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Original Investigation
November 17, 2019

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

Author Affiliations
  • 1Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
  • 2Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
JAMA Cardiol. Published online November 17, 2019. doi:https://doi.org/10.1001/jamacardio.2019.4992
Key Points

Question  Does virtual reality (VR) cardiopulmonary resuscitation (CPR) training result in CPR quality and performance comparable with face-to-face training?

Findings  In this randomized noninferiority trial of 381 individuals, VR training resulted in noninferior chest compression rate but inferior compression depth; proportions of participants fulfilling guideline-endorsed compression depth or rate recommendations were lower in VR training, although overall these criteria were met in more than 50%. Cardiopulmonary resuscitation scenario performance and chest compression fraction were worse, but leaning was less common than in face-to-face training.

Meaning  Although VR training may lead to chest compression rates similar to face-to-face training, it needs further development to achieve comparable compression depth and overall CPR performance.


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

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

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

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

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

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

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

Trial Registration  ClinicalTrials.gov identifier: NCT04013633