Search

In the United States, we have a healthcare system crisis with high rates of dissatisfaction among patients and providers. To transform health and healthcare, clinical providers must be proficient in the human-centered approach of design thinking (DT).To synthesize the human-centered design (HCD) and DT literature for the creation of health interventions.We performed an integrative literature review focused on how HCD and DT are used in the clinical healthcare setting. Four research databases were searched from inception through November 6, 2020. We analyzed the methodology used, who is using the frameworks, and the DT phases included.Twenty-four articles were included in the final analysis. Of the 24 manuscripts, 6 (25%) were nurse-led and 15 (63%) had interdisciplinary first and last authors (e.g., Nursing and Medicine). Overall, 10/24 (42%) included all DT method. When analyzing the articles by approach or methodology, 12 (50%) stated they were using the HCD approach, 5 (21%) the DT methodology, and 7 (29%) stated they were using both the HCD approach and DT methodology.There are inconsistencies in who uses DT and the phases used to create healthcare interventions.

Bystander cardiopulmonary resuscitation (CPR) is critical to increasing survival from out-of-hospital cardiac arrest. However, the percentage of cases in which an individual receives bystander CPR is actually low, at only 35% to 40% globally. Preparing lay responders to recognize the signs of sudden cardiac arrest, call 9-1-1, and perform CPR in public and private locations is crucial to increasing survival from this public health problem. The objective of this scientific statement is to summarize the most recent published evidence about the lay responder experience of training, responding, and dealing with the residual impact of witnessing an out-of-hospital cardiac arrest. The scientific statement focuses on the experience-based literature of actual responders, which includes barriers to responding, experiences of doing CPR, use of an automated external defibrillator, the impact of dispatcher-assisted CPR, and the potential for postevent psychological sequelae. The large body of qualitative and observational studies identifies several gaps in crucial knowledge that, if targeted, could increase the likelihood that those who are trained in CPR will act. We suggest using the experience of actual responders to inform more contextualized training, including the implications of performing CPR on a family member, dispelling myths about harm, training and litigation, and recognition of the potential for psychologic sequelae after the event.

Aim of the study Since over 80% of sudden cardiac arrests occur in the home, cardiopulmonary resuscitation (CPR) training for family members of high-risk cardiac patients represents a promising intervention. The use of mobile application-based (mApp) CPR training may facilitate this approach, but evidence regarding its efficacy is lacking. Methods We conducted a multicenter, pragmatic, cluster-randomized trial assessing CPR training for family members of cardiac patients. The interventions were mApp (video, no manikin) and VSI (video + manikin). CPR skills were evaluated 6-months post-training. We hypothesized that chest compression (CC) rate from training with an mApp would be no worse than 5 compressions per minute (CPM) lower compared to VSI. Results From 01/2016 to 01/2018, we enrolled 1325 eligible participants (mean age 51.6 years, 68.2% female and 59.4% white). CPR skills were evaluated 6-months post-training in 541 participants (275 VSI, 266 mApp). Mean rate was 84.6 CPM (95% CI: 80.4, 88.6) in VSI, compared to 82.7 CPM (95% CI: 76.2, 89.1) in the mApp, and mean depth was 42.1 mm (95% CI: 40.3, 43.8) in VSI, compared to 38.9 mm (95% CI: 36.2, 41.6) in the mApp. After adjustment, the mean difference in CC rate was −2.3 CPM (95% CI −9.4, 4.8, p = 0.25, non-inferiority) and CC depth was −3.2 mm (95% CI −5.9, 0.1, p = 0.056). Conclusion In this large prospective trial of CPR skill retention for family members of cardiac patients, mApp training was associated with lower CC quality. Future work is required to understand additional approaches to improve CPR skill retention. Clinical Trial Registration URL: ClinicalTrials.gov, Identifier: NCT02548793 .

Nurses are continually innovating to fill gaps or inefficiencies within healthcare. This was particularly evident during the COVID-19 pandemic, when a burst in nurse-led innovation in all areas of healthcare and across the lifespan necessitated an innovation ecosystem to realize nurses' full potential. New ways of thinking and leading the future of nursing have been echoed by the National Academy of Medicine’s Future of Nursing Report 2020-2030, the American Nurses Association (ANA) innovation task force, and the American Nurses Credentialing Center (ANCC). Nurse-led hackathons, incubators, and accelerators have emerged to meet the need for a more intentional and formal pathway for nurses to add value to health and healthcare within an innovation and design thinking framework. This article describes a brief historical background of hackathons, innovation incubators, and innovation accelerators and considers their evolution within the nursing profession, including implications for practice and education.

As interest in nurse-led health and health care innovation grows, we must prepare nurses with the skills, knowledge, and experiences necessary to lead in these areas. In this article we describe how schools of nursing can integrate innovation in their mission, describe actionable steps to position nurses as leaders in this space, and provide a case study example of how to infuse innovation into a school of nursing. CLINICAL RELEVANCE: In order for nurses to lead in health and healthcare innovation, schools of nursing and nursing programs must think strategically about the knowledge and skills the next generation of nurses will need and then support those innovation needs at all levels of research, education, and practice.

Background Using a mobile virtual reality (VR) platform to heighten realism for cardiopulmonary resuscitation (CPR) training has the potential to improve bystander response. Objectives We examined whether using a VR mobile application (mApp) for CPR training would improve bystander response compared with a standard mApp CPR training. Methods We randomized lay bystanders to either our intervention arm (VR mApp) or our control arm (mApp). During a post-intervention skills test, we collected bystander response data (call 911, perform CPR, ask for an automated external defibrillator (AED)), along with CPR quality (chest compression (CC) rate and depth). Wilcox rank sum was used to analyze CC rate and CC depth as they were not normally distributed; Pearson’s Chi-square was used to analyze Chain of Survival variables. Results Between 3/2018 and 9/2018, 105 subjects were enrolled: 52 VR mApp and 53 mApp. Mean age was 46 ± 16 years, 34% were female, 59% were Black, and 17% were currently CPR trained (≤2 years). Bystander response was significantly higher in the VR mApp arm: called 911 (82% vs 58%, p = 0.007) and asked for an AED (57% vs 28%, p = 0.003). However there was no difference in CPR performed (98% vs 98%, p = NS) and the application of the AED (90% vs 93%, p = NS). When comparing the VR mApp to the mApp, mean CC rate was 104 ± 42 cpm vs 112 ± 30 cpm (p = NS), and mean CC depth was 38 ± 15 mm vs 44 ± 13 mm (p = 0.05). Conclusion The use of the VR mApp significantly increased the likelihood of calling 911 and asking for an AED, however, CC depth was decreased.

A sudden cardiac arrest (SCA) occurs when the heart abruptly stops beating; because of the nature of SCA, capturing data in the out-of-hospital setting from actual bystander response is difficult. Current technologies such as virtual reality (VR) allow the creation of scenarios programmed for heightened realism. No studies have used an immersive VR system to observe lay bystander response.We sought to characterize lay bystander response to an unannounced simulated VR SCA event during a multisensory scenario.Using a VR wearable device combined with a cardiopulmonary resuscitation (CPR) recording manikin, we created a 3-minute multisensory SCA scenario that allowed for the observation of lay bystander response. Subjects were unaware of the nature of the emergency event but were told to respond how they would to an emergency situation. Subject's ability to proceed through the American Heart Association's Chain of Survival and their CPR quality were recorded. Frequencies and percentages were calculated using descriptive statistics.Between June 2016 and June 2017, 119 lay subjects were enrolled. Of those, 92% asked for 911 to be called, 81% attempted CPR, 13% requested an automated external defibrillator (AED), and 6% used the AED; 82% stated that they felt as if they were at a real SCA event. Cardiopulmonary resuscitation data were collected (n = 81), the mean CC rate was 93.5 ± 22.4 cpm, and the mean CC depth was 38.4 ± 13.8 mm.In our unannounced, immersive VR SCA observational study of lay bystanders, most subjects attempted CPR, although the majority did not use an AED.

Background: As COVID-19 forced in-person courses to transition online, an active learning course focused on design thinking in health and health care embraced the challenge. Lessons learned, mistakes made, and thoughts on the future of online education in nursing are discussed. Method: During the online transition, it was thought the flipped-classroom approach would transition well using the same design thinking methodology taught in the course. Because the course promoted rapid innovation and iteration, such a challenge served as a call to action, and the course became a valuable real-time case study. Results: Based on student surveys, the overall quality of the transitioned course increased slightly compared with the previous semester's in-person course, indicating schools of nursing can innovate both the way students are taught as well as what students are taught. Conclusion: Rather than mourn the loss of in-person learning, the newfound possibilities of virtual education should celebrated. [ J Nurs Educ . 2021;60(5):298–300.] .

BACKGROUND Septic shock is a low-frequency but high-stakes condition in children requiring prompt resuscitation, which makes it an important target for simulation-based education. OBJECTIVE In this study, we aimed to design and implement an augmented reality app (PediSepsisAR) for septic shock simulation, test the feasibility of measuring the timing and volume of fluid administration during septic shock simulation with and without PediSepsisAR, and describe PediSepsisAR as an educational tool. We hypothesized that we could feasibly measure our desired data during the simulation in 90% of the participants in each group. With regard to using PediSepsisAR as an educational tool, we hypothesized that the PediSepsisAR group would report that it enhanced their awareness of simulated patient blood flow and would more rapidly verbalize recognition of abnormal patient status and desired management steps. METHODS We performed a randomized controlled feasibility trial with a convenience sample of pediatric care providers at a large tertiary care pediatric center. Participants completed a prestudy questionnaire and were randomized to either the PediSepsisAR or control (traditional simulation) arms. We measured the participants’ time to administer 20, 40, and 60 cc/kg of intravenous fluids during a septic shock simulation using each modality. In addition, facilitators timed how long participants took to verbalize they had recognized tachycardia, hypotension, or septic shock and desired to initiate the sepsis pathway and administer antibiotics. Participants in the PediSepsisAR arm completed a poststudy questionnaire. We analyzed data using descriptive statistics and a Wilcoxon rank-sum test to compare the median time with event variables between groups. RESULTS We enrolled 50 participants (n=25 in each arm). The timing and volume of fluid administration were captured in all the participants in each group. There was no statistically significant difference regarding time to administration of intravenous fluids between the two groups. Similarly, there was no statistically significant difference between the groups regarding time to verbalized recognition of patient status or desired management steps. Most participants in the PediSepsisAR group reported that PediSepsisAR enhanced their awareness of the patient’s perfusion. CONCLUSIONS We developed an augmented reality app for use in pediatric septic shock simulations and demonstrated the feasibility of measuring the volume and timing of fluid administration during simulation using this modality. In addition, our findings suggest that PediSepsisAR may enhance participants’ awareness of abnormal perfusion.

Background The traditional model of promotion and tenure in the health professions relies heavily on formal scholarship through teaching, research, and service. Institutions consider how much weight to give activities in each of these areas and determine a threshold for advancement. With the emergence of social media, scholars can engage wider audiences in creative ways and have a broader impact. Conventional metrics like the h-index do not account for social media impact. Social media engagement is poorly represented in most curricula vitae (CV) and therefore is undervalued in promotion and tenure reviews. Objective The objective was to develop crowdsourced guidelines for documenting social media scholarship. These guidelines aimed to provide a structure for documenting a scholar’s general impact on social media, as well as methods of documenting individual social media contributions exemplifying innovation, education, mentorship, advocacy, and dissemination. Methods To create unifying guidelines, we created a crowdsourced process that capitalized on the strengths of social media and generated a case example of successful use of the medium for academic collaboration. The primary author created a draft of the guidelines and then sought input from users on Twitter via a publicly accessible Google Document. There was no limitation on who could provide input and the work was done in a democratic, collaborative fashion. Contributors edited the draft over a period of 1 week (September 12-18, 2020). The primary and secondary authors then revised the draft to make it more concise. The guidelines and manuscript were then distributed to the contributors for edits and adopted by the group. All contributors were given the opportunity to serve as coauthors on the publication and were told upfront that authorship would depend on whether they were able to document the ways in which they met the 4 International Committee of Medical Journal Editors authorship criteria. Results We developed 2 sets of guidelines: Guidelines for Listing All Social Media Scholarship Under Public Scholarship (in Research/Scholarship Section of CV) and Guidelines for Listing Social Media Scholarship Under Research, Teaching, and Service Sections of CV. Institutions can choose which set fits their existing CV format. Conclusions With more uniformity, scholars can better represent the full scope and impact of their work. These guidelines are not intended to dictate how individual institutions should weigh social media contributions within promotion and tenure cases. Instead, by providing an initial set of guidelines, we hope to provide scholars and their institutions with a common format and language to document social media scholarship.

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

BACKGROUND The traditional model of promotion and tenure in the health professions relies heavily on formal scholarship through teaching, research, and service. Institutions consider how much weight to give activities in each of these areas and determine a threshold for advancement. With the emergence of social media, scholars can engage wider audiences in creative ways and have a broader impact. Conventional metrics like the h-index do not account for social media impact. Social media engagement is poorly represented in most curricula vitae (CV) and therefore is undervalued in promotion and tenure reviews. OBJECTIVE The objective was to develop crowdsourced guidelines for documenting social media scholarship. These guidelines aimed to provide a structure for documenting a scholar’s general impact on social media, as well as methods of documenting individual social media contributions exemplifying innovation, education, mentorship, advocacy, and dissemination. METHODS To create unifying guidelines, we created a crowdsourced process that capitalized on the strengths of social media and generated a case example of successful use of the medium for academic collaboration. The primary author created a draft of the guidelines and then sought input from users on Twitter via a publicly accessible Google Document. There was no limitation on who could provide input and the work was done in a democratic, collaborative fashion. Contributors edited the draft over a period of 1 week (September 12-18, 2020). The primary and secondary authors then revised the draft to make it more concise. The guidelines and manuscript were then distributed to the contributors for edits and adopted by the group. All contributors were given the opportunity to serve as coauthors on the publication and were told upfront that authorship would depend on whether they were able to document the ways in which they met the 4 International Committee of Medical Journal Editors authorship criteria. RESULTS We developed 2 sets of guidelines: Guidelines for Listing All Social Media Scholarship Under Public Scholarship (in Research/Scholarship Section of CV) and Guidelines for Listing Social Media Scholarship Under Research, Teaching, and Service Sections of CV. Institutions can choose which set fits their existing CV format. CONCLUSIONS With more uniformity, scholars can better represent the full scope and impact of their work. These guidelines are not intended to dictate how individual institutions should weigh social media contributions within promotion and tenure cases. Instead, by providing an initial set of guidelines, we hope to provide scholars and their institutions with a common format and language to document social media scholarship.

BackgroundWith the “Artemis”-mission mankind will return to the Moon by 2024. Prolonged periods in space will not only present physical and psychological challenges to the astronauts, but also pose risks concerning the medical treatment capabilities of the crew. So far, no guideline exists for the treatment of severe medical emergencies in microgravity. We, as a international group of researchers related to the field of aerospace medicine and critical care, took on the challenge and developed a an evidence-based guideline for the arguably most severe medical emergency – cardiac arrest.MethodsAfter the creation of said international group, PICO questions regarding the topic cardiopulmonary resuscitation in microgravity were developed to guide the systematic literature research. Afterwards a precise search strategy was compiled which was then applied to “MEDLINE”. Four thousand one hundred sixty-five findings were retrieved and consecutively screened by at least 2 reviewers. This led to 88 original publications that were acquired in full-text version and then critically appraised using the GRADE methodology. Those studies formed to basis for the guideline recommendations that were designed by at least 2 experts on the given field. Afterwards those recommendations were subject to a consensus finding process according to the DELPHI-methodology.ResultsWe recommend a differentiated approach to CPR in microgravity with a division into basic life support (BLS) and advanced life support (ALS) similar to the Earth-based guidelines. In immediate BLS, the chest compression method of choice is the Evetts-Russomano method (ER), whereas in an ALS scenario, with the patient being restrained on the Crew Medical Restraint System, the handstand method (HS) should be applied. Airway management should only be performed if at least two rescuers are present and the patient has been restrained. A supraglottic airway device should be used for airway management where crew members untrained in tracheal intubation (TI) are involved.DiscussionCPR in microgravity is feasible and should be applied according to the Earth-based guidelines of the AHA/ERC in relation to fundamental statements, like urgent recognition and action, focus on high-quality chest compressions, compression depth and compression-ventilation ratio. However, the special circumstances presented by microgravity and spaceflight must be considered concerning central points such as rescuer position and methods for the performance of chest compressions, airway management and defibrillation.

Background: Guidelines-based cardiopulmonary resuscitation (CPR) during in-hospital cardiac arrest is a significant predictor of survival, yet the quality of healthcare provider (HCP) CPR (e.g., nurses, physicians etc.) has been shown to be poor. Studies have found that providing HCPs with simulated CPR refresher trainings can improve their CPR quality, however, no studies have compared the use of an augmented reality (AR) CPR refresher training with a standard audio-visual (AV) feedback manikin to improve HCP training. Objectives: In our pilot study, HCPs were randomized to a refresher CPR simulation training with either our AR CPR training application (CPReality) or a standard AV feedback manikin. All subjects completed 2 min of CPR on their respective CPR training modalities, followed by an additional 2 min post-simulation CPR evaluation with no feedback. We hypothesized that the AR CPR training application would confer improved CPR quality defined as chest compression rate and depth compared with the standard AV feedback training. Results: Between January 2019 and May 2019, 100 HCPs were enrolled (50 in the CPReality cohort and 50 in the standard AV manikin cohort). The mean chest compression (CC) rate for all subjects during the intervention was 118 ± 15 cpm, and CC depth was 50 ± 8; post-intervention the CC rate was 120 ± 13 and CC depth was 51 ± 8. The mean CC rate for those trained with CPReality was 121 ± 3 compared with the standard CPR manikin training which was 114 ± 1 cpm (p < 0.006); CC depth was 48 ± 1 mm vs. 52 ± 1 (p = 0.007), respectively. Post-simulation CPR quality with no feedback showed a mean CC rate for the CPReality application at 122 ± 15 cpm compared with the standard CPR manikin at 117 ± 11 cpm (p = 0.09); depth was 49 ± 8 mm vs. 52 ± 8 (p = 0.095), respectively. In the post-survey, 79% of CPReality subjects agreed that the AR application provided a realistic patient presence compared with 59% (p = 0.07) of subjects in the standard CPR manikin cohort. Conclusions: In a randomized trial of an AR CPR training application compared with a standard CPR manikin training, the AR CPR application did not improve the quality of CPR performed during a CPR refresher training compared with the standard training in HCPs. Future studies should investigate the use of this and other digital technologies for CPR training and education.

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations , the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

Background: Studies examining the association between hyperoxia exposure after resuscitation from cardiac arrest and clinical outcomes have reported conflicting results. Our objective was to test the hypothesis that early postresuscitation hyperoxia is associated with poor neurological outcome. Methods: This was a multicenter prospective cohort study. We included adult patients with cardiac arrest who were mechanically ventilated and received targeted temperature management after return of spontaneous circulation. We excluded patients with cardiac arrest caused by trauma or sepsis. Per protocol, partial pressure of arterial oxygen (Pa o 2 ) was measured at 1 and 6 hours after return of spontaneous circulation. Hyperoxia was defined as a Pa o 2 >300 mm Hg during the initial 6 hours after return of spontaneous circulation. The primary outcome was poor neurological function at hospital discharge, defined as a modified Rankin Scale score >3. Multivariable generalized linear regression with a log link was used to test the association between Pa o 2 and poor neurological outcome. To assess whether there was an association between other supranormal Pa o 2 levels and poor neurological outcome, we used other Pa o 2 cut points to define hyperoxia (ie, 100, 150, 200, 250, 350, 400 mm Hg). Results: Of the 280 patients included, 105 (38%) had exposure to hyperoxia. Poor neurological function at hospital discharge occurred in 70% of patients in the entire cohort and in 77% versus 65% among patients with versus without exposure to hyperoxia respectively (absolute risk difference, 12%; 95% confidence interval, 1–23). Hyperoxia was independently associated with poor neurological function (relative risk, 1.23; 95% confidence interval, 1.11–1.35). On multivariable analysis, a 1-hour-longer duration of hyperoxia exposure was associated with a 3% increase in risk of poor neurological outcome (relative risk, 1.03; 95% confidence interval, 1.02–1.05). We found that the association with poor neurological outcome began at ≥300 mm Hg. Conclusions: Early hyperoxia exposure after resuscitation from cardiac arrest was independently associated with poor neurological function at hospital discharge.

Background Septic shock is a low-frequency but high-stakes condition in children requiring prompt resuscitation, which makes it an important target for simulation-based education. Objective In this study, we aimed to design and implement an augmented reality app (PediSepsisAR) for septic shock simulation, test the feasibility of measuring the timing and volume of fluid administration during septic shock simulation with and without PediSepsisAR, and describe PediSepsisAR as an educational tool. We hypothesized that we could feasibly measure our desired data during the simulation in 90% of the participants in each group. With regard to using PediSepsisAR as an educational tool, we hypothesized that the PediSepsisAR group would report that it enhanced their awareness of simulated patient blood flow and would more rapidly verbalize recognition of abnormal patient status and desired management steps. Methods We performed a randomized controlled feasibility trial with a convenience sample of pediatric care providers at a large tertiary care pediatric center. Participants completed a prestudy questionnaire and were randomized to either the PediSepsisAR or control (traditional simulation) arms. We measured the participants’ time to administer 20, 40, and 60 cc/kg of intravenous fluids during a septic shock simulation using each modality. In addition, facilitators timed how long participants took to verbalize they had recognized tachycardia, hypotension, or septic shock and desired to initiate the sepsis pathway and administer antibiotics. Participants in the PediSepsisAR arm completed a poststudy questionnaire. We analyzed data using descriptive statistics and a Wilcoxon rank-sum test to compare the median time with event variables between groups. Results We enrolled 50 participants (n=25 in each arm). The timing and volume of fluid administration were captured in all the participants in each group. There was no statistically significant difference regarding time to administration of intravenous fluids between the two groups. Similarly, there was no statistically significant difference between the groups regarding time to verbalized recognition of patient status or desired management steps. Most participants in the PediSepsisAR group reported that PediSepsisAR enhanced their awareness of the patient’s perfusion. Conclusions We developed an augmented reality app for use in pediatric septic shock simulations and demonstrated the feasibility of measuring the volume and timing of fluid administration during simulation using this modality. In addition, our findings suggest that PediSepsisAR may enhance participants’ awareness of abnormal perfusion.

Background Wide variation in out-of-hospital cardiac arrest (OHCA) survival has been reported, with low survival in urban settings. We sought to describe the epidemiology of OHCA in Philadelphia, Pennsylvania, the fifth largest U.S. city, and identify potential areas for targeted interventions to improve survival. Methods and results Retrospective chart review of adult, non-traumatic, OHCA occurring in Philadelphia between 2008 and 2012. We determined incidence and epidemiological factors including: demographics, initial cardiac rhythm, bystander cardiopulmonary resuscitation, automated external defibrillator use, return of spontaneous circulation and 30-day survival. 5198 cases of adult, non-traumatic OHCA were identified. The incidence was 81.5/100,000. The majority of cases occurred in a residence (76.2%); 30.4% were witnessed events; the initial cardiac rhythm was pulseless ventricular tachycardia or ventricular fibrillation in 6.2% of cases, pulseless electrical activity in 21.0%, asystole in 38.3% and was unknown or undocumented in the remaining 34.5%. Multivariate logistic regression analysis demonstrated increased 30-day survival with younger age, shockable cardiac rhythms, and daytime arrest. 30-day survival was 8.1% for EMS-assessed patients and 8.6% for EMS-transported patients. Conclusions Philadelphia's reported incidence is consistent with urban settings although the survival rate is higher than other urban centers.

Purpose Cerebral Performance Category (CPC) scores are often an outcome measure for post-arrest neurologic function, collected worldwide to compare performance, evaluate therapies, and formulate recommendations. At most institutions, no formal training is offered in their determination, potentially leading to misclassification. Materials and Methods We identified 171 patients at 2 hospitals between 5/10/2005 and 8/31/2012 with two CPC scores at hospital discharge recorded independently – in an in-house quality improvement database and as part of a national registry. Scores were abstracted retrospectively from the same electronic medical record by two separate non-clinical researchers. These scores were compared to assess inter-rater reliability and stratified based on whether the score was concordant or discordant among reviewers to determine factors related to discordance. Results Thirty-nine CPC scores (22.8%) were discordant (kappa: 0.66), indicating substantial agreement. When dichotomized into "favorable" neurologic outcome (CPC 1–2)/"unfavorable" neurologic outcome (CPC 3–5), 20 (11.7%) scores were discordant (kappa: 0.70), also indicating substantial agreement. Patients discharged home (as opposed to nursing/other care facility) and patients with suspected cardiac etiology of arrest were statistically more likely to have concordant scores. For the quality improvement database, patients with discordant scores had a statistically higher median CPC score than those with concordant scores. The registry had statistically lower median CPC score (CPC 1) than the quality improvement database (CPC 2); p Conclusions CPC scores have substantial inter-rater reliability, which is reduced in patients who have worse outcomes, have a non-cardiac etiology of arrest, and are discharged to a location other than home.

Introduction: Since over 75% of sudden cardiac arrest events occur in the home where family members may be first responders, broad cardiopulmonary resuscitation (CPR) training for family members of high-risk cardiac patients represents a promising intervention. The use of mobile application-based (mApp) CPR training may facilitate this, but data on the approach are limited. Objectives: We compared CPR skill retention among those trained with an mApp and hypothesized that training with the mApp would be non-inferior to training with a well-established video self-instruction (VSI) kit. As a secondary analysis, we examined dissemination via the “multiplier rate” (i.e., those additionally trained by primary trainees) by intervention. Methods: We conducted a multicenter pragmatic, randomized control trial assessing non-inferiority of training family members of cardiac patients in CPR with an mApp (video, but no practice manikin) to training with an established VSI method (video and manikin). Subject’s CPR skills were tested 6-months post-training. We hypothesized that mApp training would be non-inferior to VSI training, with a non-inferiority margin set at 5 chest compressions (cc) per min. Results: From 01/2016-01/2018, 1446 subjects were enrolled at 8 hospitals with 685 trained with VSI, and 761 trained with the mApp. Of those, 541 were included in the skills analysis (275 VSI, 266 App). The mean age was 52±16 years and 69% were female. Mean cc rate was 85±34 per min; mean cc depth was 40±14 mm. When stratified by intervention arm, those trained with VSI had a mean rate of 86 per min (83, 90), compared to 88 per min (84, 92) with the mApp; those trained with VSI had a mean depth of 42 mm (41, 44), compared to 39 mm (38, 41) with the mApp. Findings were similar when accounting for loss to follow-up. We concluded non-inferiority of the mApp with a mean difference of 1 (-5, 7) cc per min for rate. Subjects trained with VSI shared with an additional 2±4 individuals compared to 1±2 (p Conclusion: In this large prospective trial of CPR skill retention, the mApp CPR training approach was non-inferior to VSI training for family members of cardiac patients. Future work may include evaluating additional means for adoption and dissemination of the mApp.

Background: The provision of high-quality cardiopulmonary resuscitation (CPR) is a significant predictor of survival from cardiac arrest, yet healthcare provider (HCP) CPR quality is known to be poor. Although refresher CPR simulation training has been shown to improve HCP CPR quality, no studies have compared an immersive augmented reality (AR) application to a standard audio-visual feedback (AVF) manikin (Laerdal ResusciAnne) as a refresher training modality. Objectives: We randomized HCPs to refresher CPR simulation training with either a novel AR CPR training application (CPReality, Figure 1) or a validated AVF manikin; both cohorts completed a post-simulation CPR quality evaluation with no feedback immediately following the intervention. We sought to assess the efficacy of AR as a CPR simulation modality compared with an AVF manikin. We hypothesized that the AR application would confer similar skills to the AVF manikin. Results: We enrolled 100 experienced HCPs (e.g. RN, MD, APP) between 1/19-5/19. Mean chest compression (CC) rate for the AR application compared with the AVF manikin was 114±1 vs 121±3 cpm (p Conclusions: In a post-test scenario, the AR CPR simulation training produced similar CPR quality as the standard AVF manikin in refreshing CPR skills in HCP. Further studies should explore the use of innovative technologies for CPR training. Figure 1 . CPReality (CPReality).

Introduction: Augmented reality (AR) has the potential to offer a novel approach to CPR training that supplements conventional training methods with gamification and a more interactive learning experience. This is done through computer-generated imagery superimposed on users’ view of the real environment to simulate interactive training scenarios. Objective: We sought to test the feasibility of an AR CPR training system (CPReality) for health care providers (HCPs). Methods: In this feasibility trial, a CPR training manikin was integrated with a commercial AR device (Microsoft HoloLens) to provide participants with real-time audio-visual feedback via a holographic overlay of blood flow to vital organs dependent on CC quality. In this system, higher quality CC visually improved virtual blood circulation. HCPs performed a 2-minute cycle of hands-only CPR using only the AR system, and CC parameters were recorded. Descriptive data on participants’ demographics, CC quality, and satisfaction with the training environment were reported. Results: Between 10/2019-11/2019, we enrolled a convenience sample of 51 HCPs. The median age of participants was 31 years (IQR 27-41), 71% (36/51) were female, and 67% (34/51) were registered nurses. CC rates (mean 126 ± 12.9 cpm), depths (median 53 mm, IQR 46-58), and percent with complete recoil (median 80%, IQR 12-100) were consistent with guideline recommendations for good quality CPR. Participants were predominantly satisfied with the system, with 82% perceiving the experience as realistic, 98% recognizing the visualizations as helpful for training, and 94% willing to use the application in future CPR training. Conclusions: As AR is increasingly applied in the healthcare setting, integration in CPR training offers a novel and promising educational approach. In this convenience sample of trained HCPs, high quality CC delivery was feasible using the AR CPR training system which was received favorably by most participants.

Aim of the study Augmented reality (AR) has the potential to offer a novel approach to CPR training that supplements conventional training methods with gamification and a more interactive learning experience. This is done through computer-generated imagery superimposed on users’ view of the real environment to simulate interactive training scenarios. We sought to test the feasibility of an AR CPR training system (CPReality) for health care providers (HCPs). Methods In this feasibility trial, a CPR training manikin was integrated with a commercial AR device (Microsoft HoloLens) to provide participants with real-time audio-visual feedback via a holographic overlay of blood flow to vital organs dependent on CC quality. In this system, higher quality CC visually improved virtual blood circulation. HCPs performed a 2-minute cycle of hands-only CPR using only the AR system, and CC parameters were recorded. Descriptive data on participants’ demographics, CC quality, and satisfaction with the training environment were reported using quantitative and qualitative analysis. Results Between 10/2018–11/2018, we enrolled a convenience sample of 51 HCPs. The median age of participants was 31 years (IQR 27–41), 71% (36/51) were female, and 67% (34/51) were registered nurses. CC rates (mean 126 ± 12.9 cpm), depths (median 53 mm, IQR 46–58), and percent with complete recoil (median 80%, IQR 12–100) were consistent with guideline recommendations for good quality CPR. Participants were predominantly satisfied with the system, with 82% perceiving the experience as realistic, 98% recognizing the visualizations as helpful for training, and 94% willing to use the application in future CPR training. Conclusions As AR is increasingly applied in the healthcare setting, integration in CPR training offers a novel and promising educational approach. In this convenience sample of trained HCPs, high quality CC delivery was feasible using the AR CPR training system which was received favorably by most participants.

BACKGROUND: Understanding bystander reactions to an emergency is an important component of effective training. Four stages of bystander intervention (BI) have been previously described: noticing the situation as a problem, interpreting when it is appropriate to intervene, recognizing personal responsibility to intervene, and knowing how to intervene. Using virtual reality (VR) to simulate emergencies such as sudden cardiac arrest (SCA) can be used to study these stages. METHODS: In a secondary analysis of an observational cohort study, we analyzed bystander self-efficacy for stages of BI before and after simulated SCA. Each subject participated in a single-player, immersive, VR SCA scenario. Subjects interacted with simulated bystanders through voice commands (“call 911”, “get an AED”). Actions taken in scenario, like performing CPR, were documented. Scenario BI actions were compared based on dichotomized comfort/discomfort. RESULTS: From June 2016 to June 2017, 119 subjects participated. Average age was 37±14 years, 44% were female and 46% reported CPR training within 2 years. During the scenario, 98% “noticed the event” and “interpreted it as a problem”, 78% “took responsibility”, and 54% “possessed the necessary skills”. Self-efficacy increased from pre- to post-scenario: noticing the event increased from 80% to 96%; interpreting as a problem increased from 86% to 97%; taking responsibility increased from 56% to 93%; possessing necessary skills increased from 47% to 63% (P

Recent work has demonstrated low rates of layperson CPR training across the US. In an attempt to increase rates, some states passed legislation that requires CPR training before high school graduation. We hypothesized laypeople in states with required training would exhibit a greater likelihood of being currently trained in CPR when compared with laypeople in states without required CPR training.We used a previously conducted nationwide cross-sectional random-digit dial survey of the US adult population (09/2015-11/2015). Survey weighted descriptive statistics and logistic regression were used to assess the primary association of likelihood of CPR training and required CPR training by graduation.Of the 9022 participants, 677 healthcare workers were excluded. Among those living in states with required training, 17% of laypersons were currently trained, while 14% of laypersons in states without required training were currently trained (p 0.01). Amongst younger individuals (18-24), 29% were currently trained in states with required CPR training compared with 19% currently trained in states without required training (p 0.01). Those in required training states were 34% more likely to be currently trained than individuals in states without required training (OR: 1.34, 95%CI: 1.20-1.50, p 0.01). In a secondary analysis, younger laypersons in required training states were almost two times more likely to be currently trained (OR: 1.81, 95% CI: 1.18-2.78, p = 0.01).Individuals were more likely to be currently trained in CPR in states with mandatory CPR training for high school graduation, suggesting a need for additional research on this public policy.

Introduction Targeted temperature management (TTM) is recommended for cardiac arrest patients. Successful implementation of a TTM protocol depends on the nurses’ knowledge and skills. The study’s aim was to compare the level of knowledge, psychomotor skills, confidence and satisfaction before, immediately after and at 6 weeks after training nurses on the delivery of TTM with video lecture versus video lecture and high fidelity simulation. Method Demographic variables were compared across treatment groups using t-tests and Chi-square tests. Change over 6 weeks after intervention was tested with mixed effects model. Results Fifty-two registered nurses were enrolled. Knowledge test scores, the primary outcome, did not differ between the groups immediately after the training (beta = 3.80, SE = 3.47, p = .27), but there was a strong trend 6 weeks after the training in favor of simulation (beta = 7.93, SE = 3.88, p = .04). Skills were significantly better immediately after the training in the simulation group, but no different 6 weeks later. No difference in confidence was found at either post-test point. Simulation-trained nurses were more satisfied with their training at both post-testing points. Conclusion In this study of training approaches to TTM after cardiac arrest, nurses trained with video lecture and high fidelity simulation benefitted from this approach by maintaining their TTM knowledge longer.

Aim of the study We sought to understand how individual factors and neighborhood characteristics are associated with a layperson's likelihood of being trained in CPR. We hypothesized that higher socioeconomic status (educational attainment, and median household income (MHI)) would be associated with a higher likelihood of previous CPR training. Methods Through the Mobile CPR Project, a program providing hands-only CPR and AED education in Philadelphia, we surveyed participants regarding socioeconomic factors and prior CPR training. Survey questions pertained to race, gender, education, prior CPR training, automated external defibrillator (AED) awareness, and residential area. Community MHI was extrapolated via residential address and census tract data. Results From 7/2016 to 4/2018, 1703 subjects completed surveys, including location information, prior to participating in a Mobile CPR Project training event. Of these, 70% were female, 70% were non-white, mean age was 42 ± 20 years, and MHI was $39,318 [IQR $27,708–$60,795]. Subjects residing in census tracts with MHI below the cohort median were significantly less likely to have ever received CPR training (lowest quartile: OR 0.65, CI 0.49–0.85, p = 0.002). In multiple logistic regression controlling for age, race, gender, MHI, and education, higher educational attainment was associated with a higher likelihood of ever receiving CPR training (OR 7.96 Masters or Doctoral compared to less than high school, CI 5.24–12.11, p Conclusions There is a strong association between socioeconomic factors (MHI and educational attainment) and likelihood of prior layperson CPR training.

Aim Targeting basic life support (BLS) training to bystanders who are most likely to witness an out of hospital cardiac arrest (OHCA) is an important public health intervention. We performed a systematic review examining the evidence of the effectiveness of providing BLS training to family members of high-risk cardiac patients. Methods A search of Ovid MEDLINE, CINAL, EMBASE, Informit, Cochrane Library, Web of Science, Scopus, ERIC and ProQuest Dissertations and Theses Global was conducted. We included all studies training adult family members of high-risk cardiac patients regardless of methods used for cardiopulmonary resuscitation (CPR) or BLS training. Two reviewers independently extracted data and evaluated the quality of evidence using GRADE (Grades of Recommendation, Assessment, Development and Evaluation). Results We included 26 of the 1172 studies identified. The majority of studies were non-randomised controlled trials ( n =18), of very low to moderate quality. Currently, there is insufficient evidence to indicate a benefit of this intervention for patients; largely because of low numbers of OHCA events and high loss to follow-up. However, the majority of trained individuals were able to competently perform BLS skills, reported a willingness to use these skills and experienced lower anxiety. Conclusion Whilst there is no current evidence for improvement in patient outcomes from targeted BLS training for family members, this group are willing and capable to learn these skills. Future research may need to examine longer periods of follow-up using alternate methods (e.g. cardiac arrest registries), and examine the effectiveness of training in the modern era.

Aim of the Study: Prompt bystander CPR is a crucial intervention to improve cardiac arrest survival. However, recent work suggests that the prevalence of layperson CPR training remains low. We sought to understand how individual factors and neighborhood characteristics influence an individual’s likelihood of being trained in CPR within a large U.S. city. We hypothesized that higher socioeconomic status (educational attainment, and median household income (MHI)) would be associated with a higher likelihood of having previously received CPR training. Methods: Through The Mobile CPR Project, a program providing hands-only CPR and AED education to underserved communities in the greater Philadelphia region, we surveyed participants regarding prior CPR training. Survey questions pertained to race, gender, education, prior CPR training, Automated External Defibrillator (AED) awareness, and nearest street intersection to their residence. MHI was extrapolated via census tract data. Results: From 7/2016 to 4/2018, 1665 subjects completed surveys prior to CPR training. Of these, 70% were female, 70% were non-white, median age was 41 [IQR 25-59] yrs, and MHI was $39,318 [IQR $27,708-$60,795]. Subjects residing in tracts with MHI below the cohort median were significantly less likely to have ever received CPR training (first quartile: OR 0.646, CI 0.491 -0.850, p=0.002; second quartile: OR 0.576, CI 0.437 - 0.759, p Conclusions: Among laypersons attending a free CPR training session, there is a strong association between socioeconomic factors (MHI, educational attainment) and likelihood of prior CPR training.

Introduction: Bystander response to a sudden cardiac arrest (SCA) should ideally be the same for all victims, however studies have shown disparities in response exist based on the gender of the victim. Current virtual reality (VR) wearable technology allows for the creation of high realism scenarios permitting manipulation of the victim’s gender in order to observe bystander response. Objectives: We sought to compare lay bystander response to an unannounced simulated VR SCA event based on the victim’s gender. Methods: Using our VR SCA system integrated with a CPR recording manikin, we randomized the avatar victim’s gender to either female or male (Figure 1). Subjects were able to interact with simulated bystanders, give vocal commands such as “call 911” or “get an AED”, and perform CPR on the simulated victim in the virtual environment while simultaneously performing CPR on the manikin. Subjects were unaware of the nature of the event but were told to respond however they would in real-life to an emergency situation. Subject’s ability to proceed through the Chain of Survival (Call 911, Perform CPR, Ask for and Use an AED) and CPR quality were recorded. Results: Between 9/2017 and 12/2017, 75 subjects were enrolled; mean age was 31±11 yrs, 35% were female, 49% were White, and 66% had never been trained in CPR or were trained >2 yrs prior. In total, 59% of subjects performed CPR, and 11% used an AED. CPR was performed on male victims 65% of the time vs 54% on female victims (p=NS, Figure 2a); An AED was used 21% of the time for male victims vs 15% for female victims (p=NS, Figure 2b). If the subject was male, CPR was performed on a female victim 56% of the time vs 71% for a male victim; female subjects performed CPR on a female victim 50% vs 58% on a male victim (p=NS). Conclusion: In our unannounced, immersive VR SCA study, there was a trend toward less CPR and AED use on female avatar victims. Future work will need to be powered to evaluate disparities in CPR and AED use based on gender.

Introduction: Virtual Reality (VR) via a mobile platform has the ability to heighten realism for CPR training. Whether training with VR compared with a standard mobile application (mApp) would improve CPR quality and response is unknown. Objectives: We sought to test whether a VR mApp would confer improved CPR skills compared with an existing CPR training on a standard mApp. Methods: Using a VR viewer combined with a smartphone for multisensory immersion, we created a VR CPR training mApp based on our established CPR mApp (Figure 1); both included Hands-only CPR instruction. Subjects were randomized to our intervention arm (VR mApp) or our control arm (mApp). Subjects in the VR mApp arm underwent CPR training and were able to interact with avatar bystanders, “perform” CPR via VR viewer click button, and acquire an AED. The standard mApp arm underwent our established CPR training, but did not have the VR immersion. We collected bystander response data (Call 911, Perform CPR, Ask for an AED), along with CPR quality during a 3-min post-intervention scenario. Results: Between 3/2018 and 5/2018, 38 subjects were enrolled: 19 VR mApp and 19 mApp. Mean age was 45±15 yrs, 34% were female, and 32% were currently CPR trained. In total, 70% called 911, 97% performed CPR, and 41% asked for an AED. Mean chest compression (CC) rate was 102±40 compressions per minute (cpm), depth was 40±13 mm. When comparing the VR mApp arm to the mApp arm, mean CC rate was 102±48 cpm vs 102±33 cpm, and mean CC depth was 40±13 mm vs 40±13 mm, respectively. The percentage of bystander response was higher in the VR mApp arm compared with the standard mApp arm: calling 911 (88% vs 52%), asking for an AED (55% vs 26%) (Figure 2). Conclusion: In our study comparing a VR mApp versus a standard mApp for CPR training, CPR quality did not differ but a trend toward increased bystander response was found in the VR mApp arm. Further studies will need to be powered to detect difference using immersive VR trainings and their effect on bystander response.

Introduction: Although bystander CPR has been shown to increase rates of survival from out-of-hospital cardiac arrest, recent work has demonstrated low rates of layperson training across the US. In an attempt to increase layperson CPR training, states have passed legislation that mandates CPR training before high school graduation. No study has assessed the impact of this legislation on likelihood of CPR training. Objectives: We assessed whether an association existed between state mandated CPR training during high school and the likelihood of young adults being currently trained or ever trained in CPR. We hypothesized younger individuals in states with required CPR training by graduation would be more likely to be currently trained or ever trained in CPR. Methods: From 09/2015-11/2015, we conducted a nationwide cross-sectional study of the US adult population using random-digit telephone dialing (n=9,022). Data were weighted by state and assessed through univariate and multivariate analyses controlling for confounding variables. Individuals age 18-24 years old were considered “young” and healthcare workers were excluded in the analysis. Subjects in the five states whose mandatory training laws began in or before the 2013-2014 school year were considered. Results: Of the 9,022 participants, individuals were classified by whether they lived in state that mandated training (n=924) or did not (n=8,084). After accounting for confounding variables, 33% of all laypeople in states with mandated training were currently trained while 27% of laypeople in states without mandated training were currently trained (OR: 1.28, 95%CI: 1.07-1.48, p=0.01). Younger adults were 59% more likely to be currently trained in states with mandated training than in states without it (OR: 1.59, 95%CI 1.34-1.89, p Conclusion: Younger adults were more likely to be trained in states with laws mandating CPR training for high school graduation. In addition, younger adults were more likely to have ever been trained in states with laws requiring compulsory CPR training for high school graduation.

Introduction: Four stages of bystander intervention (BI) have been described in social behavioral research: noticing the situation as a problem, interpreting when it is appropriate to intervene, recognizing personal responsibly to intervene, and knowing how to intervene (i.e. having the skills to respond). Using virtual reality (VR), emergency events such as sudden cardiac arrest (SCA), can be used to observe the progression through these stages. Objective: We sought to compare bystander self-efficacy with action, based on each stage of BI before and after an unannounced simulated VR SCA scenario. Methods: In a secondary analysis of an observational cohort study, we analyzed self-efficacy with each stage of BI using a forced Likert scale survey before and after a simulated SCA. Each subject participated in a single-player, immersive, VR SCA scenario. Subjects interacted with avatars through voice commands such as “call 911” and “get an AED”. Actions taken in the scenario, such as performing CPR, were recorded. Scenario BI stage progression was compared based on dichotomized comfort/discomfort. Results: From 9/2016 to 6/2017, 119 subjects completed the study. Average age was 37±14 yrs, 44% were female and 58% had a bachelor’s degree or higher. During the scenario, 98% of subjects “noticed the event” and “interpreted it as a problem”, 78% “took responsibility”, and 54% “possessed the necessary skills” to act. Self-efficacy increased from pre- to post-scenario: noticing the event as a problem increased from 80% to 96%; interpreting it as a problem increased from 86% to 97%; taking responsibility increased from 56% to 93%; possessing necessary skills to intervene increased from 47% to 63% (p Conclusion: Bystanders who felt more comfortable taking responsibility for an emergency event pre-scenario were more likely to respond appropriately during the scenario. VR represents a potentially powerful tool to promote self-efficacy and understand how bystanders may respond during emergency situations.

Background: Survival from out-of-hospital cardiac arrest varies by race, possibly due to poor penetration of CPR training in minority communities. Targeted trainings and campaigns to increase access to CPR education have sought to address these gaps, yet it is unknown if these initiatives have equalized training rates. Objectives: We sought to examine racial variation of CPR training status on the individual-level by assessing current CPR training and ever CPR trained status. We hypothesized that whites would be more likely to hold current CPR training and be ever trained in CPR compared to minorities. Methods: As a secondary analysis to a previous random digit dial survey of a nationally-representative adult sample, we defined CPR training status of individuals as currently trained (only ≤2 years) and ever trained. Chi-squared test and multivariate logistic regression were used to determine variation by race. Results: From 09/2015-11/2015, 9,022 individuals completed the national survey. Of those, 65% had been CPR trained at some point in time, while 18% reported being currently trained. Minorities were significantly less likely to ever be trained in CPR compared to whites (54.9% vs 70.8%, p Conclusions: Significant disparities by race were observed in those ever trained in CPR, however no significant difference exists in attainment of current CPR training. Increased access to CPR education and targeted training campaigns may have closed the gap in current CPR training status disparities. Continued surveillance of CPR training rates is needed to monitor these findings over time.