@Article{info:doi/10.2196/57057, author="Louvel, Anne-Claire and Dopff, C{\'e}cile and Loron, Gauthier and Michelet, Daphne", title="Impact of a 3-Month Recall Using High-Fidelity Simulation or Screen-Based Simulation on Learning Retention During Neonatal Resuscitation Training for Residents in Anesthesia and Intensive Care: Randomized Controlled Trial", journal="JMIR Serious Games", year="2025", month="Mar", day="21", volume="13", pages="e57057", keywords="screen-based simulation", keywords="high-fidelity simulation", keywords="neonatal resuscitation", keywords="pediatric", keywords="infant", keywords="neonatal", keywords="newborns", keywords="emergency", keywords="urgent", keywords="simulation", keywords="resuscitation", keywords="intensive care", keywords="medical education", keywords="anesthesia", keywords="anesthesiology", keywords="high fidelity", keywords="educational", keywords="student", keywords="resident", keywords="knowledge retention", keywords="learner", keywords="teaching", keywords="intensive care unit", keywords="ICU", abstract="Background: Retention capacities are dependent on the learning context. The optimal interval between two learning sessions to maintain a learner's knowledge is often a subject of discussion, along with the methodology being used. Screen-based simulation could represent an easy alternative for retraining in neonatal resuscitation. Objective: The aim of the study was to evaluate the benefits of a 3-month recall session using high-fidelity simulation or screen-based simulation, assessed 6 months after an initial neonatal resuscitation training session among anesthesia and intensive care residents. Methods: All participating anesthesia and intensive care residents were volunteers, and they underwent training in the same session, which included a theoretical course and high-fidelity simulation. The attendees were then randomized into three groups: one with no 3-month recall, one with a high-fidelity simulation recall, and one with a screen-based simulation recall. To reassess the skills of each participant, a high-fidelity simulation was performed at 6 months. The primary outcomes included expert assessment of technical skills using the Neonatal Resuscitation Performance Evaluation score and nontechnical skills assessed by the Anesthesia Non-Technical Skills score. Secondary outcomes included a knowledge quiz and self-assessment of confidence. We compared the results between groups and analyzed intragroup progressions. Results: Twenty-eight participants were included in the study. No significant differences were observed between groups at the 6-month evaluation. However, we observed a significant improvement in theoretical knowledge and self-confidence among students over time. Regarding nontechnical skills, as evaluated by the Anesthesia Non-Technical Skills score, there was significant improvement between the initial training and the 6-month session in both recall groups (16 vs 12.8, P=.01 in the high-fidelity group; 16 vs 13.9, P=.05 in the simulation group; 14.7 vs 15.1, P=.50 in the control group). For technical skills assessed by the Neonatal Resuscitation Performance Evaluation score, a nonsignificant trend toward improvement was observed in the two recall groups, while a regression was observed in the control group (all Ps>.05). The increase in students' self-confidence was significant across all groups but remained higher in the two 3-month recall groups. Conclusions: Initial neonatal resuscitation training for anesthesia and intensive care residents leads to improved knowledge and self-confidence that persist at 6 months. A 3-month recall session, whether through high-fidelity simulation or screen-based simulation, improves nontechnical skills (eg, situation management and team communication) and technical skills. Screen-based simulation, which saves time and resources, appears to be an effective educational method for recall after initial training. The study outcomes justify the need for further studies with larger sample sizes to confirm the promising role of serious games in educational programs for medical students. ", doi="10.2196/57057", url="https://games.jmir.org/2025/1/e57057" } @Article{info:doi/10.2196/49895, author="Zucca, Alison and Bryant, Jamie and Purse, Jeffrey and Szwec, Stuart and Sanson-Fisher, Robert and Leigh, Lucy and Richer, Mike and Morrison, Alan", title="Evaluation of the Effectiveness of Advanced Technology Clinical Simulation Manikins in Improving the Capability of Australian Paramedics to Deliver High-Quality Cardiopulmonary Resuscitation: Pre- and Postintervention Study", journal="JMIR Cardio", year="2024", month="Dec", day="24", volume="8", pages="e49895", keywords="paramedicine", keywords="cardiopulmonary resuscitation", keywords="clinical simulation", keywords="professional development", keywords="manikins", keywords="effectiveness", keywords="technology", keywords="paramedics", keywords="patient care", keywords="simulation-based training", keywords="deployment", abstract="Background: Emergency medical services attend out-of-hospital cardiac arrests all across Australia. Resuscitation by emergency medical services is attempted in nearly half of all cases. However, resuscitation skills can degrade over time without adequate exposure, which negatively impacts patient survival. Consequently, for paramedics working in areas with low out-of-hospital cardiac arrest case volumes, ambulance services and professional bodies recognize the importance of alternative ways to maintain resuscitation skills. Simulation-based training via resuscitation manikins offers a potential solution for maintaining paramedic clinical practice skills. Objective: The aim of the study is to examine the effectiveness of advanced technology clinical simulation manikins and accompanying simulation resources (targeted clinical scenarios and debriefing tools) in improving the demonstrable capability of paramedics to deliver high-quality patient care, as measured by external cardiac compression (ECC) performance. Methods: A pre- and postintervention study design without a control group was used. Data were collected at the start of the manikin training forum (baseline), immediately following the training forum (time 2), and 6 to 11 months after the training forum (time 3). The study was conducted with paramedics from 95 NSW Ambulance locations (75 regional locations and 20 metropolitan locations). Eligible participants were paramedics who were employed by NSW Ambulance (N=106; 100\% consent rate). As part of the intervention, paramedics attended a training session on the use of advanced technology simulation manikins. Manikins were then deployed to locations for further use. The main outcome measure was an overall compression score that was automatically recorded and calculated by the simulator manikin in 2-minute cycles. This score was derived from compressions that were fully released and with the correct hand position, adequate depth, and adequate rate. Results: A total of 106 (100\% consent rate) paramedics participated, primarily representing regional ambulance locations (n= 75, 78.9\%). ECC compression scores were on average 95\% or above at all time points, suggesting high performance. No significant differences over time (P>.05) were identified for the overall ECC performance score, compressions fully released, compressions with adequate depth, or compressions with the correct hand position. However, paramedics had significantly lower odds (odds ratio 0.30, 95\% CI 0.12-0.78) of achieving compressions with adequate rate at time 3 compared to time 2 (P=.01). Compressions were of a slower rate, with an average difference of 2.1 fewer compressions every minute. Conclusions: Despite this difference in compression rate over time, this did not cause significant detriment to overall ECC performance. Training and deployment of simulator manikins did not significantly change paramedics' overall ECC performance. The high baseline performance (ceiling effect) of paramedics in this sample may have prevented the potential increase in skills and performance. ", doi="10.2196/49895", url="https://cardio.jmir.org/2024/1/e49895" } @Article{info:doi/10.2196/58780, author="Farooq, Munawar and Al Jufaili, Mahmood and Hanjra, K. Faisal and Ahmad, Shabbir and Dababneh, Hanna Emad and Al Nahhas, Omar and Bashir, Khalid", title="Bystander Response and Out-of-Hospital Cardiac Arrest Outcomes (Bro. Study) in 3 Gulf Countries: Protocol for a Prospective, Observational, International Collaboration Study", journal="JMIR Res Protoc", year="2024", month="Nov", day="12", volume="13", pages="e58780", keywords="out-of-hospital cardiac arrest", keywords="cardiac arrest outcomes", keywords="bystander response", keywords="cardiopulmonary resuscitation", keywords="CPR", keywords="automated external defibrillator", keywords="AED", keywords="survival to discharge", keywords="emergency medical services", keywords="prehospital care", keywords="Utstein style", abstract="Background: : Globally, there is significant variation in the out-of-hospital cardiac arrest (OHCA) survival rate. Early links in the chain of survival, including bystander cardiopulmonary resuscitation (CPR) and the use of an automated external defibrillator at the scene, are known to be of crucial importance, with strong evidence of increased survival rate with good neurological outcomes. The data from the Middle East are limited and report variable rates of bystander CPR and survival. It is crucial to get prospective, reliable data on bystander response in these regions to help plan interventions to improve bystander response and outcomes. Objective: This international collaborative study aims to describe the characteristics, including bystander interventions and outcomes, of OHCAs brought to hospitals enrolled in the study from Abu Dhabi, United Arab Emirates; Doha, Qatar; and Muscat, Oman. It also aims to describe the strength of the association between bystander response and OHCA outcomes, including the return of spontaneous circulation, survival to hospital admission, survival to discharge, and good neurological outcome at discharge in the local context of low bystander CPR rates. Methods: This multicenter, prospective, noninterventional observational study (Bro. Study) will be conducted at the emergency departments of 4 participating tertiary care hospitals in 3 countries. The data will be collected prospectively according to the Utstein style (a set of internationally accepted guidelines for uniform reporting of cardiac arrests) on demographic variables (age, sex, nationality, country, participating center, and comorbidities), peri--cardiac arrest variables (location, witnessed or not, bystander CPR, use of automated external defibrillator, time of emergency medical services arrival, initial rhythm, number of shocks, and time of prehospital CPR), and outcome variables (return of spontaneous circulation, survival to discharge, and neurological outcome at discharge and 3 months). Univariate and multivariate analysis with logistic regression models will be used to measure the strength of the association of bystander interventions with outcomes using SPSS (version 22). Results: Data collection began in November 2023 and will continue for 2 years, with publication expected by early 2026. Conclusions: Bystander response to an OHCA is critical to a favorable outcome. The reliable, baseline bystander CPR data will be a cornerstone in the team's next planned projects, which are to qualitatively identify the barriers to bystander CPR, conduct a scoping review of community interventions in the Gulf and other Asian countries, and design and implement strategies to help improve the bystander CPR rate in the community. International Registered Report Identifier (IRRID): DERR1-10.2196/58780 ", doi="10.2196/58780", url="https://www.researchprotocols.org/2024/1/e58780" } @Article{info:doi/10.2196/55333, author="Flato, Prync Uri Adrian and Beffa dos Santos, Jos{\'e} Emilio and Bispo Diaz T Martins, Isabella and Rossignoli, Gazin Vinicius and Dias Midega, Thais and Kallas-Silva, Lucas and Ferreira Mendes de Oliveira, Ricardo and do Socorro Lima Figueiredo Flato, Adriana and Vicente Guimar{\~a}es, Mario and Penna Guimar{\~a}es, H{\'e}lio", title="Interactive Serious Game to Teach Basic Life Support Among Schoolchildren in Brazil: Design and Rationale", journal="JMIR Serious Games", year="2024", month="Oct", day="9", volume="12", pages="e55333", keywords="cardiopulmonary resuscitation", keywords="basic life support", keywords="serious game", keywords="CPR training", keywords="usability", keywords="cardiopulmonary", keywords="emergency", keywords="life support", keywords="CPR", keywords="training", keywords="education", keywords="game", keywords="gaming", keywords="educational", keywords="resuscitation", keywords="survey", keywords="satisfaction", keywords="SUS", keywords="user experience", keywords="System Usability Scale", doi="10.2196/55333", url="https://games.jmir.org/2024/1/e55333" } @Article{info:doi/10.2196/53577, author="Wang, Yun and Fu, Junzuo and Wang, Shaoping and Wang, Huijuan and Gao, Wei and Huang, Lina", title="Impact of Video-Based Error Correction Learning for Cardiopulmonary Resuscitation Training: Quasi-Experimental Study", journal="JMIR Serious Games", year="2024", month="Oct", day="3", volume="12", pages="e53577", keywords="video-based error correction", keywords="video-prompting", keywords="cardiopulmonary resuscitation training", keywords="anesthesiology resident", keywords="quasi-experimental study", keywords="anesthesiology", keywords="cardiopulmonary", keywords="cardiopulmonary resuscitation", keywords="training", keywords="video", keywords="learning", keywords="residents", keywords="CPR training", keywords="CPR", keywords="video prompting", abstract="Background: Video-based error correction (VBEC) in medical education could offer immediate feedback, promote enhanced learning retention, and foster reflective practice. However, its application in cardiopulmonary resuscitation (CPR) training has not been investigated. Objective: The objective of this study is to assess whether the VBEC procedure could improve the training performance of CPR among anesthesiology residents. Methods: A quasi-experimental study was conducted among anesthesiology residents between December 2022 and April 2023. Primary outcomes included a posttraining knowledge test and practical assessment scores. Secondary outcomes included the number of residents who correctly conducted CPR at each step, the rate of common mistakes during the CPR process, and the self-assessment results. A total of 80 anesthesiology residents were divided into a VBEC group (n=40) and a control group (n=40). The VBEC group underwent a 15-minute VBEC CPR training, whereas the control group underwent a 15-minute video-prompting CPR training. Results: The posttraining knowledge test score of the VBEC group was significantly higher than that of the control group (73, SD 10.5 vs 65.1, SD 11.4; P=.002). The residents in the VBEC group had lower error rates in ``failure to anticipate the next move'' (n=3, 7.5\% vs n=13, 32.5\%; P=.01) and ``failure to debrief or problem solve after the code'' (n=2, 5\% vs n=11, 27.5\%; P=.01), as well as better performance in the ``secure own safety'' step (n=34, 85\% vs n=18, 45\%; P<.001) than those in the control group. The VBEC group showed significantly higher confidence in CPR than the control group (n=?, 62.5\% vs n=?, 35\%; P=.03). Conclusions: VBEC may be a promising strategy compared to video prompting for CPR training among anesthesiology residents. ", doi="10.2196/53577", url="https://games.jmir.org/2024/1/e53577" } @Article{info:doi/10.2196/53212, author="Min, Jennifer Hyojin and Andler, Caroline and Barber, Banca Rebecca Ortiz La and Chang, P. Todd and Abelairas-Gomez, Cristian and Knowlin, T. Laquanda and Liu, R. Deborah and Fija{\v c}ko, Nino", title="Virtual Reality for Basic Life Support Training in High School Students: Thematic Analysis of Focus Group Interviews", journal="JMIR XR Spatial Comput", year="2024", month="Apr", day="16", volume="1", pages="e53212", keywords="virtual reality", keywords="mixed reality", keywords="technology", keywords="basic life support", keywords="cardiovascular pulmonary resuscitation", keywords="near-peer mentoring", keywords="education", keywords="high school students", abstract="Background: High-quality and engaging cardiopulmonary resuscitation (CPR) training of both health care professionals and members of the public is necessary to provide timely and effective CPR to maximize survival and minimize injuries. Virtual reality (VR) is a novel method to enhance CPR engagement and training. However, a near-peer mentoring framework has not been applied in such training to date. Objective: The purpose of this pilot qualitative study was to understand the acceptability and feasibility of using VR technology to introduce basic life support (BLS) to high school students reinforced by near-peer coaching. Methods: Dyads of high school students underwent BLS training in CPR using a VR experience reinforced by the near-peer mentoring model. Focus group interviews were performed following the intervention. The interview sessions were recorded, transcribed verbatim, and subjected to thematic analysis. VR software data were analyzed after five cycles of chest compressions between the two participants. Results: The overwhelming responses from the three dyads of high school students indicated positive acceptance of learning CPR using VR. Analysis of emerging themes revealed three main categories of barriers and facilitators: (1) motivation to learn CPR, (2) CPR learning modality, and (3) coaching CPR content. These themes supported the theoretical framework of an ``intention-focused'' paradigm leading to acquiring the skills needed to perform CPR and ultimately increasing the chances of a bystander performing CPR. Conclusions: This study highlights the potential for training a unique population to increase bystander effects using novel VR technology coupled with a near-peer mentoring method. Further research is warranted to measure the outcome of the knowledge attained and the intention to perform CPR by high school students who participate in CPR education using VR and a near-peer mentoring method. ", doi="10.2196/53212", url="https://xr.jmir.org/2024/1/e53212" } @Article{info:doi/10.2196/52990, author="Cheng, Pengfei and Huang, Yangxi and Yang, Pengyu and Wang, Haizhen and Xu, Baichao and Qu, Chaoran and Zhang, Hua", title="The Effects of Serious Games on Cardiopulmonary Resuscitation Training and Education: Systematic Review With Meta-Analysis of Randomized Controlled Trials", journal="JMIR Serious Games", year="2024", month="Feb", day="6", volume="12", pages="e52990", keywords="CPR", keywords="education", keywords="meta-analysis", keywords="serious game", keywords="training", abstract="Background: Serious games have emerged as an innovative educational strategy with the potential to significantly enhance the quality and effectiveness of cardiopulmonary resuscitation (CPR) training. Despite their promise, there remains a degree of controversy when comparing the advantages of serious games with traditional CPR training methods. This study seeks to provide a comprehensive assessment of the impact of serious games on CPR training and education by systematically analyzing the results of previous research. Objective: This study aimed to assess the effect of serious games on CPR training and education by summarizing and pooling the results of previous studies. Methods: We conducted a thorough and systematic search across 9 prominent web-based databases, encompassing the period from the inception of these databases until April 1, 2023. The databases included in our search were PubMed, Cochrane Library, Wiley Online Library, EBSCO (PsycInfo), SpringerLink, Chinese Biology Medicine Disc, Vip Journal Integration Platform, Wanfang Database, and Chinese National Knowledge Infrastructure. The studies selected adhered to the following criteria: (1) being a randomized controlled trial comparing serious games and traditional methods for CPR training; (2) having participants aged 12 years or older in CPR; (3) having an experimental group using serious games and a control group using nongame methods for CPR instruction; and (4) having outcomes including theoretical and skill assessments, compression depth, and rate. The Cochrane risk of bias assessment tool was used to evaluate the risk of bias. Data analysis was performed using RevMan (version 5.3; Cochrane Training), and mean differences (MDs) and standardized mean differences (SMDs) with 95\% CIs were used to calculate continuous variables. Results: A total of 9 articles were included, involving 791 study participants, of whom 395 in the experimental group taught CPR training using serious games and 396 in the control group taught CPR training using traditional methods. The results of our meta-analysis indicate that the use of serious games in CPR training yields outcomes that are comparable in effectiveness to traditional training methods across several key areas. Specifically, serious games demonstrated equivalence to traditional formats in theory assessment (SMD --0.22, 95\% CI -- 0.96 to 0.51; P=.55), skill assessment (SMD --0.49, 95\% CI --1.52 to 0.55; P=.36), compression depth (MD --3.17, 95\% CI --0.18 to 6.53; P=.06), and compression rate (MD --0.20, 95\% CI --7.29 to 6.89; P=.96). Conclusions: In summary, serious games offer a viable and effective CPR education approach, yielding results comparable to traditional formats. This modality is a valuable addition to CPR training methodologies. However, caution is warranted in interpreting these findings due to limited controlled trials, small sample sizes, and low-quality meta-analyzed evidence. ", doi="10.2196/52990", url="https://games.jmir.org/2024/1/e52990", url="http://www.ncbi.nlm.nih.gov/pubmed/38319697" } @Article{info:doi/10.2196/36423, author="Lim, Amanda Xiu Ming and Liao, Ariel Wenxin and Wang, Wenru and Seah, Betsy", title="The Effectiveness of Technology-Based Cardiopulmonary Resuscitation Training on the Skills and Knowledge of Adolescents: Systematic Review and Meta-analysis", journal="J Med Internet Res", year="2022", month="Dec", day="15", volume="24", number="12", pages="e36423", keywords="cardiac arrest", keywords="education", keywords="methods", keywords="first responders", keywords="resuscitation training", keywords="effectiveness", keywords="adolescents", keywords="schoolchildren", abstract="Background: Cardiopulmonary resuscitation (CPR) training for adolescents is a prominent strategy to increase the number of community first responders who can recognize cardiac arrest and initiate CPR. More schools are adopting technology-based CPR training modalities to reduce class time and reliance on instructor availability and increase their capacity for wider training dissemination. However, it remains unclear whether these technology-based modalities are comparable with standard training. Objective: This study aimed to systematically review and perform meta-analyses to evaluate the effectiveness of technology-based CPR training on adolescents' CPR skills and knowledge. Methods: Searches were conducted in PubMed, Embase, Cochrane Library, Ovid MEDLINE, CINAHL, PsycINFO, Education Resources Information Center, ProQuest Dissertations and Theses Global, and Scopus from inception to June 25, 2021. Eligible randomized controlled trials (RCTs) compared technology-based training with standard training for adolescents aged 12 to 18 years. Studies were appraised using the Cochrane risk-of-bias tool. Random-effects meta-analyses were performed using Review Manager (The Cochrane Collaboration). Subgroup analyses were conducted to explore sources of heterogeneity. Overall certainty of evidence was appraised using the Grading of Recommendations Assessment, Development, and Evaluation approach. Results: Seventeen RCTs involving 5578 adolescents were included. Most of the studies had unclear risks of selection bias (9/17, 53\%) and high risks of performance bias (16/17, 94\%). Interventions that included instructor guidance increased the likelihood of adolescents checking the responsiveness of the person experiencing cardiac arrest (risk ratio 1.39, 95\% CI 1.19-1.63) and calling the emergency medical services (risk ratio 1.11, 95\% CI 1.00-1.24). Self-directed technology-based CPR training without instructor guidance was associated with poorer overall skill performance (Cohen d=--0.74, 95\% CI --1.02 to --0.45). Training without hands-on practice increased mean compression rates (mean difference 9.38, 95\% CI 5.75-13.01), whereas real-time feedback potentially yielded slower compression rates. Instructor-guided training with hands-on practice (Cohen d=0.45, 95\% CI 0.13-0.78) and the use of computer programs or mobile apps (Cohen d=0.62, 95\% CI 0.37-0.86) improved knowledge scores. However, certainty of evidence was very low. Conclusions: Instructor-guided technology-based CPR training that includes hands-on practice and real-time feedback is noninferior to standard training in CPR skills and knowledge among adolescents. Our findings supported the use of technology-based components such as videos, computer programs, or mobile apps for self-directed theoretical instruction. However, instructor guidance, hands-on practice, and real-time feedback are still necessary components of training to achieve better learning outcomes for adolescents. Such a blended learning approach may reduce class time and reliance on instructor availability. Because of the high heterogeneity of the studies reviewed, the findings from this study should be interpreted with caution. More high-quality RCTs with large sample sizes and follow-up data are needed. Finally, technology-based training can be considered a routine refresher training modality in schools for future research. ", doi="10.2196/36423", url="https://www.jmir.org/2022/12/e36423", url="http://www.ncbi.nlm.nih.gov/pubmed/36520524" } @Article{info:doi/10.2196/28595, author="Ricci, Serena and Calandrino, Andrea and Borgonovo, Giacomo and Chirico, Marco and Casadio, Maura", title="Viewpoint: Virtual and Augmented Reality in Basic and Advanced Life Support Training", journal="JMIR Serious Games", year="2022", month="Mar", day="23", volume="10", number="1", pages="e28595", keywords="basic and advanced life support", keywords="first aid", keywords="cardiopulmonary resuscitation", keywords="emergency", keywords="training", keywords="simulation training", keywords="medical simulation", keywords="healthcare simulation", keywords="virtual reality", keywords="augmented reality", doi="10.2196/28595", url="https://games.jmir.org/2022/1/e28595", url="http://www.ncbi.nlm.nih.gov/pubmed/35319477" } @Article{info:doi/10.2196/30456, author="Sadeghi, H. Amir and Peek, J. Jette and Max, A. Samuel and Smit, L. Liselot and Martina, G. Bryan and Rosalia, A. Rodney and Bakhuis, Wouter and Bogers, JJC Ad and Mahtab, AF Edris", title="Virtual Reality Simulation Training for Cardiopulmonary Resuscitation After Cardiac Surgery: Face and Content Validity Study", journal="JMIR Serious Games", year="2022", month="Mar", day="2", volume="10", number="1", pages="e30456", keywords="cardiac surgery", keywords="cardiopulmonary resuscitation", keywords="emergency resternotomy", keywords="virtual reality", keywords="simulation training", keywords="serious games", keywords="virtual reality simulation", keywords="digital health", keywords="medical training", keywords="virtual training", abstract="Background: Cardiac arrest after cardiac surgery commonly has a reversible cause, where emergency resternotomy is often required for treatment, as recommended by international guidelines. We have developed a virtual reality (VR) simulation for training of cardiopulmonary resuscitation (CPR) and emergency resternotomy procedures after cardiac surgery, the Cardiopulmonary Resuscitation Virtual Reality Simulator (CPVR-sim). Two fictive clinical scenarios were used: one case of pulseless electrical activity (PEA) and a combined case of PEA and ventricular fibrillation. In this prospective study, we researched the face validity and content validity of the CPVR-sim. Objective: We designed a prospective study to assess the feasibility and to establish the face and content validity of two clinical scenarios (shockable and nonshockable cardiac arrest) of the CPVR-sim partly divided into a group of novices and experts in performing CPR and emergency resternotomies in patients after cardiac surgery. Methods: Clinicians (staff cardiothoracic surgeons, physicians, surgical residents, nurse practitioners, and medical students) participated in this study and performed two different scenarios, either PEA or combined PEA and ventricular fibrillation. All participants (N=41) performed a simulation and completed the questionnaire rating the simulator's usefulness, satisfaction, ease of use, effectiveness, and immersiveness to assess face validity and content validity. Results: Responses toward face validity and content validity were predominantly positive in both groups. Most participants in the PEA scenario (n=26, 87\%) felt actively involved in the simulation, and 23 (77\%) participants felt in charge of the situation. The participants thought it was easy to learn how to interact with the software (n=24, 80\%) and thought that the software responded adequately (n=21, 70\%). All 15 (100\%) expert participants preferred VR training as an addition to conventional training. Moreover, 13 (87\%) of the expert participants would recommend VR training to other colleagues, and 14 (93\%) of the expert participants thought the CPVR-sim was a useful method to train for infrequent post--cardiac surgery emergencies requiring CPR. Additionally, 10 (91\%) of the participants thought it was easy to move in the VR environment, and that the CPVR-sim responded adequately in this scenario. Conclusions: We developed a proof-of-concept VR simulation for CPR training with two scenarios of a patient after cardiac surgery, which participants found was immersive and useful. By proving the face validity and content validity of the CPVR-sim, we present the first step toward a cardiothoracic surgery VR training platform. ", doi="10.2196/30456", url="https://games.jmir.org/2022/1/e30456", url="http://www.ncbi.nlm.nih.gov/pubmed/35234652" } @Article{info:doi/10.2196/35399, author="Siebert, N. Johan and Gosetto, La{\"e}titia and Sauvage, Manon and Bloudeau, Laurie and Suppan, Laurent and Rodieux, Fr{\'e}d{\'e}rique and Haddad, Kevin and Hugon, Florence and Gervaix, Alain and Lovis, Christian and Combescure, Christophe and Manzano, Sergio and Ehrler, Frederic and ", title="Usability Testing and Technology Acceptance of an mHealth App at the Point of Care During Simulated Pediatric In- and Out-of-Hospital Cardiopulmonary Resuscitations: Study Nested Within 2 Multicenter Randomized Controlled Trials", journal="JMIR Hum Factors", year="2022", month="Mar", day="1", volume="9", number="1", pages="e35399", keywords="cardiopulmonary resuscitation", keywords="drugs", keywords="emergency medical services", keywords="medication errors", keywords="mobile health", keywords="mobile apps", keywords="out-of-hospital cardiac arrest", keywords="paramedics", keywords="pediatrics", keywords="System Usability Scale", keywords="Unified Theory of Acceptance and Use of Technology", keywords="smartphone", keywords="mobile phone", abstract="Background: Mobile apps are increasingly being used in various domains of medicine. Few are evidence-based, and their benefits can only be achieved if end users intend to adopt and use them. To date, only a small fraction of mobile apps have published data on their field usability and end user acceptance results, especially in emergency medicine. Objective: This study aims to determine the usability and acceptance of an evidence-based mobile app while safely preparing emergency drugs at the point of care during pediatric in- and out-of-hospital cardiopulmonary resuscitations by frontline caregivers. Methods: In 2 multicenter randomized controlled parent trials conducted at 6 pediatric emergency departments from March 1 to December 31, 2017, and 14 emergency medical services from September 3, 2019, to January 21, 2020, the usability and technology acceptance of the PedAMINES (Pediatric Accurate Medication in Emergency Situations) app were evaluated among skilled pediatric emergency nurses and advanced paramedics when preparing continuous infusions of vasoactive drugs and direct intravenous emergency drugs at pediatric dosages during standardized, simulation-based, pediatric in- and out-of-hospital cardiac arrest scenarios, respectively. Usability was measured using the 10-item System Usability Scale. A 26-item technology acceptance self-administered survey (5-point Likert-type scales), adapted from the Unified Theory of Acceptance and Use of Technology model, was used to measure app acceptance and intention to use. Results: All 100\% (128/128) of nurses (crossover trial) and 49.3\% (74/150) of paramedics (parallel trial) were assigned to the mobile app. Mean total scores on the System Usability Scale were excellent and reached 89.5 (SD 8.8; 95\% CI 88.0-91.1) for nurses and 89.7 (SD 8.7; 95\% CI 87.7-91.7) for paramedics. Acceptance of the technology was very good and rated on average >4.5/5 for 5 of the 8 independent constructs evaluated. Only the image construct scored between 3.2 and 3.5 by both participant populations. Conclusions: The results provide evidence that dedicated mobile apps can be easy to use and highly accepted at the point of care during in- and out-of-hospital cardiopulmonary resuscitations by frontline emergency caregivers. These findings can contribute to the implementation and valorization of studies aimed at evaluating the usability and acceptance of mobile apps in the field by caregivers, even in critical situations. Trial Registration: ClinicalTrials.gov NCT03021122; https://clinicaltrials.gov/ct2/show/NCT03021122. ClinicalTrials.gov NCT03921346; https://clinicaltrials.gov/ct2/show/NCT03921346 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-019-3726-4 ", doi="10.2196/35399", url="https://humanfactors.jmir.org/2022/1/e35399", url="http://www.ncbi.nlm.nih.gov/pubmed/35230243" } @Article{info:doi/10.2196/31748, author="Lacour, Matthieu and Bloudeau, Laurie and Combescure, Christophe and Haddad, Kevin and Hugon, Florence and Suppan, Laurent and Rodieux, Fr{\'e}d{\'e}rique and Lovis, Christian and Gervaix, Alain and Ehrler, Fr{\'e}d{\'e}ric and Manzano, Sergio and Siebert, N. Johan and ", title="Impact of a Mobile App on Paramedics' Perceived and Physiologic Stress Response During Simulated Prehospital Pediatric Cardiopulmonary Resuscitation: Study Nested Within a Multicenter Randomized Controlled Trial", journal="JMIR Mhealth Uhealth", year="2021", month="Oct", day="7", volume="9", number="10", pages="e31748", keywords="cardiopulmonary resuscitation", keywords="drugs", keywords="emergency medical services", keywords="medication errors", keywords="mobile health", keywords="mobile apps", keywords="out-of-hospital cardiac arrest", keywords="paramedics", keywords="pediatrics", keywords="State-Trait Anxiety Inventory", keywords="stress", abstract="Background: Out-of-hospital cardiac arrests (OHCAs) are stressful, high-stake events that are associated with low survival rates. Acute stress experienced in this situation is associated with lower cardiopulmonary resuscitation performance in calculating drug dosages by emergency medical services. Children are particularly vulnerable to such errors. To date, no app has been validated to specifically support emergency drug preparation by paramedics through reducing the stress level of this procedure and medication errors. Objective: This study aims to determine the effectiveness of an evidence-based mobile app compared with that of the conventional preparation methods in reducing acute stress in paramedics at the psychological and physiological levels while safely preparing emergency drugs during simulated pediatric OHCA scenarios. Methods: In a parent, multicenter, randomized controlled trial of 14 emergency medical services, perceived and physiologic stress of advanced paramedics with drug preparation autonomy was assessed during a 20-minute, standardized, fully video-recorded, and highly realistic pediatric OHCA scenario in an 18-month-old child. The primary outcome was participants' self-reported psychological stress perceived during sequential preparations of 4 intravenous emergency drugs (epinephrine, midazolam, 10\% dextrose, and sodium bicarbonate) with the support of the PedAMINES (Pediatric Accurate Medication in Emergency Situations) app designed to help pediatric drug preparation (intervention) or conventional methods (control). The State-Trait Anxiety Inventory and Visual Analog Scale questionnaires were used to measure perceived stress. The secondary outcome was physiologic stress, measured by a single continuous measurement of the participants' heart rate with optical photoplethysmography. Results: From September 3, 2019, to January 21, 2020, 150 advanced paramedics underwent randomization. A total of 74 participants were assigned to the mobile app (intervention group), and 76 did not use the app (control group). A total of 600 drug doses were prepared. Higher State-Trait Anxiety Inventory--perceived stress increase from baseline was observed during the scenario using the conventional methods (mean 35.4, SD 8.2 to mean 49.8, SD 13.2; a 41.3\%, 35.0 increase) than when using the app (mean 36.1, SD 8.1 to mean 39.0, SD 8.4; a 12.3\%, 29.0 increase). This revealed a 30.1\% (95\% CI 20.5\%-39.8\%; P<.001) lower relative change in stress response in participants who used the app. On the Visual Analog Scale questionnaire, participants in the control group reported a higher increase in stress at the peak of the scenario (mean 7.1, SD 1.8 vs mean 6.4, SD 1.9; difference: ?0.8, 95\% CI ?1.3 to ?0.2; P=.005). Increase in heart rate during the scenario and over the 4 drugs was not different between the 2 groups. Conclusions: Compared with the conventional method, dedicated mobile apps can reduce acute perceived stress during the preparation of emergency drugs in the prehospital setting during critical situations. These findings can help advance the development and evaluation of mobile apps for OHCA management and should be encouraged. Trial Registration: ClinicalTrials.gov NCT03921346; https://clinicaltrials.gov/ct2/show/NCT03921346 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-019-3726-4 ", doi="10.2196/31748", url="https://mhealth.jmir.org/2021/10/e31748", url="http://www.ncbi.nlm.nih.gov/pubmed/34617916" } @Article{info:doi/10.2196/28345, author="Schmucker, Michael and Haag, Martin", title="Automated Size Recognition in Pediatric Emergencies Using Machine Learning and Augmented Reality: Within-Group Comparative Study", journal="JMIR Form Res", year="2021", month="Sep", day="20", volume="5", number="9", pages="e28345", keywords="resuscitation", keywords="emergency medicine", keywords="mobile applications", keywords="mobile phone", keywords="user-computer interface", keywords="augmented reality", keywords="machine learning", abstract="Background: Pediatric emergencies involving children are rare events, and the experience of emergency physicians and the results of such emergencies are accordingly poor. Anatomical peculiarities and individual adjustments make treatment during pediatric emergency susceptible to error. Critical mistakes especially occur in the calculation of weight-based drug doses. Accordingly, the need for a ubiquitous assistance service that can, for example, automate dose calculation is high. However, few approaches exist due to the complexity of the problem. Objective: Technically, an assistance service is possible, among other approaches, with an app that uses a depth camera that is integrated in smartphones or head-mounted displays to provide a 3D understanding of the environment. The goal of this study was to automate this technology as much as possible to develop and statistically evaluate an assistance service that does not have significantly worse measurement performance than an emergency ruler (the state of the art). Methods: An assistance service was developed that uses machine learning to recognize patients and then automatically determines their size. Based on the size, the weight is automatically derived, and the dosages are calculated and presented to the physician. To evaluate the app, a small within-group design study was conducted with 17 children, who were each measured with the app installed on a smartphone with a built-in depth camera and a state-of-the-art emergency ruler. Results: According to the statistical results (one-sample t test; P=.42; $\alpha$=.05), there is no significant difference between the measurement performance of the app and an emergency ruler under the test conditions (indoor, daylight). The newly developed measurement method is thus not technically inferior to the established one in terms of accuracy. Conclusions: An assistance service with an integrated augmented reality emergency ruler is technically possible, although some groundwork is still needed. The results of this study clear the way for further research, for example, usability testing. ", doi="10.2196/28345", url="https://formative.jmir.org/2021/9/e28345", url="http://www.ncbi.nlm.nih.gov/pubmed/34542416" } @Article{info:doi/10.2196/22920, author="Perron, Elizabeth Janaya and Coffey, Jonathon Michael and Lovell-Simons, Andrew and Dominguez, Luis and King, E. Mark and Ooi, Y. Chee", title="Resuscitating Cardiopulmonary Resuscitation Training in a Virtual Reality: Prospective Interventional Study", journal="J Med Internet Res", year="2021", month="Jul", day="29", volume="23", number="7", pages="e22920", keywords="pediatrics", keywords="cardiopulmonary resuscitation", keywords="virtual reality", keywords="medical education", 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. ", doi="10.2196/22920", url="https://www.jmir.org/2021/7/e22920", url="http://www.ncbi.nlm.nih.gov/pubmed/34326040" } @Article{info:doi/10.2196/25437, author="Fija{\v c}ko, Nino and Masterson Creber, Ruth and Gosak, Lucija and {\vS}tiglic, Gregor and Egan, Dominic and Chaka, Brian and Debeljak, Nika and Strnad, Matej and Skok, Pavel", title="Evaluating Quality, Usability, Evidence-Based Content, and Gamification Features in Mobile Learning Apps Designed to Teach Children Basic Life Support: Systematic Search in App Stores and Content Analysis", journal="JMIR Mhealth Uhealth", year="2021", month="Jul", day="20", volume="9", number="7", pages="e25437", keywords="cardiopulmonary resuscitation", keywords="basic life support", keywords="mobile learning", keywords="mobile phone", keywords="gamification", keywords="schoolchildren", abstract="Background: Globally, 3.7 million people die of sudden cardiac death annually. Following the World Health Organization endorsement of the Kids Save Lives statements, initiatives to train school-age children in basic life support (BLS) have been widespread. Mobile phone apps, combined with gamification, represent an opportunity for including mobile learning (m-learning) in teaching schoolchildren BLS as an additional teaching method; however, the quality of these apps is questionable. Objective: This study aims to systematically evaluate the quality, usability, evidence-based content, and gamification features (GFs) of commercially available m-learning apps for teaching guideline-directed BLS knowledge and skills to school-aged children. Methods: We searched the Google Play Store and Apple iOS App Store using multiple terms (eg, cardiopulmonary resuscitation [CPR] or BLS). Apps meeting the inclusion criteria were evaluated by 15 emergency health care professionals using the user version of the Mobile Application Rating Scale and System Usability Scale. We modified a five-finger mnemonic for teaching schoolchildren BLS and reviewed the apps' BLS content using standardized criteria based on three CPR guidelines. GFs in the apps were evaluated using a gamification taxonomy. Results: Of the 1207 potentially relevant apps, only 6 (0.49\%) met the inclusion criteria. Most apps were excluded because the content was not related to teaching schoolchildren BLS. The mean total scores for the user version of the Mobile Application Rating Scale and System Usability Scale score were 3.2/5 points (95\% CI 3.0-3.4) and 47.1/100 points (95\% CI 42.1-52.1), respectively. Half of the apps taught hands-only CPR, whereas the other half also included ventilation. All the apps indicated when to start chest compressions, and only 1 app taught BLS using an automated external defibrillator. Gamification was well integrated into the m-learning apps for teaching schoolchildren BLS, whereas the personal and fictional, educational, and performance gamification groups represented most GFs. Conclusions: Improving the quality and usability of BLS content in apps and combining them with GFs can offer educators novel m-learning tools to teach schoolchildren BLS skills. ", doi="10.2196/25437", url="https://mhealth.jmir.org/2021/7/e25437", url="http://www.ncbi.nlm.nih.gov/pubmed/34283034" } @Article{info:doi/10.2196/27108, author="Naylor, Katarzyna and Torres, Kamil", title="Transitioning to Web-Based Learning in Basic Life Support Training During the COVID-19 Pandemic to Battle the Fear of Out-of-Hospital Cardiac Arrest: Presentation of Novel Methods", journal="J Med Internet Res", year="2021", month="May", day="25", volume="23", number="5", pages="e27108", keywords="COVID-19", keywords="web-based training", keywords="basic life support", keywords="formative assessment", keywords="out-of-hospital cardiac arrest", keywords="web-based learning", keywords="web-based education", keywords="first aid", keywords="medical education", keywords="life support", keywords="transition", keywords="outcome", keywords="formative", doi="10.2196/27108", url="https://www.jmir.org/2021/5/e27108", url="http://www.ncbi.nlm.nih.gov/pubmed/33886488" } @Article{info:doi/10.2196/25125, author="Sturny, Ludovic and Regard, Simon and Larribau, Robert and Niquille, Marc and Savoldelli, Louis Georges and Sarasin, Fran{\c{c}}ois and Schiffer, Eduardo and Suppan, Laurent", title="Differences in Basic Life Support Knowledge Between Junior Medical Students and Lay People: Web-Based Questionnaire Study", journal="J Med Internet Res", year="2021", month="Feb", day="23", volume="23", number="2", pages="e25125", keywords="basic life support", keywords="cardiopulmonary resuscitation", keywords="medical students", keywords="undergraduate medical education", keywords="out-of-hospital cardiac arrest", keywords="life support", keywords="cardiopulmonary", keywords="medical education", abstract="Background: Early cardiopulmonary resuscitation and prompt defibrillation markedly increase the survival rate in the event of out-of-hospital cardiac arrest (OHCA). As future health care professionals, medical students should be trained to efficiently manage an unexpectedly encountered OHCA. Objective: Our aim was to assess basic life support (BLS) knowledge in junior medical students at the University of Geneva Faculty of Medicine (UGFM) and to compare it with that of the general population. Methods: Junior UGFM students and lay people who had registered for BLS classes given by a Red Cross--affiliated center were sent invitation links to complete a web-based questionnaire. The primary outcome was the between-group difference in a 10-question score regarding cardiopulmonary resuscitation knowledge. Secondary outcomes were the differences in the rate of correct answers for each individual question, the level of self-assessed confidence in the ability to perform resuscitation, and a 6-question score, ``essential BLS knowledge,'' which only contains key elements of the chain of survival. Continuous variables were first analyzed using the Student t test, then by multivariable linear regression. Fisher exact test was used for between-groups comparison of binary variables. Results: The mean score was higher in medical students than in lay people for both the 10-question score (mean 5.8, SD 1.7 vs mean 4.2, SD 1.7; P<.001) and 6-question score (mean 3.0, SD 1.1 vs mean 2.0, SD 1.0; P<.001). Participants who were younger or already trained scored consistently better. Although the phone number of the emergency medical dispatch center was well known in both groups (medical students, 75/80, 94\% vs lay people, 51/62, 82\%; P=.06), most participants were unable to identify the criteria used to recognize OHCA, and almost none were able to correctly reorganize the BLS sequence. Medical students felt more confident than lay people in their ability to perform resuscitation (mean 4.7, SD 2.2 vs mean 3.1, SD 2.1; P<.001). Female gender and older age were associated with lower confidence, while participants who had already attended a BLS course prior to taking the questionnaire felt more confident. Conclusions: Although junior medical students were more knowledgeable than lay people regarding BLS procedures, the proportion of correct answers was low in both groups, and changes in BLS education policy should be considered. ", doi="10.2196/25125", url="https://www.jmir.org/2021/2/e25125", url="http://www.ncbi.nlm.nih.gov/pubmed/33620322" } @Article{info:doi/10.2196/16114, author="M{\"u}ller, Dueholm Sune and Lauridsen, Glerup Kasper and Palic, Hadrovic Amra and Frederiksen, Nygaard Lotte and Mathiasen, Morten and L{\o}fgren, Bo", title="Mobile App Support for Cardiopulmonary Resuscitation: Development and Usability Study", journal="JMIR Mhealth Uhealth", year="2021", month="Jan", day="5", volume="9", number="1", pages="e16114", keywords="the Kano model", keywords="cardiopulmonary resuscitation", keywords="healthcare", keywords="smartphone apps", keywords="public health", keywords="ALS CPR algorithm", keywords="app evaluation", keywords="mobile phone", abstract="Background: The user requirements for in-hospital cardiopulmonary resuscitation (CPR) support apps are understudied. To study usability, functionality, and design based on user requirements, we applied a mixed methods research design using interviews, observations, and a Kano questionnaire to survey perspectives of both physicians and nurses. Objective: This study aims to identify what an in-hospital CPR support app should include to meet the requirements and expectations of health care professionals by evaluating the CprPrototype app. Methods: We used a mixed methods research design. The qualitative methods consisted of semistructured interviews and observations from an advanced life support (ALS) course; both provided input to the subsequent questionnaire development. The quantitative method is a questionnaire based on the Kano model classifying user requirements as must-be, one-dimensional (attributes causing satisfaction when present and dissatisfaction when absent), attractive, indifferent, and reverse (attributes causing dissatisfaction when present and satisfaction when absent). The questionnaire was supplemented with comment fields. All respondents were physicians and nurses providing ALS at hospitals in the Central Denmark Region. Results: A total of 83 physicians and nurses responded to the questionnaire, 15 physicians and nurses were observed during ALS training, and 5 physicians were interviewed. On the basis of the Kano questionnaire, 53\% (9/17) of requirements were classified as indifferent, 29\% (5/17) as attractive, and 18\% (3/17) as one-dimensional. The comments revealed 7 different categories of user requirements with noticeable differences between those of physicians and nurses: technological challenges, keep track of time, documentation and history, disturbing element, improvement areas: functions, improvement areas: design, and better guidance. Conclusions: The study provides recommendations to developers on the user requirements that need to be addressed when developing CPR support apps. Three features (one-dimensional attributes) must be incorporated in an in-hospital CPR support app: reminder of rhythm check, reminder of resuscitation drugs, and differentiate between adults and children. In addition, 5 features (attractive attributes) would result in higher user satisfaction: all functions on one side, access to the patient journal in the app, automatic time recording when cardiac arrest is called, sound to guide the chest compression rate (metronome), and send CPR history to the DANARREST(Danish in-hospital cardiac arrest registry) database. ", doi="10.2196/16114", url="https://mhealth.jmir.org/2021/1/e16114", url="http://www.ncbi.nlm.nih.gov/pubmed/33399539" } @Article{info:doi/10.2196/21855, author="Cutumisu, Maria and Ghoman, K. Simran and Lu, Chang and Patel, D. Siddhi and Garcia-Hidalgo, Catalina and Fray, Caroline and Brown, G. Matthew R. and Greiner, Russell and Schm{\"o}lzer, M. Georg", title="Health Care Providers' Performance, Mindset, and Attitudes Toward a Neonatal Resuscitation Computer-Based Simulator: Empirical Study", journal="JMIR Serious Games", year="2020", month="Dec", day="21", volume="8", number="4", pages="e21855", keywords="infant", keywords="newborn", keywords="delivery room", keywords="neonatal resuscitation", keywords="performance", keywords="neonatal resuscitation program", keywords="serious games", keywords="computer-based game simulation", keywords="mindset", abstract="Background: Neonatal resuscitation involves a complex sequence of actions to establish an infant's cardiorespiratory function at birth. Many of these responses, which identify the best action sequence in each situation, are taught as part of the recurrent Neonatal Resuscitation Program training, but they have a low incidence in practice, which leaves health care providers (HCPs) less prepared to respond appropriately and efficiently when they do occur. Computer-based simulators are increasingly used to complement traditional training in medical education, especially in the COVID-19 pandemic era of mass transition to digital education. However, it is not known how learners' attitudes toward computer-based learning and assessment environments influence their performance. Objective: This study explores the relation between HCPs' attitudes toward a computer-based simulator and their performance in the computer-based simulator, RETAIN (REsuscitation TrAINing), to uncover the predictors of performance in computer-based simulation environments for neonatal resuscitation. Methods: Participants were 50 neonatal HCPs (45 females, 4 males, 1 not reported; 16 respiratory therapists, 33 registered nurses and nurse practitioners, and 1 physician) affiliated with a large university hospital. Participants completed a demographic presurvey before playing the game and an attitudinal postsurvey after completing the RETAIN game. Participants' survey responses were collected to measure attitudes toward the computer-based simulator, among other factors. Knowledge on neonatal resuscitation was assessed in each round of the game through increasingly difficult neonatal resuscitation scenarios. This study investigated the moderating role of mindset on the association between the perceived benefits of understanding the terminology used in the computer-based simulator, RETAIN, and their performance on the neonatal resuscitation tasks covered by RETAIN. Results: The results revealed that mindset moderated the relation between participants' perceived terminology used in RETAIN and their actual performance in the game (F3,44=4.56, R2=0.24, adjusted R2=0.19; P=.007; estimate=--1.19, SE=0.38, t44=--3.12, 95\% CI --1.96 to --0.42; P=.003). Specifically, participants who perceived the terminology useful also performed better but only when endorsing more of a growth mindset; they also performed worse when endorsing more of a fixed mindset. Most participants reported that they enjoyed playing the game. The more the HCPs agreed that the terminology in the tutorial and in the game was accessible, the better they performed in the game, but only when they reported endorsing a growth mindset exceeding the average mindset of all the participants (F3,44=6.31, R2=0.30, adjusted R2=0.25; P=.001; estimate=--1.21, SE=0.38, t44=?3.16, 95\% CI --1.99 to --0.44; P=.003). Conclusions: Mindset moderates the strength of the relationship between HCPs' perception of the role that the terminology employed in a game simulator has on their performance and their actual performance in a computer-based simulator designed for neonatal resuscitation training. Implications of this research include the design and development of interactive learning environments that can support HCPs in performing better on neonatal resuscitation tasks. ", doi="10.2196/21855", url="http://games.jmir.org/2020/4/e21855/", url="http://www.ncbi.nlm.nih.gov/pubmed/33346741" } @Article{info:doi/10.2196/18959, author="Kim, Yesul and Groombridge, Christopher and Romero, Lorena and Clare, Steven and Fitzgerald, Christopher Mark", title="Decision Support Capabilities of Telemedicine in Emergency Prehospital Care: Systematic Review", journal="J Med Internet Res", year="2020", month="Dec", day="8", volume="22", number="12", pages="e18959", keywords="telemedicine", keywords="decision support", keywords="emergency", keywords="resuscitation", abstract="Background: Telemedicine offers a unique opportunity to improve coordination and administration for urgent patient care remotely. In an emergency setting, it has been used to support first responders by providing telephone or video consultation with specialists at hospitals and through the exchange of prehospital patient information. This technological solution is evolving rapidly, yet there is a concern that it is being implemented without a demonstrated clinical need and effectiveness as well as without a thorough economic evaluation. Objective: Our objective is to systematically review whether the clinical outcomes achieved, as reported in the literature, favor telemedicine decision support for medical interventions during prehospital care. Methods: This systematic review included peer-reviewed journal articles. Searches of 7 databases and relevant reviews were conducted. Eligibility criteria consisted of studies that covered telemedicine as data- and information-sharing and two-way teleconsultation platforms, with the objective of supporting medical decisions (eg, diagnosis, treatment, and receiving hospital decision) in a prehospital emergency setting. Simulation studies and studies that included pediatric populations were excluded. The procedures in this review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The Risk Of Bias In Non-randomised Studies--of Interventions (ROBINS-I) tool was used for the assessment of risk of bias. The results were synthesized based on predefined aspects of medical decisions that are made in a prehospital setting, which include diagnostic decision support, receiving facility decisions, and medical directions for treatment. All data extractions were done by at least two reviewers independently. Results: Out of 42 full-text reviews, 7 were found eligible. Diagnostic support and medical direction and decision for treatments were often reported. A key finding of this review was the high agreement between prehospital diagnoses via telemedicine and final in-hospital diagnoses, as supported by quantitative evidence. However, a majority of the articles described the clinical value of having access to remote experts without robust quantitative data. Most telemedicine solutions were evaluated within a feasibility or short-term preliminary study. In general, the results were positive for telemedicine use; however, biases, due to preintervention confounding factors and a lack of documentation on quality assurance and protocol for telemedicine activation, make it difficult to determine the direct effect on patient outcomes. Conclusions: The information-sharing capacity of telemedicine enables access to remote experts to support medical decision making on scene or in prolonged field care. The influence of human and technology factors on patient care is poorly understood and documented. ", doi="10.2196/18959", url="http://www.jmir.org/2020/12/e18959/", url="http://www.ncbi.nlm.nih.gov/pubmed/33289672" } @Article{info:doi/10.2196/24798, author="Regard, Simon and Rosa, Django and Suppan, M{\'e}lanie and Giangaspero, Chiara and Larribau, Robert and Niquille, Marc and Sarasin, Fran{\c{c}}ois and Suppan, Laurent", title="Evolution of Bystander Intention to Perform Resuscitation Since Last Training: Web-Based Survey", journal="JMIR Form Res", year="2020", month="Nov", day="30", volume="4", number="11", pages="e24798", keywords="out-of-hospital cardiac arrest", keywords="cardiopulmonary resuscitation", keywords="basic life support", keywords="confidence", keywords="first aid", keywords="bystander", keywords="behavior", keywords="cardiac arrest", keywords="heart attack", keywords="intention", keywords="resuscitation", keywords="survey", keywords="attitude", keywords="belief", abstract="Background: Victims of out-of-hospital cardiac arrest (OHCA) have higher survival rates and more favorable neurological outcomes when basic life support (BLS) maneuvers are initiated quickly after collapse. Although more than half of OHCAs are witnessed, BLS is infrequently provided, thereby worsening the survival and neurological prognoses of OHCA victims. According to the theory of planned behavior, the probability of executing an action is strongly linked to the intention of performing it. This intention is determined by three distinct dimensions: attitude, subjective normative beliefs, and control beliefs. We hypothesized that there could be a decrease in one or more of these dimensions even shortly after the last BLS training session. Objective: The aim of this study was to measure the variation of the three dimensions of the intention to perform resuscitation according to the time elapsed since the last first-aid course. Methods: Between January and April 2019, the two largest companies delivering first-aid courses in the region of Geneva, Switzerland sent invitation emails on our behalf to people who had followed a first-aid course between January 2014 and December 2018. Participants were asked to answer a set of 17 psychometric questions based on a 4-point Likert scale (``I don't agree,'' ``I partially agree,'' ``I agree,'' and ``I totally agree'') designed to assess the three dimensions of the intention to perform resuscitation. The primary outcome was the difference in each of these dimensions between participants who had followed a first-aid course less than 6 months before taking the questionnaire and those who took the questionnaire more than 6 months and up to 5 years after following such a course. Secondary outcomes were the change in each dimension using cutoffs at 1 year and 2 years, and the change regarding each individual question using cutoffs at 6 months, 1 year, and 2 years. Univariate and multivariable linear regression were used for analyses. Results: A total of 204 surveys (76\%) were analyzed. After adjustment, control beliefs was the only dimension that was significantly lower in participants who took the questionnaire more than 6 months after their last BLS course (P<.001). Resisting diffusion of responsibility, a key element of subjective normative beliefs, was also less likely in this group (P=.001). By contrast, members of this group were less afraid of disease transmission (P=.03). However, fear of legal action was higher in this group (P=.02). Conclusions: Control beliefs already show a significant decrease 6 months after the last first-aid course. Short interventions should be designed to restore this dimension to its immediate postcourse state. This could enhance the provision of BLS maneuvers in cases of OHCA. ", doi="10.2196/24798", url="http://formative.jmir.org/2020/11/e24798/", url="http://www.ncbi.nlm.nih.gov/pubmed/33252342" } @Article{info:doi/10.2196/24664, author="Suppan, Laurent and Herren, Tara and Taramarcaz, Victor and Regard, Simon and Martin-Achard, S{\'e}bastien and Zamberg, Ido and Larribau, Robert and Niquille, Marc and Mach, Francois and Suppan, M{\'e}lanie and Schiffer, Eduardo", title="A Short Intervention Followed by an Interactive E-Learning Module to Motivate Medical Students to Enlist as First Responders: Protocol for a Prospective Implementation Study", journal="JMIR Res Protoc", year="2020", month="Nov", day="6", volume="9", number="11", pages="e24664", keywords="basic life support", keywords="cardiopulmonary resuscitation", keywords="medical students", keywords="undergraduate medical education", keywords="out-of-hospital cardiac arrest", abstract="Background: In Geneva, Switzerland, basic life support (BLS) maneuvers are provided in only 40\% of out-of-hospital cardiac arrests (OHCAs) cases. As OHCA outcomes are markedly improved when BLS maneuvers are swiftly applied, a ``first-responder'' system was introduced in 2019. When emergency dispatchers identify a possible OHCA, first responders receive an alert message on a specific app (Save-a-Life) installed on their smartphones. Those nearest to the victim and immediately available are sent the exact location of the intervention. First-year medical students only have limited knowledge regarding BLS procedures but might nevertheless need to take care of OHCA victims. Medical students responding to out-of-hospital emergencies are off-duty in half of these situations, and offering junior medical students the opportunity to enlist as first responders might therefore not only improve OHCA outcomes but also foster a greater recognition of the role medical students can hold in our society. Objective: Our aim is to determine whether providing first-year medical students with a short intervention followed by an interactive e-learning module can motivate them to enlist as first responders. Methods: After obtaining the approval of the regional ethics committee and of the vice-dean for undergraduate education of the University of Geneva Faculty of Medicine (UGFM), 2 senior medical students will present the project to their first-year colleagues at the beginning of a lecture. First-year students will then be provided with a link to an interactive e-learning module which has been designed according to the Swiss Resuscitation Council's first aid guidelines. After answering a first questionnaire and completing the module, students will be able to register for practice sessions. Those attending and successfully completing these sessions will receive a training certificate which will enable them to enlist as first responders. The primary outcome will be the proportion of first-year medical students enlisting as first responders at the end of the study period. Secondary outcomes will be the proportion of first-year medical students electing to register on the platform, to begin the e-learning module, to complete the e-learning module, to register for practice sessions, to attend the practice sessions, and to obtain a certificate. The reasons given by medical students for refusing to participate will be analyzed. We will also assess how comfortable junior medical students would feel to be integrated into the first responders system at the end of the training program and whether it affects the registration rate. Results: The regional ethics committee (Req-2020-01143) and the UGFM vice-dean for undergraduate education have given their approval to the realization of this study, which is scheduled to begin in January 2021. Conclusions: This study should determine whether a short intervention followed by an interactive e-learning module can motivate first-year medical students to enlist as first responders. International Registered Report Identifier (IRRID): PRR1-10.2196/24664 ", doi="10.2196/24664", url="http://www.researchprotocols.org/2020/11/e24664/", url="http://www.ncbi.nlm.nih.gov/pubmed/33155574" } @Article{info:doi/10.2196/19070, author="Corazza, Francesco and Snijders, Deborah and Arpone, Marta and Stritoni, Valentina and Martinolli, Francesco and Daverio, Marco and Losi, Giulia Maria and Soldi, Luca and Tesauri, Francesco and Da Dalt, Liviana and Bressan, Silvia", title="Development and Usability of a Novel Interactive Tablet App (PediAppRREST) to Support the Management of Pediatric Cardiac Arrest: Pilot High-Fidelity Simulation-Based Study", journal="JMIR Mhealth Uhealth", year="2020", month="Oct", day="1", volume="8", number="10", pages="e19070", keywords="cardiac arrest", keywords="resuscitation", keywords="mobile app", keywords="high-fidelity simulation training", keywords="cognitive aid", keywords="pediatrics", keywords="emergency medicine", abstract="Background: Pediatric cardiac arrest (PCA), although rare, is associated with high mortality. Deviations from international management guidelines are frequent and associated with poorer outcomes. Different strategies/devices have been developed to improve the management of cardiac arrest, including cognitive aids. However, there is very limited experience on the usefulness of interactive cognitive aids in the format of an app in PCA. No app has so far been tested for its usability and effectiveness in guiding the management of PCA. Objective: To develop a new audiovisual interactive app for tablets, named PediAppRREST, to support the management of PCA and to test its usability in a high-fidelity simulation-based setting. Methods: A research team at the University of Padova (Italy) and human--machine interface designers, as well as app developers, from an Italian company (RE:Lab S.r.l.) developed the app between March and October 2019, by applying an iterative design approach (ie, design--prototyping--evaluation iterative loops). In October--November 2019, a single-center nonrandomized controlled simulation--based pilot study was conducted including 48 pediatric residents divided into teams of 3. The same nonshockable PCA scenario was managed by 11 teams with and 5 without the app. The app user's experience and interaction patterns were documented through video recording of scenarios, debriefing sessions, and questionnaires. App usability was evaluated with the User Experience Questionnaire (UEQ) (scores range from --3 to +3 for each scale) and open-ended questions, whereas participants' workload was measured using the NASA Raw-Task Load Index (NASA RTLX). Results: Users' difficulties in interacting with the app during the simulations were identified using a structured framework. The app usability, in terms of mean UEQ scores, was as follows: attractiveness 1.71 (SD 1.43), perspicuity 1.75 (SD 0.88), efficiency 1.93 (SD 0.93), dependability 1.57 (SD 1.10), stimulation 1.60 (SD 1.33), and novelty 2.21 (SD 0.74). Team leaders' perceived workload was comparable (P=.57) between the 2 groups; median NASA RTLX score was 67.5 (interquartile range [IQR] 65.0-81.7) for the control group and 66.7 (IQR 54.2-76.7) for the intervention group. A preliminary evaluation of the effectiveness of the app in reducing deviations from guidelines showed that median time to epinephrine administration was significantly longer in the group that used the app compared with the control group (254 seconds versus 165 seconds; P=.015). Conclusions: The PediAppRREST app received a good usability evaluation and did not appear to increase team leaders' workload. Based on the feedback collected from the participants and the preliminary results of the evaluation of its effects on the management of the simulated scenario, the app has been further refined. The effectiveness of the new version of the app in reducing deviations from guidelines recommendations in the management of PCA and its impact on time to critical actions will be evaluated in an upcoming multicenter simulation-based randomized controlled trial. ", doi="10.2196/19070", url="https://mhealth.jmir.org/2020/10/e19070", url="http://www.ncbi.nlm.nih.gov/pubmed/32788142" } @Article{info:doi/10.2196/18633, author="Michelet, Daphne and Barre, Jessy and Truchot, Jennifer and Piot, Marie-Aude and Cabon, Philippe and Tesniere, Antoine", title="Effect of Computer Debriefing on Acquisition and Retention of Learning After Screen-Based Simulation of Neonatal Resuscitation: Randomized Controlled Trial", journal="JMIR Serious Games", year="2020", month="Aug", day="11", volume="8", number="3", pages="e18633", keywords="screen-based simulation", keywords="debriefing", keywords="neonatal resuscitation", keywords="simulation", keywords="medical education", keywords="midwifery", keywords="neonatal", abstract="Background: Debriefing is key in a simulation learning process. Objective: This study focuses on the impact of computer debriefing on learning acquisition and retention after a screen-based simulation training on neonatal resuscitation designed for midwifery students. Methods: Midwifery students participated in 2 screen-based simulation sessions, separated by 2 months, session 1 and session 2. They were randomized in 2 groups. Participants of the debriefing group underwent a computer debriefing focusing on technical skills and nontechnical skills at the end of each scenario, while the control group received no debriefing. In session 1, students participated in 2 scenarios of screen-based simulation on neonatal resuscitation. During session 2, the students participated in a third scenario. The 3 scenarios had an increasing level of difficulty, with the first representing the baseline level. Assessments included a knowledge questionnaire on neonatal resuscitation, a self-efficacy rating, and expert evaluation of technical skills as per the Neonatal Resuscitation Performance Evaluation (NRPE) score and of nontechnical skills as per the Anaesthetists' Non-Technical Skills (ANTS) system. We compared the results of the groups using the Mann-Whitney U test. Results: A total of 28 midwifery students participated in the study. The participants from the debriefing group reached higher ANTS scores than those from the control group during session 1 (13.25 vs 9; U=47.5; P=.02). Their scores remained higher, without statistical difference during session 2 (10 vs 7.75; P=.08). The debriefing group had higher self-efficacy ratings at session 2 (3 vs 2; U=52; P=.02). When comparing the knowledge questionnaires, the significant baseline difference (13 for debriefing group vs 14.5 for control group, P=.05) disappeared at the end of session 1 and in session 2. No difference was found for the assessment of technical skills between the groups or between sessions. Conclusions: Computer debriefing seems to improve nontechnical skills, self-efficacy, and knowledge when compared to the absence of debriefing during a screen-based simulation. This study confirms the importance of debriefing after screen-based simulation. Trial Registration: ClinicalTrials.gov NCT03844009; https://clinicaltrials.gov/ct2/show/NCT03844009 ", doi="10.2196/18633", url="http://games.jmir.org/2020/3/e18633/", url="http://www.ncbi.nlm.nih.gov/pubmed/32780021" } @Article{info:doi/10.2196/15762, author="Hejjaji, Vittal and Malik, O. Ali and Peri-Okonny, A. Poghni and Thomas, Merrill and Tang, Yuanyuan and Wooldridge, David and Spertus, A. John and Chan, S. Paul", title="Mobile App to Improve House Officers' Adherence to Advanced Cardiac Life Support Guidelines: Quality Improvement Study", journal="JMIR Mhealth Uhealth", year="2020", month="May", day="19", volume="8", number="5", pages="e15762", keywords="cardiac arrest", keywords="advanced cardiac life support", keywords="mHealth", keywords="quality improvement", keywords="medical education", abstract="Background: Effective and timely delivery of cardiac arrest interventions during in-hospital cardiac arrest resuscitation is associated with greater survival. Whether a mobile app that provides timely reminders of critical interventions improves adherence to Advanced Cardiovascular Life Support (ACLS) guidelines among house officers, who may lack experience in leading resuscitations, remains unknown. Objective: The aim of this study was to assess the impact of a commercially available, dynamic mobile app on house officers' adherence to ACLS guidelines. Methods: As part of a quality improvement initiative, internal medicine house officers were invited to participate and randomized to lead 2 consecutive cardiac arrest simulations, one with a novel mobile app and one without a novel mobile app. All simulations included 4 cycles of cardiopulmonary resuscitation with different cardiac arrest rhythms and were video recorded. The coprimary end points were chest compression fraction and number of correct interventions in each simulation. The secondary end point was incorrect interventions, defined as interventions not indicated by the 2015 ACLS guidelines. Paired t tests compared performance with and without the mobile app. Results: Among 53 house officers, 26 house officers were randomized to lead the first simulation with the mobile app, and 27 house officers were randomized to do so without the app. Use of the mobile app was associated with a higher number of correct ACLS interventions (out of 7; mean 6.2 vs 5.1; absolute difference 1.1 [95\% CI 0.6 to 1.6]; P<.001) as well as fewer incorrect ACLS interventions (mean 0.3 vs 1.0; absolute difference --0.7 [95\% CI --0.3 to --1.0]; P<.001). Simulations with the mobile app also had a marginally higher chest compression fraction (mean 90.9\% vs 89.0\%; absolute difference 1.9\% [95\% CI 0.6\% to 3.4\%]; P=.007). Conclusions: This proof-of-concept study suggests that this novel mobile app may improve adherence to ACLS protocols, but its effectiveness on survival in real-world resuscitations remains unknown. ", doi="10.2196/15762", url="https://mhealth.jmir.org/2020/5/e15762", url="http://www.ncbi.nlm.nih.gov/pubmed/32427115" } @Article{info:doi/10.2196/14910, author="Ingrassia, Luigi Pier and Mormando, Giulia and Giudici, Eleonora and Strada, Francesco and Carfagna, Fabio and Lamberti, Fabrizio and Bottino, Andrea", title="Augmented Reality Learning Environment for Basic Life Support and Defibrillation Training: Usability Study", journal="J Med Internet Res", year="2020", month="May", day="12", volume="22", number="5", pages="e14910", keywords="augmented reality", keywords="cardiopulmonary resuscitation", keywords="automated external defibrillators", abstract="Background: Basic life support (BLS) is crucial in the emergency response system, as sudden cardiac arrest is still a major cause of death worldwide. Unfortunately, only a minority of victims receive cardiopulmonary resuscitation (CPR) from bystanders. In this context, training could be helpful to save more lives, and technology-enhanced BLS simulation is one possible solution. Objective: The aim of this study is to assess the feasibility and acceptability of our augmented reality (AR) prototype as a tool for BLS training. Methods: Holo-BLSD is an AR self-instruction training system, in which a standard CPR manikin is ``augmented'' with an interactive virtual environment that reproduces realistic scenarios. Learners can use natural gestures, body movements, and spoken commands to perform their tasks, with virtual 3D objects anchored to the manikin and the environment. During the experience, users were trained to use the device while being guided through an emergency simulation and, at the end, were asked to complete a survey to assess the feasibility and acceptability of the proposed tool (5-point Likert scale; 1=Strongly Disagree, 5=Strongly Agree). Results: The system was rated easy to use (mean 4.00, SD 0.94), and the trainees stated that most people would learn to use it very quickly (mean 4.00, SD 0.89). Voice (mean 4.48, SD 0.87), gaze (mean 4.12, SD 0.97), and gesture interaction (mean 3.84, SD 1.14) were judged positively, although some hand gesture recognition errors reduced the feeling of having the right level of control over the system (mean 3.40, SD 1.04). Conclusions: We found the Holo-BLSD system to be a feasible and acceptable tool for AR BLS training. ", doi="10.2196/14910", url="https://www.jmir.org/2020/5/e14910", url="http://www.ncbi.nlm.nih.gov/pubmed/32396128" } @Article{info:doi/10.2196/17425, author="Katz, Daniel and Shah, Ronak and Kim, Elizabeth and Park, Chang and Shah, Anjan and Levine, Adam and Burnett, Garrett", title="Utilization of a Voice-Based Virtual Reality Advanced Cardiac Life Support Team Leader Refresher: Prospective Observational Study", journal="J Med Internet Res", year="2020", month="Mar", day="12", volume="22", number="3", pages="e17425", keywords="video game", keywords="experimental game", keywords="virtual reality", keywords="advanced cardiac life support", abstract="Background: The incidence of cardiac arrests per year in the United States continues to increase, yet in-hospital cardiac arrest survival rates significantly vary between hospitals. Current methods of training are expensive, time consuming, and difficult to scale, which necessitates improvements in advanced cardiac life support (ACLS) training. Virtual reality (VR) has been proposed as an alternative or adjunct to high-fidelity simulation (HFS) in several environments. No evaluations to date have explored the ability of a VR program to examine both technical and behavioral skills and demonstrate a cost comparison. Objective: This study aimed to explore the utility of a voice-based VR ACLS team leader refresher as compared with HFS. Methods: This prospective observational study performed at an academic institution consisted of 25 postgraduate year 2 residents. Participants were randomized to HFS or VR training and then crossed groups after a 2-week washout. Participants were graded on technical and nontechnical skills. Participants also completed self-assessments about the modules. Proctors were assessed for fatigue and task saturation, and cost analysis based on local economic data was performed. Results: A total of 23 of 25 participants were included in the scoring analysis. Fewer participants were familiar with VR compared with HFS (9/25, 36\% vs 25/25, 100\%; P<.001). Self-reported satisfaction and utilization scores were similar; however, significantly more participants felt HFS provided better feedback: 99 (IQR 89-100) vs 79 (IQR 71-88); P<.001. Technical scores were higher in the HFS group; however, nontechnical scores for decision making and communication were not significantly different between modalities. VR sessions were 21 (IQR 19-24) min shorter than HFS sessions, the National Aeronautics and Space Administration task load index scores for proctors were lower in each category, and VR sessions were estimated to be US \$103.68 less expensive in a single-learner, single-session model. Conclusions: Utilization of a VR-based team leader refresher for ACLS skills is comparable with HFS in several areas, including learner satisfaction. The VR module was more cost-effective and was easier to proctor; however, HFS was better at delivering feedback to participants. Optimal education strategies likely contain elements of both modalities. Further studies are needed to examine the utility of VR-based environments at scale. ", doi="10.2196/17425", url="http://www.jmir.org/2020/3/e17425/", url="http://www.ncbi.nlm.nih.gov/pubmed/32163038" } @Article{info:doi/10.2196/16987, author="Phungoen, Pariwat and Promto, Songwoot and Chanthawatthanarak, Sivit and Maneepong, Sawitree and Apiratwarakul, Korakot and Kotruchin, Praew and Mitsungnern, Thapanawong", title="Precourse Preparation Using a Serious Smartphone Game on Advanced Life Support Knowledge and Skills: Randomized Controlled Trial", journal="J Med Internet Res", year="2020", month="Mar", day="9", volume="22", number="3", pages="e16987", keywords="CPR training", keywords="gamified learning", keywords="medical education", keywords="serious game learning", abstract="Background: In the past several years, gamified learning has been growing in popularity in various medical educational contexts including cardiopulmonary resuscitation (CPR) training. Furthermore, prior work in Basic Life Support (BLS) training has demonstrated the benefits of serious games as a method for pretraining among medical students. However, there is little evidence to support these benefits with regard to Advanced Life Support (ALS) training. Objective: We compare the effects of a brief precourse ALS preparation using a serious smartphone game on student knowledge, skills, and perceptions in this area with those of conventional ALS training alone. Methods: A serious game (Resus Days) was developed by a Thai physician based on global ALS clinical practice guidelines. Fifth-year medical students were enrolled and randomized to either the game group or the control group. Participants in both groups attended a traditional ALS lecture, but the game group was assigned to play Resus Days for 1 hour before attending the lecture and were allowed to play as much as they wished during the training course. All students underwent conventional ALS training, and their abilities were evaluated using multiple-choice questions and with hands-on practice on a mannequin. Subject attitudes and perceptions about the game were evaluated using a questionnaire. Results: A total of 105 students participated in the study and were randomly assigned to either the game group (n=52) or the control group (n=53). Students in the game group performed better on the ALS algorithm knowledge posttest than those in the control group (17.22 [SD 1.93] vs 16.60 [SD 1.97], P=.01; adjusted mean difference [AMD] 0.93; 95\% CI 0.21-1.66). The game group's pass rate on the skill test was also higher but not to a statistically significant extent (79\% vs 66\%, P=.09; adjusted odds ratio [AOR] 2.22; 95\% CI 0.89-5.51). Students indicated high satisfaction with the game (9.02 [SD 1.11] out of 10). Conclusions: Engaging in game-based preparation prior to an ALS training course resulted in better algorithm knowledge scores for medical students than attending the course alone. Trial Registration: Thai Clinical Trials Registry HE611533; https://tinyurl.com/wmbp3q7 ", doi="10.2196/16987", url="http://www.jmir.org/2020/3/e16987/", url="http://www.ncbi.nlm.nih.gov/pubmed/32149711" } @Article{info:doi/10.2196/10428, author="Subki, Hussein Ahmed and Mortada, Hisham Hatan and Alsallum, Saad Mohammed and Alattas, Taleb Ali and Almalki, Ali Mohammed and Hindi, Mohammed Muhab and Subki, Hussein Siham and Alhejily, Awad Wesam", title="Basic Life Support Knowledge Among a Nonmedical Population in Jeddah, Saudi Arabia: Cross-Sectional Study", journal="Interact J Med Res", year="2018", month="Nov", day="28", volume="7", number="2", pages="e10428", keywords="basic life support", keywords="BLS", keywords="cardiopulmonary resuscitation", keywords="CPR", keywords="awareness", keywords="public", keywords="knowledge", keywords="Jeddah", keywords="Saudi Arabia", abstract="Background: Providing basic life support (BLS) at the site of an accident is crucial to increase the survival rates of the injured people. It is especially relevant when health care is far away. Objective: The aim of our study is to assess the BLS knowledge level of the Saudi Arabian population and identify influencing factors associated with level of knowledge about BLS. Methods: Our study is a cross-sectional descriptive study, which was conducted using a self-administered online questionnaire derived from the BLS practice test. The Saudi population was the target population. The questionnaire was divided into two parts: one contained demographic data and the second part contained questions to test the population's perception about how to perform BLS techniques properly. The data were collected between July and August 2017. Statistically significant differences were defined as those with a P value <.05, and a score of five or more was considered a passing score on the second part. We used SPSS version 21 for data analysis. Results: Our study included 301 participants. Our participants' BLS online exam scores ranged from 0 to 10, with a mean of 4.1 (SD 1.7). Only 39.2\% (118/301) of the participants passed the test. The percentage of bachelor's degree or higher holders constituted 60.1\% (181/301) of the study population. In addition, higher income was significantly associated with higher scores on the test (P=.04). Conclusions: This study demonstrated that the theoretical knowledge level of BLS among the general population in Jeddah was below average. There is a critical need to increase the public's exposure to BLS education through raising awareness campaigns and government-funded training programs that aim to curb the incidence of out-of-hospital cardiac arrest mortalities in the Saudi community. ", doi="10.2196/10428", url="http://www.i-jmr.org/2018/2/e10428/", url="http://www.ncbi.nlm.nih.gov/pubmed/30487122" } @Article{info:doi/10.2196/mhealth.9651, author="Metelmann, Bibiana and Metelmann, Camilla and Schuffert, Louisa and Hahnenkamp, Klaus and Brinkrolf, Peter", title="Medical Correctness and User Friendliness of Available Apps for Cardiopulmonary Resuscitation: Systematic Search Combined With Guideline Adherence and Usability Evaluation", journal="JMIR Mhealth Uhealth", year="2018", month="Nov", day="06", volume="6", number="11", pages="e190", keywords="mHealth", keywords="resuscitation", keywords="review", keywords="guidelines", keywords="mobile phones", keywords="health care information systems", keywords="health informatics", abstract="Background: In case of a cardiac arrest, start of cardiopulmonary resuscitation by a bystander before the arrival of the emergency personnel increases the probability of survival. However, the steps of high-quality resuscitation are not known by every bystander or might be forgotten in this complex and time-critical situation. Mobile phone apps offering real-time step-by-step instructions might be a valuable source of information. Objective: The aim of this study was to examine mobile phone apps offering real-time instructions in German or English in case of a cardiac arrest, to evaluate their adherence to current resuscitation guidelines, and to test their usability. Methods: Our 3-step approach combines a systematic review of currently available apps guiding a medical layperson through a resuscitation situation, an adherence testing to medical guidelines, and a usability evaluation of the determined apps. The systematic review followed an adapted preferred reporting items for systematic reviews and meta-analyses flow diagram, the guideline adherence was tested by applying a conformity checklist, and the usability was evaluated by a group of mobile phone frequent users and emergency physicians with the system usability scale (SUS) tool. Results: The structured search in Google Play Store and Apple App Store resulted in 3890 hits. After removing redundant ones, 2640 hits were checked for fulfilling the inclusion criteria. As a result, 34 apps meeting all inclusion criteria were identified. These included apps were analyzed to determine medical accuracy as defined by the European Resuscitation Council's guidelines. Only 5 out of 34 apps (15\%, 5/34) fulfilled all criteria chosen to determine guideline adherence. All other apps provided no or wrong information on at least one relevant topic. The usability of 3 apps was evaluated by 10 mobile phone frequent users and 9 emergency physicians. Of these 3 apps, solely the app ``HELP Notfall'' (median=87.5) was ranked with an SUS score above the published average of 68. This app was rated significantly superior to ``HAMBURG SCHOCKT'' (median=55; asymptotic Wilcoxon test: z=?3.63, P<.01, n=19) and ``Mein DRK'' (median=32.5; asymptotic Wilcoxon test: z=?3.83, P<.01, n=19). Conclusions: Implementing a systematic quality control for health-related apps should be enforced to ensure that all products provide medically accurate content and sufficient usability in complex situations. This is of exceptional importance for apps dealing with the treatment of life-threatening events such as cardiac arrest. ", doi="10.2196/mhealth.9651", url="http://mhealth.jmir.org/2018/11/e190/", url="http://www.ncbi.nlm.nih.gov/pubmed/30401673" } @Article{info:doi/10.2196/jmir.7379, author="Siebert, N. Johan and Ehrler, Frederic and Gervaix, Alain and Haddad, Kevin and Lacroix, Laurence and Schrurs, Philippe and Sahin, Ayhan and Lovis, Christian and Manzano, Sergio", title="Adherence to AHA Guidelines When Adapted for Augmented Reality Glasses for Assisted Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial", journal="J Med Internet Res", year="2017", month="May", day="29", volume="19", number="5", pages="e183", keywords="resuscitation", keywords="emergency medicine", keywords="pediatrics", keywords="biomedical technologies", keywords="equipment and supplies", keywords="eyeglasses", abstract="Background: The American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) are nowadays recognized as the world's most authoritative resuscitation guidelines. Adherence to these guidelines optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite their availability, suboptimal quality of CPR is still common. Currently, the median hospital survival rate after pediatric in-hospital cardiac arrest is 36\%, whereas it falls below 10\% for out-of-hospital cardiac arrest. Among emerging information technologies and devices able to support caregivers during resuscitation and increase adherence to AHA guidelines, augmented reality (AR) glasses have not yet been assessed. In order to assess their potential, we adapted AHA Pediatric Advanced Life Support (PALS) guidelines for AR glasses. Objective: The study aimed to determine whether adapting AHA guidelines for AR glasses increased adherence by reducing deviation and time to initiation of critical life-saving maneuvers during pediatric CPR when compared with the use of PALS pocket reference cards. Methods: We conducted a randomized controlled trial with two parallel groups of voluntary pediatric residents, comparing AR glasses to PALS pocket reference cards during a simulation-based pediatric cardiac arrest scenario---pulseless ventricular tachycardia (pVT). The primary outcome was the elapsed time in seconds in each allocation group, from onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, as well as the time intervals between defibrillation attempts and drug doses, shock doses, and number of shocks. All these outcomes were assessed for deviation from AHA guidelines. Results: Twenty residents were randomized into 2 groups. Time to first defibrillation attempt (mean: 146 s) and adherence to AHA guidelines in terms of time to other critical resuscitation endpoints and drug dose delivery were not improved using AR glasses. However, errors and deviations were significantly reduced in terms of defibrillation doses when compared with the use of the PALS pocket reference cards. In a total of 40 defibrillation attempts, residents not wearing AR glasses used wrong doses in 65\% (26/40) of cases, including 21 shock overdoses >100 J, for a cumulative defibrillation dose of 18.7 Joules per kg. These errors were reduced by 53\% (21/40, P<.001) and cumulative defibrillation dose by 37\% (5.14/14, P=.001) with AR glasses. Conclusions: AR glasses did not decrease time to first defibrillation attempt and other critical resuscitation endpoints when compared with PALS pocket cards. However, they improved adherence and performance among residents in terms of administering the defibrillation doses set by AHA. ", doi="10.2196/jmir.7379", url="http://www.jmir.org/2017/5/e183/", url="http://www.ncbi.nlm.nih.gov/pubmed/28554878" } @Article{info:doi/10.2196/jmir.7005, author="Siebert, N. Johan and Ehrler, Frederic and Combescure, Christophe and Lacroix, Laurence and Haddad, Kevin and Sanchez, Oliver and Gervaix, Alain and Lovis, Christian and Manzano, Sergio", title="A Mobile Device App to Reduce Time to Drug Delivery and Medication Errors During Simulated Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial", journal="J Med Internet Res", year="2017", month="Feb", day="01", volume="19", number="2", pages="e31", keywords="resuscitation", keywords="medication errors", keywords="pharmaceutical preparations", keywords="pediatrics", keywords="biomedical technology", abstract="Background: During pediatric cardiopulmonary resuscitation (CPR), vasoactive drug preparation for continuous infusion is both complex and time-consuming, placing children at higher risk than adults for medication errors. Following an evidence-based ergonomic-driven approach, we developed a mobile device app called Pediatric Accurate Medication in Emergency Situations (PedAMINES), intended to guide caregivers step-by-step from preparation to delivery of drugs requiring continuous infusion. Objective: The aim of our study was to determine whether the use of PedAMINES reduces drug preparation time (TDP) and time to delivery (TDD; primary outcome), as well as medication errors (secondary outcomes) when compared with conventional preparation methods. Methods: The study was a randomized controlled crossover trial with 2 parallel groups comparing PedAMINES with a conventional and internationally used drugs infusion rate table in the preparation of continuous drug infusion. We used a simulation-based pediatric CPR cardiac arrest scenario with a high-fidelity manikin in the shock room of a tertiary care pediatric emergency department. After epinephrine-induced return of spontaneous circulation, pediatric emergency nurses were first asked to prepare a continuous infusion of dopamine, using either PedAMINES (intervention group) or the infusion table (control group), and second, a continuous infusion of norepinephrine by crossing the procedure. The primary outcome was the elapsed time in seconds, in each allocation group, from the oral prescription by the physician to TDD by the nurse. TDD included TDP. The secondary outcome was the medication dosage error rate during the sequence from drug preparation to drug injection. Results: A total of 20 nurses were randomized into 2 groups. During the first study period, mean TDP while using PedAMINES and conventional preparation methods was 128.1 s (95\% CI 102-154) and 308.1 s (95\% CI 216-400), respectively (180 s reduction, P=.002). Mean TDD was 214 s (95\% CI 171-256) and 391 s (95\% CI 298-483), respectively (177.3 s reduction, P=.002). Medication errors were reduced from 70\% to 0\% (P<.001) by using PedAMINES when compared with conventional methods. Conclusions: In this simulation-based study, PedAMINES dramatically reduced TDP, to delivery and the rate of medication errors. ", doi="10.2196/jmir.7005", url="http://www.jmir.org/2017/2/e31/", url="http://www.ncbi.nlm.nih.gov/pubmed/28148473" } @Article{info:doi/10.2196/games.6448, author="Creutzfeldt, Johan and Hedman, Leif and Fell{\"a}nder-Tsai, Li", title="Cardiopulmonary Resuscitation Training by Avatars: A Qualitative Study of Medical Students' Experiences Using a Multiplayer Virtual World", journal="JMIR Serious Games", year="2016", month="Dec", day="16", volume="4", number="2", pages="e22", keywords="avatars", keywords="cardiopulmonary resuscitation", keywords="educational technology", keywords="medical students", keywords="experiences", keywords="multiplayer virtual worlds", keywords="patient simulation", keywords="virtual learning environments", abstract="Background: Emergency medical practices are often team efforts. Training for various tasks and collaborations may be carried out in virtual environments. Although promising results exist from studies of serious games, little is known about the subjective reactions of learners when using multiplayer virtual world (MVW) training in medicine. Objective: The objective of this study was to reach a better understanding of the learners' reactions and experiences when using an MVW for team training of cardiopulmonary resuscitation (CPR). Methods: Twelve Swedish medical students participated in semistructured focus group discussions after CPR training in an MVW with partially preset options. The students' perceptions and feelings related to use of this educational tool were investigated. Using qualitative methodology, discussions were analyzed by a phenomenological data-driven approach. Quality measures included negotiations, back-and-forth reading, triangulation, and validation with the informants. Results: Four categories characterizing the students' experiences could be defined: (1) Focused Mental Training, (2) Interface Diverting Focus From Training, (3) Benefits of Practicing in a Group, and (4) Easy Loss of Focus When Passive. We interpreted the results, compared them to findings of others, and propose advantages and risks of using virtual worlds for learning. Conclusions: Beneficial aspects of learning CPR in a virtual world were confirmed. To achieve high participant engagement and create good conditions for training, well-established procedures should be practiced. Furthermore, students should be kept in an active mode and frequent feedback should be utilized. It cannot be completely ruled out that the use of virtual training may contribute to erroneous self-beliefs that can affect later clinical performance. ", doi="10.2196/games.6448", url="http://games.jmir.org/2016/2/e22/", url="http://www.ncbi.nlm.nih.gov/pubmed/27986645" } @Article{info:doi/10.2196/resprot.5107, author="Plaisance, Ariane and Witteman, O. Holly and Heyland, Keith Daren and Ebell, H. Mark and Dupuis, Audrey and Lavoie-B{\'e}rard, Carole-Anne and L{\'e}gar{\'e}, France and Archambault, Michel Patrick", title="Development of a Decision Aid for Cardiopulmonary Resuscitation Involving Intensive Care Unit Patients' and Health Professionals' Participation Using User-Centered Design and a Wiki Platform for Rapid Prototyping: A Research Protocol", journal="JMIR Res Protoc", year="2016", month="Feb", day="11", volume="5", number="1", pages="e24", keywords="cardiopulmonary resuscitation", keywords="end-of-life planning", keywords="goals of care discussions", keywords="intensive care medicine", keywords="medical informatics", keywords="shared decision making", keywords="user-centered design", keywords="wikis", abstract="Background: Cardiopulmonary resuscitation (CPR) is an intervention used in cases of cardiac arrest to revive patients whose heart has stopped. Because cardiac arrest can have potentially devastating outcomes such as severe neurological deficits even if CPR is performed, patients must be involved in determining in advance if they want CPR in the case of an unexpected arrest. Shared decision making (SDM) facilitates discussions about goals of care regarding CPR in intensive care units (ICUs). Patient decision aids (DAs) are proven to support the implementation of SDM. Many patient DAs about CPR exist, but they are not universally implemented in ICUs in part due to lack of context and cultural adaptation. Adaptation to local context is an important phase of implementing any type of knowledge tool such as patient DAs. User-centered design supported by a wiki platform to perform rapid prototyping has previously been successful in creating knowledge tools adapted to the needs of patients and health professionals (eg, asthma action plans). This project aims to explore how user-centered design and a wiki platform can support the adaptation of an existing DA for CPR to the local context. Objective: The primary objective is to use an existing DA about CPR to create a wiki-based DA that is adapted to the context of a single ICU and tailorable to individual patient's risk factors while employing user-centered design. The secondary objective is to document the use of a wiki platform for the adaptation of patient DAs. Methods: This study will be conducted in a mixed surgical and medical ICU at H{\^o}tel-Dieu de L{\'e}vis, Quebec, Canada. We plan to involve all 5 intensivists and recruit at least 20 alert and oriented patients admitted to the ICU and their family members if available. In the first phase of this study, we will observe 3 weeks of daily interactions between patients, families, intensivists, and other allied health professionals. We will specifically observe 5 dyads of attending intensivists and alert and oriented patients discussing goals of care concerning CPR to understand how a patient DA could support this decision. We will also conduct individual interviews with the 5 intensivists to identify their needs concerning the implementation of a DA. In the second phase of the study, we will build a first prototype based on the needs identified in Phase I. We will start by translating an existing DA entitled ``Cardiopulmonary resuscitation: a decision aid for patients and their families.'' We will then adapt this tool to the needs we identified in Phase I and archive this first prototype in a wiki. Building on the wiki's programming architecture, we intend to integrate the Good Outcome Following Attempted Resuscitation risk calculator into our DA to determine personal risks and benefits of CPR for each patient. We will then present the first prototype to 5 new patient-intensivist dyads. Feedback about content and visual presentation will be collected from the intensivists through short interviews while longer interviews will be conducted with patients and their family members to inform the visual design and content of the next prototype. After each rapid prototyping cycle, 2 researchers will perform qualitative content analysis of data collected through interviews and direct observations. We will attempt to solve all content and visual design issues identified before moving to the next round of prototyping. In all, we will conduct 3 prototyping cycles with a total of 15 patient-intensivist dyads. Results: We expect to develop a multimedia wiki-based DA to support goals of care discussions about CPR adapted to the local needs of patients, their family members, and intensivists and tailorable to individual patient risk factors. The final version of the DA as well as the development process will be housed in an open-access wiki and free to be adapted and used in other contexts. Conclusions: This study will shed new light on the development of DAs adapted to local context and tailorable to individual patient risk factors employing user-centered design and a wiki to support rapid prototyping of content and visual design issues. ", doi="10.2196/resprot.5107", url="http://www.researchprotocols.org/2016/1/e24/", url="http://www.ncbi.nlm.nih.gov/pubmed/26869137" } @Article{info:doi/10.2196/jmir.2951, author="Kalz, Marco and Lenssen, Niklas and Felzen, Marc and Rossaint, Rolf and Tabuenca, Bernardo and Specht, Marcus and Skorning, Max", title="Smartphone Apps for Cardiopulmonary Resuscitation Training and Real Incident Support: A Mixed-Methods Evaluation Study", journal="J Med Internet Res", year="2014", month="Mar", day="19", volume="16", number="3", pages="e89", keywords="basic life support (BLS)", keywords="cardiopulmonary resuscitation (CPR)", keywords="external chest compression (ECC)", keywords="smartphone apps", keywords="mobile phone", keywords="mobile health", abstract="Background: No systematic evaluation of smartphone/mobile apps for resuscitation training and real incident support is available to date. To provide medical, usability, and additional quality criteria for the development of apps, we conducted a mixed-methods sequential evaluation combining the perspective of medical experts and end-users. Objective: The study aims to assess the quality of current mobile apps for cardiopulmonary resuscitation (CPR) training and real incident support from expert as well as end-user perspective. Methods: Two independent medical experts evaluated the medical content of CPR apps from the Google Play store and the Apple App store. The evaluation was based on pre-defined minimum medical content requirements according to current Basic Life Support (BLS) guidelines. In a second phase, non-medical end-users tested usability and appeal of the apps that had at least met the minimum requirements. Usability was assessed with the System Usability Scale (SUS); appeal was measured with the self-developed ReactionDeck toolkit. Results: Out of 61 apps, 46 were included in the experts' evaluation. A consolidated list of 13 apps resulted for the following layperson evaluation. The interrater reliability was substantial (kappa=.61). Layperson end-users (n=14) had a high interrater reliability (intraclass correlation 1 [ICC1]=.83, P<.001, 95\% CI 0.75-0.882 and ICC2=.79, P<.001, 95\% CI 0.695-0.869). Their evaluation resulted in a list of 5 recommendable apps. Conclusions: Although several apps for resuscitation training and real incident support are available, very few are designed according to current BLS guidelines and offer an acceptable level of usability and hedonic quality for laypersons. The results of this study are intended to optimize the development of CPR mobile apps. The app ranking supports the informed selection of mobile apps for training situations and CPR campaigns as well as for real incident support. ", doi="10.2196/jmir.2951", url="http://www.jmir.org/2014/3/e89/", url="http://www.ncbi.nlm.nih.gov/pubmed/24647361" } @Article{info:doi/10.2196/jmir.1715, author="Creutzfeldt, Johan and Hedman, Leif and Heinrichs, LeRoy and Youngblood, Patricia and Fell{\"a}nder-Tsai, Li", title="Cardiopulmonary Resuscitation Training in High School Using Avatars in Virtual Worlds: An International Feasibility Study", journal="J Med Internet Res", year="2013", month="Jan", day="14", volume="15", number="1", pages="e9", keywords="Serious games", keywords="virtual learning environments", keywords="MMVW", keywords="avatars", keywords="students", keywords="cardiopulmonary resuscitation", keywords="patient simulation", keywords="self-efficacy", keywords="concentration", abstract="Background: Approximately 300,000 people suffer sudden cardiac arrest (SCA) annually in the United States. Less than 30\% of out-of-hospital victims receive cardiopulmonary resuscitation (CPR) despite the American Heart Association training over 12 million laypersons annually to conduct CPR. New engaging learning methods are needed for CPR education, especially in schools. Massively multiplayer virtual worlds (MMVW) offer platforms for serious games that are promising learning methods that take advantage of the computer capabilities of today's youth (ie, the digital native generation). Objective: Our main aim was to assess the feasibility of cardiopulmonary resuscitation training in high school students by using avatars in MMVM. We also analyzed experiences, self-efficacy, and concentration in response to training. Methods: In this prospective international collaborative study, an e-learning method was used with high school students in Sweden and the United States. A software game platform was modified for use as a serious game to train in emergency medical situations. Using MMVW technology, participants in teams of 3 were engaged in virtual-world scenarios to learn how to treat victims suffering cardiac arrest. Short debriefings were carried out after each scenario. A total of 36 high school students (Sweden, n=12; United States, n=24) participated. Their self-efficacy and concentration (task motivation) were assessed. An exit questionnaire was used to solicit experiences and attitudes toward this type of training. Among the Swedish students, a follow-up was carried out after 6 months. Depending on the distributions, t tests or Mann-Whitney tests were used. Correlation between variables was assessed by using Spearman rank correlation. Regression analyses were used for time-dependent variables. Results: The participants enjoyed the training and reported a self-perceived benefit as a consequence of training. The mean rating for self-efficacy increased from 5.8/7 (SD 0.72) to 6.5/7 (SD 0.57, P<.001). In the Swedish follow-up, it subsequently increased from 5.7/7 (SD 0.56) to 6.3/7 (SD 0.38, P=.006). In the Swedish group, the mean concentration value increased from 52.4/100 (SD 9.8) to 62.7/100 (SD 8.9, P=.05); in the US group, the concentration value increased from 70.8/100 (SD 7.9) to 82.5/100 (SD 4.7, P<.001). We found a significant positive correlation (P<.001) between self-efficacy and concentration scores. Overall, the participants were moderately or highly immersed and the software was easy to use. Conclusions: By using online MMVWs, team training in CPR is feasible and reliable for this international group of high school students (Sweden and United States). A high level of appreciation was reported among these adolescents and their self-efficacy increased significantly. The described training is a novel and interesting way to learn CPR teamwork, and in the future could be combined with psychomotor skills training. ", doi="10.2196/jmir.1715", url="http://www.jmir.org/2013/1/e9/", url="http://www.ncbi.nlm.nih.gov/pubmed/23318253" }