Out-of-hospital cardiac arrest (OHCA) is the third leading cause of death in industrialised nations (Gräsner et al, 2020). The EuReCa TWO study (Gräsner et al, 2020) collects data from 28 countries in Europe covering a total population of 178 879 118. Between 1 October and 31 December 2017, it reported 37 054 confirmed OHCAs, and cardiopulmonary resuscitation (CPR) was started in 25 171 cases.
Despite significant advances in interventions provided by emergency medical services (EMS), OHCA survival rates have not improved significantly across these 28 countries in 30 years, and range from 8.6% to 20% (Hawkes et al, 2017a; 2017b; Dyson et al, 2019; NHS England 2020). OHCA survival in the UK is around 8% (NHS England, 2020), which is lower than in similar developed countries, where survival rates of over 20% are achieved (Division of Emergency Medical Services, Public Health–Seattle & King County, 2013; Hawkes et al, 2017a; Dyson et al, 2019).
High survival rates can be gained through improvements to basic life support (BLS) training, public education and access to automatic external defibrillators (AEDs), as reflected in the chain of survival, which includes actions to be taken to improve chances of survival from OHCA.
The EuReCa TWO study (Gräsner et al, 2020) found that the bystander CPR rate ranged from 13–82% between countries (average 58%), and survival-to-hospital discharge was higher in patients when a bystander-performed CPR with ventilations, compared to compression-only CPR (14% vs 8% respectively). Barriers preventing bystanders from engaging in CPR include a lack of knowledge, training, skills and confidence to initiate CPR and use of an AED (Dobbie et al, 2018).
Hawkes et al (2017b) recently conducted a survey exploring adults' attitudes to CPR and defibrillator use in the UK. This study included Welsh people in their sample of 2084 participants and used YouGov's methods. Hawkes et al (2017b) found that 19% of participants had witnessed an OHCA and approximately 60% had undertaken some form of CPR training. These figures, however, fell to 27% for those trained within the past 5 years. While the workplace was the most frequently reported place of training (55%), 27% were trained at school or in a youth organisation. Hawkes et al (2017b) found that such training makes a difference to people's willingness to act in the event of an OHCA.
The Resuscitation Council UK (RCUK) guidelines (Perkins et al, 2015) recognise the importance of early defibrillation and, if it is delivered within 5 minutes of OHCA, survival rates of 50–70% can be achieved (Valenzuela et al, 1997; Berdowski et al, 2011; Blom et al, 2014; Ringh et al, 2015). For every minute of delay to defibrillation, the probability of survival is reduced by 10%; yet, in the UK, fewer than 2% of these patients have an AED deployed before the ambulance arrives (Deakin et al, 2014).
People experiencing an OHCA are two to four times more likely to survive if they receive bystander CPR (Van Hoeyweghen et al, 1993), and up to 70% of OHCAs are witnessed by family members, friends and other bystanders (Breckwoldt et al, 2009).
CPR teaching in schools in Wales
Teaching CPR to children in school in various ways can be effective (Plant and Taylor, 2015), and mandatory CPR training for schoolchildren may provide an opportunity to improve the bystander CPR rate. The highest bystander CPR rates are in Scandinavia, where CPR training in schools has been mandatory for decades (Wissenberg et al, 2013).
To support this, the World Health Organization (WHO) has endorsed the Kids Save Lives statement, a joint initiative from the European Resuscitation Council, European Patient Safety Foundation, International Liaison Committee on Resuscitation and World Federation of Societies of Anesthesiologists (Böttiger et al, 2015). This statement recommends 2 hours of CPR training annually from the age of 12 years in all schools worldwide.
Wales has progressive policies relating to the younger generation; for example, the Well-being of Future Generations (Wales) Act (2015) reflects a society in which people's health is maximised through an understanding of the choices and behaviour that benefit future health. This act also advocates an inclusive approach to achieving wellbeing goals by involving children and young people.
Many initiatives have been introduced in Wales to improve CPR teaching, including Save a Life Cymru, which is a partnership between a wide range of organisations offering CPR and defibrillation support and advice (Welsh Government, 2019). The Welsh Ambulance Services NHS Trust (WAST) leads the Defibruary initiative which aims to raise awareness of defibrillators across Wales and supports mass CPR training events such as Restart a Heart (RCUK, 2021a).
In a letter to the Emergency Medical Journal, Phillips and Chapman (2020) highlighted how Wales was at risk of being left behind the rest of the UK. This was because, at the time of that and other present studies, CPR training was a mandatory part of the secondary school curriculum in England, and Scotland's 32 local authorities had all committed to teach CPR to every schoolchild but Wales has been slower than other home nations in committing to CPR training in schools. However, in March 2021, the RCUK celebrated the vote by the Welsh Senedd to pass the Curriculum and Assessment (Wales) Bill with a commitment to lifesaving skills being taught in Welsh schools from 2022 (RCUK, 2021b).
All secondary schools in Wales can access a free British Heart Foundation (BHF) Call, Push, Rescue kit, as well as lesson plans and training videos. Implementation of national initiatives and strategies for mandatory resuscitation training in schools to strengthen bystander resuscitation attempts (Wissenberg et al, 2013) may however conflict with the demands of the regular curriculum.
The Welsh Government (2019) OHCA plan has adopted elements of the chain of survival, which involves taking sequential actions to improve chances of survival from an OHCA (Figure 1). These actions include early access and early recognition of cardiac arrest, early CPR, early defibrillation and early advanced care. The plan recognises that CPR is an important component of health education for all of the population, and that all school pupils and further higher education students should be given opportunities to learn CPR techniques.
The proposal described in this article recognises how technology may support achieving high rates of CPR learning in schools.
Phillips and Chapman (2019) highlighted the approach of gamification of CPR teaching, which Otero-Agra et al (2020) suggest is an effective way of teaching and engaging schoolchildren. Such innovations in CPR teaching, they suggest, may remove some of the barriers to teaching it in schools and leave little excuse for its absence from the curriculum.
In February 2019, a team of virtual reality (VR) developers, researchers, paramedics and trainers from the University of Chester and the WAST engaged in the development of Virtual Cardio Pulmonary Resuscitation (VCPR), aiming to explore the development and adoption of VR for teaching CPR in schools.
Methods
Following review against Medical Research Council and NHS Health Research Authority (2021) guidance, the project was not classed as research at this stage but as a service improvement, as research has previously demonstrated benefits of VR in teaching CPR to schoolchildren.
However, WAST maintains oversight, and future development and validation of the technology will be required before it can be adopted. The authors' team engaged in the development of VCPR in the stages outlined in the next section.
Requirements specification
The University of Chester, WAST and the BHF worked with school representatives to specify the requirements for VR from their perspective regarding CPR training in schools. These were documented by the university and used to drive the development of the prototype system.
At this stage, the team secured Health and Care Research Wales Pathway to Portfolio funding to develop and deliver the project.
Virtual CPR prototype development
An initial VR environment for teaching CPR was produced. This was demonstrated to key stakeholders and the team gathered unstructured feedback.
The Oculus Quest VR technology, a tether-less device that does not require connection to a PC, was used. The team envisaged using tangible haptics so the user would press down on a suitably deformable block of material but see a realistic person who needed CPR. The team planned to recreate different scenarios with variations in patient outcome.
Virtual reality scene
The simulator contained a physical model of a human torso (manikin), which was used for teaching palpation during the CPR procedure.
The user wore the head-mounted display (Figure 2) and placed their hands onto a physical torso. In the virtual world, a model of a human male (lying on the ground following a cardiac arrest) was also shown in 3D stereo. These had to be accurately registered so they are co-located in the real and virtual worlds (Figure 3). To achieve this, one of the hand controllers was mounted in a retort stand (Figure 2) at a carefully measured distance from the manikin.
The Oculus Quest supports positional tracking with six degrees of freedom using internal sensors and an array of cameras in the front of the headset. The position of the hand controllers in relation to the headset is thus always known. This information was used to overlay the virtual avatar on top of the physical location of the manikin.
Performing CPR
The second hand controller is worn around the wrist like a bracelet (Figure 2). This is pragmatic because both hands have to be used together to compress the chest wall during CPR.
As the user performs a chest compression, the up and down motion of the hands is captured by the hand controller. The team could therefore determine the rate (beats per minute) that was being given and give the user hints as to whether they were going too fast or too slow. This information was displayed on a pop-up panel (Figure 3), which was deemed by both users and developers to make the activity more meaningful.
Educators taught the other components of high-quality CPR, such as depth, hand position and recoil, as per BHF/RCUK guidelines. This will be done in future studies.
The virtual scene was enhanced with ambient sound effects appropriate to the environment that the user was immersed in. The key to performing CPR successfully is to find and maintain the correct rhythm for the chest compressions. When being taught the procedure, it is often recommended that the user sings to themselves a classic song such as Stayin’ Alive by the Bee Gees, which helps to achieve the 100–120 beats per minute needed. In the virtual environment, the user could select a song that was played to them as they carried out CPR.
Virtual environment 3D software development
The virtual environment for the CPR simulator was designed to reflect the spontaneous nature of CPR, which can occur in unpredictable locations such as at the scene of a car accident at the roadside or in a town square (Figure 3).
The environment was developed using a 3D games engine called Unity. Unity includes realistic physics modelling and allows us to import the assets for any 3D scene that the team wanted to build. It also has excellent support for the latest VR devices such as the Oculus Quest. The functionality for calculating the beats per minute was implemented in a custom script that is integrated into the scene.
Evaluation, testing and feedback
A range of individuals, groups and organisations gave feedback. This included the study team, which included paramedics, trainers, the WAST cardiac lead and BHF Cymru. The team also demonstrated and received input from schools and children during a mass CPR training event RCUK (2021a). The authors sought feedback from 12 participants and, in total, eight questionnaires were completed.
Feedback was positive, with respondents agreeing or strongly agreeing to all questions (Table 1). In this simulation, the user's hands were not visible, and the authors asked if users would like to see their hands; they all agreed or strongly agreed. This is something that needs to be addressed and future VR prototypes will be designed so that users can view their hands.
| Schoolchildren were asked to answer questions using a Likert sale from 1 for strongly agree to 5 for strongly disagree | ||
|---|---|---|
| Questions | Mode | Median |
| Being immersed in the accident scene was more realistic than being in a classroom | 1 | 2 |
| The VR simulation was more realistic than just using the MiniAnne model | 1 | 2 |
| The feedback panel in VR was useful | 2 | 2 |
| The soundtrack helped to get the rhythm of the chest compressions | 1 | 1 |
| In the current simulation the users hands are not visible and users were asked if they would like to see their hands | 1 | 2 |
Presentations and question-and-answer sessions were conducted at a WAST and Bevan Commission Innovators event at the Senedd Cymru/Welsh Parliament (Bevan Commission, 2020) and at the International Conference on Cyberworlds in Kyoto, Japan in 2019 (Vaughan et al, 2019). These events were attended by a wide range of paramedics, trainers, political figures, policy makers, academics, researchers, industry and senior operational and clinical staff.
The authors continue to work closely with these groups to demonstrate the developed system and gather feedback. They also continue to monitor the literature, gather critical evidence and carry out evaluation that will further demonstrate the applicability, as well as the clinical and commercial potential of the developed technology for teaching CPR to schoolchildren in Wales and, ultimately, to improve survival from OHCA.
The authors continue to complete further in-depth clinical evaluation, which is being strengthened by having support from political and policy processes, other organisations and sectors, and industry collaborators.
Management
While the software is being developed, a collaboration agreement will be finalised. The authors will also start investigating options for further funding and the eventual commercialisation of VCPR for schools. The prototype developed during this project will leverage further grant monies and investment for this project.
Discussion
This project was started in 2018 and, since then, VRCPR training has been further developed and evaluated by a small number of investigators who conclude that it can be an acceptable tool for training programmes for general populations, schoolchildren and health professionals with a gamification approach (Semeraro et al, 2009; Leary et al, 2019).
While this study did not set out to evaluate the impact of VCPR fully, the initial positive feedback indicated that students felt more motivated through the use of VR. The authors recognise that further evaluation is needed to assess the efficiency, effectiveness and acceptability of CPR learned using VCPR.
Nonetheless, the positive feedback given in this project is consistent with the growing evidence base for the role of VR in CPR learning. In an online survey conducted in collaboration with the European Resuscitation Council and the Research NET community, Böttiger et al (2017) sought to evaluate and test attitudes on VR from the CPR instructor community (consisting of key persons in the national resuscitation council, educator, instructor and members of the ERC Research NET). While only 2.4% (n=6) reported using serious games and 1.6% (n=4) VR devices, 72.8% (n=180) believed that VR could play a role in future training and 63.9% (n=158) indicated that it would be particularly suitable for children.
Development of technology
Technological developments in VR teaching of CPR have evolved from studies carried out before and during this study. Boada et al (2015) developed and evaluated LISSA (Life Support Simulation Activities), a serious game designed to complement CPR teaching and refresh CPR skills in an enjoyable way. LISSA presents an emergency situation in a 3D virtual environment where the player has to apply CPR actions to save a person experiencing an OHCA.
Boada et al (2015) performed a randomised controlled trial involving LISSA with a population of 109 undergraduate nursing students to compare the classical CPR teaching involving manikin practice. They found that students using LISSA had significantly better learning acquisition scores than those following traditional classes, as well as significant improvements in student performance of the main steps of CPR protocol with LISSA.
Semeraro et al (2009; 2017) and the Italian Resuscitation Council have led the way in using VR to raise awareness and teach CPR to children through a VR-enhanced mannequin (VREM) experience. Semeraro et al (2017) evaluated the acceptance of a VREM in a sample of 39 possible users, who were positive about the feeling of immersion and realism of the environment and simulation. A majority (84.6%) of the participants found the VR experience interesting and believed its development could be useful for healthcare training.
Comparisons of approaches
RCUK developed Lifesaver VR to improve cardiac arrest awareness in schoolchildren and the general population. Yeung et al (2017) conducted a randomised controlled trial at three UK schools comparing Lifesaver, face-to-face (F2F) training and a combination of both. While F2F may be a confusing term, it was defined here as a standardised approach involving each pupil taking turns at practising BLS skills on a manikin with instruction. Yeung et al (2017) found that use of Lifesaver by schoolchildren has comparable learning outcomes with F2F training alone for several key elements of successful CPR. They also concluded that its use can be considered where resources or time do not permit formal F2F training sessions, but that the greatest benefits may be realised by pairing VR with F2F training.
Learning approaches that aim to merge traditional training with high-quality CPR feedback manikins and VR environments have been developed by the Italian Resuscitation Council through its Basic Life Support and Defibrillation, Quality CPR and Virtual Reality (BLS-D VRQ 2019) course.
Semeraro et al (2009; 2017) evaluated two CPR feedback manikins and two VR devices with the same self-directed learning programne and found that users unanimously considered the VR experience was very immersive, with a high sense of presence and provided effective feedback on participant skill performance. They concluded that the BLS-D VRQ course may be considered as an effective and acceptable alternative to traditional training courses. However, costs, equipment and initial instructor training must be acknowledged.
The project in the present study employed the Quest hand controller in a novel manner during the VCPR simulation. Semeraro et al (2019) also employed motion detection technology to accurately estimate chest-compression quality CPR parameters. They evaluated correct chest compression rate and depth compared to a standard manikin. This comparison of measurements between VCPR and a standard manikin showed equivalent results.
Leary et al (2019) examined whether using a VR mobile application (mApp) for CPR training would improve bystander response compared with a standard mApp CPR training. One hundred and five participants were enrolled in the study. Bystander response was significantly higher in the VR mApp arm regarding: calling 911 (82% vs 58%; P=0.007); and asking for an AED (57% vs 28%; P=0.003). However, there was no difference in CPR performed (98% versus 98%; P=not significant) and the application of the AED (90% versus 93%; P=not significant). When comparing the VR mApp to the mApp, the mean chest compression rate was 104 ± 42 cpm vs 112 ± 30 cpm (P=not significant), and mean chest compression depth was 38 ± 15 mm vs 44 ± 13 mm (p = 0.05). The authors concluded that use of the VR mApp significantly increased the likelihood of calling 911 and asking for an AED; however, chest compression depth was less. This highlights the need for rigorous development and evaluation to avoid any unintended harmful consequences of using the VR applications.
Commercial and policy aspects
The authors' development of VCPR and work by other groups have operated in parallel to expand knowledge and present opportunities to improve the teaching of CPR in schools.
As this body of knowledge, the evidence base and technology continue to develop and mature, there is a need for discussion on the commercial, policy and political aspects of the vital issue of teaching CPR in schools to improve survival from OHCA and use of VR in this process.
Limitations
The current project has explored the development of VR for teaching CPR in schools in Wales through VCPR.
Despite recommendations that schoolchildren receive 2 hours of CPR training annually, as with many countries across the world, this is not mandatory in Wales. The authors' experiences may not transfer into other contexts but have, however, drawn on a growing international evidence base pointing to the role of VR in supporting the teaching of CPR in schools.
The present study should not limit the central message around the importance of mandatory CPR training in schools but should serve to highlight the need to maintain the focus on this important issue for Wales.
Before VR is adopted, further technological development of VCPR will be required and, while other VR versions may be available, VCPR can be tailored to local needs, including requirements such as a Welsh language version, and may benefit from the flexibility of VR, as large-scale, inexpensive tailored software upgrades may be introduced in response to emerging changes in practice in a way that expensive physical models cannot.
Conclusion
Survival from OHCA in the UK remains low in comparison to developed regions. Early CPR is known to be key to survival, yet there is wide variation in delivery of these lifesaving skills.
Recognising an opportunity to reach entire populations and improve bystander CPR rates, WHO has endorsed Kids Save Lives, which calls for the mandatory teaching of CPR to schoolchildren.
All UK nations, including Wales, have made some form of commitment to teaching CPR in schools but, despite this, may face problems including securing the costs, time and effort needed to implement the teaching programme and sustain its delivery.
VCPR was developed to address some of the challenges and raise the profile of CPR training for schoolchildren. Building on work they had conducted using VR for infrequently used paramedic skills, the authors designed VCPR in partnership with researchers, computer scientists, paramedics, policy makers, teachers and children.
VCPR incorporates the latest VR technologies including Oculus Quest and many of these technologies have been used by other investigators. Along with other investigators, the authors have found hat VR can be an acceptable and effective way to teach CPR to schoolchildren.
However, while the need to deploy such technology to support teaching CPR to schoolchildren may be urgent, the authors continue to develop the simulator. They aim to produce more advanced versions incorporating artificial intelligence technology for further formal evaluation, clinical testing and future commercialisation.
In the meantime, the authors call for a continued focus on policy and political processes to ensure that the commitments made for all children to receive mandatory CPR training in schools are realised.