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Just-In-Time CPR Training Studied in Pediatric Cardiopulmonary Arrest


Clinical question: Does the use of “just-in-time” (JIT) CPR training, with or without visual feedback (VisF), improve the quality of CPR in simulated pediatric cardiopulmonary arrest (CPA)?

Background: Rates of survival to discharge after in-hospital pediatric CPA range from 25%-50%, with three-quarters of survivors having good neurological outcomes.1 The quality of basic life support interventions has been found to be a critical factor influencing survival outcomes.1 Traditional basic life support (BLS) training has not been found to significantly increase compliance with 2010 AHA BLS Guidelines, however.2 Two recent advances have been found to improve the ability of CPR providers to estimate chest compression (CC) depth:

  • JIT CPR training, where learners are given video-based training immediately before simulated CPA and
  • real-time VisF, where learners are given feedback during CPR regarding rate and depth of CC by a small electronic device.

Visual CPR feedback devices used in recent studies are small (credit card-sized), are placed in the middle of the chest, and use accelerometer technology to provide real-time data regarding CC rate and depth. Prior studies utilizing VisF technology have found learners overestimate their compliance with target CC depth and rate.3

Study design: Prospective, randomized, 2 x 2 factorial-design trial.

Setting: Ten tertiary care teaching hospitals in the U.S. and Canada.

Synopsis: Researchers recruited participants from 10 tertiary care teaching hospitals that are part of the International Network for Simulation-Based Pediatric Innovation, Research, and Education (INSPIRE). Participants included medical students, resident/fellow physicians, nurses, and nurse practitioners. Participants were organized into teams of three, with one participant designated as team leader and two others assigned to perform CCs. Teams were then randomized into four arms as follows:

  • Arm 1: No JIT / no VisF
  • Arm 2: No JIT / + VisF
  • Arm 3: + JIT / no VisF
  • Arm 4: + JIT / + VisF

All participants watched a standard video orientation to the study, practiced CPR for two minutes, and participated in a pediatric septic shock simulation scenario (to minimize the Hawthorne effect of being videotaped). Depending on randomization, some teams received JIT CPR training prior to a simulated pediatric CPA scenario. Randomization also determined which teams would utilize a VisF device during CPR to give feedback regarding rate and depth of CCs. Actors were used to play roles of respiratory therapist and medication nurse, and all sites used standardized locations of defibrillator and medication cart.

Overall, quality of CPR was poor, but the JIT CPR training and VisF real-time feedback did result in improvement in CC depth and rate compliance:

  • JIT CPR training resulted in a 20% absolute increase in CC depth compliance and a 12% increase in CC rate compliance;
  • Real-time VisF resulted in a 15% absolute increase in CC depth compliance and a 40% absolute increase in CC rate compliance; and
  • Use of both JIT CPR training and real-time VisF during CPA resulted in the highest rates of CC depth and rate compliance, but no significant interaction effect was observed.

Bottom line: Use of JIT CPR training prior to pediatric CPA and a real-time visual feedback device during CPR improves compliance with CC rate and depth guidelines during simulated pediatric CPA.

Citation: Cheng A, Brown LL, Duff JP. Improving cardiopulmonary resuscitation with a CPR feedback device and refresher simulations (CPR CARES study): a randomized clinical trial. JAMA Pediatr. 2015;169(2):137-144.

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.


  1. Topjian AA, Nadkarni VM, Berg RA. Cardiopulmonary resuscitation in children. Curr Opin Crit Care. 2009;15(3):203-208.
  2. Sutton RM, Wolfe H, Nishisaki A. Pushing harder, pushing faster, minimizing interruptions but falling short of 2010 cardiopulmonary resuscitation targets during in-hospital pediatric and adolescent resuscitation. Resuscitation. 2013;84(12):1680-1684.
  3. Cheng A, Overly F, Kessler D, et al. Perception of CPR quality: influence of CPR feedback, Just-in-Time CPR training and provider role. Resuscitation. 2015;87: 44-50.

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