approaches to healthcare.

Marion Leary is the Director of Innovation Research for the Center for Resuscitation Science at the University of Pennsylvania and the Innovation Specialist at Penn’s School of Nursing. In addition she is an Instructor in the Penn Master of Public Health program. Ms. Leary has focused her research and education on cardiac arrest with the current goal of developing innovative strategies to improve CPR and resuscitation training. Ms. Leary currently serves on the Science Subcommittee of the American Heart Association (AHA)’s Emergency Cardiovascular Care Committee and was a member of the AHA’s Education Innovation Summit. Ms. Leary is a contributor to the Huffington Post, and is the founder of the ImmERge Labs, LLC, focusing on using mixed reality platforms to reimagine how the world prepares for emergencies. Ms. Leary was recently named Philadelphia’s Geek of the Year for 2017. 

Conflict of Interest Statement

Marion Leary has received research support from the Medtronic Foundation, Laerdal Foundation, the American Heart Association and the Astrazeneca Foundation. Ms. Leary has received in-kind support from Laerdal Medical. Ms. Leary has ownership in ImmERge Labs, LLC a University of Pennsylvania UPstart company.

End Notes

1 Mark L. DeBard. “The history of cardiopulmonary resuscitation.” Annals of Emergency Medicine. 9, no 5 (1980): 273-5

2 Akshay Bagai, et al. “Temporal differences in out-of-hospital cardiac arrest incidence and survival.” Circulation, 128, no. 24 (2013): 2595-2602

3 Ian Stiell, et al. “Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest.” New England Journal of Medicine, 351, no. 7 (2004): 647-656

4 Jasenka Demirovic “Cardiopulmonary Resuscitation Programs Revisited: Results of a Community Study Among Older African Americans.” The American Journal of Geriatric Cardiology 14, no. 4 (2004): 182-187

5 Alan S. Go, et al. “Executive summary: heart disease and stroke statistics—2014 update: a report from the American Heart Association.” Circulation, 129, no 3 (2014): 399-410

6 Audrey Blewer, et al. “Cardiopulmonary Resuscitation Training Disparities in the United States.” Journal of the American Heart Association, 6, no. 5 (2017)

7 Audrey Blewer, et al. “The majority of laypersons trained in CPR do not maintain current certification training.” Circulation. (2016): 134:A15787

8 Peter A. Meaney, et al. “Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital a consensus statement from the American Heart Association.” Circulation, 128, no. 4 (2013): 417-435

9 Pierre Pasquier, et al. “A Serious Game for Massive Training and Assessment of French Soldiers Involved in Forward Combat Casualty Care (3D-SC1): Development and Deployment.” JMIR serious games, 4, no. 1 (2016): e5

10 Comilla Sasson, et al. “Increasing cardiopulmonary resuscitation provision in communities with low bystander cardiopulmonary resuscitation rates: a science advisory from the American Heart Association for healthcare providers, policymakers, public health departments, and community leaders.” Circulation 127, no. 12 (2013): 1342-1350

11 Comilla Sasson, et al. "Association of neighborhood characteristics with bystander-initiated CPR." New England Journal of Medicine 367, no. 17 (2012): 1607-615

12 Jasenka Demirovic “Cardiopulmonary Resuscitation Programs Revisited: Results of a Community Study Among Older African Americans.” The American Journal of Geriatric Cardiology 14, no. 4 (2004): 182-187

13 Wallace, et al, “Band Racial Differences in Prehospital Care of Out-of-Hospital Cardiac Paper” (presentation, Society of Academic Emergency Medicine Annual Meeting, Chicago, IL, 2012

14 Thomas Rea, et al. “Increasing use of cardiopulmonary resuscitation during out of-hospital ventricular fibrillation arrest: survival implications of guideline changes.” Circulation, 114, no. 25 (2006): 2760-2765

15 Lauren W. Conlon, et al. “Impact of levels of simulation fidelity on training of interns in ACLS.” Hospital Practice, 42, no. 4 (1995): 135-141

16 Lindsey E. Davis, et al. “High-Fidelity Simulation for Advanced Cardiac Life Support Training.” American Journal of Pharmaceutical Education, 77, no. 3 (2013): 59

17 Tara M. Serwetnyk, et al. “Comparison of Online and Traditional Basic Life Support Renewal Training Methods for Registered Professional Nurses.” Journal for nurses in professional development, 31, no. 6 (2015): E1-10

18 John S. Rumsfeld, et al. "Use of Mobile Devices, Social Media, and Crowdsourcing as Digital Strategies to Improve Emergency Cardiovascular Care." Circulation 134, no. 8 (2016)

19 Robert. Graham, Margaret A. McCoy, and Andrea M. Schultz. "Strategies to Improve Cardiac Arrest Survival." National Academies Press, 2015. 

20 Gilson Giraldi, Rodrigo Silva, and Juavane deOliveira. “Introduction to Virtual Reality.” LNCC-National Laboratory for Scientific Visualization and Virtual Reality Laboratory. Link

21 Alaraj A, et al. “Virtual reality cerebral aneurysm clipping simulation with real time haptic feedback.” Neurosurgery, 11, no 2. (2015): 52

22 Albert Rizzo, et al. “Virtual reality goes to war: a brief review of the future of military behavioral healthcare.” Journal of Clinical Psychology in Medical Settings, 18, no. 2 (2011): 176-187

23 Anthony Gallagher, et al. “Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training.” Annals of Surgery, 241, no. 2 (2005): 364-372

24 Felix Nickel, et al. “Virtual reality training versus blended learning of laparoscopic cholecystectomy: a randomized controlled trial with laparoscopic novices.” Medicine, 94, no. 20 (2015)

25 Nexhmedin Morina, et al. “Can virtual reality exposure therapy gains be generalized to real-life? A meta-analysis of studies applying behavioral assessments.” Behavior Research and Therapy, 74 (2015): 18-24

26 Marion Leary, et al. “Using Immersive Virtual Reality to Observe Differences in Lay Provider Response to an Unannounced Simulated Sudden Cardiac Arrest Based on Demographics.” Circulation. (2017);136:A14891

27 Alfredo Almodovar et al. “Examining Lay Provider Response to an Unannounced Simulated Sudden Cardiac Arrest Using an Immersive Virtual Reality System.” Circulation. (2017);136:A14871