In-hospital pediatric cardiac arrests (IHCA), although rare, require immediate, coordinated response from resuscitation teams under intense pressure to provide guideline-compliant clinical care [1]. Standardized protocols, such as the American Heart Association pediatric advanced life support (PALS) guidelines, emphasize uniform responses [2], yet adherence remains suboptimal, with frequent deviations from recommended timing of defibrillation and drug administration, errors in dosing, and omissions of key steps in both real and simulated pediatric cardiac arrest scenarios [3-6]. These deviations are strongly influenced by human factors such as high cognitive load, stress, impaired decision-making, communication breakdowns, and challenges in maintaining team situational awareness and a shared mental model during complex emergencies [4]. These lapses compromise quality of care and survival rates [7]. As a result, there is increasing interest in tools that support team cognition and real-time guideline adherence during pediatric cardiopulmonary resuscitation (CPR).

Digital cognitive aids and decision support systems have emerged as promising approaches to mitigate these problems. In adult and mixed emergency settings, cognitive aids and electronic decision support tools have been associated with fewer errors and better adherence to resuscitation algorithms in simulated IHCA [8-11]. In pediatrics, few are purpose-built for real-time use in resuscitation [12]. Tablet-based apps were developed specifically to support pediatric cardiac arrest management and showed good usability in high-fidelity simulation with reduced deviations from guideline recommendations [13-15]. A recent systematic review of cognitive aids in resuscitation similarly concluded that cognitive aids tend to reduce deviations from guidelines and improve resuscitation performance in simulated settings across adult and pediatric populations [16]. However, most existing systems are designed as single-user, handheld interfaces that primarily support the team leader, rather than functioning as shared, team-centered displays that make time-critical information visible to the entire resuscitation team in real time.

Only a few technological solutions have been conceived as large situation displays to enhance team communication and situational awareness during emergency resuscitations. Pilot work in emergency departments has suggested that dedicated situation displays can facilitate teamwork, communication, and perceived situational awareness among resuscitation teams [17,18]. More recently, an interactive, large-screen clinical decision display designed for team-wide viewing has been evaluated and shown to improve adherence to guideline time intervals in simulated advanced cardiac life support [8]. Despite these advances, pediatric-specific evidence for team-centered digital decision support during IHCA remains limited, and there is a need for tools explicitly designed around the information needs and workflows of pediatric resuscitation teams.

To address these limitations, we developed Interconnected and Focused Mobile Applications on Patient Care Environment (InterFACE), a suite of interconnected digital tools (Figure 1) designed to enhance team coordination and PALS adherence during pediatric CPR [19,20]. Building on an earlier prototype [15] that demonstrated improvements in defibrillation timing and adherence to resuscitation algorithms but also highlighted risks of cognitive overload, we refined the system into an updated concept. This system integrates role-specific, interconnected digital tools—TeamScreen, Guiding Pad (a tablet app), and augmented reality (AR) headsets [21]—to standardize care, reduce variability, and enhance CPR quality [22]. TeamScreen provides real-time resuscitation oversight, with shared access to drug and shock dose calculations and PALS workflows to support the entire team [20]. Developed iteratively with multidisciplinary input from 2 pediatric emergency departments, it addresses prior shortcomings and aligns with calls for innovative resuscitation aids [16].

The design and evaluation of InterFACE-AR followed human factors and usability engineering recommendations for high-risk medical technologies. Regulatory guidance from the US Food and Drug Administration on applying human factors and usability engineering to medical devices emphasizes structured processes, identifying critical tasks, conducting formative evaluations, and performing summative usability testing to minimize use-related risks [23]. Usability research in health information technology further supports the use of task-based testing and think-aloud methods as core, user-centered approaches to uncover interaction problems in complex interfaces [24,25]. In this context, this study focuses specifically on evaluating the usability of the updated TeamScreen interface during a simulated pediatric IHCA scenario, as an essential step before broader assessments of its impact on team performance and clinical outcomes.

This study aimed to evaluate the usability of the TeamScreen app in supporting resuscitation teams during pediatric IHCA management. By assessing the prototype’s strengths and limitations, we sought to identify potential usability challenges and propose targeted improvements. The insights gathered were intended to inform the refinement of TeamScreen ahead of its full-scale clinical deployment and to contribute to the broader development of digital tools aimed at enhancing team performance and adherence to resuscitation guidelines.

The usability of the TeamScreen app was assessed through a scenario-based information retrieval evaluation, combining both quantitative and qualitative methods. Multitask quantitative and qualitative usability metrics were used and are described in detail in subsequent sections. Usability was defined, according to ISO 9241‐210, as “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use” [26]. The usability of a digital tool can be assessed by how effectively and completely users are able to perform key tasks aligned with its core functionalities. In contrast, poor usability often results in reduced task efficiency, incomplete goal achievement, or even abandonment of the technology [27]. Effectiveness was measured by task completion rates. Efficiency was evaluated through time-on-task metrics. User satisfaction was assessed using the Post-Study System Usability Questionnaire (PSSUQ) version 3 [28] and a custom posttest evaluation questionnaire. In addition, think-aloud discussions were recorded verbatim and analyzed to extract key user insights and perceptions throughout the sessions.

TeamScreen is a web-based app designed to centralize and display, in real time, critical information related to the patient’s condition and resuscitation progress to support adherence to PALS algorithms during CPR. Displayed on a 75-inch wall-mounted screen in the resuscitation room, it provides resuscitation teams with a clear, shared overview of clinical status and required actions, aligned with PALS algorithms. This dynamic interface offers a visual overview of key data such as patient information (eg, weight, pulse presence, cardiac rhythm, and ventilation status), intervention timelines, upcoming clinical tasks, and medication dosing details without requiring direct user interaction. Instead, it relies on input from the charting nurse via the Guiding Pad, a tablet app that dynamically records interventions tailored to the patient’s status. TeamScreen is part of the broader InterFACE-AR suite [22], named for its AR foundation, which also includes AR headsets (HoloLens 2, Microsoft Corp), worn by the team leader and medication nurse [21]. These deliver role-specific guidance via mixed reality, an advanced form of AR that—unlike standard overlays—enables interactive 3D holograms anchored in the environment [29], to support clinical decision-making and medication preparation. The usability testing approach mirrored this role distribution, reflecting real-world dynamics where the Guiding Pad feeds data to TeamScreen for team-wide visibility. These tools collectively aim to improve situational awareness, communication, and adherence to PALS guidelines during IHCA, ensuring more efficient and guideline-compliant interventions. The TeamScreen prototype used in this study replicated all core functionalities of the current InterFACE-AR TeamScreen module, including the algorithm flow, task lists, timers, and weight-based drug and shock displays, but it was operated as a stand-alone simulated interface that was not technically connected to the AR headsets or live clinical systems. The Guiding Pad and AR headset components will be described and evaluated in separate studies.

The usability tests were conducted in mid-September 2024. A total of 20 health care professionals participated in the study, of which 14 (70%) were women. The sample included 15 nurses (75%) and 5 physicians (25%). Of the 20 participants, 10 (50%) had completed PALS certification, including 3 of 5 physicians (60%) and 7 of 15 nurses (46.67%). Notably, 8 of 15 nurses (53.33%) had no PALS certification. The participants had a median experience of 6.00 (IQR 2.00-11.75) years in pediatric emergency care. All had prior exposure to real pediatric resuscitations, with the number of cases ranging from 2 to 100 and 30 cases being the most frequently reported value. Similarly, all had experience with simulated resuscitations, with the reported number of cases ranging widely, most commonly around 20 simulations.

Participants’ self-reported familiarity with digital devices varied: of 20 participants, 10 (50%) described themselves as “comfortable” using tablets and smartphones, whereas 6 (30%) reported being “very comfortable.” The remaining participants were either “neutral” (3/20, 15%) or “slightly uncomfortable” (1/20, 5%) with digital tools.

Following the usability analysis, several targeted refinements were implemented, each addressing a specific usability issue summarized in Table 4. First, limited visibility and ambiguous interpretation of the CPR timer led us to relocate the main timer to the top of the screen and clarify its label to ensure continuous and unambiguous visibility throughout the resuscitation process. Second, difficulties in reading and using the reversible causes (6H5T; hypovolemia, hypoxia, hydrogen ion [acidosis], hypokalemia/hyperkalemia, hypoglycemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis [pulmonary], thrombosis [coronary]) prompted an increase in font size and a permanent display to provide immediate access to correction measures. Third, issues related to information overload and poor readability of the list of completed tasks motivated a restyling of the task list, replacing square markers with bullet points, and secondary tasks were repositioned higher in the interface to make them more noticeable and actionable. Fourth, in response to concerns that timers were easy to overlook as they approached zero, countdown timers were enhanced to blink when nearing expiry, drawing the team’s attention and reducing the risk of delayed interventions. Finally, frequent misinterpretation of medication icons and confusion around drug administration stages led to the introduction of 3 distinct, clearly labeled icons indicating whether a drug was in preparation, prepared, or already administered. Collectively, these modifications aimed to alleviate information overload, improve navigation, and highlight essential cues in high‐stress pediatric resuscitation scenarios.

TeamScreen introduces a new generation of context-aware clinical displays aimed at reinforcing shared cognition and temporal coordination among resuscitation teams rather than replacing clinical judgment. This single-center, mixed methods study evaluating its usability during simulated IHCA management yielded several salient insights.

With an overall task success rate of 81%, most participants effectively located and interpreted essential clinical information under simulated urgency, despite challenges in early pediatric IHCA response [40]. Tasks 7 (Shocks given), 13 (Intubation time), 15 (Shock time), 18 (“Other tasks” section status), and 20 (Reversible causes), covering shock delivery logs, intubation timestamps, and reversible‐causes guidance, achieved 100% success, suggesting that these interface elements were well designed and intuitive. Conversely, tasks 5 (CPR status), 8 (Medication status I), and 9 (CPR time) related to tracking ongoing CPR and upcoming interventions (eg, epinephrine administration) exhibited the highest failure rates. Participants who struggled with these tasks frequently cited uncertainty regarding the location of real-time information, highlighting a need for improved visual hierarchy in high-density interface areas, in line with cognitive load theory [41].

Task completion times demonstrated substantial variability across the 21 tasks, reflecting heterogeneity in task complexity and cognitive processing demands. Task 21 (Patient status: general understanding) exhibited the longest mean completion time, indicating that tasks involving a broader synthesis of patient information were more time-consuming. Conversely, task 4 (Define weight II) was completed most rapidly, suggesting minimal cognitive load and straightforward retrieval. This efficiency may also be attributed to task 4 representing the second occurrence of a previous task, that is, task 1 (Define weight I), whereby participants were already familiar with the location of the relevant information on the display.

Correlation analysis showed errors clustering around related data points, such as medication timing and dosage, underscoring the importance of consistent navigation cues and harmonized data presentation across the algorithm view, timeline, and “Completed Tasks” sections. This aligns with evidence that protocol adherence significantly improves IHCA outcomes [42], emphasizing TeamScreen’s potential to enhance care quality through better design. The PSSUQ scores indicated high user satisfaction, with participants valuing TeamScreen’s consolidation of vital parameters, current tasks, and next‐step recommendations into a central, readable display. These findings suggest that TeamScreen excels where clarity is prioritized (eg, timestamps and shock logs) but requires refinement in areas with visual clutter, icon ambiguity, or subtle task distinctions. Given varying roles in IHCA response where nurses often manage documentation and physicians lead decisions [43], future studies should explore whether task success or perceived usability differs across these groups.

TeamScreen shares similarities with real-time dashboard systems aggregating patient vitals, medication records, and intervention timelines onto shared displays, as seen in prior work improving clinicians’ access to critical data and reducing cognitive load [44]. However, unlike passive aggregators, TeamScreen integrates real-time visualization with interactive PALS-aligned algorithmic guidance, supporting both team situational awareness and decision-making during IHCA. This dual functionality addresses a gap in traditional dashboards, which often lack structured support for resuscitation guidelines. For instance, Siebert et al [45] demonstrated that AR glasses improved defibrillation dosing adherence compared to PALS pocket cards, although without broader workflow integration. A recent systematic review by Cheng et al [46] highlights the potential of AR and virtual reality to enhance resuscitation skills but notes inconsistent superiority over traditional methods, underscoring the need for integrated solutions such as TeamScreen. TeamScreen extends this concept by offering a centralized, algorithm-synchronized interface, positioning it within an emerging class of digital tools designed to optimize shared cognition and temporal alignment in high-acuity care.

The usability evaluation of TeamScreen has identified critical areas for future refinement, and the following enhancements will be implemented to optimize its support for resuscitation teams. The information hierarchy will be restructured to minimize visual overload, consolidating related elements such as medication timing and dosage into a distinct, clearly labeled panel, guided by cognitive load principles [41]. This adjustment could streamline data retrieval and lessen cognitive strain during time-sensitive tasks. Dynamic visual cues, such as color shifts or blinking countdowns for medication intervals, could prompt timely actions, provided they adhere to ergonomic principles to avoid distraction in high‐stress settings. Functionally, adaptive role-based prompts tied to PALS algorithms could guide users step-by-step, improving coordination and adherence. Standardizing labels, icons, and visual styles (eg, font sizes, colors, and legends) would enhance consistency and reduce the likelihood of misinterpretation, particularly for the 6H5T mnemonic and streamlined task lists. Finally, given its intuitive design, brief, role‐specific onboarding is advised—especially for users with varying digital fluency—to ensure efficient navigation in multitasking, high-stakes scenarios such as CPR. Paired with these design refinements and enhancements, targeted training could maximize TeamScreen’s potential to support resuscitation teams effectively.

This study has several limitations. Testing TeamScreen in a simulated environment without direct user interaction limits conclusions about real-world PALS algorithms adherence or patient outcomes. The heightened stress of a real-life IHCA situation might exacerbate usability challenges not fully captured in this study. Additionally, evaluating TeamScreen isolation (ie, without AR Headsets or Guiding Pad) potentially reduces ecological validity, as the full InterFACE-AR suite’s interplay was not assessed. This may also not fully capture the usability of the complete system. However, the Guiding Pad and AR headset modules have been evaluated in separate component-level usability studies, and the integrated InterFACE-AR system has recently been tested in a multicenter randomized controlled trial in a high-fidelity simulated setting. Third, the passive display design, reliant on a charting nurse’s input via the Guiding Pad, aligns with its intended use but restricted participants’ ability to explore the interface freely, potentially skewing engagement. Fourth, the study sample size and various clinical backgrounds of participants further limit generalizability. Fifth, our evaluation was supposedly conducted in a dedicated emergency department resuscitation bay using a fixed, wall-mounted TeamScreen display, which may limit generalizability to ward-based pediatric IHCA where mobile configurations of TeamScreen and the Guiding Pad would be required and should be evaluated in future work. Finally, while cognitive overload was frequently noted in feedback, this dimension remained unquantified owing to the absence of a validated instrument such as the NASA-Task Load Index (NASA-TLX) [47]. This should be addressed in future studies.

Several of the usability issues identified in this study point to general design principles that are relevant for other digital tools in acute care. Information that is crucial for safe care (such as timers, current patient status, and key tasks) should be clearly visible on a shared team display. The amount of information on screen needs to be limited and well structured to avoid overload, and icons or color codes must be immediately understandable, even under stress. These lessons can guide the design of other real-time decision support systems that aim to support teamwork rather than only individual users.

The next phase of our program consists of 2 multicenter, simulation randomized controlled trials in 2025. The first, conducted in the second quarter of 2025, has now been completed, and the second, initiated in the fourth quarter of 2025, is currently underway, integrating TeamScreen with AR Headsets and Guiding Pad to evaluate clinical decision‐making, teamwork, communication, and patient safety outcomes across diverse hospital settings. Structured, role-specific onboarding will mitigate the learning curve effects observed in this study, offering a clearer performance baseline under realistic pressures. Because adherence to advanced life support guidelines is associated with better IHCA outcomes [42], metrics such as drug administration timing, error rates, and PALS adherence will provide deeper insights into how digital support influences care quality. Role differences (eg, nurses’ documentation vs physicians’ leadership [43]) will also be examined to further adapt the interfaces. Cognitive workload will be quantified using tools such as the NASA-TLX [47] to address qualitative feedback about overload and to test whether the system genuinely reduces cognitive burden.

Future iterations could incorporate artificial intelligence–driven predictive analytics to anticipate tasks (eg, rhythm reassessment), further reducing manual tracking demands. Qualitative feedback and high usability scores suggest that TeamScreen may alleviate cognitive load, although formal workload assessments are needed. Future work also needs to address more practical questions that apply to many medical digital tools, including feasibility of deployment, interoperability with existing hospital systems, and implementation costs, for widespread adoption. Integration with electronic health records, automated monitoring data capture, and tailored role-specific interfaces represent key translational goals to support clinical use of InterFACE-AR and similar decision support systems.

This study provides a structured usability evaluation of TeamScreen, a shared digital interface designed to assist pediatric resuscitation teams during IHCA, with its clinical impact still to be validated. Using a mixed methods approach, we identified its strengths and limitations in a simulated setting. Results revealed an 81% task success rate and high user satisfaction, confirming TeamScreen’s ability to deliver accessible, interpretable clinical data under time pressure. However, issues with information hierarchy and task clarity, evidenced by correlated failures in navigation and updates, highlighted areas for refinement. The combined analyses of error categorization, verbal feedback, and questionnaire responses provided insights about the prototype’s strengths and areas requiring refinement. This comprehensive evaluation not only identified critical usability challenges but also validated the potential of the TeamScreen prototype to optimize pediatric resuscitation workflows.