When your heart stops you’re dead.

Many people are trained in Basic Life Support techniques, such as CPR, which are designed to maintain life until help is available. Hospital clinicians are trained in Advanced Life Support (ALS) techniques, which maintain life and also identify and resolve the cause of the cardiac arrest, so that a normal rhythm is restored.

Cardiac arrests don’t happen very often but are life or death events. Because the standard of care in hospitals is constantly improving, cardiac arrests are occurring less often. As a result, hospital clinicians are receiving less exposure to managing cardiac arrests but are still required to perform effectively as a team when they do occur.

During a cardiac arrest, an ALS Team Leader organizes a number of clinicians (Airway, Drugs, Scribe, Defib, Compressions) to manage the resuscitation. The Team Leader must ensure critical tasks are performed to maintain life while using the Australian Resuscitation Guidelines to identify the cause of the cardiac arrest.

Currently standard ALS Team Leader training is delivered in a clinical simulation lab with a sophisticated mannequin or a staff member substituting for the patient. This process is time consuming and labour intensive. Additionally when providing the assessment process at the culmination of the day or for mandatory annual re-accreditation the team roles are represented by two clinical educators, an unrealistic reproduction of a real ALS event.

For this reason, the Western Sydney Local Health District, Sydney University and the Sydney Children’s Hospital Network have partnered with Frameless Interactive to build a Virtual Reality training app called ALS-SimVR. This app is undergoing clinical trials to measure how effective it is for training an ALS Team Leader, compared to current practice.

What is ALS?


Advanced Life Support (ALS) is the advanced clinical management of a patient in a cardiac arrest, beyond Basic Life Support. It follows the Nationally endorsed algorithm that determines clinical actions in response to patient progress.

Cardiac arrest is a low frequency yet high stakes event. With ever decreasing cardiac arrest rates in the hospital setting, clinicians are receiving reduced exposure to cardiac arrest management but still require a high standard of performance when these events do occur.

During a cardiac arrest, the ALS Team Leader is required to manage a group of 6 -10 staff. The Team Leader must ensure critical tasks are performed to maintain life while using the algorithm to identify the cause of the cardiac arrest.

How is Traditional ALS Training Conducted

Traditional ALS training is a two-day program. Because of constraints on staffing levels, in the final assessment two instructors stand in for the team of 6-10 clinicians to recreate a simulated scenario for the participant to apply their skills. This limitation requires the participant to “fill in the gaps”caused by the missing team members.

On a course day, multiple concurrent assessment scenarios are conducted in adjacent rooms. Assessments can also be staged in the clinical environment. This assessment process is repeated on an annual basis for mandatory re-accreditation.

Benefits of VR For ALS Training

For a number of reasons we hypothesize that the ALS-SimVR app will be an effective ALS Team Leader training tool.

First, the role of ALS Team Leader is a “hands off” role. For a Team Leader to have good situational awareness they must not be preoccupied by the technical demands of a specific hands-on role. Because the Team Leader role is hands-off it does not require the haptic feedback that would be necessary to simulate a hands-on role in a VR environment, such as performing compressions. This also eliminates the need to deploy synchronized, multi-user hardware.

Secondly there are significant workplace barriers that prevent getting an adequate number of clinicians together to accurately replicate an ALS scenario for assessment purposes. VR is a cost-effective way to recreate a scenario for the Team Leader to manage in which all the roles are represented. Additionally, by loaning standalone headsets to participants the skills can be rehearsed in their own time. This is a more flexible training schedule with potential savings of time off roster.

The Research

The research supporting this project is examining several topics over a number of steps. First, looking at the content validity with expert clinicians to determine that the created scenario is realistic and that the interventions have a realistic pathway. Second, we will be exploring the experience of a small group of clinicians using the application as an adjunct to their ALS program or annual ALS re-accreditation. We will be interviewing them and surveying their view on usability and usefulness of the application.


Then, we will be researching its effect on participant performance in the ALS program and assessment process. This will occur first at our local hospital and then be expanded to other hospitals and districts. Finally, subject to the research providing evidence that this is an effective training tool for ALS team leaders, we will research what changes are required to provide evidence that this a valid tool for the assessment of ALS team leader competence.


An initial usability research study has commenced with appropriate ethics approval to further guide the development of the application. The application has been accepted to be demonstrated at the upcoming VRST 2019 conference.


Current Application of ALS VR

Proof Concept Stage

We have already completed testing of the application with a group of 20 Nurses, Their feedback has been translated into functionalities and features which we believe will enhance the application for all users.

We have already begun investigating core changes like voice control and analytics.

Pixel Streaming
Pixel streaming is already working and we can provide an i.p for testing on request.

Oculus Go to Quest
We have currently two builds, Oculus go with 3DOF and Oculus Quest with 6DOF.

Application Features

Interactive Dialogue:
Interactive and responsive events. Each decision you make has a ripple effect throughout the scenario.
Intuitive Interface:
Decisions are made via dialogue/context menus using a point and click laser pointer.
Medical Realism:
The medical equipment is accurately represents the hardware participants will encounter in the real-world.
Assessment and Metrics:
All decisions, response times, and other metrics are gathered and used to assess the trainee.

Interactivity Workflow

  1. We create a decision tree which is set in stages. This allows us to create complex nonlinear user interactions in a manageable manner which means the content writer and other stakeholders can easily visualize the app prior to it being built.
  2. The decision trees can also be used for client feedback and alterations.
  3. Below is 1 example of many used to create the ALS training solution.

What Will the Grant Achieve?

The goal of the proof of concept was to allow preliminary testing which has now occurred. Now we have feedback and design plans driven by this testing we have adequate data to progress to MVP.

Our aim for the final version is to have a clean educational experience with minimal steps to activation for even the least tech savvy Clinicians. Our next aim is to increase visual quality to increase immersion. This project is a passion project to all involved and we hope to continually evolve this training application to not only enhance ALS training but also prove the superiority of virtual reality training as a whole thanks to Nathans Doctorate which will focus on this.

Improved Art and Animation

  1. Oculus Quest Support
  2. Additional animations for other tasks (post resuscitation assessment, additional clinical interventions for different scenarios).
  3. Realistic environment
  4. New more realistic Characters
  5. Voice actors
  6. Improved shaders and materials
  7. More interactions with environment and objects

Expanded Scenarios

  • Intelligent randomisation based on core rules and variables to increase user engagement and increase replay value.
  • Scenario Editing functionality for educators 
    • varied patient pre-conditions 
    • varied patient results and imaging
    • altered clinical pathways and patient responses to interventions
    • distractors (students, relatives, interruptions, etc)
    • additional resources available within the app

New Mechanics

  • Voice control
  • Voice recording for participant handover review
  • Student Mode with Realtime feedback on incorrect actions
  • Voice recording and playback for participant handover review
  • Observer and assessor
  • Multiplayer functionality

Skill Trainers

  • Defibrillator familiarization & Pacing/Cardioversion
  • Advanced life support algorithms
  • Patient A to G assessment
  • Airway training – Oropharyngeal airway
  • Intubation preparation
  • Access training – Intra osseous
  • Intravenous cannulation procedure and prep
  • Emergency trolley familiarization

Website Portal for Assessment and Analytics

  • Server and database
  • Front End
  • Preconfigured Filters and Queries for database
  • Custom Search
  • Graphs and Heatmaps

International Guideline adjustment to meet international training standards

  • Scenario editing with the ability to change the core underlying pathway to align with international guidelines (Australian Resuscitation Council, American Heart Association, British Heart Association etc).

The Partnership & Collaboration

This project is a partnership between Western Sydney Local Health District – Research and Education Network, the Sydney Childrens Hospital Network and the University of Sydney – Westmead Initiative.


Nathan Moore

Content Specialist | Researcher

Nathan is the Nurse Educator for Simulation Training at Westmead Hospital. With several years' experience training multidisciplinary staff of all levels in critical care training, the use of simulation and debriefing. He has a deep interest in the effective implementation of innovative technologies

Martin Brown

Project Manager

Martin is an experienced educator with a background in the media industry. He produced Moulin Rouge, was co-producer of Romeo+Juliet and art director of Strictly Ballroom. He was Director of Award Courses at the Australian Film Television and Radio School. He is now Program Manager Innovative Technologies for USYD at Westmead. He leads the Westmead Innovative Technologies Steering Group, which is contributing to the development of this and several other VR apps in training in the health sector.

Russel Tommy

Technical Director

Virtual Reality Content Creator and Developer based in Sydney. With over 10 Years experience working Within 3D and Visualization, Game Development, TVC, Virtual Reality, Production, Post Production, Education And Training.

Michael Coleman

Lead Programmer

Michael has 6 Years programming experience specializing in Virtual Reality, Augmeneted reality and Unreal. He is a Master at Blueprints and Automation Tools within Unreal, along with his c++ abilities Michael is also a workflow specialist in the AEC Industry. His ability to create rapid prototypes has allowed frameless interactive to demonstrate the advantages and capabilities of Virtual Reality.