Stressful Environments Negatively Impact the Resuscitation Skills of Doctors of Different Experience. A Randomized Controlled Cross-Over Trial.

Background: Cardio-pulmonary resuscitation (CPR) is an essential skill that all health providers must master. Simulation training on traditional manikins in a normal classroom does not prepare the trainees for the stress that could reduce the resuscitation performance of especially inexperienced providers during a real cardiac arrest. The aim of this randomized cross-over trial was to explore whether training using augmented reality (AR) was realistic enough to induce stress and impact the resuscitation skills of doctors of different experience levels. Methods: Novices, intermediates, and experienced physicians participated in this single-center, randomized, cross-over, simulation-based study. All participants had to perform CPR on a high-fidelity manikin with and without AR. In the immersive AR environment, sounds from multiple sources and visuals of bustling crowds were used to simulate a stressful environment. The State-Trait Anxiety Inventory (STAI) were used to measure the participants' perceived stress levels during the simulation sessions. Frequency and depth of chest compressions, and the ratio of chest compression time to the entire recovery cycle, i.e. the Chest Compression Fraction (CCF) were used to objectively measure the quality of the resuscitation. Trial Registration: not applicable. Results: This study included 80 participants, novices=28, intermediates=27, and experienced=25. The novices reported significantly more stress during the AR simulation while participants with a higher level of experience were less affected by the stressful environment induced by the AR system. All three groups performed significantly worse regarding compression depth when they were in the stressful AR environment. Overall, 66 (83%) participants used the correct compression rate in the standard environment vs. 44 (55%) in the AR induced stressful environment, p<0.001; only the experienced did not perform significantly worse, p=0.36. The CCF increased significantly from 56% to 60% when performing resuscitation while using AR, indicating slightly better adherence to international recommendations. Conclusions: AR successfully added stress to performance of resuscitation in a simulated environment. It made it difficult for participants to achieve accurate depth of compression under pressure and the inexperienced also performed worse regarding compression rate and reported feeling more stressed. Training resuscitation using AR might prepare health care providers for the stressful situations of a clinical cardiac arrest.