# Remote Augmented Reality Versus Traditional Simulation for Team Leader Assessment in a Cardiac Arrest Scenario: Noninferiority Randomized Controlled Trial

## TL;DR

This study shows that remote augmented reality training for cardiac arrest scenarios is as effective as traditional in-person simulation for assessing team leader performance.

## Contribution

Demonstrates the noninferiority of remote AR simulation compared to traditional in-person simulation for team leader assessment in cardiac arrest.

## Key findings

- Remote AR group showed noninferior performance compared to the traditional group in cognitive leadership and behavioral measures.
- AR participants reported high usability and low ergonomic burden of the headset.
- Mean checklist scores were nearly identical between the two groups, with AR meeting the noninferiority threshold.

## Abstract

Simulation-based education is crucial for training health care professionals in advanced cardiac life support. However, access to high-fidelity in-person simulation is frequently limited by geographic, logistical, and financial constraints. Augmented reality (AR) offers the potential to deliver remote, immersive training experiences that may overcome these barriers, but its effectiveness compared with traditional simulation remains uncertain.

This study aimed to determine whether remote AR simulation is noninferior to traditional in-person simulation for assessing team leader performance during a ventricular fibrillation cardiac arrest scenario.

This noninferiority randomized trial enrolled participants at the State University of Campinas (UNICAMP), Brazil, and used cross-continental remote instruction from Stanford University (in the United States) for the AR arm. A total of 50 health care professionals were randomized to either remote AR simulation with a geographically distant instructor (n=25) or traditional in-person simulation (n=25). All participants completed an identical ventricular fibrillation cardiac arrest case as team leaders. Leader performance was assessed using an adapted, validated checklist-based instrument for cognitive leadership and an observational behavioral measure (Behaviorally Anchored Rating Scale). Secondary outcomes included AR participants’ evaluations of usability and ergonomics.

A total of 42 participants fully completed the study procedures (remote AR group: n=22; traditional in-person group: n=20). The AR group demonstrated noninferior performance compared to the traditional group across all outcomes. The mean checklist scores were 41.6 (SD 6.2) and 42.6 (SD 5.8) in the remote AR group and traditional in-person group, respectively. The AR group’s 95% CI (38.9‐44.4) was above the 20% noninferiority threshold of 34.1. Usability and ergonomics were favorably reported by most participants.

Participants in the remote AR simulation demonstrated noninferior team leader decision-making and behavioral performance compared with those in traditional in-person simulation. These findings suggest that remote AR may be a viable strategy to expand access to scenario-based assessment of cardiac arrest leadership, particularly in resource-limited settings. AR participants also reported high usability and low ergonomic burden, indicating comfortable headset use.