The goal of this prospective trial is to compare CPR skill and attitudes in lay rescuers. The main question[s] it aims to answer are:

• What is the optimal training timing, duration, and frequency for lay rescuers that leads to CPR skill retention?
• What is the impact of CPR manikin type (high-fidelity, inflatable, nontraditional objects) on skill retention?
• How do specific features of training modality -- such as contextualization, gamification, and emotional engagement -- impact skill proficiency, knowledge retention, and attitudes about CPR?

Participants will

• Answer pre-training questionnaires
• Participate in CPR training
• Participate in CPR skills testing
• Answer post-training questionnaires

Researchers will compare different methods of training, different frequencies of training, and different manikin types.

Out-of-hospital cardiac arrest (OHCA) remains a major public health crisis in the United States, with over 350,000 cases annually and low survival rates. Lay rescuer cardiopulmonary resuscitation (CPR) can double survival, yet widespread gaps in training access, skill retention, and emotional readiness persist. While most U.S. states mandate high school CPR training, implementation quality varies, and traditional formats have remained unchanged for over 60 years. These methods are often time-consuming, expensive, and poorly suited for adolescents, leading to low participation and rapid skill decay.

This study addresses these critical gaps by comparing various CPR training methods and procedures. The project tests the effectiveness of different training frequencies, durations, and delivery modes-including traditional instructor-led sessions, brief refreshers, and a novel, emotionally immersive serious game. The serious game leverages gamification, competition, and scenario-based learning to build "emotional muscle memory" and prepare students for real-world emergencies.

Participants are enrolled from two high schools-one rural, one suburban-and randomized by class or individual into training arms with varied schedules and compression practice tools. These tools range from high-fidelity manikins to low-fidelity devices and improvised household objects. Outcomes include CPR performance metrics (compression rate, depth, recoil, and hand placement), knowledge retention, emotional engagement (measured via validated psychometric scales), and confidence in responding to cardiac arrest.

Training sessions are delivered during the academic year, and students are assessed immediately after training and again at annual follow-up points. Data are collected in a de-identified format using school-issued ID numbers, ensuring participant confidentiality. Analysis will use generalized estimating equations and mixed-effects models to assess the impact of training method and frequency on skill retention and psychosocial readiness. The study also explores the role of contextualization, emotional engagement, and gamification as mediators of improved CPR performance.

Ultimately, this multi-year trial aims to identify scalable, cost-effective strategies that optimize CPR training outcomes for lay rescuers. By improving technical skill retention and emotional preparedness, the study addresses key priorities for public health impact and aligns with NHLBI's strategic goals to reduce mortality from sudden cardiac arrest.

Inclusion Criteria:

• All students at participating schools

Exclusion Criteria:

• Previous CPR training (will be included in the CPR training but excluded from analysis)
• Physical injury which prevents performing CPR
• Student or parent opt-out

All data is gathered and reported in de-identified, aggregate form, per IRB and school official direction.

The statistical analysis will be masked as to which intervention subjects received, with simple "A," "B," etc. designation.