Article Data

  • Views 3097
  • Dowloads 290

Original Research

Open Access

The immediate effect of deliberate practice and real-time feedback on high-quality CPR training in intern doctors, acute care providers, and lay rescuers

  • Serpil Yaylaci1
  • Kamil Kayayurt1
  • Hasan Aldinc1
  • Cem Gun1
  • Alphan Sekuri2

1Department of Emergency Medicine, Acibadem Mehmet Ali Aydinlar University, School of Medicine, 34684 Istanbul, Turkey

2Acibadem Mehmet Ali Aydinlar University, School of Medicine, 34684 Istanbul, Turkey

DOI: 10.22514/sv.2021.119 Vol.18,Issue 2,March 2022 pp.48-55

Submitted: 07 May 2021 Accepted: 31 May 2021

Published: 08 March 2022

*Corresponding Author(s): Serpil Yaylaci E-mail:


The quality of cardiopulmonary resuscitation (CPR) is the main determinant of survival in cardiac arrest, so high-quality CPR (HQ-CPR) from bystanders is essential. The best instructional model for HQ-CPR performed by bystanders remains under investigation, and an instructional model’s effect on various learner types is unknown. This study examined the immediate effect of a brief, blended instructional design that combines deliberate practice (DP) with real-time feedback (RTF) on the booster training of intern doctors (IDs) and acute care providers (ACPs) as well as on the skills acquisition training of lay rescuers (LRs). This cohort crossover study was conducted in a university-affiliated hospital in January 2020. Just-in-time training on HQ-CPR that featured a popular song was provided to IDs (n = 24), ACPs (n = 29), LRs (n = 25); groups performed one-minute cardiac compressions twice, without RTF and with verbal coaching, followed by debriefing, and then with only RTF. The impact of RTF on depth, rate, compression quality (CQ), and recoil was assessed. RTF significantly improved depth, rate, CQ, and recoil (p < 0.001). Among the LRs, the depth was 0.2 millimeters below the lower cutoff. Without RTF, the previously trained IDs and ACPs tended to perform inadequately faster and deeper compressions, while the untrained LRs performed slower, shallow compressions. DP combined with RTF yielded a significant immediate effect on the HQ- CPR training outcomes of all learner types.


Audio feedback; Cardiopulmonary resuscitation; Deliberate practice; Public participation; Visual feedback

Cite and Share

Serpil Yaylaci,Kamil Kayayurt,Hasan Aldinc,Cem Gun,Alphan Sekuri. The immediate effect of deliberate practice and real-time feedback on high-quality CPR training in intern doctors, acute care providers, and lay rescuers. Signa Vitae. 2022. 18(2);48-55.


[1] Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics—2020 update: A report from the American Heart Association. Circulation. 2020; 141: e139–e596.

[2] Nishi T, Takei Y, Kamikura T, Ohta K, Hashimoto M, Inaba H. Improper bystander-performed basic life support in cardiac arrests managed with public automated external defibrillators. The American Journal of Emergency Medicine. 2015; 33: 43–49.

[3] Gyllenborg T, Granfeldt A, Lippert F, Riddervold IS, Folke F. Quality of bystander cardiopulmonary resuscitation during real-life out-of-hospital cardiac arrest. Resuscitation. 2017; 120: 63–70.

[4] Nord A, Svensson L, Karlsson T, Claesson A, Herlitz J, Nilsson L. Increased survival from out-of-hospital cardiac arrest when off duty medically educated personnel perform CPR compared with laymen. Resuscitation. 2017; 120: 88–94.

[5] Hunt EA, Duval-Arnould JM, Chime NO, Jones K, Rosen M, Hollingsworth M, et al. Integration of in-hospital cardiac arrest contextual curriculum into a basic life support course: a randomized, controlled simulation study. Resuscitation. 2017; 114: 127–132.

[6] Wayne DB, Siddall VJ, Butter J, Fudala MJ, Wade LD, Feinglass J, et al. A longitudinal study of internal medicine residents’ retention of advanced cardiac life support skills. Academic Medicine. 2006; 81: S9–S12.

[7] Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. Journal of the American Medical Association. 2008; 300: 1423-1431.

[8] Abella BS, Sandbo N, Vassilatos P, Alvarado JP, O’Hearn N, Wigder HN, et al. Chest compression rates during cardiopulmonary resuscitation are suboptimal: a prospective study during in-hospital cardiac arrest. Circulation. 2005; 111: 428–434.

[9] Merchant RM, Topjian AA, Panchal AR, Cheng A, Aziz K, Berg KM, et al. Part 1: Executive Summary: 2020 American Heart Association Guide-lines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020; 142: S337–S357.

[10] Perkins GD, Graesner JT, Semeraro F, Olasveengen T, Soar J, Lott C, et al. European Resuscitation Council Guidelines 2021: Executive summary. Resuscitation. 2021; 161: 1–60.

[11] Cheng A, Overly F, Kessler D, Nadkarni VM, Lin Y, Doan Q, et al. Perception of CPR quality: Influence of CPR feedback, Just-in-Time CPR training and provider role. Resuscitation. 2015; 87: 44–50.

[12] Bhanji F, Mancini ME, Sinz E, Rodgers DL, McNeil MA, Hoadley TA, et al. Part 16: education, implementation, and teams: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122: S920–S933.

[13] Bhanji F, Donoghue AJ, Wolff MS, Flores GE, Halamek LP, Berman JM, et al. Part 14: Education: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132: S561–S573.

[14] Søreide E, Morrison L, Hillman K, Monsieurs K, Sunde K, Zideman D, et al. The formula for survival in resuscitation. Resuscitation. 2014; 84: 1487–1493.

[15] Yeung J, Meeks R, Edelson D, Gao F, Soar J, Perkins GD. The use of CPR feedbackprompt devices during training and CPR performance: a systematic review. Resuscitation. 2009; 80: 743–751.

[16] Cheng A, Magid DJ, Auerbach M, Bhanji F, Bigham BL, Blewer AL, et al. Part 6: Resuscitation Education Science: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020; 142: S551–S579.

[17] Cheng A, Nadkarni VM, Mancini MB, Hunt EA, Sinz EH, Merchant RM, et al. Resuscitation Education Science: Educational Strategies to Improve Outcomes from Cardiac Arrest: a Scientific Statement from the American Heart Association. Circulation. 2018; 138: e82–e122.

[18] Bobrow BJ, Spaite DW, Berg RA, Stolz U, Sanders AB, Kern KB, et al. Chest compression-only CPR by lay rescuers and survival from out-of-hospital cardiac arrest. Journal of the American Medical Association. 2010; 304: 1447–1454.

[19] Girotra S, van Diepen S, Nallamothu BK, Carrel M, Vellano K, Anderson ML, et al. Regional Variation in out-of-Hospital Cardiac Arrest Survival in the United States. Circulation. 2016; 133: 2159–2168.

[20] Greif R, Lockey A, Breckwoldt J, Carmona F, Conaghan P, Kuzovlev A, et al. European Resuscitation Council Guidelines 2021: Education for resuscitation. Resuscitataion. 2021; 161: 388–407.

[21] American Heart Association. Requirement on Use of Feedback Devices in Adult CPR Training Courses. 2017. Available at: (Accessed: 24 June 2021).

[22] Riggs M, Franklin R, Saylany L. Associations between cardiopulmonary resuscitation (CPR) knowledge, self-efficacy, training history and willingness to perform CPR and CPR psychomotor skills: a systematic review. Resuscitation. 2019; 138: 259–272.

[23] Sugerman NT, Edelson DP, Leary M, Weidman EK, Herzberg DL, Vanden Hoek TL, et al. Rescuer fatigue during actual in-hospital cardiopulmonary resuscitation with audiovisual feedback: a prospective multicenter study. Resuscitation. 2009; 80: 981–984.

[24] Kovacs A, Vadeboncoeur TF, Stolz U, Spaite DW, Irisawa T, Silver A, et al. Chest compression release velocity: Association with survival and favorable neurologic outcome after out-of-hospital cardiac arrest. Resuscitation. 2015; 92: 107–114.

[25] Goharani R, Vahedian-Azimi A, Farzanegan B, Bashar FR, Hajiesmaeili M, Shojaei S, et al. Real-time compression feedback for patients with in-hospital cardiac arrest: a multi-center randomized controlled clinical trial. Journal of Intensive Care. 2019; 7: 5.

[26] Wang S, Su C, Fan H, Hou W, Chen Y. Effects of real-time feedback on cardiopulmonary resuscitation quality on outcomes in adult patients with cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2020; 155: 82–90.

[27] Hirakawa A, Hatakeyama T, Kobayashi D, Nishiyama C, Kada A, Kiguchi T, et al. Real-time feedback, debriefing, and retraining system of cardiopulmonary resuscitation for out-of-hospital cardiac arrests: a study protocol for a cluster parallel-group randomized controlled trial. Trials. 2018; 19: 510.

[28] Kardong-Edgren S, Oermann MH, Odom-Maryon T. Findings from a nursing student CPR study: implications for staff development educators. Journal for Nurses in Staff Development. 2012; 28: 9–15.

[29] Oermann MH, Kardong-Edgren SE, Odom-Maryon T. Effects of monthly practice on nursing students’ CPR psychomotor skill performance. Resuscitation. 2011; 82: 447–453.

[30] Tanaka S, Tsukigase K, Hara T, Sagisaka R, Myklebust H, Birkenes TS, et al. Effect of real-time visual feedback device ‘Quality Cardiopulmonary Resuscitation (QCPR) Classroom’ with a metronome sound on layperson CPR training in Japan: a cluster randomized control trial. BMJ Open. 2019; 9: e026140.

[31] Lu T, Chen Y, Ho T, Chang Y, Lee Y, Wang Y, et al. A novel depth estimation algorithm of chest compression for feedback of high-quality cardiopulmonary resuscitation based on a smartwatch. Journal of Biomedical Informatics. 2018; 87: 60–65.

[32] Roppolo LP, Pepe PE, Campbell L, Ohman K, Kulkarni H, Miller R, et al. Prospective, randomized trial of the effectiveness and retention of 30-min layperson training for cardiopulmonary resuscitation and automated external defibrillators: the American Airlines Study. Resuscitation. 2007; 74: 276–285.

[33] Saraç L, Ok A. The effects of different instructional methods on students’ acquisition and retention of cardiopulmonary resuscitation skills. Resuscitation. 2010; 81: 555–561.

[34] Bobrow BJ, Vadeboncoeur TF, Spaite DW, Potts J, Denninghoff K, Chikani V, et al. The effectiveness of ultrabrief and brief educational videos for training lay responders in hands-only cardiopulmonary resuscitation: implications for the future of citizen cardiopulmonary resuscitation training. Circulation. Cardiovascular Quality and Outcomes. 2011; 4: 220–226.

[35] Chung CH, Siu AYC, Po LLK, Lam CY, Wong PCY. Comparing the effectiveness of video self-instruction versus traditional classroom in-struction targeted at cardiopulmonary resuscitation skills for laypersons: a prospective randomised controlled trial. Hong Kong Medical Journal. 2010; 16: 165–170.

[36] Kim CH, Kim TH, Shin SD, Song KJ, Ro YS, Ahn KO, et al. The effect of automatic external defibrillator with a real-time feedback on quality of bystander cardiopulmonary resuscitation: a before-and-after simulation study. Health & Social Care in the Community. 2019; 27: e744–e751.

Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.

Index Copernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.

Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.

Scopus: CiteScore 1.0 (2022) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.

Submission Turnaround Time