Immersive virtual reality-assisted anatomy training improves endotracheal intubation performance in simulation: a randomized controlled trial among Chinese non-anesthesiology residents

ERCT Criteria Breakdown

• Level 1 Criteria

  • C

    Class-level RCT

    • Randomisation was conducted at the individual student level, not at the class or school level, and the intervention is not a one-to-one tutoring exception.
    • "Participants were randomly assigned, using a computer-generated randomization sequence ... to either the IVR group (n=45) or the control group (n=45)." (p. 2)
    • Relevant Quotes: 1) "Participants were randomly assigned, using a computer-generated randomization sequence (Microsoft Excel, Microsoft Corp., Redmond, WA, USA), to either the IVR group (n=45) or the control group (n=45)." (p. 2) 2) "An instructor who was not involved in the study recruited participants and generated the allocation sequence." (p. 2) 3) "A total of 90 non-anesthesiology residents without prior ETI experience were randomly assigned to either an IVR group ... (n=45) or a control group ... (n=45)." (Abstract) 4) "Each group was further divided into three subgroups of about 15 residents per session, resulting in a total of six training sessions to accommodate all 90 participants." (p. 4) Detailed Analysis: Criterion C requires that randomisation be conducted at the class level or stronger (school level), unless the intervention is a personal/one-to-one tutoring intervention in which case student-level randomisation is acceptable. Here the unit of randomisation was the individual resident: each of the 90 residents was individually assigned via a computer-generated sequence to the IVR or control condition. There is no mention of intact classes or cohorts being randomised; the participants are individual first-year residents drawn from a single institution and then divided into training subgroups after randomisation. The intervention is a group-based anatomy/skills training course delivered to subgroups of about 15 residents, not a one-to-one tutoring or personal-teaching intervention, so the tutoring exception does not apply. Although the authors took care to train groups in separate rooms "to prevent cross-contamination," this addresses contamination operationally but does not change the fact that the unit of randomisation was the individual student rather than a class or school. Criterion C is not met because randomisation was performed at the individual student level, not at the class or school level, and the intervention is not a personal tutoring exception.
  • E

    Exam-based Assessment

    • The study used a custom-built MCQ test plus a program-specific checklist and generic rating scale, not a widely recognised standardised exam.
    • "Post-test items were based exclusively on the lecture, procedural video, and anatomical content provided to both groups during self-directed learning." (p. 4)
    • Relevant Quotes: 1) "The primary endpoint was residents' ETI performance on a simulator, assessed using both the Global Rating Scale (GRS) and a task-specific checklist." (Abstract) 2) "Both pre- and post-tests comprised 20 multiple-choice questions (MCQs), with each correct answer worth five points (total score: 100) and a 15-minute time limit (Supplementary Files 2 and 3)." (p. 4) 3) "Post-test items were based exclusively on the lecture, procedural video, and anatomical content provided to both groups during self-directed learning." (p. 4) 4) "ETI performance was assessed by two other independent experienced anesthesiologists using a task-specific checklist and a Global Rating Scale (GRS) ... The checklist, routinely used in summative assessments within the residency program, evaluated task completion and procedural accuracy, while the validated GRS, comprising four subscales and an overall rating, assessed performance quality ..." (pp. 4-5) 5) "Following assessment, subjective feedback was collected using a purpose-designed perception survey ... Formal psychometric validation was not undertaken; therefore, the questionnaire was used for exploratory purposes." (p. 5) Detailed Analysis: Criterion E requires the study to use a standardised, widely recognised exam-based assessment that was not specially designed for the study. The outcomes here are: (a) a manikin-based task-specific checklist that is described as "routinely used in summative assessments within the residency program" but is specific to this ETI procedure and to this program, not a widely recognised standardised exam; (b) a Global Rating Scale (GRS) for procedural performance, which is a generic competency rating instrument, not a standardised exam of academic achievement; and (c) a 20-item multiple-choice knowledge test whose items were created "based exclusively on the lecture, procedural video, and anatomical content provided" - i.e., a custom-built test designed for this study. None of these constitutes a national or widely-recognised standardised exam. The MCQ test and checklist were assembled/used specifically for this training course and intervention, exactly the kind of custom assessment that the criterion warns against. Criterion E is not met because the study relied on a custom multiple-choice test, a program-specific task checklist, and a generic rating scale rather than a widely recognised standardised exam.
  • T

    Term Duration

    • Outcomes were measured immediately after a single short training course, far short of the required term-long follow-up.
    • "Third, outcomes were assessed immediately post-training, without evaluation of long-term knowledge and skill retention." (p. 9)
    • Relevant Quotes: 1) "The study was conducted at this single academic-affiliated medical center between December 2024 and March 2025." (p. 2) 2) "They then attended a 40-minute PowerPoint lecture on ETI ... Subsequently, residents completed a 30-minute self-directed learning session ... Each resident completed a 2-hour individual hands-on training session on the airway management manikin ..." (pp. 4) 3) "Knowledge acquisition was evaluated via a post-test administered at the end of the course." (p. 4) 4) "Third, outcomes were assessed immediately post-training, without evaluation of long-term knowledge and skill retention." (p. 9) Detailed Analysis: Criterion T requires that outcomes be measured at least one full academic term (approximately 3-4 months) after the intervention begins, allowing term-long follow-up tracking even for short interventions. Here the intervention was an extremely short training course: a 40-minute lecture, a 10-minute video, a 30-minute self-directed anatomy learning session, and a 2-hour hands-on manikin session, all delivered as a single course. The primary outcome (manikin ETI performance) and the knowledge post-test were both assessed at the end of the course / immediately post-training. The authors explicitly acknowledge as a limitation that "outcomes were assessed immediately post-training, without evaluation of long-term knowledge and skill retention." Although the overall study window spans December 2024 to March 2025, this reflects enrolment of successive participants, not a term-long follow-up of each individual after the intervention. There is therefore no follow-up interval of one academic term between intervention start and outcome measurement. Criterion T is not met because outcomes were measured immediately after a single short training course, with no term-long follow-up tracking.
  • D

    Documented Control Group

    • The control group's size, demographics, baseline knowledge, and conditions are clearly documented in the text, Table 1, Table 3, and the CONSORT diagram.
    • "There were no significant differences in demographic or baseline characteristics between the IVR and control groups (all p>0.05; Table 1)."
    • Relevant Quotes: 1) "Participants were randomly assigned ... to either the IVR group (n=45) or the control group (n=45). ... the control group was taught using conventional 2D anatomical images. Both groups received identical theoretical content and training objectives ..." (p. 2) 2) "Table 1. Demographic and baseline characteristics of participants. IVR group (n=44) ... Control group (n=42) ... Gender ... Age (yr) 24 (23,25.75) vs. 25 (23,26.25) ... Previous learning about endotracheal intubation: Textbooks 33 (75.00%) vs. 29 (69.05%); Clinical observation 17 (38.64%) vs. 19 (45.24%); Clinical practice 0 (0.00%) vs. 0 (0.00%)." (Table 1, p. 6) 3) "There were no significant differences in demographic or baseline characteristics between the IVR and control groups (all p>0.05; Table 1)." (pp. 5-6) 4) "the control group was taught using conventional 2D anatomical images. ... the control group studied using a conventional 2D anatomical atlas." (pp. 2, 4) Detailed Analysis: Criterion D requires that the control group be well-documented, including demographic information, baseline performance, size, and the conditions/ treatment it received. The paper provides a clear control-group sample size (n=45 randomised, n=42 analysed), demographic data (gender, age, prior learning about ETI) in Table 1, baseline knowledge (pre-test scores: 53.21+/-12.96 in Table 3), and a description of what the control group received (conventional 2D anatomical atlas / images with identical theoretical content and objectives). A CONSORT flow diagram (Figure 1) documents allocation, receipt of intervention, and analysis numbers for the control arm. This level of detail allows assessment of comparability at baseline. Criterion D is met because the control group's size, demographics, baseline performance, and conditions are clearly documented in the text, Table 1, Table 3, and the CONSORT diagram.

• Level 2 Criteria

  • S

    School-level RCT

    • The study was conducted at a single center with individual-level randomisation, so no school-level randomisation occurred.
    • "First, its single-center design may restrict the generalizability of the findings ..." (p. 9)
    • Relevant Quotes: 1) "Participants were randomly assigned, using a computer-generated randomization sequence ... to either the IVR group (n=45) or the control group (n=45)." (p. 2) 2) "The study was conducted at this single academic-affiliated medical center between December 2024 and March 2025." (p. 2) 3) "First, its single-center design may restrict the generalizability of the findings ..." (p. 9) Detailed Analysis: Criterion S requires randomisation at the school level (the educational institution or implementing unit), with multiple schools/sites randomised. Here the entire study was conducted at a single institution (one medical center), and randomisation was performed at the individual resident level. No schools, sites, or institutions were randomised; only one site was involved. The authors themselves describe the study as "single-center." Therefore school-level randomisation did not occur. Criterion S is not met because randomisation was at the individual student level within a single institution, with no randomisation of schools or sites.
  • I

    Independent Conduct

    • The same authoring team designed, conducted, and analysed the trial, so the study was not conducted independently despite the use of blinded assessors.
    • "Thus, we conducted a prospective randomized controlled trial to evaluate the effectiveness of IVR-assisted anatomy training in ETI training." (p. 2)
    • Relevant Quotes: 1) "We hypothesized that integrating IVR-assisted anatomy training into ETI training would more effectively facilitate skill acquisition compared with conventional approaches. Thus, we conducted a prospective randomized controlled trial ..." (p. 2) 2) "CRediT: Xu-Feng Zhang: Conceptualization, Writing - original draft, Writing - review & editing; Xia Xu: Investigation; Dong Ye: Data curation; Xin-Xia Yang: Investigation; Ke-Wei Wu: Investigation; Li-Hong Hu: Conceptualization, Writing - review & editing." (p. 10) 3) "ETI performance was assessed by two other independent experienced anesthesiologists ... Before data collection, two outcome assessors underwent standardized training and calibration ... Both were blinded to participants' group allocation until study completion." (pp. 4-5) 4) "An instructor who was not involved in the study recruited participants and generated the allocation sequence." (p. 2) 5) "No potential conflict of interest was reported by the author(s)." (p. 10) Detailed Analysis: Criterion I requires that the study be conducted independently from the people who designed the intervention, i.e., a third-party / external evaluation, to reduce bias in implementation and analysis. In this study, the same authors conceived, designed, and conducted the trial: they conceptualised it, performed the investigation and data curation, and wrote the analysis. While the paper introduces some independence safeguards - the outcome assessors were two independent anesthesiologists blinded to allocation, and a separate instructor not involved in the study generated the allocation sequence - these address assessor blinding and allocation concealment rather than overall independent conduct of the trial. The intervention design, delivery, data curation, and analysis were all carried out by the authoring team itself, with no external evaluation agency or third-party oversight of the study as a whole. Criterion I is not met because the same team that designed and ran the intervention also conducted and analysed the trial; blinded outcome assessors alone do not establish independent conduct of the study.
  • Y

    Year Duration

    • Criterion T is not met and outcomes were measured immediately post-training, so the year-duration requirement is not met.
    • "Third, outcomes were assessed immediately post-training, without evaluation of long-term knowledge and skill retention." (p. 9)
    • Relevant Quotes: 1) "Third, outcomes were assessed immediately post-training, without evaluation of long-term knowledge and skill retention." (p. 9) 2) "Knowledge acquisition was evaluated via a post-test administered at the end of the course." (p. 4) Detailed Analysis: Criterion Y requires that outcomes be measured at least 75% of one full academic year (approximately 9-10 months) after the intervention begins. Per the criteria-specific rule, if criterion T (Term Duration) is not met, then criterion Y is automatically not met. Criterion T is not met here because the intervention was a single short course with outcomes measured immediately. The follow-up interval is essentially zero, far below a full academic year, and the authors explicitly note the absence of any long-term follow-up. Criterion Y is not met because the term-duration criterion is not met and outcomes were measured immediately post-training rather than across a full academic year.
  • B

    Balanced Control Group

    • Instructional time and content were matched between groups, with the control receiving a time-equivalent 2D-atlas activity, and the differing IVR modality is the integral treatment variable.
    • "Subsequently, residents completed a 30-minute self-directed learning session with identical learning objectives and core anatomical content; only the learning modality differed between groups."
    • Relevant Quotes: 1) "Both groups received identical theoretical content and training objectives, covering the principles of safe airway management, the procedural steps of ETI, and competency standards." (p. 2) 2) "Subsequently, residents completed a 30-minute self-directed learning session with identical learning objectives and core anatomical content; only the learning modality differed between groups. The IVR group used immersive and desktop 3D virtual reality to explore airway models, whereas the control group studied using a conventional 2D anatomical atlas." (p. 4) 3) "The IVR group received a 3-minute orientation on operating the IVR equipment prior to training. To minimize the risk of cybersickness, IVR training exposure was limited to 10min per resident ... During the 10-minute immersive phase ... For the remaining 20min, residents viewed the same 3D model on a computer screen in a non-immersive format." (p. 4) 4) "Each resident completed a 2-hour individual hands-on training session on the airway management manikin ... The same certified anesthesiology instructor conducted ETI training for both the IVR and conventional training groups to ensure consistency of instruction." (p. 4) Detailed Analysis: Criterion B compares the time, budget, and materials given to intervention and control groups, asking whether the control received a comparable substitute unless the additional resource is itself the explicit treatment variable. Here both groups received identical theoretical content (same 40-minute lecture, same 10-minute video), the same 30-minute self-directed learning session (only the modality differed: IVR/3D vs 2D atlas), and the same 2-hour hands-on manikin training from the same instructor. The instructional time is therefore matched between groups; the control group received an equivalent amount of educational time using a 2D atlas as an active comparator. The only difference is the delivery modality (immersive VR + desktop 3D vs 2D images), which is precisely the treatment variable being tested. The IVR group's extra equipment (Oculus headset, 3D Organon software) is integral to the intervention under test, and the control received a time-matched alternative activity, so there is no unbalanced extra time or budget functioning as a confound. Criterion B is met because instructional time was matched between the groups (identical lectures, video, equal-length self-directed session, and equal 2-hour manikin practice), with the control receiving a time-equivalent 2D-atlas activity, and the only difference (the IVR modality) is the integral treatment variable being tested.

• Level 3 Criteria

  • R

    Reproduced

    • No independent replication of this specific IVR-for-ETI trial by a different research team has been published.
    • Relevant Quotes: 1) "However, the impact of IVR-assisted anatomy training on ETI skill acquisition among novice non-anesthesiology residents remains unclear." (p. 2) 2) "These results were consistent with prior research demonstrating that IVR training can enhance novice clinicians' procedural competence. For instance, Li et al. reported that IVR anatomy training improved proficiency in ultrasound-guided brachial plexus blocks [18], while Ryan et al. found that IVR-assisted surgical training enhanced both learning efficiency and knowledge transfer [5]." (p. 8) Detailed Analysis: Criterion R requires that this specific study be independently replicated by a different research team in a different context, published in a peer-reviewed journal. This is a newly published 2026 trial, and the authors explicitly state that the impact of IVR-assisted anatomy training on ETI skill acquisition in this population "remains unclear," indicating a novel question. While related IVR/anatomy training studies exist (e.g., brachial plexus blocks, surgical training), these are not replications of this specific ETI-training trial. An internet/literature search (web searches and registry checks performed during verification) identified no independent replication of this particular study (IVR-assisted anatomy training for ETI among non-anesthesiology residents) by a separate team, which is expected given its very recent April 2026 publication. Criterion R is not met because no independent replication of this specific study by a different research team has been published.
  • A

    All-subject Exams

    • Criterion E is not met and only a single narrow ETI-related domain was assessed, so the all-subject requirement is not met.
    • "The primary endpoint was residents' ETI performance on a simulator, assessed using both the Global Rating Scale (GRS) and a task-specific checklist."
    • Relevant Quotes: 1) "The primary endpoint was residents' ETI performance on a simulator, assessed using both the Global Rating Scale (GRS) and a task-specific checklist." (Abstract) 2) "Both pre- and post-tests comprised 20 multiple-choice questions (MCQs) ... Post-test items were based exclusively on the lecture, procedural video, and anatomical content provided ..." (p. 4) Detailed Analysis: Criterion A requires that the study measure impact across all main subjects using standardised exam-based assessments, and it explicitly depends on criterion E: if E is not met, A is not met. Criterion E is not met here (custom MCQ test, program-specific checklist, generic rating scale rather than a standardised exam). Moreover, the study measured only ETI-related procedural performance and ETI/anatomy knowledge - a single, narrow domain - and did not assess any other subjects. Both because the prerequisite criterion E fails and because only one narrow subject domain was assessed, this criterion cannot be satisfied. Criterion A is not met because criterion E is not met and the study assessed only a single narrow ETI- related domain rather than all main subjects with standardised exams.
  • G

    Graduation Tracking

    • Criterion Y is not met and there was no follow-up beyond immediate post-training, so no graduation tracking occurred.
    • "the absence of longitudinal follow-up limits conclusions regarding the durability of IVR-assisted training effects." (p. 9)
    • Relevant Quotes: 1) "Third, outcomes were assessed immediately post-training, without evaluation of long-term knowledge and skill retention. As procedural skills and anatomical knowledge are subject to decay over time, the absence of longitudinal follow-up limits conclusions regarding the durability of IVR-assisted training effects." (p. 9) Detailed Analysis: Criterion G requires tracking participants until graduation to assess long-term impact, and it explicitly depends on criterion Y: if Y is not met, G is not met. Criterion Y is not met here. Furthermore, the authors explicitly state there was no longitudinal follow-up at all; outcomes were measured immediately post-training. A verification search for subsequent or follow-up papers by the same authors tracking this resident cohort to completion of their residency or any later milestone found no such publications (the study itself was only published in April 2026). There is no tracking of residents toward graduation. Criterion G is not met because criterion Y is not met, the study performed no follow-up beyond immediate post-training assessment, and no subsequent graduation-tracking publication exists.
  • P

    Pre-Registered

    • The trial was prospectively registered (ChiCTR2400093689) on 10 December 2024, before the December 2024-March 2025 data collection, with pre-specified endpoints.
    • "This randomized controlled trial was registered in the Chinese Clinical Trial Registry ... ChiCTR2400093689, Date of registration: 10 December 2024." (p. 2)
    • Relevant Quotes: 1) "This randomized controlled trial was registered in the Chinese Clinical Trial Registry (https://www.chictr.org.cn, ChiCTR2400093689, Date of registration: 10 December 2024). The trial protocol and statistical analysis plan are available from the corresponding author upon reasonable request." (p. 2) 2) "The study was conducted at this single academic-affiliated medical center between December 2024 and March 2025." (p. 2) 3) "The primary and secondary endpoints were pre-specified. ... No changes to the trial outcomes were made after the trial commenced." (p. 5) 4) "A deviation from the originally registered sample size occurred during the conduct of this trial. ... the planned sample size was increased to 60 participants per group at the time of trial registration. After the enrollment of the first 30 participants in each group, an interim analysis was conducted ... Thus, the final sample size was set at 45 participants per group. We acknowledge this deviation from the registered protocol ..." (p. 8) Detailed Analysis: Criterion P requires that the full study protocol be pre-registered (hypotheses, methods, planned analyses) before data collection begins, with a registry link/ID and a date demonstrably prior to data collection. The study was registered in the Chinese Clinical Trial Registry (ChiCTR2400093689) on 10 December 2024, and the study was conducted between December 2024 and March 2025. The registry ID prefix (2400...) is consistent with a 2024 registration. The registration date thus falls at the very start of the December 2024-March 2025 study window, indicating registration occurred before (or at the outset of) data collection. The endpoints were pre-specified, and the authors transparently document and explain a deviation in sample size relative to the registered protocol. The registration provides a specific registry ID and date prior to data collection, satisfying the pre-registration requirement; the documented sample-size deviation is disclosed transparently and does not negate prospective registration. (Note: a direct verification fetch of the ChiCTR registry page for ChiCTR2400093689 could not be completed during this check; the assessment relies on the in-paper registration statement, which is internally consistent.) Criterion P is met because the trial was prospectively registered (ChiCTR2400093689, 10 December 2024) before data collection, with pre-specified endpoints and a transparently disclosed protocol deviation.