iCPR: a new application of high-quality cardiopulmonary resuscitation training.

Resuscitation 82 (2011) 436–441
Contents lists available at ScienceDirect
Resuscitation
journa l homepage: www.e lsev ier .com/ lo
Simulation and education
iCPR: A pu
Federico Gu
Luca Mar
a Department o
b d-Sign, Bolog
a r t i c l
Article history:
Received 31 M
Received in re
10 September
Accepted 22 N
Keywords:
Cardiopulmonary resuscitation
Chest compression
Education
Training
Cardiac arrest
Accelerometer
Feedback devi
iPhone
s a ne
nce t
ional
ficall
uide
o eva
ned
to an
more minutes of CC. The first group performing the sequence of CC with iCPR – questions – CC without
feedback, and the second the sequence CC without feedback – questions CC with iCPR.
Results: The mean compression rate was 101±2.8min−1 when CC were performed with iCPR and
107.8±20.5min−1 when performed without iCPR (p<0.01). Overall, the participants considered iCPR
useful to maintain CC at the desired rate of 100 compressions per minute.
1. Introdu
The cons
(CPR) for th
with the rol
When teste
people and
cantly with
also often p
high-qualit
The Euro
the importa
a target com
number of d
CPR,3,6–8 an
settings.
� A Spanish
in the final on
∗ Correspon
E-mail add
0300-9572/$ –
doi:10.1016/j.ce Conclusions: The iCPR feedback tool was able to significantly improve the performance of chest com-
pressions in terms of the compression rate in a simulated cardiac arrest scenario. The participants also
believed that iCPR helped them to achieve the correct chest compression rate and most users found this
device easy to use.
© 2010 Elsevier Ireland Ltd. All rights reserved.
ction
olidated importance of cardiopulmonary resuscitation
e survival of cardiac arrest patients has been integrated
eofhigh-qualityCPR to significantly improveoutcomes.
d on mannequins, the quality of CPR performed by lay
healthcare professionals tends to deteriorate signifi-
in a few months after training.1,2 The quality of CPR is
oor in the clinical setting, though the survival benefit of
y CPR is well documented.3,4
pean Resuscitation Council (ERC) guidelines emphasise
nce of high-quality, uninterrupted CPR and also specify
pression depth of 4–5 cm and a rate of 100min−1.5 A
evices havebeendeveloped toprovide guidanceduring
d these have been used in both training and clinical
translated version of the abstract of this article appears as Appendix
line version at doi:10.1016/j.resuscitation.2010.11.023.
ding author. Tel.: +39 3336592670; fax: +39 0516478867.
ress: fsemeraro2008@gmail.com (F. Semeraro).
The devices range in complexity from a simple metronome,
which guides the compression rate, to more complex devices that
monitor and provide combined audiovisual feedback on the actual
CPR performance. The present study evaluates a new CPR feed-
back application for the iPhone and iPod (iCPR – www.icpr.it) in
a cardiac arrest simulation based on improvements in the exter-
nal chest compression performance and acceptance by healthcare
professionals and lay people.
2. Materials and methods
We built an application specifically dedicated to self-directed
CPR training through a tutorial that includes a simple feedback
module dedicated to guide the training in relation to the qual-
ity of chest compressions. The software can be used with iPods
and iPhones on armbands commonly used for running (Fig. 1). The
accelerometer mounted inside of iPods and iPhones measures the
rate of compressions and gives audiovisual feedback to the opera-
tor on the performance in order to reach the guideline target (100
compressions perminute). TheApp Store is a service for the iPhone,
iPod Touch and iPad created by Apple Inc. which allows users to
browse and download applications from the iTunes Store thatwere
see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
resuscitation.2010.11.023new application of high-quality cardio
Semeraroa,∗, Floriana Taggia, Gaetano Tammaroa,
chettib, Erga L. Cerchiari a
f Anaesthesia and Intensive Care, Ospedale Maggiore, Bologna, Italy
na, Italy
e i n f o
ay 2010
vised form
2010
ovember 2010
a b s t r a c t
Objectives: The present study evaluate
improve chest compression performa
and acceptance by healthcare profess
Methods:Webuilt anapplicationspeci
includesa simple feedbackmodule tog
We tested it in a sample of 50 users t
The participants were randomly assig
of 2min of chest compressions (CC),cate / resusc i ta t ion
lmonary resuscitation training�
glielmo Imbriacoa,
w CPR feedback application for the iPhone (iCPR) designed to
ested in a cardiac arrest simulation to evaluate performance
s and lay people.
ydedicated to self-directedCPR training througha tutorial that
training inorder to improve thequalityof chest compressions.
luate the effect of iCPR on performance and it is acceptance.
to one of the study groups and were asked to perform a trial
swer a predefined set of questions and then to perform two

F. Semeraro et al. / Resuscitation 82 (2011) 436–441 437
developed
Depending
cost.
The iCPR
band and k
A built-in m
gives the us
The disp
quency and
A visual
by green/re
between 95
is under an
The softw
3-axis acce
tude of the
The samplin
is 50Hz. Th
tracking sub
is displayed
magnitude
0.20g durin
ments. No m
trigger the
depend onFig. 1. iCPR application for the iPhone an
with the iPhone SDK and published through Apple.
on the application, they are available either free, or at a
application is used wearing the device with an arm-
eeping it with the display clearly visible for the user.
etronome, producing a clearly audible sound sample,
er the right chest compression rate.
lay shows two indicators: the chest compression fre-
count.
feedback of the quality of chest compressions is shown
d color on the frequency display. The green zone ranges
and 105 chest compressions per second. The red zone
d over this range.
are detects the gravity vector and subtracts it from the
leration detected by the accelerometer and the magni-
resulting acceleration vector is used for computation.
g frequency used to quantize the instant acceleration
e frequency of the chest compressions is computed by
stantial changes in thedirection of the acceleration and
as the average of the three last chest compressions. A
threshold of 0.28g during the compression phase and
g release phase is used to filter out unwanted move-
inimal depth of the chest compression is necessary to
frequency calculation and the algorithm used does not
the device orientation.
The iCPR
and Europe
canbeused
Our study w
Surgical an
the d-Sign O
nurses, doc
sonnel. We
asked the p
the scenario
for the stud
All subj
dardised le
evaluated.
acquisition
nation of th
the device
Afterwards
study grou
tinuous che
questions (
minutes of
iCPR feedba
the second
questions ad iPod.
tutorial is based on ILCOR (American Heart Association
an Resuscitation Council guidelines) and periodically
to easily refresh theCPRalgorithmthrougha slideshow.
as carried out in the intensive care unit (ICU) at the
d Obstetric Department of the Maggiore Hospital and at
ffice in November of 2009. The participants comprised
tors, healthcare professionals and administrative per-
used a prospective, randomized crossover design and
articipants not to inform the other participants about
set-up. In Fig. 2 is described theCONSORTflowdiagram
y.
ects were informed about the study through a stan-
aflet and were told that their performance would be
Each participant provided written consent for the data
and analysis. All subjects received a standardised expla-
e feedback features of iCPR using a demonstration of
and gained familiarisation without further instruction.
, participants were randomly assigned to one of the
ps and were asked to perform a trial of 2min of con-
st compressions (CC), to answer a predefined set of
about 10min of pause) and then to perform two more
CC. The first group performing the sequence of CC with
ck, then questions and then CC without feedback, and
performing the sequence of CC without feedback, then
nd then CC with iCPR feedback.

438 F. Semeraro et al. / Resuscitation 82 (2011) 436–441
At the e
questionna
The ques
designed to
friendliness
commercia
audio recor
and a Resus
cue bed wit
The data
CPR Review
the device,
rect. A com
because the
For each
recorded: r
tor, nurse or
statements
compressio
10=very ef
sions” (scal
3. Results
We ana
included 5
34.4±7.3 y
doctors, 44%Fig. 2. CONSORT flow diagram of random
nd, each participant was then asked to respond to a
ire about iCPR.
tionnaire, based on a seven-point Likert scale (LS), was
explore the trainee’s perception in the areas of user
, wearability and audibility of the device. We used a
lly available monitor/defibrillator with CPR-quality and
ding capabilities (MRx-QCPR, Philips Medical Systems)
ci Anne mannequin that was placed on Emergency Res-
h a thin mattress.
regarding the quality of CPR were collected with Q-
(Laerdal Medical). According to the default settings of
a compression depth of 38–51mm was assessed as cor-
pression rate between 90 and 120min−1 was accepted
device was programmed according to 2005 guidelines.
subject, the following demographic parameters were
escuer gender, age, weight, height and profession (doc-
other). Eachparticipantwas asked to rate the following
using a 10-cm visual analogue scale (VAS): “The chest
ns I performed were effective” (scale: 0 =not effective,
fective); “It was exhausting to deliver chest compres-
e: 0 =no exhaustion at all, 10 = extreme exhaustion).
lysed data from 50 iCPR participants. The sample
8% males and 42% females, with an average age of
ears and a BMI of 24.23±4.2. The sample included 8%
nurses and 48% lay people.
The mea
compressio
when perfo
The mea
41.1±13.1
All parti
guidance, a
VAS. Perfor
reported to
affect fatigu
The eval
bility are re
with an iPo
The visib
the audibili
evaluated a
The CPR
to be non-h
considered
a rate of 10
4. Discussi
There is
resuscitatio
required to
Howeve
healthcare
pressions eization.
n compression rate was 101±2.8min−1 when chest
ns were performed with iCPR and 107.8±20.5min−1
rmed without iCPR (p<0.01).
n compression depth was 37.2±12mm with iCPR and
mm without iCPR guidance (p=0.57) (Table 1).
cipants performed CPR scenarios with and without iCPR
nd the opinions regarding CPR were assessed using the
ming chest compressions without iCPR guidance was
be less efficient (p=0.0059), and iCPR guidance did not
e (p=0.13) (Table 1).
uations of the user-friendliness, wearability and audi-
ported in Table 2. The difficulty in wearing the armband
d (Q1: 2.3±1.9) was judged to be low.
ility of the numbers on the monitor (Q2: 6.3±1.2) and
ty of themetronomeduring theCPR (Q3: 6.4±1.2)were
s good.
manoeuvreswith the armband and iPhonewere judged
ampered (Q4: 1.7±1.8), and finally, the participants
it useful to use iCPR to perform chest compressions at
0 compressions per minute (Q5: 6.3±1) (Table 2).
on
general agreement on the need to improve outcomes in
n, and it is recognised that changes in practise may be
make this possible.
r, concerns remain about the ability of lay people and
professionals to perform or recognise good chest com-
ven shortly after training.

F. Semeraro et al. / Resuscitation 82 (2011) 436–441 439
Table 1
Participants’ chest compression data without and with iCPR feedback during 2min. Participants’ opinions regarding fatigue and chest compression efficacy without and with
iCPR guidance using visual analogue scale (VAS).
Mean SD *p<0.01
Compression data without iCPR feedback
Average compression rate [min−1] [90–120] 107.8
Average compression depth [mm] [38–51] 41.1
Total number of compressions 215.6
Average count per minute 107.8
Compression data with iCPR feedback
Average compression rate [min−1] [90–120] 101.1
Average compression depth [mm] [38–51] 37.2
Total number of compressions 202.4
Average count per minute 101.1
The compression data are presented as the mean and standard deviation and were analysed with the Stud
Without iCPR
VAS efficacy 6 (1–9)
VAS fatigue
The results are
This stu
quality of th
nario. Whe
was within
chest comp
ance had no
difference i
The Euro
a rescuer sh
In our s
without the
tions. The u
recommend
Recently
of healthca
depth of co
For in-h
chest comp
observed ti
The sur
whereas th
of 79min−1
4.1. CPR fee
Many d
the resuscit
audio-feedb
an automat
applied in t
practice.14
The first
in1992,wh
formance w
a few years
Table 2
User response
point Likert sc
Q1. It was di
Q2. The num
Q3. The met
Q4. The arm
compression
Q5. iCPR hel
a rate of 100
ould
st sta
com
a re
effe
with
pro
the
ized
in th
essio
ng e
s goo
s du
on. T
an o
PR. Y
sure
erati
g per
auth
sh if
in pa
R on
App
The
tion
17.326 (1–10)
presented as the medians (range) and were analysed with the Wilcoxon test.
dy demonstrated that iCPR guidance did improve the
e chest compression rate during a simulated CPR sce-
n iCPR guidance was used, the chest compression rate
the current guidelines, and the number of performed
ressions per minute was correct. In addition, iCPR guid-
effect on the depth of compressions, and there was no
n rescuer fatigue.
pean Resuscitation Council (ERC) guidelines state that
ould compress the chest at a rate of about 100min−1.5
tudy, the mean chest compression rate (107.8±20.5)
use of iCPR was much higher than the recommenda-
se of the iCPR completely corrected the rate to that
ed in the guidelines (101±2.8).
published data demonstrate the weak performance
re professionals, especially regarding the rate and the
mpressions.
ospital resuscitation, Abella et al. detected a correct
ression rate of 90–110min−1 during only 31.4% of the
me during resuscitation attempts.
vivors had a mean compression rate of 90min−1,
e non-survivors received compressions at a mean rate
.3
dback
ifferent methods have been employed to improve
ation skills, including video-recording evaluations,9,10
ack systems during training12 or integration into
ed external defibrillator13. Most methods have been
he training environment rather than in actual clinical
ance c
the fir
on the
strated
fatigue
a test
cant im
during
random
ments
compr
Yeu
there i
system
retenti
part of
ity of C
to mea
consid
is bein
The
establi
ments
4.2. CP
In
tions.
applica
tions (example of a chest compression feedback system came
enKernet al. demonstrated that chest compressionper-
as improved by employing a simple metronome,15 and
later Milander et al. concluded that audible tone guid-
s to iCPR. Participants rated the following statements using a seven-
ale (1 = completely disagree, 7 = completely agree).
Mean SD
fficult to wear the armband with an iPod 2.3 1.9
bers on the monitor were easily visible 6.3 1.2
ronome was easily audible during the CPR 6.4 1.2
band with the iPhone hampered the chest
s
1.7 1.8
ped you to perform chest compressions at
bpm
6.3 1
28,771 app
teenth with
the iTunes s
tions. iCPR
an assessm
The CPR
1st Septem
strations on
Aid & CPR
tions, inclu
seizures, di
to respond
prompting
for adult, ch
with first a
bites, burns20.5 *
13.1
42.4 *
21.1 *
2.8 *
12
6 *
2.8 *
ent’s t-test
With iCPR p value
6.25 (0–10) 0.0059*
5 (3–9) 0.13
lead to higher compression rates.11 The CPR-Plus was
nd-alone support developed to provide feedback only
pression depth and incomplete release, but it demon-
duction in the number of incorrect compressions and
cts.16 The CPREzyTM was evaluated by Boyle et al. in
non-medical hospital staff, and they reported signifi-
vements in the compression rate and depth, especially
last minute of CPR. These results were validated in a
controlled study with 202 laypersons, with improve-
e same parameters and a learning effect regarding the
n depth.17
t al.14 in a recent systematic review concluded that
d evidence supporting the use of CPR feedback/prompt
ring CPR training to improve CPR skill acquisition and
he author suggests that their use in clinical practice as
verall strategy might be beneficial to improve the qual-
eung et al. underlines that the accuracy of the devices
compression depth should be calibrated to take into
on the stiffness of the support surface upon which CPR
formed (e.g. floor/mattress).
ors also declared that further studies are required to
the improvements in CPR quality can bring improve-
tient’s outcomes.
Apple Store
Store there is a large number of active applica-
latest report describes approximately 250,000 active
s.18 The first three categories are: books 43,809 applica-
%); games 36,719 applications (14.52%); entertainment
lications (11.38%). The medical category is the seven-
3820 applications (1.51%). In the US App Store using
earch engine with the term “CPR” there are 77 applica-
is the seventh application among CPR applications with
ent rating of 3.5 out of 5 (average of 310 ratings).
top ten contains the following applications (update on
ber 2010): “CPR & Choking”,19 a series of video demon-
CPR and choking in adults and children; “Pocket First
from the American Heart Association”20 with illustra-
ding topics such as CPR, choking, bites, bruises, burns,
abetic emergencies and detailed videos showing how
in critical first aid situations; “CPR-App”21 with voice
to the persons trained in CPR through rescueprocedures
ild and baby victims; “ResQr First Aid & CPR Coach”22
id scenarios, including topics such as CPR, choking,
, seizures, diabetic emergencies, severe wounds, head

440 F. Semeraro et al. / Resuscitation 82 (2011) 436–441
Table 3
Apple iTunes – top ten CPR applications comparison (update on 1st September 2010).
Name App Reference
guidelines
Audio
Visual
Audio
Visual
Depth
Rate
Average
Ratings
Cost
CPR and cho
Pocket first a
CPR-App
ResQr first a nome
CPR video in
Pocket CPR
Hand-only C
iCPR
CPR baby
CPR buddy
injuries, to
pacing m
Instruction”
CPR; “Pock
on CPR. Th
device Pock
Association
instructions
less”27 with
year old bab
tutorial and
Since 18
Store, the to
3% in Cana
the differen
the referen
rial, the pre
depth/rate
the cost of
App Store w
CPR and iC
chest comp
and whethe
voice prom
set at 100 b
pressions ra
compressio
per minute
the iPhone,
will measur
the iPhone
perform ch
is the cost o
is free. Pock
CPR trainin
They can
trainer’s ha
the phone m
allows Pock
rew
arre
. It is
s, es
ality
pre
babl
l sett
Q-C
tress
study
e thi
that
se an
e an
h peVideo
Tutorial
Tactile
Feedback
king AHA
ILCOR
Video –
id and CPR AHA Visual
Video
–
AHA Audio Audio
id & CPR coach AHA
Red cross
Visual Audio (Metro
struction Red cross Video –
AHA
ILCOR
Audio
Visual
Audio
(Metronome)
Visual
PR AHA Visual
Video
–
AHA
ERC
Visual Audio
(Metronome)
Visual
Red cross Visual –
– Slide Audio
(Metronome)
Tactile-visual
GPS assistance nearest ER location and proper CPR
etronome and adult instructions; “CPR Video
23 includes a series of video demonstrations on
et CPR”24 gives real-time feedback and instructions
e technology is the same as that used in medical
et CPR25; “Hand-Only CPR”26 from the American Heart
teaches how to perform Hand-Only CPR through video
; “CPR Baby – Know CPR for babies one year old or
a tutorial teaching how to perform CPR to any one
y or less in just 5 steps; “CPR Buddy”28 includes a CPR
a CPR chest compression metronome.
th November 2009, date of publication of iCPR on App
tal downloads were 16,023: 69% in the United States,
da, 3% in Italy, 23% in other countries. We compared
ces in between top ten CPR applications regarding
ce guidelines, the presence of audio/visual/video tuto-
The
cardiac
reality
nequin
the qu
the com
are pro
clinica
The
of mat
In this
(despit
design
of pau
exclud
in whicsence of audio/visual/tactile feedback, the presence of
feedback, the average rating and number of ratings and
application (see Table 3). The only two applications on
hich give feedback on chest compressions are Pocket
PR. Pocket CPR measures the actual rate and depth of
ressions andgivevoiceprompts topush faster or slower,
r you should push harder or softer. In addition to the
pts you can always hear the sound of the metronome
eats per minute. iCPR measures the actual chest com-
te and gives visual prompts about rate and number of
ns with a sound metronome prompt set at 100 beats
. In Pocket CPR when chest compressions are started,
when placed between or on top of the rescuer’s hands,
e the compression depth and rate. Whereas iCPR using
placed on the armband is leaving your hands free to
est compressions with no difficulty. Another difference
f application: Pocket CPR actually costs $3.99 and iCPR
et CPR and iCPR are both intended to be used only for
g.
not be used in both cases if the iPhone is placed under
nds on patient’s chest; the screenwill be obstructed and
ay be broken. Recently, iSkin produces a soft cases that
et CPR and iCPR to be worn on the knuckles.29
“carry-over
of the trea
avoided wi
formances a
are three pr
Zanner e
clip and foll
time and ca
shown that
score, inclu
ing. Anima
achieving e
In our st
help and st
compared.
previous stu
and starting
Participants
band and iP
Therefore, f
to simplify
instruction
actions witFeedback (1–5)
Number ratings
– 3.5
1698
Free
– 3.5
1025
$3.99
$3.99
– 0
0
) – 2.5
20
$3.99
– 2.5
50
$0.99
Depth (inches)
Rate
3
1053
$3.99
– 3.5
247
Free
Rate 3.5
310
Free
– 2.5
8
$0.99
– 2
31
$0.99
ere some limitations in our study. The use of a simulated
st model with a mannequin differs from the clinical
not clear whether the quality of CPR given to man-
pecially the chest compression depth, is equivalent to
of CPR given to patients. However, the parameters of
ssion rate and total number of chest compressions given
y very close in the mannequin scenario and in a similar
ing.
PR and other accelerometer devices include the amount
compression when reporting chest compression depth.
weusedanEmergencyRescuebedwith a thinmattress
s probableunderestimatedepthby1–1.5 cm). The study
includes 2min of chest compressions, about 10min
d two more minutes of chest compressions does not
order and carry over effect: it is possible that the order
rformances are made may affect both the result and the
” between treatments, which confound the estimates
tment effects. In practice, “carry-over” effects can be
th a sufficiently long “wash-out” period between per-
nd most probably 10min of pause is not enough. There
evious studies that used mobile phones to prompt CPR.
t al.30 implied that the action of activating the video
owing cellular phone instructions does takeupprecious
n delay important actions. Choa et al.31,32 instead have
animation-assisted CPR group reached better checklist
ding chest compression rate, depth and hand position-
tion-assisted CPR could be used as a reminder tool in
ffective one person-CPR performance.
udy, however, the time to confirming arrest, calling for
arting first chest compression were not calculated and
This is a limitation that does not allow comparison with
dies. Nevertheless, the opening time of the application
iCPR takes about 5 s in experienced users of the iPhone.
also declare that the CPR manoeuvres with the arm-
hone were judged to be non-hampering (Q4: 1.7±1.8).
urther research and technology development is needed
the operation of cellular phones, as well as, simplifying
method for thebystander tobeable toperformessential
hout unnecessary delays.

F. Semeraro et al. / Resuscitation 82 (2011) 436–441 441
In future studies, it would be interesting to examine the use
of iCPR for different clinical scenarios and with depth feedback.
The new iPhone 4 features an accelerometer motion detector and
a gyroscope that can be used to improve the measurement of chest
compression rate and depth. Further studies are required to assess
if the iPhone 4 can improve iCPR performances.
Furthermore iCPR needs to be tested comparing healthcare pro-
fessionals and lay people with previous CPR training versus people
who had no training whatever.
5. Conclusion
The iCPR feedback described here was able to significantly
improve the performance of chest compressions by healthcare pro-
fessionals and lay people in a simulated cardiac arrest scenario
in terms of the compression rate. The participants also believed
that iCPR helped them to achieve the correct chest compression
rate, and overall, most users found this device to be simple and
usable.
Conflict of interest statement
No relationship exists between any of the authors and any com-
mercial ent
represent a
any comme
within 3 ye
Acknowled
Wethan
ment healt
study. We w
the applica
Finally, we
technical su
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