Use of a Real-Time Training Software (Laerdal QCPR®) Compared to Instructor-Based Feedback for High-Quality Chest Compressions Acquisition in Secondary School Students: A Randomized Trial

High-quality chest compressions are pivotal to improve survival from cardiac arrest. Basic life support training of school students is an international priority. The aim of this trial was to assess the effectiveness of a real-time training software (Laerdal QCPR®) compared to a standard instructor-based feedback for chest compressions acquisition in secondary school students. After an interactive frontal lesson about basic life support and high quality chest compressions, 144 students were randomized to two types of chest compressions training: 1) using Laerdal QCPR® (QCPR group– 72 students) for real-time feedback during chest compressions with the guide of an instructor who considered software data for students’ correction 2) based on standard instructor-based feedback (SF group– 72 students). Both groups had a minimum of a 2-minute chest compressions training session. Students were required to reach a minimum technical skill level before the evaluation. We evaluated all students at 7 days from the training with a 2-minute chest compressions session. The primary outcome was the compression score, which is an overall measure of chest compressions quality calculated by the software expressed as percentage. 125 students were present at the evaluation session (60 from QCPR group and 65 from SF group). Students in QCPR group had a significantly higher compression score (median 90%, IQR 81.9–96.0) compared to SF group (median 67%, IQR 27.7–87.5), p = 0.0003. Students in QCPR group performed significantly higher percentage of fully released chest compressions (71% [IQR 24.5–99.0] vs 24% [IQR 2.5–88.2]; p = 0.005) and better chest compression rate (117.5/min [IQR 106–123.5] vs 125/min [115–135.2]; p = 0.001). In secondary school students, a training for chest compressions based on a real-time feedback software (Laerdal QCPR®) guided by an instructor is superior to instructor-based feedback training in terms of chest compression technical skill acquisition. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000383460

one the most import maneuver for the improvement of the outcome. The European Resuscitation Council Guidelines 2015 underline the importance of cardiopulmonary resuscitation performed by bystanders while waiting for the arrival of medical support (1)(2). The education is an essential part of lay people and medical training on cardiopulmonary resuscitation. The education on cardiopulmonary resuscitation of primary and secondary school students is an international priority. The role of high quality chest compressions is increasingly recognized as pivotal for the outcome of cardiopulmonary resuscitation and for the reduction of organs damage. The gold standard for BLS-D training if the role of a qualified instructor. However, new electronic tools for feedback during the training give trainees information on their performance (3)(4). Laerdal QCPR is a computerized system connected to a manikin for BLS-D training able to give real-time feedback on chest compressions quality. Evaluated parameters encompass: compression rate, depth, chest recoil, and hand position. (5). The system is able to calculate an overall score defined as compression score, which summarize all these parameters.
To our knowledge, a comparison between instructor-based training and software-based training POLICLINICO (Laerdal QCPR) in secondary school students in a randomized trial has never been performed.

Aim of the study
This study aims to evaluate the efficacy of feedback by a computerized skill-reporting system (Laerdal QCPR) during the cardiopulmonary resuscitation training among secondary school students. The study focuses on chest compression training. The efficacy of feedback from Laedarl QCPR will be compared to the gold standard that is feedback from a qualified instructor.

Study design
Randomized trial. The study will include secondary school students of the last two years of study course. They will follow a frontal lesson performed by a qualified instructor about cardiac arrest, BLS-D and high-quality chest compressions. Students will be randomized in two groups 1) QCPR group 2) control group. In the QCPR group students will familiarize with equipment (manikin and QCPR software). Then, they will perform a 2-minute training session guided by the feedback from the software evaluating compression rate, depth, chest recoil and hand position. After this session, students will have a discussion with the instructor basing on the output of the system. Students will proceed to the next phase of the trial if they reach a compression score >=60% otherwise they will repeat the training session until they reach this cut-off. In the other group, students will performed a 2-minute training session guided by the instructor and at the end, they will discuss with him about their performance. Students of this group will proceed to the next phase according to instructor's judgment. After 7 days, all students will perform a 2-minute session of chest compressions on the manikin connected to the QCPR system for the evaluation. An instructor will also evaluate the session. Neither the student nor the instructor will be able to see the output of the QCPR software during or after the session.
Students will also asked to complete an appreciation subjective questionnaire. We will perform the study at the Liceo Scientifico Statale S. Cannizzaro. The primary outcome of the study if the compression score which is an overall score of chest compression quality calculated by the software.

Inclusion criteria
Students of the last two years of study course of the secondary school Liceo Scientifico Statale S.

Exclusion Criteria
Students not present at one the study phases Students who refuse to participate. Students who do not give informed consent.

Materials
To perform all trial phases we will use one manikin connected to the QCPR system and a personal computer running the specific software (Resusci Annie Skill Reporter -QCPRlaerdal) and one simple training manikin (Resusci Annie