Development and validation of a distance-based training program of Basic Cardiac Life Support for laypersons and comparison with traditional in-person methodology: A non-inferiority study

Development and validation of a distance-based training program of Basic Cardiac Life Support for laypersons and comparison with traditional in-person methodology: A non-inferiority study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and validation of a distance-based training program of Basic Cardiac Life Support for laypersons and comparison with traditional in-person methodology: A non-inferiority study Marcia Corvetto, David Acuña, Andrés Schneider, Jerónimo Rojas, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7509928/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: This study aimed to compare a distance-based CPR training program with asynchronous feedback for laypersons to a traditional in-person Basic Life Support (BLS) course. Methods: After approval by the ethics committee, 192 non-medical personnel were recruited to participate in this study. Participants were randomly assigned to two different training methods: - Traditional American Heart Association BLS in-person course (T-course). - Distance-based course offering asynchronous feedback through an online platform (D-course). For the distance-based course, materials for practice were available at the participants' workplace (pad, resuscitation torso, an automated external defibrillator). The video-based assessment and feedback platform C1DO1 was used (https://c1do1.ai/). The course was structured in 9 stages on the platform, with theoretical and practical steps. Participants reviewed the videos and practiced unsupervised, uploading video recordings of their practice, and instructors assessed and provided feedback asynchronously on these videos. Participants then reviewed their own videos with the feedback and practiced again until approval. Both groups completed a pre-training (PRE) and post-training assessment (POST). During both assessments, participants were recorded performing CPR. Videos were evaluated by two independent, blinded reviewers who rated participants’ performance using the AHA CPR and AED Skills Testing Checklist. Additionally, the quality of chest compressions (CC) was measured with the Prestan simulator application. Results: Of the 192 participants recruited, 172 completed the training, and 158 took the PRE and POST assessments. (83 finished the T-course and 75 the D-course). Median AHA CPR and AED Skills Checklist scores increased from 2 (0-3) to 15 (14-16.5) points in the T-course and from 1 (0-2.5) to 16 (15.5-17) points in the D-course. The difference in POST assessment median scores between groups was -1 (95% CI: [-1.5, -0.5]), with the lower bound above the pre-established non-inferiority margin, confirming the non-inferiority of the D-course. The median CC rate increased from 82 (0-106)/min to 105 (102-110)/min in the T-course and from 86 (0-109.5)/min to 105 (105-108)/min in the D-course. The median CC depth rose from 38 (0-57.5) mm to 58 (49.5-60) mm in the T-course and from 32 (0-56) mm to 59 (55-60) mm in the D-course. Conclusions: Both training programs significantly improve participants’ proficiency in CPR. The distance-based course with asynchronous platform feedback was non-inferior to the traditional BLS course. Simulation Training Basic Cardiac Life Support Cardiopulmonary Resuscitation Distance-Based Simulation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Cardiovascular diseases are the leading cause of death in Chile, accounting for 27% of deaths, according to the Department of Health Statistics and Information (DEIS, 2022). Particularly concerning is the increase in heart attacks among the young population, with a 34% rise in adults aged 30 to 50 years between 2017 and 2023, during which cases increased from 1,868 to 2,510 registered instances ( 1 ). This trend underscores the growing need for quick and effective responses in cardiovascular emergency situations, especially when they lead to cardiopulmonary arrest (CPA). Several reports, including those from the American Heart Association (AHA), indicate that patients’ prognosis following CPA depends directly on the activation of the emergency medical system, the early initiation of chest compressions, and the quality of resuscitation ( 2 – 5 ). Specifically, the survival rate after cardiac arrest decreases by 10% for every minute that passes without intervention, which highlights the importance of acting immediately ( 2 ). The proportion of patients hospitalized with CPA and discharged alive increases significantly when bystanders initiate CPR within the first four minutes and deliver defibrillation within eight minutes ( 6 ). In Chile, quick access to cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs) is limited, especially in rural areas, where response times can be over 20–30 minutes ( 7 ). Moreover, CPR training and AED use remain inadequate. A study in Santiago, Chile, showed that only 28% of patients with out-of-hospital cardiac arrest received bystander resuscitation ( 8 ). Conversely, another study surveying physical education teachers about their resuscitation training found that 71% of respondents felt unqualified to perform CPR, despite 70% having previously attended training courses ( 9 ). Since May 2019, Law 21.156 has been in effect in Chile, requiring high-traffic establishments to have AEDs. The law states that AEDs, due to their operational features and safety, allow individuals with minimal training to perform defibrillation. When combined with basic CPR maneuvers, this can save lives ( 10 ). Although this law mandates certain public establishments to have defibrillators, implementing it faces major challenges ( 11 ). The absence of widespread CPR training programs limits the impact of these devices, creating a significant gap between resource availability and their effective use during emergencies. Unfortunately, reports have emerged of school staff failing to assist ( 12 ). International experiences, like in Denmark, have demonstrated that mandatory CPR training programs for schoolchildren and drivers can substantially increase bystander resuscitation rates and improve survival outcomes in cardiac arrests ( 13 , 14 ). In this context, the study aimed to compare a distance-based CPR training program with asynchronous feedback for non-medical personnel to a traditional in-person Basic Life Support (BLS) course. The hypothesis was that the distance-based program would be non-inferior to the traditional course based on performance measures of CPR skills. Methods Study design This was a prospective, randomized study aimed at comparing two different training methodologies: the traditional in-person BLS course of the American Heart Association (T-course) and a distance-based course with asynchronous feedback through an online platform (D-course). The institutional review board approved this report and waived the need for informed consent, with approval number 221118007. (Comité de Ética en Investigación, Facultad de Medicina, Pontificia Universidad Católica de Chile). After approval by the ethics committee, 200 non-medical personnel were recruited to participate in this protocol. Participants and recruitment Non-healthcare personnel such as teachers, psychologists, security guards, coaches, and athletes were recruited from five different educational and sports institutions that had an AED defibrillator on their premises. The principal investigator contacted each institution's director, explained the project, and outlined the inclusion and exclusion criteria. The inclusion criteria were non-healthcare personnel, while the exclusion criteria included healthcare professionals and individuals who had previously completed CPR courses. Each director provided the number of potential eligible participants from their institution. Participants received an invitation email explaining the protocol, and they could choose whether to participate. After assessing eligibility, a second email was sent describing the assigned group. Participants were randomly assigned to two different training methods. Traditional in-person BLS course from the American Heart Association (T-course). Distance-based course with asynchronous feedback via an online platform (D-course). Randomization Before the protocol started, we used the GraphPad Prism calculator to perform randomization. One of the researchers responsible for statistical analysis generated the random allocation sequence. This sequence was sent to the coordinator at the simulation center. We then emailed participants to inform them of their assigned group intervention and the next steps. In this study, the institutions reported the number of participants who would be taking the course before the protocol began, so the entire list of participants was completely randomized at the beginning of the protocol. Therefore, an allocation concealment process was not done in this study. Interventions For the traditional in-person BLS course offered by the American Heart Association, another simulation center with AHA certification was contacted to send the participants. Participants were scheduled for specific dates and times according to the agenda of the Simulation Center at Los Andes University in Chile to complete the Heartsaver certification. Offered by the AHA, the Heartsaver certification provides training in CPR, AED use, and first aid for individuals with little or no medical experience. Participants received an email from Los Andes University with the instructional materials and instructions for arriving on the day of their course. Those who did not attend their scheduled session were rescheduled a second time to reduce drop-offs. For the distance-based course, materials for practice—including a pad, resuscitation torso, and automated external defibrillator—were delivered by our simulation center staff to each institution, and a workstation was set up (Fig. 1 ). Depending on the number of participants from each institution, one or two workstations were established, allowing participants to practice at their workplaces during their free time. To complete the course, the online platform C1DO1 was used ( https://c1do1.ai/ ). This platform is a desktop and mobile application accessible from any location for participants and instructors with internet access ( 15 ). Participants received an email to create a user account and gain access to the platform. The course was organized into stages on the platform, with both theoretical and practical components. It consisted of nine stages: five theoretical stages, three practical exercises, and a final stage with a multiple-choice assessment. The theoretical and instructional material stages were delivered through short video capsules. During practical stages, participants needed to practice and upload a video of their performance to the platform. It is required that participants complete each stage before moving on to the next. The course was designed to ensure that the objectives and training duration matched those of the BLS course. Each stage is briefly described in Table 1 . Table 1 Structure of the stages of the CPR course on the online platform Stage 1 Introduction Stage 2 Recognizing Cardiorespiratory Arrest. Stage 3 Quality of chest compressions. Stage 4 Practice stage : Quality chest compressions. At this stage, the student must upload a video to the platform. Stage 5 Use of Automated External Defibrillator (AED). Stage 6 Practice stage : Use of AED: At this stage, the student must upload a video to the platform. Stage 7 Complete Resuscitation Sequence. Stage 8 Practice stage : Complete Resuscitation Sequence. At this stage, the student must upload a video to the platform. Stage 9 Multiple-Choice Test. The objective of this stage is to reinforce knowledge, it was not for research assessment purposes. The methodology used for distance-based courses has been successfully applied in prior studies ( 15 – 17 ). As mentioned above, the platform enabled students to access didactic materials on cardiopulmonary resuscitation and procedure-specific instructional videos for practice. Participants practiced and recorded themselves performing the procedure using a smartphone and uploaded their videos to the platform without supervision. In this study, participants had the practice station at their workplace. Instructors provided remote, asynchronous feedback within a 72-hour window. Participants reviewed the feedback and practiced again until they received approval for the stage. The methodology for participant practice and instructor feedback through the platform is illustrated in Fig. 2 . Feedback was provided by three instructors, all emergency medicine MDs, who are experts in healthcare simulation and feedback. The platform allowed them to give audio, written, and drawing feedback. Finally, an online satisfaction survey was sent to participants to evaluate their perceptions after completing each training program. Outcome measures Both groups completed a pre-training assessment (PRE) and a post-training assessment (POST). Our simulation center staff visited each institution to conduct the assessments for both groups. During each assessment, participants were videotaped by our staff during a CPR scenario. To ensure consistency, all participants watched a short video illustrating a situation at their workplace where a colleague becomes unconscious and needs medical attention. Later, two independent, blinded reviewers evaluated the videos, rating the participants' performance using the AHA CPR and AED Skills Testing Checklist. These reviewers were different from the instructors providing feedback in the D-course. Additionally, the quality of chest compressions (CC) was assessed using a Prestan® mannequin with a skill reporter connected to an application on a tablet device, which recorded the rate and depth of chest compressions. Definition of non-inferiority margins Based on a pilot distance-based CPR course, the main outcome (AHA CPR and AED Skills Testing Checklist) was expected to improve from 10–15% to 80–85% points ( 18 ). Previous studies testing clinical learning outcomes indicated that a 10–15% points non-inferiority limit is fair ( 19 ). Concepts of non-inferiority in medical education have used examples like the comparison of Basic Life Support trainings and supported these limits ( 20 ). Based on this data, it was decided to establish a difference of 2 points (performance difference of 10% between the trainings) as the non-inferiority margin for this study. Sample size calculation A sample size of 156 subjects was calculated to detect a non-inferiority margin of 10% points on the checklist, with a significance level of 0.05 and a power of 0.8. The calculation was performed using the web calculator for non-inferiority trials provided by Sealed Envelope ( 21 ). Considering this is a non-captive study population, meaning participants are not students of our institution, a 30% drop-off rate was considered. In a previous study with distance-based courses, the percentage of participants who finished and passed ranged from 20 to 60% depending on the course ( 16 ). To ensure the adequacy of the calculated sample size, we ultimately assessed 200 participants for eligibility. Statistical Analysis The data were analyzed using JASP software version 0.19.3 for MacOS. Demographic data are presented as mean and standard deviation (SD). Checklist scores and chest compression (CC) data are shown as median and interquartile range (IQR). The intraclass correlation coefficient (ICC) was calculated to evaluate interobserver agreement. Two-sided 95% confidence intervals (CI) were used to assess the significance of non-inferiority. Mann-Whitney U test and Wilcoxon signed-rank test were employed to compare independent and paired groups, respectively. A p-value of 0.05 was considered statistically significant. Only participants who fully adhered to the study protocol, meaning they finished the assigned course and completed the POST assessment, were included in the analysis (Per-Protocol Analysis). Results Recruitment and baseline characteristics After verifying the participants' eligibility with the participating institutions, a total of 192 non-medical personnel were recruited—96 for the traditional course and 96 for the distance-based course. Out of the total recruited, 172 participants completed the training: 94 finished the traditional course and 78 completed the distance-based course. Finally, 158 participants completed both the training and the PRE and POST assessments (Fig. 3 ). Demographic data from participants are presented in Table 2 . Table 2 Demographic data. Data are expressed in Mean ± SD or n (%). T-course (n = 83) D-course (n = 75) Age 43.1 (12.1) 37.7 (8.5) Sex Male 39 (47) 34 (45.3) Female 44 (53) 41 (54.7) Institution from Educational institution 56 (67.5) 55 (73.3) Sports institution 27 (32.5) 20 (26.7) Profession or occupation Teacher 39 (47) 36 (48) Psychologists 3 (3.61) 4 (5.33) Security guards 5 (6.02) 4 (5.33) Administrative 9 (10.84) 11 (14.67) Coaches 6 (7.23) 4. (5.33) Athletes 21 (25.3) 16 (21.33) Implementation of intervention The traditional course was conducted at the Simulation Center of Los Andes University. The Heartsaver certification offers 3 hours of training by a certified instructor, including practice with a manikin using AHA materials. A total of 5 courses were held to accommodate all participants assigned to this group. Regarding the distance-based course, participants accessed the platform and practiced at their workplaces as planned. From the moment they entered the platform, they were allowed to complete the course and exercises at their own pace for a period of 4 weeks. Primary outcome The interrater reliability for the observers' video AHA CPR and AED Skills Checklist scores was an ICC of 0.91. Median AHA CPR and AED Skills checklist scores improved markedly from baseline in both groups (T course: from 2 [0–3] to 15 [14–16.5] points; D-course: from 1 [0–2.5] to 16 [15.5–17] points). The score improvements from the PRE to the POST assessment are shown in Fig. 4 . Improvements were significant in both courses (p < 0.01) (Table 3 ). Regarding the difference between T-course and D-course, there was no difference in scores at the PRE assessment (p = 0.868) (Table 3 ). Table 3 Median and IQR values of Checklist scores during PRE and POST assessments. T-course (n = 83) D-course (n = 75) P value Checklist PRE 2 (0–3) 1 (0-2.5) 0.868 Checklist POST 15 (14-16.5) 16 (15.5–17) p < 0.01 P value p < 0.01 p < 0.01 The absolute difference in POST assessment median scores between groups was − 1 (95% CI: [-1.5, -0.5]), with the lower bound above the predefined non-inferiority margin, confirming non-inferiority in the per-protocol analysis (Fig. 5 ). The absolute difference was calculated by subtracting the control group's POST assessment median scores from those of the new course. Although the post-training median score was slightly higher in the distance-based group (p < 0.01), the effect size was small, and the difference stayed well within the non-inferiority threshold, showing that both training methods achieved similar levels of competence. Secondary outcomes The median chest compression (CC) rate improved from 82 (0-106) per minute to 105 (102–110) per minute in the T-course and from 86 (0-109.5) per minute to 105 (105–108) per minute in the D-course (Table 4 ). Both improvements were statistically significant (p < 0.01). Regarding the difference between T-course and D-course, there was no difference between groups in the PRE and POST assessments. Table 4 Median and IQR values of Chest Compressions rate during PRE and POST assessments. T-course (n = 83) D-course (n = 75) P value CC rate PRE 82 (0-106) 86 (0-109.5) 0.640 CC rate POST 105 (102–110) 105 (105–108) 0.721 P value p < 0.01 p < 0.01 The median CC depth increases from 38 (0-57.5) mm to 58 (49.5–60) mm in the T-course and from 32 (0–56) mm to 59 (55–60) mm in the D-course (Table 5 ). Both improvements were statistically significant (p < 0.01). Table 5 Median and IQR values of Chest Compressions depth during PRE and POST assessments. T-course (n = 83) D-course (n = 75) P value CC depth PRE 38 (0-57.5) 32 (0–56) 0.441 CC depth POST 58 (49.5–60) 59 (55–60) 0.044 P value p < 0.01 p < 0.01 Finally, the satisfaction survey shows high levels of satisfaction. Participants in both courses agreed or totally agreed with the statements asked (Table 6 ). Some interesting comments about the D-course concern the time interval for completing the course. Table 6 Satisfaction Survey. Percentages of answers agree and totally agree in a 5-Likert scale. T-course (n = 83) D-course (n = 75) Program's objectives of the course were clear 100% 96.5% The instructional material provided promoted your learning 92.9% 93% The evaluation conditions were communicated in a timely manner 98.2% 95.9% Instructor’s feedback was fitting and centered on the learning objectives 98.2% 96% Practical exercises seemed sufficient to me. 96.4% 93.5% The duration of the course was adequate 100% 100% The platform used to develop the course easy to use NA 90.7% The instructional videos in the platform clearly explain the content NA 96.5% This course was important for me 92.9% 100% Overall satisfaction with the course 100% 93% I would set a limit on the estimated training time. As a suggestion, I could offer a shorter timeframe. Since you left the timeframe open, it took me a long time to watch the videos. It would be better if you activate the course and evaluate it within a limited time frame. Discussion This prospective randomized study aimed to demonstrate the non-inferiority of CPR training with a distance-based course that provides asynchronous feedback via the C1DO1 platform compared to the traditional BLS course. The lower limit of the CI is greater than the non-inferiority threshold, so the results presented in this manuscript support the non-inferiority hypothesis within the established margin of 10% points of the checklist score (difference of 2 points). This means that the observed difference, even in its worst-case scenario (the lower limit of the CI), is no worse than the non-inferiority threshold. According to these findings, distance-based training with asynchronous feedback may be as effective as traditional face-to-face training for laypersons. The acquisition of CPR competencies among non-medical personnel was very similar across both methodologies. These results are consistent with previous findings under similar training conditions. Skill improvement, measured by post-training CPR performance scores, is comparable to those reported in medical students ( 22 ) and other health science students ( 23 ). In terms of chest compression quality achieved with the D-course, the parameters established as CPR quality metrics are met (CC rate of 100–120/min and CC depth of 50–60 mm) ( 24 , 25 ). Regarding training for laypersons, although assessment tools are diverse, skill improvement remains comparable ( 26 , 27 ). In education, several factors such as geographical barriers, costs, infrastructure deficiencies, and instructor availability may lead us to adopt a different or new didactic method for teaching a specific medical skill. That’s why a distance-based course can help extend CPR training to schools, universities, sports institutions, and other venues with large public attendance. Our main goal is to provide access to laypersons and help save the lives of patients experiencing cardiopulmonary arrest. In this context, before implementing the course broadly, we sought to determine whether this new method achieves a comparable level of learning success as the traditional standard approach ( 20 ). Previous evidence about the global prevalence of basic life support training showed low rates of laypersons' training within the past two years, with significant regional variation in bystander training rates. Socioeconomic status was a factor that correlates with the prevalence of bystander training. Despite a lack of South American references, this systematic review and meta-analysis concluded that bystander training should be promoted worldwide ( 28 ). Supporting this evidence, some organizations, such as “The World Restart a Heart” (WRAH) initiative of the International Liaison Committee on Resuscitation, have pushed the message to save more lives with high-quality layperson CPR ( 29 ). In response to this need, distance-based training could be a scalable method to reach remote and rural areas. It allows training programs to be easily accessible and available at any time or location. Additionally, this approach does not require the presence of expert trainers on-site. Despite these benefits and the growth of distance-based simulation over recent years, a recent review indicated that it remains in early development stages both methodologically and in terms of quality ( 30 ). Specifically, some challenges were encountered in developing this type of course. Some participants started the course and progressed through several stages but did not complete it. Participants had the freedom to advance through the stages and perform practices within a 4-week period. During a satisfaction survey, three participants suggested that the course period could be shortened. Further research is needed to determine the optimal duration during which the course should be open to maximize completion rates. In this context, Ko et al. identified factors that can either facilitate or hinder laypersons' participation in resuscitation training. Facilitators included prior experience witnessing someone collapse, awareness of automated external defibrillators in public places, certain occupations, and legal training requirements. Barriers to participation included personal factors such as advanced age, lower socioeconomic status, and educational background. Another good example to highlight of the search for new methodologies to train laypersons in basic life support is the rise of virtual reality training. A recent systematic review showed that virtual reality and augmented reality-based training were as effective as traditional face-to-face CPR training ( 32 ). Outcomes measured were similar to those presented in this study, such as chest compression rate, chest compression depth, and performance scores. This study has several limitations. First, this project did not analyze the content of the feedback inputs in asynchronous feedback (video, audio, drawing) during the D-course. Second, despite the scheduled training sessions for the distance-based course, we do not know how much time the participants practiced or whether students continued training chest compressions after the second practical stage. Third, in the T-course, we rescheduled participants to meet the calculated sample size. Some participants were rescheduled three times at the associate’s cost. This approach was not feasible with participants of the D-course because they were free to train and complete the course stages within a 4-week period. Finally, given the nature and design of the study, only a per-protocol analysis was done. It is not possible to perform an intention-to-treat analysis, since the data of the post-course assessments are required. Conclusions Both training programs significantly enhance participants’ CPR skills. The distance-based course with asynchronous feedback via the C1DO1 platform was not inferior to the traditional BLS course. Since we have validated this training methodology, the next step for this project is to try to reach more users in sports and academic institutions throughout the country. Mass adoption of the course across the country will help us make progress toward this goal and improve bystander resuscitation opportunities in a country facing geographical and economic challenges. Further research is needed to compare this distance-based approach with other emerging methods and ultimately evaluate the impact of distance-based training on real-world CPR performance and patient outcomes. Abbreviations AHA: American Heart Association. CPA: Cardiopulmonary arrest. BLS: Basic Life Support. CPR: Cardiopulmonary Resuscitation: AED: Automated external defibrillator CC: Chest compressions. ICC: Intraclass correlation coefficient. Declarations Ethics approval and consent to participate This project was approved by the Comité Ético Científico de Ciencias de la Salud UC, Facultad de Medicina, Pontificia Universidad Católica de Chile (approval number ID 221118007). Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Financial disclosure: The study was funded by a Research Grant Fondef IDEA 2023-2025 ID23I10263 from the National Agency of Research and Development, Government of Chile. Authors' contributions FA, MCA: Study design, data analysis, draft and approved the manuscript. JR, AS: Training session and feedback, approved the manuscript. DA, JV: Video analysis (PRE and POST assessments), approved the manuscript. EZ: Case enrollment, coordination of courses and participants approved the manuscript. Acknowledgments: We would like to thank Dr. Catalina Ortiz, MD, Dr. Brandon Valencia, MD, and Ivan Paul, MD, for their assistance with the research fund application. Additionally, we appreciate Dr. Sofia Abedrapo, MD, Dr. Cristian Jarry, MD, and Carlos Campos for their help during assessment sessions; Ignacio Cortinez, MD, and Gonzalo Boncompte for their assistance with statistical analysis. Finally, we acknowledge the support of the resuscitation committee of the Chilean Society of Anesthesia, represented by Dr. Antonia Valderrama, MD. References Nazzal, Carolina, Lefian, Alejandro, & Alonso, Faustino. (2021). Incidencia de infarto agudo de miocardio en Chile, 2008-2016. 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Revista médica de Chile, 150(10), 1283-1290. https://dx.doi.org/10.4067/S0034-98872022001001283 Mayanz S, Barreto J, Grove X, Iglesias V, Breinbauer H. “Paro cardiorrespiratorio extra- hospitalario de causa cardiaca en Santiago de Chile: Experiencia del equipo medicalizado del SAMU Metropolitano” Rev Chil Med Int 2009; 24(1):9-16. Acevedo, Stephanie, Córdova, Guiliana, Clavería, Cristián, & Larios, Guillermo. (2020). Preparación de los colegios y profesores de educación física en prevención de muerte súbita y soporte vital básico. Revista chilena de cardiología, 39(3), 229-236. https://dx.doi.org/10.4067/S0718-85602020000300229 Ministerio de Salud (MINSAL) (2011) “Norma Nacional de Reanimación Cardiopulmonar del Adulto y Pediátrica”. Disponible en: http://www.repositoriodigital.minsal.cl/handle/2015/438 https://www.bcn.cl/leychile/navegar?idNorma=1150508 https://www.t13.cl/noticia/nacional/nino-esta-internado-gravedad-tras-recibir-pelotazo-colegio-acusan-falta-asisten-21-8-2024 Juul Grabmayr A, Andelius L, Bo Christensen N, Folke F, Bundgaard Ringgren K, Torp-Pedersen C, Gislason G, Jensen TW, Rolin Kragh A, Tofte Gregers MC, Samsoee Kjoelbye J, Malta Hansen C. Contemporary levels of cardiopulmonary resuscitation training in Denmark. Resusc Plus. 2022 Jul 1;11:100268. doi: 10.1016/j.resplu.2022.100268. Malta Hansen C, Zinckernagel L, Ersbøll AK, Tjørnhøj-Thomsen T, Wissenberg M, Lippert FK, Weeke P, Gislason GH, Køber L, Torp-Pedersen C, Folke F. Cardiopulmonary Resuscitation Training in Schools Following 8 Years of Mandating Legislation in Denmark: A Nationwide Survey. J Am Heart Assoc. 2017 Mar 14;6(3):e004128. doi: 10.1161/JAHA.116.004128. 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Corvetto MA, Kattan E, Varas J, Caro I, Altermatt FR. Designing Sustainable Solutions to Implement a Distance-Based Simulation Basic Life Support Training Program During COVID-19 Pandemic in Low-Income Countries. Simul Healthc. 2022 Oct 1;17(5):351-352. doi: 10.1097/SIH.0000000000000651. Berg, H., Steinsbekk, A. Is individual practice in an immersive and interactive virtual reality application non-inferior to practicing with traditional equipment in learning systematic clinical observation? A randomized controlled trial. BMC Med Educ 20 , 123 (2020). https://doi.org/10.1186/s12909-020-02030-7 Klasen M, Sopka S. Demonstrating equivalence and non-inferiority of medical education concepts. Med Educ. 2021 Apr;55(4):455-461. doi: 10.1111/medu.14420. Epub 2020 Dec 6. PMID: 33206411. Sealed Envelope Ltd. 2012. Power calculator for binary outcome non- inferiority trial. [Online] Available from: https://www.sealedenvelope.com/power/continuous-noninferior/ [Accessed Wed Feb 25 2020]. Sianipar IR, Tantri AR, Muktiarti D, Dwijayanti A, Manggala SK, Muliyah E. Comparison Between Self-Deliberate Practice and Directed Learning Training Methods for Basic Life Support Knowledge and High-Quality Cardiopulmonary Resuscitation Skill Retention in Second-Year Medical Students 3 and 6 Months After Training. Med Sci Educ. 2023 Feb 18;33(2):395-400. doi: 10.1007/s40670-023-01746-7. García-Suárez M, Méndez-Martínez C, Martínez-Isasi S, Gómez-Salgado J, Fernández-García D. Basic Life Support Training Methods for Health Science Students: A Systematic Review. Int J Environ Res Public Health. 2019 Mar 3;16(5):768. doi: 10.3390/ijerph16050768. PMID: 30832440; PMCID: PMC6427599. Rao G, Savage DW, Erickson G, Kyryluk N, Lingras P, Mago V. Enhancing Cardiopulmonary Resuscitation Quality Using a Smartwatch: Neural Network Approach for Algorithm Development and Validation. JMIR Mhealth Uhealth. 2025 May 5;13:e57469. doi: 10.2196/57469. Considine J, Gazmuri RJ, Perkins GD, Kudenchuk PJ, Olasveengen TM, Vaillancourt C, Nishiyama C, Hatanaka T, Mancini ME, Chung SP, Escalante-Kanashiro R, Morley P. Chest compression components (rate, depth, chest wall recoil and leaning): A scoping review. Resuscitation. 2020 Jan 1;146:188-202. doi: 10.1016/j.resuscitation.2019.08.042. Bjørnshave, Katrinea,b; Krogh, Lise Q.a; Hansen, Svend B.a,c; Nebsbjerg, Mette A.a; Thim, Troelsd,e; Løfgren, Boa,e,f. Teaching basic life support with an automated external defibrillator using the two-stage or the four-stage teaching technique. European Journal of Emergency Medicine 25(1):p 18-24, February 2018. | DOI: 10.1097/MEJ.0000000000000410 González-Salvado V, Rodríguez-Ruiz E, Abelairas-Gómez C, Ruano-Raviña A, Peña-Gil C, González-Juanatey JR, Rodríguez-Núñez A. Training adult laypeople in basic life support. A systematic review. Rev Esp Cardiol (Engl Ed). 2020 Jan;73(1):53-68. doi: 10.1016/j.rec.2018.11.013. Ng TP, Eng SW, Ting JXR, Bok C, Tay GYH, Kong SYJ, Stassen W, Zhang L, de Kleijn DPV, Ong MEH, Blewer AL, Yeo JW, Ho AFW; GOALS Workgroup. Global prevalence of basic life support training: A systematic review and meta-analysis. Resuscitation. 2023 May;186:109771. doi: 10.1016/j.resuscitation.2023.109771. Elkin R, Duff JP, LaForest ML, Stapleton S, Ramachandra G, Palaganas JC, Gross IT. Distance simulation in the health professions: a scoping review. Adv Simul (Lond). 2023 Nov 17;8(1):27. doi: 10.1186/s41077-023-00266-z. Nakagawa NK, Lockey A, Carmona MJC, Hoover A, Nanda P, Böttiger BW; WRAH collaborators. It is time to spread the message of high-quality layperson cardiopulmonary resuscitation all over the world. Clinics (Sao Paulo). 2024 Apr 27;79:100355. doi: 10.1016/j.clinsp.2024.100355. Sun R, Wang Y, Wu Q, Wang S, Liu X, Wang P, He Y, Zheng H. Effectiveness of virtual and augmented reality for cardiopulmonary resuscitation training: a systematic review and meta-analysis. BMC Med Educ. 2024 Jul 5;24(1):730. doi: 10.1186/s12909-024-05720-8. Ko YC, Hsieh MJ, Schnaubelt S, Matsuyama T, Cheng A, Greif R. Disparities in layperson resuscitation education: A scoping review. Am J Emerg Med. 2023 Oct;72:137-146. doi: 10.1016/j.ajem.2023.07.033. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 21 Apr, 2026 Reviews received at journal 12 Oct, 2025 Reviewers agreed at journal 01 Oct, 2025 Reviewers agreed at journal 12 Sep, 2025 Reviewers invited by journal 06 Sep, 2025 Editor assigned by journal 04 Sep, 2025 Submission checks completed at journal 04 Sep, 2025 First submitted to journal 01 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Corvetto","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYLCCBATTBogZGw8Qq4Wx4QBDGpQmEoCUHgaz8GrRbT/78MODGjs58xnJxx9/qDhvt7b9MFBrjU00Li1mZ9KNJRKOJRvL3EhLbDhw5nbytjNAmuFYWm4DLi0H0tgYEtgOJM7gOWPYcLDtdrLZAaAWxobDuLWcfwbU8g+k5fxHoJZzyWbnHxLQcgNoS2IbUAt7DyNQywE7sxuEbLnxjFkisS/ZWIK9zXDGmTPJCWY3gLYk4PPL+TTGjz++2clJMDM/+FBRYWdvdj794YMPNTY4tWCARLDKBGKVg4A9KYpHwSgYBaNgZAAAK65oV7k3wW0AAAAASUVORK5CYII=","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":true,"prefix":"","firstName":"Marcia","middleName":"","lastName":"Corvetto","suffix":""},{"id":511320693,"identity":"9fe06b02-2d8b-452d-bd69-2337c162a3d0","order_by":1,"name":"David Acuña","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Acuña","suffix":""},{"id":511320694,"identity":"59bee6bc-4b8a-4cb1-9d0c-d431856d791d","order_by":2,"name":"Andrés Schneider","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Andrés","middleName":"","lastName":"Schneider","suffix":""},{"id":511320695,"identity":"37877844-b452-4081-9132-c10d21950bef","order_by":3,"name":"Jerónimo Rojas","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Jerónimo","middleName":"","lastName":"Rojas","suffix":""},{"id":511320696,"identity":"642eca84-6920-407a-9e00-55a6c7a7b07a","order_by":4,"name":"Julián Varas","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Julián","middleName":"","lastName":"Varas","suffix":""},{"id":511320697,"identity":"8547c417-0db7-4c86-afcd-f46c2c6aca20","order_by":5,"name":"Elga Zamorano","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Elga","middleName":"","lastName":"Zamorano","suffix":""},{"id":511320698,"identity":"7465357c-e7b0-41e6-b88b-56fc647736b8","order_by":6,"name":"Fernando Altermatt","email":"","orcid":"","institution":"Pontificia Universidad Católica de Chile","correspondingAuthor":false,"prefix":"","firstName":"Fernando","middleName":"","lastName":"Altermatt","suffix":""}],"badges":[],"createdAt":"2025-09-01 15:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7509928/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7509928/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91196041,"identity":"f11537ea-670d-4ffd-8286-88d69afb3532","added_by":"auto","created_at":"2025-09-12 15:01:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":129898,"visible":true,"origin":"","legend":"\u003cp\u003eMaterials for practice in the distance-based course (pad, resuscitation torso, and automated external defibrillator).\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7509928/v1/ad3930be27657249134134d8.png"},{"id":91198854,"identity":"cd1c1462-c66b-4643-90bc-78b81c1dac41","added_by":"auto","created_at":"2025-09-12 15:17:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":204822,"visible":true,"origin":"","legend":"\u003cp\u003eAsynchronous remote feedback method through the C1DO1 platform.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7509928/v1/9296f607069dd26fa954b61e.png"},{"id":91196044,"identity":"8aba1e82-0874-455a-8633-71414816166e","added_by":"auto","created_at":"2025-09-12 15:01:14","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":446967,"visible":true,"origin":"","legend":"\u003cp\u003eConsort flow diagram.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7509928/v1/7f09de18891ba60fa1691b70.png"},{"id":91196046,"identity":"14854531-9f11-4a81-a5eb-72000bb19ad1","added_by":"auto","created_at":"2025-09-12 15:01:14","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":97331,"visible":true,"origin":"","legend":"\u003cp\u003eMedian values of checklist scores in PRE and POST assessments of T-course (white) and D-course (black).\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-7509928/v1/5296d538d44ca76049d49ee9.png"},{"id":91196047,"identity":"f858916c-34b5-4b2d-8c95-1247ad35c95e","added_by":"auto","created_at":"2025-09-12 15:01:14","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":92000,"visible":true,"origin":"","legend":"\u003cp\u003eNon-inferiority results for overall performance measured with the AHA CPR and AED Skills Testing Checklist. Values \u0026lt;0 favor T-course and values \u0026gt;0 favor D-course. The black line indicates the lower and upper 95% CI of skills performance. The red line indicates the non-inferiority margin. Significant non-inferiority is given when the lower CI lies above this margin.\u003c/p\u003e","description":"","filename":"Figura5.png","url":"https://assets-eu.researchsquare.com/files/rs-7509928/v1/f63a0af49f1655264856980a.png"},{"id":91332427,"identity":"51bcff15-a10b-4fc9-b33d-283f02ab3608","added_by":"auto","created_at":"2025-09-15 11:11:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1809651,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7509928/v1/83b394d6-8115-4878-8343-6c7f0fc0c791.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and validation of a distance-based training program of Basic Cardiac Life Support for laypersons and comparison with traditional in-person methodology: A non-inferiority study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCardiovascular diseases are the leading cause of death in Chile, accounting for 27% of deaths, according to the Department of Health Statistics and Information (DEIS, 2022). Particularly concerning is the increase in heart attacks among the young population, with a 34% rise in adults aged 30 to 50 years between 2017 and 2023, during which cases increased from 1,868 to 2,510 registered instances (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This trend underscores the growing need for quick and effective responses in cardiovascular emergency situations, especially when they lead to cardiopulmonary arrest (CPA).\u003c/p\u003e\u003cp\u003eSeveral reports, including those from the American Heart Association (AHA), indicate that patients\u0026rsquo; prognosis following CPA depends directly on the activation of the emergency medical system, the early initiation of chest compressions, and the quality of resuscitation (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Specifically, the survival rate after cardiac arrest decreases by 10% for every minute that passes without intervention, which highlights the importance of acting immediately (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The proportion of patients hospitalized with CPA and discharged alive increases significantly when bystanders initiate CPR within the first four minutes and deliver defibrillation within eight minutes (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Chile, quick access to cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs) is limited, especially in rural areas, where response times can be over 20\u0026ndash;30 minutes (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Moreover, CPR training and AED use remain inadequate. A study in Santiago, Chile, showed that only 28% of patients with out-of-hospital cardiac arrest received bystander resuscitation (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Conversely, another study surveying physical education teachers about their resuscitation training found that 71% of respondents felt unqualified to perform CPR, despite 70% having previously attended training courses (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSince May 2019, Law 21.156 has been in effect in Chile, requiring high-traffic establishments to have AEDs. The law states that AEDs, due to their operational features and safety, allow individuals with minimal training to perform defibrillation. When combined with basic CPR maneuvers, this can save lives (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Although this law mandates certain public establishments to have defibrillators, implementing it faces major challenges (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The absence of widespread CPR training programs limits the impact of these devices, creating a significant gap between resource availability and their effective use during emergencies. Unfortunately, reports have emerged of school staff failing to assist (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). International experiences, like in Denmark, have demonstrated that mandatory CPR training programs for schoolchildren and drivers can substantially increase bystander resuscitation rates and improve survival outcomes in cardiac arrests (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn this context, the study aimed to compare a distance-based CPR training program with asynchronous feedback for non-medical personnel to a traditional in-person Basic Life Support (BLS) course. The hypothesis was that the distance-based program would be non-inferior to the traditional course based on performance measures of CPR skills.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eThis was a prospective, randomized study aimed at comparing two different training methodologies: the traditional in-person BLS course of the American Heart Association (T-course) and a distance-based course with asynchronous feedback through an online platform (D-course). The institutional review board approved this report and waived the need for informed consent, with approval number 221118007. (Comit\u0026eacute; de \u0026Eacute;tica en Investigaci\u0026oacute;n, Facultad de Medicina, Pontificia Universidad Cat\u0026oacute;lica de Chile). After approval by the ethics committee, 200 non-medical personnel were recruited to participate in this protocol.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants and recruitment\u003c/h3\u003e\n\u003cp\u003eNon-healthcare personnel such as teachers, psychologists, security guards, coaches, and athletes were recruited from five different educational and sports institutions that had an AED defibrillator on their premises. The principal investigator contacted each institution's director, explained the project, and outlined the inclusion and exclusion criteria. The inclusion criteria were non-healthcare personnel, while the exclusion criteria included healthcare professionals and individuals who had previously completed CPR courses. Each director provided the number of potential eligible participants from their institution. Participants received an invitation email explaining the protocol, and they could choose whether to participate. After assessing eligibility, a second email was sent describing the assigned group.\u003c/p\u003e\u003cp\u003eParticipants were randomly assigned to two different training methods.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eTraditional in-person BLS course from the American Heart Association (T-course).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDistance-based course with asynchronous feedback via an online platform (D-course).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eRandomization\u003c/h3\u003e\n\u003cp\u003eBefore the protocol started, we used the GraphPad Prism calculator to perform randomization. One of the researchers responsible for statistical analysis generated the random allocation sequence. This sequence was sent to the coordinator at the simulation center. We then emailed participants to inform them of their assigned group intervention and the next steps.\u003c/p\u003e\u003cp\u003eIn this study, the institutions reported the number of participants who would be taking the course before the protocol began, so the entire list of participants was completely randomized at the beginning of the protocol. Therefore, an allocation concealment process was not done in this study.\u003c/p\u003e\n\u003ch3\u003eInterventions\u003c/h3\u003e\n\u003cp\u003eFor the traditional in-person BLS course offered by the American Heart Association, another simulation center with AHA certification was contacted to send the participants. Participants were scheduled for specific dates and times according to the agenda of the Simulation Center at Los Andes University in Chile to complete the Heartsaver certification. Offered by the AHA, the Heartsaver certification provides training in CPR, AED use, and first aid for individuals with little or no medical experience. Participants received an email from Los Andes University with the instructional materials and instructions for arriving on the day of their course. Those who did not attend their scheduled session were rescheduled a second time to reduce drop-offs.\u003c/p\u003e\u003cp\u003eFor the distance-based course, materials for practice\u0026mdash;including a pad, resuscitation torso, and automated external defibrillator\u0026mdash;were delivered by our simulation center staff to each institution, and a workstation was set up (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Depending on the number of participants from each institution, one or two workstations were established, allowing participants to practice at their workplaces during their free time.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTo complete the course, the online platform C1DO1 was used (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://c1do1.ai/\u003c/span\u003e\u003cspan address=\"https://c1do1.ai/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). This platform is a desktop and mobile application accessible from any location for participants and instructors with internet access (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Participants received an email to create a user account and gain access to the platform. The course was organized into stages on the platform, with both theoretical and practical components. It consisted of nine stages: five theoretical stages, three practical exercises, and a final stage with a multiple-choice assessment. The theoretical and instructional material stages were delivered through short video capsules. During practical stages, participants needed to practice and upload a video of their performance to the platform. It is required that participants complete each stage before moving on to the next. The course was designed to ensure that the objectives and training duration matched those of the BLS course. Each stage is briefly described in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStructure of the stages of the CPR course on the online platform\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStage 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntroduction\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStage 2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRecognizing Cardiorespiratory Arrest.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStage 3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQuality of chest compressions.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStage 4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePractice stage\u003c/b\u003e: Quality chest compressions. At this stage, the student must upload a video to the platform.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStage 5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUse of Automated External Defibrillator (AED).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStage 6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePractice stage\u003c/b\u003e: Use of AED: At this stage, the student must upload a video to the platform.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStage 7\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComplete Resuscitation Sequence.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStage 8\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePractice stage\u003c/b\u003e: Complete Resuscitation Sequence. At this stage, the student must upload a video to the platform.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStage 9\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMultiple-Choice Test. The objective of this stage is to reinforce knowledge, it was not for research assessment purposes.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe methodology used for distance-based courses has been successfully applied in prior studies (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). As mentioned above, the platform enabled students to access didactic materials on cardiopulmonary resuscitation and procedure-specific instructional videos for practice. Participants practiced and recorded themselves performing the procedure using a smartphone and uploaded their videos to the platform without supervision. In this study, participants had the practice station at their workplace. Instructors provided remote, asynchronous feedback within a 72-hour window. Participants reviewed the feedback and practiced again until they received approval for the stage. The methodology for participant practice and instructor feedback through the platform is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Feedback was provided by three instructors, all emergency medicine MDs, who are experts in healthcare simulation and feedback. The platform allowed them to give audio, written, and drawing feedback.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFinally, an online satisfaction survey was sent to participants to evaluate their perceptions after completing each training program.\u003c/p\u003e\n\u003ch3\u003eOutcome measures\u003c/h3\u003e\n\u003cp\u003eBoth groups completed a pre-training assessment (PRE) and a post-training assessment (POST). Our simulation center staff visited each institution to conduct the assessments for both groups. During each assessment, participants were videotaped by our staff during a CPR scenario. To ensure consistency, all participants watched a short video illustrating a situation at their workplace where a colleague becomes unconscious and needs medical attention. Later, two independent, blinded reviewers evaluated the videos, rating the participants' performance using the AHA CPR and AED Skills Testing Checklist. These reviewers were different from the instructors providing feedback in the D-course. Additionally, the quality of chest compressions (CC) was assessed using a Prestan\u0026reg; mannequin with a skill reporter connected to an application on a tablet device, which recorded the rate and depth of chest compressions.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eDefinition of non-inferiority margins\u003c/h2\u003e\u003cp\u003eBased on a pilot distance-based CPR course, the main outcome (AHA CPR and AED Skills Testing Checklist) was expected to improve from 10\u0026ndash;15% to 80\u0026ndash;85% points (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Previous studies testing clinical learning outcomes indicated that a 10\u0026ndash;15% points non-inferiority limit is fair (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Concepts of non-inferiority in medical education have used examples like the comparison of Basic Life Support trainings and supported these limits (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Based on this data, it was decided to establish a difference of 2 points (performance difference of 10% between the trainings) as the non-inferiority margin for this study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSample size calculation\u003c/h3\u003e\n\u003cp\u003eA sample size of 156 subjects was calculated to detect a non-inferiority margin of 10% points on the checklist, with a significance level of 0.05 and a power of 0.8. The calculation was performed using the web calculator for non-inferiority trials provided by Sealed Envelope (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Considering this is a non-captive study population, meaning participants are not students of our institution, a 30% drop-off rate was considered. In a previous study with distance-based courses, the percentage of participants who finished and passed ranged from 20 to 60% depending on the course (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). To ensure the adequacy of the calculated sample size, we ultimately assessed 200 participants for eligibility.\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eThe data were analyzed using JASP software version 0.19.3 for MacOS. Demographic data are presented as mean and standard deviation (SD). Checklist scores and chest compression (CC) data are shown as median and interquartile range (IQR). The intraclass correlation coefficient (ICC) was calculated to evaluate interobserver agreement.\u003c/p\u003e\u003cp\u003eTwo-sided 95% confidence intervals (CI) were used to assess the significance of non-inferiority. Mann-Whitney U test and Wilcoxon signed-rank test were employed to compare independent and paired groups, respectively. A p-value of 0.05 was considered statistically significant.\u003c/p\u003e\u003cp\u003eOnly participants who fully adhered to the study protocol, meaning they finished the assigned course and completed the POST assessment, were included in the analysis (Per-Protocol Analysis).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eRecruitment and baseline characteristics\u003c/h2\u003e\u003cp\u003e After verifying the participants' eligibility with the participating institutions, a total of 192 non-medical personnel were recruited\u0026mdash;96 for the traditional course and 96 for the distance-based course.\u003c/p\u003e\u003cp\u003eOut of the total recruited, 172 participants completed the training: 94 finished the traditional course and 78 completed the distance-based course. Finally, 158 participants completed both the training and the PRE and POST assessments (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eDemographic data from participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eDemographic data.\u003c/b\u003e Data are expressed in Mean \u0026plusmn; SD or n (%).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT-course (n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eD-course\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43.1 (12.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37.7 (8.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34 (45.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44 (53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41 (54.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInstitution from\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducational institution\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56 (67.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55 (73.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSports institution\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (32.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (26.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProfession or occupation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTeacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (48)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychologists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (3.61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (5.33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecurity guards\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (6.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (5.33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdministrative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (10.84)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (14.67)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCoaches\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (7.23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4. (5.33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAthletes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21 (25.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (21.33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eImplementation of intervention\u003c/h2\u003e\u003cp\u003eThe traditional course was conducted at the Simulation Center of Los Andes University. The Heartsaver certification offers 3 hours of training by a certified instructor, including practice with a manikin using AHA materials. A total of 5 courses were held to accommodate all participants assigned to this group.\u003c/p\u003e\u003cp\u003eRegarding the distance-based course, participants accessed the platform and practiced at their workplaces as planned. From the moment they entered the platform, they were allowed to complete the course and exercises at their own pace for a period of 4 weeks.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003ePrimary outcome\u003c/h2\u003e\u003cp\u003eThe interrater reliability for the observers' video AHA CPR and AED Skills Checklist scores was an ICC of 0.91.\u003c/p\u003e\u003cp\u003eMedian AHA CPR and AED Skills checklist scores improved markedly from baseline in both groups (T course: from 2 [0\u0026ndash;3] to 15 [14\u0026ndash;16.5] points; D-course: from 1 [0\u0026ndash;2.5] to 16 [15.5\u0026ndash;17] points). The score improvements from the PRE to the POST assessment are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Improvements were significant in both courses (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Regarding the difference between T-course and D-course, there was no difference in scores at the PRE assessment (p\u0026thinsp;=\u0026thinsp;0.868) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMedian and IQR values of Checklist scores during PRE and POST assessments.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT-course\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eD-course\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChecklist PRE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (0\u0026ndash;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (0-2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.868\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChecklist POST\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (14-16.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (15.5\u0026ndash;17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe absolute difference in POST assessment median scores between groups was \u0026minus;\u0026thinsp;1 (95% CI: [-1.5, -0.5]), with the lower bound above the predefined non-inferiority margin, confirming non-inferiority in the per-protocol analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The absolute difference was calculated by subtracting the control group's POST assessment median scores from those of the new course.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAlthough the post-training median score was slightly higher in the distance-based group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), the effect size was small, and the difference stayed well within the non-inferiority threshold, showing that both training methods achieved similar levels of competence.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eSecondary outcomes\u003c/h2\u003e\u003cp\u003eThe median chest compression (CC) rate improved from 82 (0-106) per minute to 105 (102\u0026ndash;110) per minute in the T-course and from 86 (0-109.5) per minute to 105 (105\u0026ndash;108) per minute in the D-course (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Both improvements were statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Regarding the difference between T-course and D-course, there was no difference between groups in the PRE and POST assessments.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMedian and IQR values of Chest Compressions rate during PRE and POST assessments.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT-course\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eD-course\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCC rate PRE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82 (0-106)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e86 (0-109.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.640\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCC rate POST\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e105 (102\u0026ndash;110)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e105 (105\u0026ndash;108)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.721\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe median CC depth increases from 38 (0-57.5) mm to 58 (49.5\u0026ndash;60) mm in the T-course and from 32 (0\u0026ndash;56) mm to 59 (55\u0026ndash;60) mm in the D-course (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Both improvements were statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMedian and IQR values of Chest Compressions depth during PRE and POST assessments.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT-course\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eD-course\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCC depth PRE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38 (0-57.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (0\u0026ndash;56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.441\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCC depth POST\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58 (49.5\u0026ndash;60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59 (55\u0026ndash;60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.044\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFinally, the satisfaction survey shows high levels of satisfaction. Participants in both courses agreed or totally agreed with the statements asked (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Some interesting comments about the D-course concern the time interval for completing the course.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eSatisfaction Survey.\u003c/b\u003e Percentages of answers agree and totally agree in a 5-Likert scale.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT-course (n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eD-course (n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProgram's objectives of the course were clear\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e100%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe instructional material provided promoted your learning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e92.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe evaluation conditions were communicated in a timely manner\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInstructor\u0026rsquo;s feedback was fitting and centered on the learning objectives\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePractical exercises seemed sufficient to me.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e96.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe duration of the course was adequate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e100%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe platform used to develop the course easy to use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe instructional videos in the platform clearly explain the content\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThis course was important for me\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e92.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall satisfaction with the course\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e100%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eI would set a limit on the estimated training time.\u003c/em\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eAs a suggestion, I could offer a shorter timeframe. Since you left the timeframe open, it took me a long time to watch the videos.\u003c/em\u003e\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eIt would be better if you activate the course and evaluate it within a limited time frame.\u003c/em\u003e\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective randomized study aimed to demonstrate the non-inferiority of CPR training with a distance-based course that provides asynchronous feedback via the C1DO1 platform compared to the traditional BLS course.\u003c/p\u003e\u003cp\u003eThe lower limit of the CI is greater than the non-inferiority threshold, so the results presented in this manuscript support the non-inferiority hypothesis within the established margin of 10% points of the checklist score (difference of 2 points). This means that the observed difference, even in its worst-case scenario (the lower limit of the CI), is no worse than the non-inferiority threshold. According to these findings, distance-based training with asynchronous feedback may be as effective as traditional face-to-face training for laypersons.\u003c/p\u003e\u003cp\u003eThe acquisition of CPR competencies among non-medical personnel was very similar across both methodologies. These results are consistent with previous findings under similar training conditions. Skill improvement, measured by post-training CPR performance scores, is comparable to those reported in medical students (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) and other health science students (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In terms of chest compression quality achieved with the D-course, the parameters established as CPR quality metrics are met (CC rate of 100\u0026ndash;120/min and CC depth of 50\u0026ndash;60 mm) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Regarding training for laypersons, although assessment tools are diverse, skill improvement remains comparable (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn education, several factors such as geographical barriers, costs, infrastructure deficiencies, and instructor availability may lead us to adopt a different or new didactic method for teaching a specific medical skill. That\u0026rsquo;s why a distance-based course can help extend CPR training to schools, universities, sports institutions, and other venues with large public attendance. Our main goal is to provide access to laypersons and help save the lives of patients experiencing cardiopulmonary arrest. In this context, before implementing the course broadly, we sought to determine whether this new method achieves a comparable level of learning success as the traditional standard approach (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePrevious evidence about the global prevalence of basic life support training showed low rates of laypersons' training within the past two years, with significant regional variation in bystander training rates. Socioeconomic status was a factor that correlates with the prevalence of bystander training. Despite a lack of South American references, this systematic review and meta-analysis concluded that bystander training should be promoted worldwide (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Supporting this evidence, some organizations, such as \u0026ldquo;The World Restart a Heart\u0026rdquo; (WRAH) initiative of the International Liaison Committee on Resuscitation, have pushed the message to save more lives with high-quality layperson CPR (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn response to this need, distance-based training could be a scalable method to reach remote and rural areas. It allows training programs to be easily accessible and available at any time or location. Additionally, this approach does not require the presence of expert trainers on-site. Despite these benefits and the growth of distance-based simulation over recent years, a recent review indicated that it remains in early development stages both methodologically and in terms of quality (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Specifically, some challenges were encountered in developing this type of course. Some participants started the course and progressed through several stages but did not complete it. Participants had the freedom to advance through the stages and perform practices within a 4-week period. During a satisfaction survey, three participants suggested that the course period could be shortened. Further research is needed to determine the optimal duration during which the course should be open to maximize completion rates. In this context, Ko et al. identified factors that can either facilitate or hinder laypersons' participation in resuscitation training. Facilitators included prior experience witnessing someone collapse, awareness of automated external defibrillators in public places, certain occupations, and legal training requirements. Barriers to participation included personal factors such as advanced age, lower socioeconomic status, and educational background.\u003c/p\u003e\u003cp\u003eAnother good example to highlight of the search for new methodologies to train laypersons in basic life support is the rise of virtual reality training. A recent systematic review showed that virtual reality and augmented reality-based training were as effective as traditional face-to-face CPR training (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Outcomes measured were similar to those presented in this study, such as chest compression rate, chest compression depth, and performance scores.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, this project did not analyze the content of the feedback inputs in asynchronous feedback (video, audio, drawing) during the D-course. Second, despite the scheduled training sessions for the distance-based course, we do not know how much time the participants practiced or whether students continued training chest compressions after the second practical stage. Third, in the T-course, we rescheduled participants to meet the calculated sample size. Some participants were rescheduled three times at the associate\u0026rsquo;s cost. This approach was not feasible with participants of the D-course because they were free to train and complete the course stages within a 4-week period. Finally, given the nature and design of the study, only a per-protocol analysis was done. It is not possible to perform an intention-to-treat analysis, since the data of the post-course assessments are required.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eBoth training programs significantly enhance participants\u0026rsquo; CPR skills. The distance-based course with asynchronous feedback via the C1DO1 platform was not inferior to the traditional BLS course.\u003c/p\u003e\u003cp\u003eSince we have validated this training methodology, the next step for this project is to try to reach more users in sports and academic institutions throughout the country. Mass adoption of the course across the country will help us make progress toward this goal and improve bystander resuscitation opportunities in a country facing geographical and economic challenges.\u003c/p\u003e\u003cp\u003eFurther research is needed to compare this distance-based approach with other emerging methods and ultimately evaluate the impact of distance-based training on real-world CPR performance and patient outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAHA:\u003c/strong\u003e American Heart Association.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCPA:\u003c/strong\u003e\u0026nbsp; Cardiopulmonary arrest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBLS:\u003c/strong\u003e Basic Life Support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCPR:\u0026nbsp;\u003c/strong\u003eCardiopulmonary Resuscitation:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAED:\u0026nbsp;\u003c/strong\u003eAutomated external defibrillator\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCC:\u003c/strong\u003e Chest compressions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eICC:\u003c/strong\u003e Intraclass correlation coefficient.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was approved by the Comité Ético Científico de Ciencias de la Salud UC, Facultad de Medicina, Pontificia Universidad Católica de Chile (approval number\u0026nbsp;ID 221118007).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial disclosure:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by a Research Grant Fondef IDEA 2023-2025 ID23I10263 from the National Agency of Research and Development, Government of Chile.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFA, MCA: Study design, data analysis, draft and approved the manuscript.\u003c/p\u003e\n\u003cp\u003eJR, AS: Training session and feedback, approved the manuscript.\u003c/p\u003e\n\u003cp\u003eDA, JV: Video analysis (PRE and POST assessments), approved the manuscript.\u003c/p\u003e\n\u003cp\u003eEZ: Case enrollment, coordination of courses and participants approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Dr. Catalina Ortiz, MD, Dr. Brandon Valencia, MD, and Ivan Paul, MD, for their assistance with the research fund application. Additionally, we appreciate Dr. Sofia Abedrapo, MD, Dr. Cristian Jarry, MD, and Carlos Campos for their help during assessment sessions; Ignacio Cortinez, MD, and Gonzalo Boncompte for their assistance with statistical analysis. Finally, we acknowledge the support of the resuscitation committee of the Chilean Society of Anesthesia, represented by Dr. Antonia Valderrama, MD.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eNazzal, Carolina, Lefian, Alejandro, \u0026amp; Alonso, Faustino. (2021). Incidencia de infarto agudo de miocardio en Chile, 2008-2016. Revista m\u0026eacute;dica de Chile, 149(3), 323-329. https://dx.doi.org/10.4067/s0034-98872021000300323\u003c/li\u003e\n \u003cli\u003eMinisterio de Salud (MINSAL) (2011) \u0026ldquo;Norma Nacional de Reanimación Cardiopulmonar del Adulto y Pediátrica\u0026rdquo;. Disponible en: http://www.repositoriodigital.minsal.cl/handle/2015/438 [Último acceso: 10 de marzo, 2020]\u003c/li\u003e\n \u003cli\u003eChamberlain D, Smith A, Woollard M, Colquhoun M, Handley AJ, Leaves S, Kern KB. \u0026ldquo;Trials of teaching methods in basic life support (3): Comparison of simulated CPR performance after first training and at 6 months, with a note on the value of re-training.\u0026rdquo; Resuscitation 2002; 53(2):179-87.\u003c/li\u003e\n \u003cli\u003eSayre MR, Berg RA, Cave DM, Page RL, Potts J, White RD. \u0026ldquo;Hands-only (compression-only) cardiopulmonary resuscitation: a call to action for bystander response to adults who experience out- of-hospital sudden cardiac arrest: a science advisory for the public from the American Heart Association Emergency Cardiovascular Care Committee\u0026rdquo;. Circulation 2008;117:2162-7.\u003c/li\u003e\n \u003cli\u003eRiva G, Ringh M, Jonsson M, Svensson L, Herlitz J, Claesson A et al. \u0026ldquo;Survival in Out-of-Hospital Cardiac Arrest After Standard Cardiopulmonary Resuscitation or Chest Compressions Only Before Arrival of Emergency Medical Services\u0026rdquo;. Circulation 2019; ;10:e003194\u003c/li\u003e\n \u003cli\u003eRiggs M, Franklin R, Saylany L. \u0026ldquo;Associations between cardiopulmonary resuscitation (CPR) knowledge, self-efficacy, training history and willingness to perform CPR and CPR psychomotor skills: A systematic review\u0026rdquo; Resuscitation 2019; 138: 259-72\u003c/li\u003e\n \u003cli\u003eLara, B\u0026aacute;rbara, Chuecas, Joaqu\u0026iacute;n, Schild, Vicente, Musso, Jorge, Rojas, Jer\u0026oacute;nimo, \u0026amp; Aguilera, Pablo. (2022). Registro prospectivo de pacientes que presentan paro cardiorrespiratorio extrahospitalario en Santiago, Chile. Revista m\u0026eacute;dica de Chile, 150(10), 1283-1290. https://dx.doi.org/10.4067/S0034-98872022001001283\u003c/li\u003e\n \u003cli\u003eMayanz S, Barreto J, Grove X, Iglesias V, Breinbauer H. \u0026ldquo;Paro cardiorrespiratorio extra- hospitalario de causa cardiaca en Santiago de Chile: Experiencia del equipo medicalizado del SAMU Metropolitano\u0026rdquo; Rev Chil Med Int 2009; 24(1):9-16.\u003c/li\u003e\n \u003cli\u003eAcevedo, Stephanie, C\u0026oacute;rdova, Guiliana, Claver\u0026iacute;a, Cristi\u0026aacute;n, \u0026amp; Larios, Guillermo. (2020). Preparaci\u0026oacute;n de los colegios y profesores de educaci\u0026oacute;n f\u0026iacute;sica en prevenci\u0026oacute;n de muerte s\u0026uacute;bita y soporte vital b\u0026aacute;sico. Revista chilena de cardiolog\u0026iacute;a, 39(3), 229-236. https://dx.doi.org/10.4067/S0718-85602020000300229\u003c/li\u003e\n \u003cli\u003eMinisterio de Salud (MINSAL) (2011) \u0026ldquo;Norma Nacional de Reanimaci\u0026oacute;n Cardiopulmonar del Adulto y Pedi\u0026aacute;trica\u0026rdquo;. Disponible en: http://www.repositoriodigital.minsal.cl/handle/2015/438\u003c/li\u003e\n \u003cli\u003ehttps://www.bcn.cl/leychile/navegar?idNorma=1150508\u003c/li\u003e\n \u003cli\u003ehttps://www.t13.cl/noticia/nacional/nino-esta-internado-gravedad-tras-recibir-pelotazo-colegio-acusan-falta-asisten-21-8-2024\u003c/li\u003e\n \u003cli\u003eJuul Grabmayr A, Andelius L, Bo Christensen N, Folke F, Bundgaard Ringgren K, Torp-Pedersen C, Gislason G, Jensen TW, Rolin Kragh A, Tofte Gregers MC, Samsoee Kjoelbye J, Malta Hansen C. Contemporary levels of cardiopulmonary resuscitation training in Denmark. Resusc Plus. 2022 Jul 1;11:100268. doi: 10.1016/j.resplu.2022.100268.\u003c/li\u003e\n \u003cli\u003eMalta Hansen C, Zinckernagel L, Ersb\u0026oslash;ll AK, Tj\u0026oslash;rnh\u0026oslash;j-Thomsen T, Wissenberg M, Lippert FK, Weeke P, Gislason GH, K\u0026oslash;ber L, Torp-Pedersen C, Folke F. Cardiopulmonary Resuscitation Training in Schools Following 8 Years of Mandating Legislation in Denmark: A Nationwide Survey. J Am Heart Assoc. 2017 Mar 14;6(3):e004128. doi: 10.1161/JAHA.116.004128.\u003c/li\u003e\n \u003cli\u003eVaras J, Belmar F, Fuentes J, Vela J, Contreras C, Letelier LM, Riquelme A, Asbun D, Abbott EF, Escalona G, Alseidi A, O\u0026apos;Sullivan P, Villagr\u0026aacute;n I. Improving Medical Student Performance With Unsupervised Simulation and Remote Asynchronous Feedback. J Surg Educ. 2024 Dec;81(12):103302. doi: 10.1016/j.jsurg.2024.103302.\u003c/li\u003e\n \u003cli\u003eVera M, Kattan E, Cerda T, Niklitshek J, Monta\u0026ntilde;a R, Varas J, Corvetto MA. Implementation of Distance-Based Simulation Training Programs for Healthcare Professionals: Breaking Barriers During COVID-19 Pandemic. Simul Healthc. 2021 Dec 1;16(6):401-406. doi: 10.1097/SIH.0000000000000550.\u003c/li\u003e\n \u003cli\u003eCorvetto MA, Kattan E, Ram\u0026iacute;rez G, Besa P, Abbott E, Zamorano E, Contreras V, Altermatt FR. Simulation-Based Training Program for Peripherally Inserted Central Catheter Placement: Randomized Comparative Study of in-Person Training With Synchronous Feedback Versus Distance Training With Asynchronous Feedback. Simul Healthc. 2024 Dec 1;19(6):373-378. doi: 10.1097/SIH.0000000000000805.\u003c/li\u003e\n \u003cli\u003eCorvetto MA, Kattan E, Varas J, Caro I, Altermatt FR. Designing Sustainable Solutions to Implement a Distance-Based Simulation Basic Life Support Training Program During COVID-19 Pandemic in Low-Income Countries. Simul Healthc. 2022 Oct 1;17(5):351-352. doi: 10.1097/SIH.0000000000000651.\u003c/li\u003e\n \u003cli\u003eBerg, H., Steinsbekk, A. Is individual practice in an immersive and interactive virtual reality application non-inferior to practicing with traditional equipment in learning systematic clinical observation? A randomized controlled trial. \u003cem\u003eBMC Med Educ\u003c/em\u003e\u003cstrong\u003e20\u003c/strong\u003e, 123 (2020). https://doi.org/10.1186/s12909-020-02030-7\u003c/li\u003e\n \u003cli\u003eKlasen M, Sopka S. Demonstrating equivalence and non-inferiority of medical education concepts. Med Educ. 2021 Apr;55(4):455-461. doi: 10.1111/medu.14420. Epub 2020 Dec 6. PMID: 33206411.\u003c/li\u003e\n \u003cli\u003eSealed Envelope Ltd. 2012. Power calculator for binary outcome non- inferiority trial. [Online] Available from: https://www.sealedenvelope.com/power/continuous-noninferior/ [Accessed Wed Feb 25 2020].\u003c/li\u003e\n \u003cli\u003eSianipar IR, Tantri AR, Muktiarti D, Dwijayanti A, Manggala SK, Muliyah E. Comparison Between Self-Deliberate Practice and Directed Learning Training Methods for Basic Life Support Knowledge and High-Quality Cardiopulmonary Resuscitation Skill Retention in Second-Year Medical Students 3 and 6 Months After Training. Med Sci Educ. 2023 Feb 18;33(2):395-400. doi: 10.1007/s40670-023-01746-7.\u003c/li\u003e\n \u003cli\u003eGarc\u0026iacute;a-Su\u0026aacute;rez M, M\u0026eacute;ndez-Mart\u0026iacute;nez C, Mart\u0026iacute;nez-Isasi S, G\u0026oacute;mez-Salgado J, Fern\u0026aacute;ndez-Garc\u0026iacute;a D. Basic Life Support Training Methods for Health Science Students: A Systematic Review. Int J Environ Res Public Health. 2019 Mar 3;16(5):768. doi: 10.3390/ijerph16050768. PMID: 30832440; PMCID: PMC6427599.\u003c/li\u003e\n \u003cli\u003eRao G, Savage DW, Erickson G, Kyryluk N, Lingras P, Mago V. Enhancing Cardiopulmonary Resuscitation Quality Using a Smartwatch: Neural Network Approach for Algorithm Development and Validation. JMIR Mhealth Uhealth. 2025 May 5;13:e57469. doi: 10.2196/57469.\u003c/li\u003e\n \u003cli\u003eConsidine J, Gazmuri RJ, Perkins GD, Kudenchuk PJ, Olasveengen TM, Vaillancourt C, Nishiyama C, Hatanaka T, Mancini ME, Chung SP, Escalante-Kanashiro R, Morley P. Chest compression components (rate, depth, chest wall recoil and leaning): A scoping review. Resuscitation. 2020 Jan 1;146:188-202. doi: 10.1016/j.resuscitation.2019.08.042.\u003c/li\u003e\n \u003cli\u003eBj\u0026oslash;rnshave, Katrinea,b; Krogh, Lise Q.a; Hansen, Svend B.a,c; Nebsbjerg, Mette A.a; Thim, Troelsd,e; L\u0026oslash;fgren, Boa,e,f. Teaching basic life support with an automated external defibrillator using the two-stage or the four-stage teaching technique. European Journal of Emergency Medicine 25(1):p 18-24, February 2018. | DOI: 10.1097/MEJ.0000000000000410\u003c/li\u003e\n \u003cli\u003eGonz\u0026aacute;lez-Salvado V, Rodr\u0026iacute;guez-Ruiz E, Abelairas-G\u0026oacute;mez C, Ruano-Ravi\u0026ntilde;a A, Pe\u0026ntilde;a-Gil C, Gonz\u0026aacute;lez-Juanatey JR, Rodr\u0026iacute;guez-N\u0026uacute;\u0026ntilde;ez A. Training adult laypeople in basic life support. A systematic review. Rev Esp Cardiol (Engl Ed). 2020 Jan;73(1):53-68. doi: 10.1016/j.rec.2018.11.013.\u003c/li\u003e\n \u003cli\u003eNg TP, Eng SW, Ting JXR, Bok C, Tay GYH, Kong SYJ, Stassen W, Zhang L, de Kleijn DPV, Ong MEH, Blewer AL, Yeo JW, Ho AFW; GOALS Workgroup. Global prevalence of basic life support training: A systematic review and meta-analysis. Resuscitation. 2023 May;186:109771. doi: 10.1016/j.resuscitation.2023.109771.\u003c/li\u003e\n \u003cli\u003eElkin R, Duff JP, LaForest ML, Stapleton S, Ramachandra G, Palaganas JC, Gross IT. Distance simulation in the health professions: a scoping review. Adv Simul (Lond). 2023 Nov 17;8(1):27. doi: 10.1186/s41077-023-00266-z.\u003c/li\u003e\n \u003cli\u003eNakagawa NK, Lockey A, Carmona MJC, Hoover A, Nanda P, B\u0026ouml;ttiger BW; WRAH collaborators. It is time to spread the message of high-quality layperson cardiopulmonary resuscitation all over the world. Clinics (Sao Paulo). 2024 Apr 27;79:100355. doi: 10.1016/j.clinsp.2024.100355.\u003c/li\u003e\n \u003cli\u003eSun R, Wang Y, Wu Q, Wang S, Liu X, Wang P, He Y, Zheng H. Effectiveness of virtual and augmented reality for cardiopulmonary resuscitation training: a systematic review and meta-analysis. BMC Med Educ. 2024 Jul 5;24(1):730. doi: 10.1186/s12909-024-05720-8.\u003c/li\u003e\n \u003cli\u003eKo YC, Hsieh MJ, Schnaubelt S, Matsuyama T, Cheng A, Greif R. Disparities in layperson resuscitation education: A scoping review. Am J Emerg Med. 2023 Oct;72:137-146. doi: 10.1016/j.ajem.2023.07.033.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"advances-in-simulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"asim","sideBox":"Learn more about [Advances in Simulation](http://advancesinsimulation.biomedcentral.com/)","snPcode":"41077","submissionUrl":"https://submission.springernature.com/new-submission/41077/3","title":"Advances in Simulation","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Simulation Training, Basic Cardiac Life Support, Cardiopulmonary Resuscitation, Distance-Based Simulation ","lastPublishedDoi":"10.21203/rs.3.rs-7509928/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7509928/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground:\u003c/p\u003e\n\u003cp\u003eThis study aimed to compare a distance-based CPR training program with asynchronous feedback for laypersons to a traditional in-person Basic Life Support (BLS) course.\u003c/p\u003e\n\u003cp\u003eMethods:\u003c/p\u003e\n\u003cp\u003eAfter approval by the ethics committee, 192 non-medical personnel were recruited to participate in this study. Participants were randomly assigned to two different training methods:\u003c/p\u003e\n\u003cp\u003e- Traditional American Heart Association BLS in-person course (T-course).\u003c/p\u003e\n\u003cp\u003e- Distance-based course offering asynchronous feedback through an online platform (D-course).\u003c/p\u003e\n\u003cp\u003eFor the distance-based course, materials for practice were available at the participants' workplace (pad, resuscitation torso, an automated external defibrillator). The video-based assessment and feedback platform C1DO1 was used (https://c1do1.ai/). The course was structured in 9 stages on the platform, with theoretical and practical steps. Participants reviewed the videos and practiced unsupervised, uploading video recordings of their practice, and instructors assessed and provided feedback asynchronously on these videos. Participants then reviewed their own videos with the feedback and practiced again until approval.\u003c/p\u003e\n\u003cp\u003eBoth groups completed a pre-training (PRE) and post-training assessment (POST). During both assessments, participants were recorded performing CPR. Videos were evaluated by two independent, blinded reviewers who rated participants’ performance using the AHA CPR and AED Skills Testing Checklist. Additionally, the quality of chest compressions (CC) was measured with the Prestan simulator application.\u003c/p\u003e\n\u003cp\u003eResults:\u003c/p\u003e\n\u003cp\u003eOf the 192 participants recruited, 172 completed the training, and 158 took the PRE and POST assessments. (83 finished the T-course and 75 the D-course).\u003c/p\u003e\n\u003cp\u003eMedian AHA CPR and AED Skills Checklist scores increased from 2 (0-3) to 15 (14-16.5) points in the T-course and from 1 (0-2.5) to 16 (15.5-17) points in the D-course. The difference in POST assessment median scores between groups was -1 (95% CI: [-1.5, -0.5]), with the lower bound above the pre-established non-inferiority margin, confirming the non-inferiority of the D-course.\u003c/p\u003e\n\u003cp\u003eThe median CC rate increased from 82 (0-106)/min to 105 (102-110)/min in the T-course and from 86 (0-109.5)/min to 105 (105-108)/min in the D-course. The median CC depth rose from 38 (0-57.5) mm to 58 (49.5-60) mm in the T-course and from 32 (0-56) mm to 59 (55-60) mm in the D-course.\u003c/p\u003e\n\u003cp\u003eConclusions:\u003c/p\u003e\n\u003cp\u003eBoth training programs significantly improve participants’ proficiency in CPR. The distance-based course with asynchronous platform feedback was non-inferior to the traditional BLS course.\u003c/p\u003e","manuscriptTitle":"Development and validation of a distance-based training program of Basic Cardiac Life Support for laypersons and comparison with traditional in-person methodology: A non-inferiority study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-12 15:01:09","doi":"10.21203/rs.3.rs-7509928/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-22T02:24:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-13T01:41:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"93047031596055283898851725577339992641","date":"2025-10-01T15:44:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"249606904560915426780200773990407031577","date":"2025-09-12T06:49:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-06T22:21:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-04T22:38:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-04T22:37:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Advances in Simulation","date":"2025-09-01T15:14:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"advances-in-simulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"asim","sideBox":"Learn more about [Advances in Simulation](http://advancesinsimulation.biomedcentral.com/)","snPcode":"41077","submissionUrl":"https://submission.springernature.com/new-submission/41077/3","title":"Advances in Simulation","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5b635049-43bd-49da-a5c2-509746e4c0f0","owner":[],"postedDate":"September 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-03T21:38:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-12 15:01:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7509928","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7509928","identity":"rs-7509928","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}