What is a Critically Appraised Topic (CAT)?
A Critically Appraised Topic (CAT) is a brief, structured summary of the best available evidence on a focused first aid or resuscitation question. CATs help bridge research and practice while supporting students and emerging scholars to develop research appraisal skills. Each CAT published in the International Journal of First Aid Education undergoes peer review, contributing to the Journal’s mission to expand accessible, international scholarship in first aid education.
Clinical Scenario
Sudden cardiac arrest (SCA) accounts for a large share of cardiovascular-related mortality worldwide (Srivats et al., 2025). The global incidence of out-of-hospital cardiac arrests (OHCA) is estimated to be around 55 cases per 100,000 person-years (Yan et al., 2020). There are approximately 60,000 OHCA cases annually in Canada, with estimated survival as low as 10% (Canadian Heart and Stroke, 2024). In the United States, the numbers on OHCA cases are higher at an estimated 350,000 annually, but the survival rates are similar at around 10% (Tsao et al., 2023).
Bystander-initiated cardiopulmonary resuscitation (CPR) is a critical, immediate intervention that significantly improves survival in cases of sudden cardiac arrest. For example, one recent large observational study found a clear graded inverse relationship between time to bystander CPR and survival, even a delay of a few minutes markedly reduces the chances of discharge (Nguyen et al., 2024). Evidence also shows that each minute without CPR and defibrillation corresponds to an approximate 7–10% reduction in survival (Vahedian-Azimi et al., 2024). Data also indicate that bystander-provided CPR has improved neurological outcomes compared to those who do not receive it (Singer & Mosesso, 2020). These statistics highlight the importance of widespread and accessible CPR training to improve meaningful survival outcomes, including limits to neurological deficits and reduced length of stay in the hospital.
High-quality CPR training is essential for equipping laypersons with the knowledge, confidence, and skills to respond effectively during emergencies. According to the American Heart Association (AHA), effective CPR involves maintaining proper compression depth, rate, full chest recoil, and correct hand placement (Meaney et al., 2013). CPR courses offered through AHA are 3 hours in length and combine instructional videos with hands-on practice with manikins guided by an instructor (American Heart Association, 2025). However, the cost and limited availability of these courses can restrict access to training, especially in low-resource or rural settings (Sasson et al., 2013).
Recent studies have looked at the use of inexpensive CPR feedback devices paired with instructional videos to teach hands-only CPR. These include models built from pillows (Goldstein et al., 2018; Nehra et al., 2024), toilet paper rolls, towels, and t-shirts (Wanner et al., 2016), and mason jar lids (Ohle et al., 2021a; Ohle et al., 2021b), designed to mimic the feedback mechanisms of commercial manikins. Studies have shown that when used with structured instructional videos, low-cost compression models created with limited resources can effectively teach key CPR skills and produce outcomes comparable to traditional manikin-based training.
Highquality CPR training remains concentrated in formal, feebased courses that require commercial manikins and certified instructors, which limits access for adolescents, community members, and lowresource settings (Sasson et al., 2013). At the same time, homemade CPR devices and brief videobased training have emerged in practice, but the supporting evidence is scattered across small, singlestudy reports, making it difficult for educators and students to judge whether these lowcost tools are truly comparable to standard manikinbased training. Therefore, the purpose of this critical appraisal topic is to examine the existing literature to determine the effectiveness of homemade CPR devices compared to in-person instruction on commercially produced manikins, as a scalable and affordable solution for CPR skill acquisition (Goldstein et al., 2018; Nehra et al., 2024; Wanner et al., 2016; Ohle et al., 2021a; Ohle et al., 2021b) and provider confidence. Expanding the reach of such tools has the potential to significantly increase the number of trained bystanders and improve global cardiac arrest survival rates.
Focused Clinical Question
Among adults and adolescents (P), is training with a homemade CPR device plus instructional video (I), compared with a standard course using a commercial manikin (C), effective in improving compression-only CPR performance (i.e., depth, rate, recoil, hand placement) and self-reported confidence (O)?
Search Strategy
The literature search was conducted in two phases (April 2024 and March 2025) using a structured PICO framework. The database search used combinations of keywords related to homemade and low-cost cardiopulmonary resuscitation training devices, including the terms “homemade CPR device,” “DIY CPR trainer,” and “low-cost CPR manikin.” Additional search terms focused on the training modality and CPR technique, such as “compression-only CPR” and “hands-only CPR,” as well as delivery formats including “online CPR training” and “video-based CPR training.” To ensure appropriate comparison, terms related to standard training methods were also included, such as “commercial CPR manikin” and “standard CPR training.” Boolean operators (AND/OR) were applied to combine concepts and refine search results across databases. The following databases were systematically searched: CINAHL, PubMed, MEDLINE, Cochrane Library, ScienceDirect, and ProQuest.
Inclusion and Exclusion Criteria
Articles were included in the appraisal if they met the following criteria:
Peer-reviewed, cross-sectional, or randomized controlled trial;
Compared homemade CPR devices and instructional videos with a control group (e.g., Heart and Stroke CPR class or equivalent);
Participants were between the ages of 12 and 65;
Included CPR performance outcomes (e.g., compression depth and rate) and self-reported confidence in ability;
The study was published in the last 10 years (2015–2025).
Articles were excluded from the appraisal if they met the following criteria:
They did not compare homemade CPR devices with standard manikin-based training, or the homemade CPR device did not have an accompanying instructional video.
The study focused solely on theoretical CPR education without hands-on practice.
It was from an unpublished thesis project or abstracts lacking sufficient data.
Results of Search
An initial database search in April 2024 and the subsequent search in March 2025 identified a total of 315 records. The results can be seen in Figure 1. After removal of duplicates, titles and abstracts were screened, and 13 studies were retrieved for full text screening. Of these, five met the inclusion criteria: four level 2 randomized crossover studies and one parallel design (within-subjects) study (Wanner et al., 2016). The flow of records through identification, screening, eligibility assessment, and inclusion is shown in Figure 1, and a summary of the five included studies is presented in Table 1.
Summary of Included Studies.
| Author(s) | Study Q | Sample | Design | Intervention | Outcome Measures | Results | Level of Evidence |
| Ohle, R., Moskalyk, M., Boissonneault, E., Bilgasem, A., Tissot, E., & McIsaac, S. (2021). | Is learning CPR on a homemade toilet paper trainer non-inferior to a commercially available manikin? | 125 lay participants (adolescents and adults, all over the age of 12) attending a science museum in Canada. The study did not further specify age or gender distribution. | Non-inferiority randomized control trial. | Both groups received 10 minutes of one-on-one instruction, including a CPR demonstration and hands-on practice focused on depth, rate, and recoil. Training ended with feedback from either a commercial or homemade trainer, plus verbal feedback from instructors. | Mean overall CPR score as determined by validated high-fidelity mannequin software, which is recognized as a reliable tool for assessing CPR performance in research settings. | Both groups achieved high overall CPR performance, as measured by high-fidelity mannequin software. The commercial mannequin group had a mean CPR score of 84%, while the homemade trainer group had a mean score of 82%. Both scores were considered above the threshold for high-quality CPR in the study. | 2 |
| Nehra, A., Ravindra, P., Bhat, R., Nagesh, S. K., Alok, Y., Nisarg S., Shanmukhappa Maddani, S., & Balakrishnan, J. M. (2024). | Comparison between a low-cost model (CPR Pillow) and a mannequin in training hands only cardiopulmonary resuscitation (CPR): A randomised trial. | 206 undergraduate students | Randomized controlled trial | Participants were randomized to receive hands-only CPR training using either a low-cost homemade CPR pillow or a standard commercial mannequin. Both groups received the same instruction and hands-on practice in compression-only CPR, with performance evaluated after training. | Objective outcome measures included correct hand positioning, chest compression rate, compression depth, compression fraction, chest recoil, and overall CPR performance score, as measured by high-fidelity mannequin software. | There was no statistical difference in hand positioning, chest compression rate and fraction, depth and overall CPR score between the two groups trained via mannequin and CPR Pillow (P > 0.05). The CPR pillow group had better percentage of chest recoil as compared to the mannequin group (86% vs 73%; P < 0.001). |
2 |
| Ohle, R., Moskalyk, M., Boissonneault, E., Simmons, K., & McIsaac, S. (2021). | A homemade CPR trainer can enable real time practice during online hands-only CPR training | 87 participants | Simulation-based evaluation (laboratory study) using a homemade CPR trainer to assess CPR performance metrics. | CPR was performed on a homemade trainer constructed from two stacked toilet rolls and a mason jar lid. Performance metrics were recorded using a Zoll X series defibrillator with CPR analysis during simulated compressions. | CPR quality metrics, including compression depth, full chest recoil, and compression rate, as measured by CPR analysis software. | The homemade toilet roll trainer allowed for appropriate compression depth (2” displacement) and full chest recoil. Performance metrics met American Heart Association (AHA) 2015 guidelines for high-quality CPR. | 3 |
| Wanner, G. K., Osborne, A., & Greene, C. H. (2016). | Brief compression-only cardiopulmonary resuscitation | 24 participants, 12 trained and 12 untrained. | Parallel design study, with pre- and post-test. | All participants watched a 6-minute instructional video on compression-only CPR, including a | Primary outcomes included compression rate, compression depth, correct hand | Both untrained and previously trained participants demonstrated statistically significant improvements in several CPR | 2 |
| training video and simulation with homemade mannequin improves CPR skills. | demonstration and instructions for making a homemade CPR trainer. Participants then practiced chest compressions using a homemade trainer assembled from household items (towel, toilet paper roll, and t-shirt) as they followed along with the video. | position, correct release (recoil), and total hands-off time during a 1-minute testing period. Secondary outcomes included participants’ willingness to perform compressions and inter-rater reliability between CPR experts and mannequin sensors. | skills after training with the homemade mannequin and instructional video. In the untrained group, post-training performance showed significant increases in correct compression rate, correct hand position, correct compression release (recoil), and reductions in hands-off time during testing (all p < 0.05). The trained group also improved significantly in correct release, hands-off time, and time to first compression following the intervention. All improvements were assessed by both CPR experts and sensor-equipped manikins, with strong inter-rater reliability. Participants reported increased confidence and willingness to perform CPR after completing the training. | ||||
| Goldstein, M., Goldstein, B., Novograd, J., Carden, K., & Kirwan, M. (2018). | Is a bed pillow as effective as a manikin torso in training college students in compression-only CPR? | 242 undergraduate students: College students with no prior CPR training were randomized to one of two training rooms, one with a bed pillow (n = 119) and one with a manikin torso (n = 123) | Randomized comparative trial | Participants were randomized to a training room using either a pillow or a manikin. Each watched a 2-min video and practiced compressions using a “practice-while-watching” technique. CPR instructors were present to provide clarification. Skills were evaluated using a blinded assessor and a recording manikin. | Compression rate (cpm) and compression depth (mm), measured on a recording manikin | No significant difference in compression depth (p = 0.89). Mean rate was slightly higher in the manikin group (122.9 vs. 118.0 cpm; p = 0.028), but exceeded recommended range. No difference in overall CPR competency based on rate and depth (p = 0.81). | 2 |
PRISMA Diagram.
Summary of Search and Key Findings
A synopsis of the level of evidence and key findings from relevant articles on homemade CPR training devices using an instructional video was generated. The Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence classify research quality from Level 1 (systematic reviews of randomized controlled trials) to Level 5 (expert opinion), based on study design and methodological techniques used (University of Oxford, 2024). Within this framework, level 2 evidence is derived from well-designed randomized controlled or crossover trials and is considered strong primary evidence for evaluating intervention effectiveness (University of Oxford, 2024). The articles used in this study representing high-quality research that falls just below systematic reviews in the evidence hierarchy. The literature search was limited to studies of Level 2 evidence or higher, following the Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence (University of Oxford, 2024). Five randomized crossover studies met the inclusion criteria (Goldstein et al., 2018; Nehra et al., 2024; Wanner et al., 2016; Ohle et al., 2021a; Ohle et al., 2021b). All studies compared homemade CPR devices (CPR pillow and toilet paper roll models) with standard manikin-based training (Goldstein et al., 2018; Nehra et al., 2024; Wanner et al., 2016; Ohle et al., 2021a, 2021b).
Three studies specifically evaluated the effectiveness of homemade devices during online CPR training with an instructional video (Goldstein et al., 2018; Nehra et al., 2024; Wanner et al., 2016). The studies concluded that participants trained with homemade CPR devices were able to demonstrate high-quality CPR skills, including appropriate compression depth (Goldstein et al., 2018; Nehra et al., 2024; Wanner et al., 2016; Ohle et al., 2021b), rate (within recommended guidelines) (Goldstein et al., 2018; Nehra et al., 2024; Wanner et al., 2016; Ohle et al., 2021b), hand placement (Goldstein et al., 2018; Wanner et al., 2016; Ohle et al., 2021b), and chest recoil at levels comparable to those trained with standard manikins. Nehra et al. (2024) reported that the homemade CPR pillow group achieved better chest recoil (86%) compared to the manikin group (73%) (P < 0.001) (Goldstein et al., 2018). Factors include the CPR pillow’s combination of a soft pillow, and a plastic bottle provided different tactile feedback, which likely encouraged participants to fully release pressure between compressions, resulting in improved recoil (Goldstein et al., 2018). The touch and feel of these homemade devices varies from some commercial manikins that rely on visual or electronic feedback, allowing users to have a physical response, which may reinforce kinesthetic learning, particularly in novice learners performing compression-only CPR.
Wanner et al. (2016) found that participants using a homemade toilet roll trainer demonstrated comparable compression depth and rate to those trained with standard manikins, though depth consistency remained a challenge. They emphasized that combining homemade devices with instructional videos significantly improved CPR skills among previously untrained participants, including average compression rate per minute (64.3 to 103.9, p = 0.006 in pre- and post training respectively) (p. 4), correct hand placement compressions in one minute (8.3 to 54.3, p = 0.002, in pre- and post training respectively), and reduced hands-off time (41.8, 15.3 in pre- and post training respectively (p. 4). All studies highlighted the cost-effectiveness and/or accessibility of homemade CPR devices, suggesting their potential for widespread community training programs where traditional manikin training is inaccessible due to limited financial and human resources or accessibility. Ages ranged from adolescents (12 years and older) to adults, and gender representation was generally balanced or not significantly different (Wanner et al., 2016; Ohle et al., 2021b). The studies (Goldstein et al., 2018; Nehra et al., 2024; Wanner et al., 2016; Ohle et al., 2021a; Ohle et al., 2021b) sought to increase the accessibility of CPR education, focusing on resource-limited settings or groups who may face barriers to traditional manikin-based training. Interventions were specifically designed to be low-cost, reproducible, and feasible for home or virtual training, supporting equity in CPR education by addressing financial, geographic, and social barriers. While detailed reporting on race, ethnicity, and other PROGRESS-Plus factors (e.g., occupation, social capital) was limited, the body of evidence prioritizes inclusivity, noting the inclusion of underrepresented populations and aiming to reduce disparities in access to CPR training.
Clinical Bottom Line
Results from the studies are consistent in that a low-cost compression-only CPR training device made from items found in the home and instructional videos is as effective at teaching compression-only CPR as attending an AHA-compliant CPR course.
Strength of Recommendation
Level 2 (University of Oxford, 2024) evidence exists that homemade CPR devices, when paired with structured instructional videos, can enable participants to achieve comparable compression-only CPR skill performance and self-confidence to that obtained through standard manikin-based training. However, the use of homemade devices is not currently sufficient for formal CPR certification, which requires assessment with a standardized manikin and instructor.
Limitations
The included studies generally involved small sample sizes and assessed CPR performance immediately following training, limiting evaluation of long-term skill retention. Demographic reporting across studies was limited, restricting analysis of socioeconomic, racial, and geographic diversity among participants. Additionally, variations in performance measurement tools and reliance on short-term outcomes may introduce measurement bias. These limitations highlight the need for larger, longitudinal studies evaluating real-world skill retention and implementation outcomes.
Implications for Practice, Education, and Research
This review aimed to determine the effectiveness of homemade CPR devices with instructional videos when compared to standard manikin-based training for hands-on CPR. All included studies demonstrated that homemade CPR devices, when paired with structured instructional videos, provided comparable outcomes to standard manikin-based training in terms of CPR skill acquisition. While these tools demonstrate comparable short-term performance outcomes to standard manikin-based training, they are not substitutes for formal CPR certification pathways. Instead, these homemade devices should be viewed as scalable educational adjuncts capable of increasing bystander readiness and early intervention.
Homemade CPR devices, such as the CPR pillow and toilet roll models (Goldstein et al., 2018; Nehra et al., 2024; Wanner et al., 2016; Ohle et al., 2021a; Ohle et al., 2021b), offer a cost-effective and accessible alternative for CPR training, particularly in resource-limited or remote settings where commercial manikins are unavailable. These devices demonstrated comparable outcomes in compression depth, rate, hand placement, and chest recoil (Goldstein et al., 2018; Nehra et al., 2024; Wanner et al., 2016; Ohle et al., 2021a; Ohle et al., 2021b). The ability to replicate effective CPR skills using these homemade devices suggests that they can be integrated into community-based CPR training programs to increase accessibility. Such integration could expand CPR education and improve survival rates from OHCA.
Incorporating homemade CPR devices into educational programs can enhance learning opportunities in schools, workplaces, and communities with limited resources. Instructional videos accompanying these devices can ensure standardized training, reducing barriers related to cost and availability. Providing clear instructional guidelines and demonstrations can improve learner confidence and willingness to perform CPR, both of which are vital for effective bystander response (Srivats et al., 2025; Yan et al., 2020; Canadian Heart and Stroke, 2024; Tsao et al., 2023).
Future studies should examine long-term skill retention and confidence levels following training with homemade devices. Evidence shows that real-time feedback during CPR training significantly improves key quality metrics, such as compression depth, rate compliance, and recoil compliance, which supports the value of integrating feedback technology into low-cost models. Evaluating homemade devices in diverse populations, including adolescents and older adults, could further support their widespread adoption. Research into combining these models with modern feedback systems is warranted to optimize outcomes. Addressing these research gaps will provide deeper insights into optimizing CPR training strategies and ensuring the broadest possible access to effective, life-saving education.
Acknowledgement
Abstract translations provided by IJFAE volunteers Dr. Tina van Duijn & William Kimanzi.
Competing Interests
The authors have no competing interests to declare.
References
American Heart Association. (2025). Heartsaver® CPR AED Course Options. cpr.heart.org. https://cpr.heart.org/en/courses/heartsaver-cpr-aed-course-options
Canadian Heart and Stroke Foundation. (2024, February). 2024 Report on Cardiac Arrest. HSF – 2024 Report on Cardiac Arrest. https://issuu.com/heartandstroke/docs/cardiac_arrest_report_feb_2024?fr=sYWQ2NjY0NDEzNjI
Goldstein, M., Goldstein, B., Novograd, J., Carden, K., & Kirwan, M. (2018). Abstract 226: Comparison of a low and high resource model to effectively train college students in compression only cardiopulmonary resuscitation. Circulation, 138(Suppl_2). http://doi.org/10.1161/circ.138.suppl_2.226
Meaney, P. A., Bobrow, B. J., Mancini, M. E., Christenson, J., de Caen, A. R., Bhanji, F., Abella, B. S., Kleinman, M. E., Edelson, D. P., Berg, R. A., Aufderheide, T. P., Menon, V., & Leary, M. (2013). Cardiopulmonary resuscitation quality: Improving cardiac resuscitation outcomes both inside and outside the hospital. Circulation, 128(4), 417–435. http://doi.org/10.1161/cir.0b013e31829d8654
Nehra, A., Ravindra, P., Bhat, R., Nagesh, S. K., Alok, Y., Nisarg, S., Shanmukhappa Maddani, S., & Balakrishnan, J. M. (2024). Comparison between a low-cost model (CPR Pillow) and a mannequin in training hands only cardiopulmonary resuscitation (CPR): A randomised trial. Resuscitation Plus, 17, 100518. http://doi.org/10.1016/j.resplu.2023.100518
Nguyen, D. D., Spertus, J. A., Kennedy, K. F., Gupta, K., Uzendu, A. I., McNally, B. F., & Chan, P. S. (2024). Association between delays in time to bystander CPR and survival for witnessed cardiac arrest in the United States. Circulation: Cardiovascular Quality and Outcomes, 17(2). http://doi.org/10.1161/circoutcomes.123.010116
Ohle, R., Moskalyk, M., Boissonneault, E., Bilgasem, A., Tissot, E., & McIsaac, S. (2021a). Is a homemade cardiopulmonary resuscitation (CPR) trainer non-inferior to a commercially available CPR mannequin in teaching high-quality CPR? A non-inferiority randomized control trial. Resuscitation Plus, 6, 100134. http://doi.org/10.1016/j.resplu.2021.100134
Ohle, R., Moskalyk, M., Boissonneault, E., Simmons, K., & McIsaac, S. (2021b). A homemade CPR trainer can enable real time practice during online hands only CPR training. Resuscitation, 158, 71–72. http://doi.org/10.1016/j.resuscitation.2020.10.045
Sasson, C., Haukoos, J. S., Bond, C., Rabe, M., Colbert, S. H., King, R., Sayre, M., & Heisler, M. (2013). Barriers and facilitators to learning and performing cardiopulmonary resuscitation in neighborhoods with low bystander cardiopulmonary resuscitation prevalence and high rates of cardiac arrest in Columbus, OH. Circulation: Cardiovascular Quality and Outcomes, 6(5), 550–558. http://doi.org/10.1161/circoutcomes.111.000097
Singer, J. L., & Mosesso, V. N. (2020). After the lights and sirens: Patient access delay in cardiac arrest. Resuscitation, 155, 234–235. http://doi.org/10.1016/j.resuscitation.2020.07.027
Srivats, S., Zghyer, F., Shahrori, Z., Albert, C., Al-Khatib, S. M., Chugh, S., Etheridge, S. P., Goldberger, Z. D., Gopinathannair, R., Lakkireddy, D., Morin, D. P., Perez, M. V., Rottmann, M., Sunshine, J. E., Wang, P. J., & Chung, M. K. (2025). Sudden cardiac arrest: Limitations in risk-stratification and treatment, and the potential for digital technologies and artificial intelligence to improve prediction and outcomes. Progress in Cardiovascular Diseases, 91, 144–166. http://doi.org/10.1016/j.pcad.2025.06.005
Tsao, C. W., Aday, A. W., Almarzooq, Z. I., Anderson, C. A. M., Arora, P., Avery, C. L., Baker-Smith, C. M., Beaton, A. Z., Boehme, A. K., Buxton, A. E., Commodore-Mensah, Y., Elkind, M. S. V., Evenson, K. R., Eze-Nliam, C., Fugar, S., Generoso, G., Heard, D. G., Hiremath, S., Ho, J. E., … Martin, S. S. (2023). Heart disease and stroke Statistics—2023 update: A report from the American Heart Association. Circulation, 147(8). http://doi.org/10.1161/cir.0000000000001123
University of Oxford. (2024, June 13). OCEBM levels of evidence. Centre for Evidence-Based Medicine (CEBM), University of Oxford. https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence
Vahedian-Azimi, A., Hassan, I. F., Rahimi-Bashar, F., Elmelliti, H., Salesi, M., Alqahwachi, H., Albazoon, F., Akbar, A., Shehata, A. L., Ibrahim, A. S., & Ait Hssain, A. (2024). Prognostic effects of cardiopulmonary resuscitation (CPR) start time and the interval between CPR to extracorporeal cardiopulmonary resuscitation (ECPR) on patient outcomes under Extracorporeal Membrane Oxygenation (ECMO): A single-center, retrospective observational study. BMC Emergency Medicine, 24(1). http://doi.org/10.1186/s12873-023-00905-8
Wanner, G. K., Osborne, A., & Greene, C. H. (2016). Brief compression-only cardiopulmonary resuscitation training video and simulation with homemade mannequin improves CPR skills. BMC Emergency Medicine, 16(1). http://doi.org/10.1186/s12873-016-0110-5
Yan, S., Gan, Y., Jiang, N., Wang, R., Chen, Y., Luo, Z., Zong, Q., Chen, S., & Lv, C. (2020). The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: A systematic review and meta-analysis. Critical Care, 24(1). http://doi.org/10.1186/s13054-020-2773-2