Calidad de la Reanimación Cardiopulmonar: Impacto en la Supervivencia y Pronóstico Neurológico
Resumen
Antecedente: Según el registro (GWTG-R) de la Asociación Americana de Corazón (AHA) y del National Cardiac Arrest Auditoría del Consejo de Resucitación (Reino Unido), se estima que a nivel mundial la frecuencia del paro cardiorrespiratorio en los hospitales es de aproximadamente 4 por cada 1000 pacientes ingresados, de los cuales menos del 50% hacen retorno a la circulación espontánea, constituyéndose esto en un desafío para el personal asistencial que realiza el abordaje inicial. En consecuencia las directrices para el 2021, por el Consejo Europeo de Reanimación, junto con la AHA, establecieron cinco componentes críticos necesarios para proporcionar una reanimación cardiopulmonar (RCP) de alta calidad (profundidad, frecuencia, expansión torácica completa, ventilaciones eficaces, mínimas interrupciones) por lo tanto, las estrategias para evaluar la calidad de estos componentes dentro de la RCP en el ámbito clínico y simulado es importante analizarlas desde la evidencia científica. Objetivo: Verificar las métricas de calidad en la RCP y su impacto en la supervivencia y el pronóstico neurológico a través del uso de algunas estrategias de mejoramiento en la calidad como el checklist, debriefing, educación continua y ayudas audiovisuales. Diseño: Revisión de literatura integrativa. Métodos: Se realizó la búsqueda de literatura en las bases de datos Ebsco, Pubmed, ScienceDirect, Scopus, Lilacs, Scielo, entre los años 2015 a 2021, en idioma español, inglés y portugués; a través del uso del diagrama prisma fueron incluidos 26 artículos en total para el análisis; las calidades de las publicaciones fueron evaluadas a través de los instrumentos IMECI y COREQ. Resultados: Se encontró 26 estudios que evidencian el uso de distintas estrategias para evaluar la calidad de la reanimación y al mismo tiempo la mejora de las métricas de calidad en RCP especialmente en la profundidad, frecuencia y retroceso del tórax. Sin embargo, no se encontró datos de significancia estadística con respecto al impacto en la mejora de la tasa de supervivencia y el pronóstico neurológico. Conclusión: Al analizar el uso de las cuatro estrategias en la evidencia científica tanto en el ámbito clínico como en los escenarios simulados, se concluyó que si impactan en la mejora de las métricas de calidad de la RCP como son la tasa de compresiones, la profundidad y el retroceso del tórax. Por otra parte, el uso de las estrategias a nivel intrahospitalario no implica un impacto significativo en la tasa de supervivencia y en el pronóstico neurológico. Relevancia para la práctica clínica: el conocimiento de las pautas y habilidades de RCP no es suficiente; los profesionales de salud deben practicar y capacitarse regularmente para perfeccionar esas habilidades. Por lo tanto, es necesario identificar las estrategias de mayor impacto que contribuyan en la mejora de las simétricas de calidad que se exigen durante la RCP intrahospitalario asociado al aporte en supervivencia y pronóstico neurológico.
Descargas
Citas
Nolan JP, Soar J, Smith GB, et al.; National Cardiac Arrest Audit. Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Resuscitation. 2014;85(8):987–992. doi: 10.1016/j.resuscitation.2014.04.002
Halla Kaminska, Wojciech Wieczorek, Pawel Matusik, Lukasz Czyzewski,Jerzy Robert Ladny, Jacek Smereka, Krzysztof J. Filipiak, Lukasz Szarpak, Factors influencing high-quality chest compressions during cardiopulmonary resuscitation scenario, according to 2015 American Heart Association Guidelines, Kardiologia Polska 2018; 76, 3: 642–647; DOI: 10.5603/KP.a2018.0003
Rose Mary Ferreira Lisboa da Silva, Bruna Adriene Gomes de Lima e Silva, Fábio Junior Modesto e Silva, Carlos Faria Santos Amaral, Ressuscitação cardiopulmonar de adultos com parada cardíaca intra-hospitalar utilizando o estilo Utstein, Rev Bras Ter Intensiva. 2016;28(4):427-435 DOI: 10.5935/0103- 507X.20160076
Sarah Fernanda Gonçalves de Oliveira, Sandra Maria Belmonte Pereira Moreira, Liana Lima Vieira, Giulliano Garde, Conhecimento de parada cardiorrespiratória dos profissionais de sáude em um hospital público: estudo transversal, Rev Pesq Fisio. 2018;8(1):101-109. doi: 10.17267/2238- 2704rpf.v8i1.1830
Perkins GD, Travers AH, Considine J, et al. Part 3: adult basic life support and automated external defibrillation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment Recommendations. Resuscitation 2015; 95:43–70.
Rajeswaran L, Cox M, Moeng S, Tsima BM. Assessment of nurses’ cardiopulmonary resuscitation knowledge and skills within three district hospitals in Botswana. Afr J Prim Health Care Fam Med. 12 de abril de 2018; 10 (1): e1-e6. doi: 10.4102 / phcfm. v10i1.1633. PMID: 29781687; PMCID: PMC5913783.
Huang M, Kung L, Hou S, et alComparison of the validity of checklist assessmentin cardiac arrest simulations with an app in an academic hospital in Taiwan: a retrospective observational studyBMJ Open 2018;8: e024309. doi: 10.1136/bmjopen- 2018-02430-.
Khpal M, Coxwell Matthewman M. Cardiac arrest: a missed learning opportunity. Postgrad Med J. 2016 Oct;92(1092):608-10. doi: 10.1136/postgradmedj-2016-134117. Epub 2016 Jun 9. PMID: 27287021.
Kuchaki, Zeinab1; Taheri, Mostafa2; Esfahani, Hooman3; Erfanifam, Taher4, The effect of CPR educational package on knowledge and performance of nurses working in intensive care units, Journal of Family Medicine and Primary Care: May 2022 - Volume 11 - Issue 5 - p 1677-1682 doi: 10.4103/jfmpc.jfmpc_1938_21.
Huang MY, Kung LC, Hou SW, Lee YK, Su YC. Comparison of the validity of checklist assessment in cardiac arrest simulations with an app in an academic hospital in Taiwan: a retrospective observational study. BMJ Open. 2018 Dec 14;8(12):e024309. doi: 10.1136/bmjopen-2018-024309. PMID: 30552278; PMCID: PMC6303606.
Viraj Nevrekar, Prasan Kumar Panda, Ashutosh BiswasAn, Interventional Quality Improvement Study to Assess the Compliance to Cardiopulmonary Resuscitation Documentation in an Indian Teaching Hospital, Indian J Crit Care Med. 2017 Nov; 21(11): 758–764. doi: 10.4103/ijccm.IJCCM_249_17.
Clairton Marcos Citolino Filho, Eduesley Santana Santos, Rita de Cassia Gengo e Silva, Lilia de Souza Nogueira, Factors affecting the quality of cardiopulmonary resuscitation in inpatient units: perception of nurses, Rev. esc. enferm. USP 49 (6) Dec 2015, https://doi.org/10.1590/S0080-623420150000600005.
Lorna Rozanski Dudzik, Debra G. Heard, Russell E. Griffin, Mary Vercellino, Amanda Hunt, Adam Cates, Maureen Rebholz, Implementation of a Low-Dose, High- Frequency Cardiac Resuscitation Quality Improvement Program in a Community Hospital, The Joint Commission Journal on Quality and Patient Safety, Volume 45, 21 Issue 12, 2019, Pages 789-797, ISSN 1553-7250, https://doi.org/10.1016/j.jcjq.2019.08.010.
Karen Josey, Marshall L. Smith, Arooj S. Kayani, Geoff Young, Michael D. Kasperski, Patrick Farrer, Richard Gerkin, Andreas Theodorou, Robert A. Raschke, Hospitals with more-active participation in conducting standardized in-situ mock codes have improved survival after in-hospital cardiopulmonary arrest, Resuscitation, Volume 133, 2018, Pages 47-52, ISSN 0300-9572, https://doi.org/10.1016/j.resuscitation.2018.09.020.
Couper K, Perkins GD. Debriefing after resuscitation. Curr Opin Crit Care. 2013 Jun;19(3):188-94.doi:10.1097/MCC.0b013e32835f58aa. PMID: 23426138
Gilmartin, S., Martin, L., Kenny, S., Callanan, I., & Salter, N. (2020). Promoting hot debriefing in an emergency department. BMJ open quality, 9(3), e000913.
https://doi.org/10.1136/bmjoq-2020-000913
Wolfe, Heather A. MD, MSHP*, †; Wenger, Jesse MD‡; Sutton, Robert MD, MSCE*,†; Seshadri, Roopa PhD§; Niles, Dana E. MS*; Nadkarni, Vinay MD*,†; Duval-Arnould, Jordan MPH, DrPH¶; Sen, Anita I. MD∥ ; Cheng, Adam MD**; on behalf of the pediRES-Q Investigators Cold Debriefings after In-hospital Cardiac Arrest in an International Pediatric Resuscitation
Quality Improvement Collaborative, Pediatric Quality and Safety: July/August 2020 - Volume 5 - Issue 4 - p e319 doi: 10.1097/pq9.0000000000000319.
Couper K, Kimani PK, Abella BS, Chilwan M, Cooke MW, Davies RP, Field RA, Gao F, Quinton S, Stallard N, Woolley S, Perkins GD; Cardiopulmonary Resuscitation Quality Improvement Initiative Collaborators. The System-Wide Effect of Real-Time Audiovisual Feedback and Postevent Debriefing for In-Hospital Cardiac Arrest: The Cardiopulmonary Resuscitation
Quality Improvement Initiative. Crit Care Med. 2015 Nov;43(11):2321-31. doi: 10.1097/CCM.0000000000001202. PMID: 26186567; PMCID: PMC4603366.
Semark B, Årestedt K, Israelsson J, von Wangenheim B, Carlsson J, Schildmeijer K. Quality of chest compressions by healthcare professionals using real-time audiovisual feedback during in-hospital cardiopulmonary resuscitation. Eur J Cardiovasc Nurs. 2017 Jun;16(5):453-457. doi: 10.1177/1474515117701060. Epub 2017 Mar 15. PMID: 28565967.
Goharani R, Vahedian-Azimi A, Farzanegan B, Bashar FR, Hajiesmaeili M, Shojaei S, Madani SJ, Gohari-Moghaddam K, Hatamian S, Mosavinasab SMM, Khoshfetrat M, Khabiri Khatir MA, Miller AC; MORZAK Collaborative. Real-time compression feedback for patients with in-hospital cardiac arrest: a multi-center randomized controlled clinical trial. J Intensive Care. 2019 Jan 22;7:5. doi: 10.1186/s40560-019-0357-5. PMID: 30693086; PMCID: PMC6341760
Daniel M. Rolston, MD, MSHPM,corresponding author, Timmy Li, PhD, Casey Owens, MPH, Ghania Haddad, MD, Timothy J. Palmieri, MD, Veronika Blinder, DO, Jennifer L. Wolff, MD, Michael Cassara, DO, Qiuping Zhou, DO, and Lance B. Becker, MD, Mechanical, Team-Focused, Video-Reviewed Cardiopulmonary Resuscitation Improves Return of Spontaneous Circulation After Emergency Department Implementation, J Am Heart Assoc. 2020;9:e014420. DOI: 10.1161/JAHA.119.014420
Keith Couper, Alexina J. Mason, Doug Gould, Jerry P. Nolan, Jasmeet Soar, Joyce Yeung, David Harrison, Gavin D. Perkins, The impact of resuscitation system factors on in-hospital cardiac arrest outcomes across UK hospitals: An observational study, Resuscitation, Volume 151, 2020,Pages 166-172, ISSN 0300-9572,https://doi.org/10.1016/j.resuscitation.2020.04.006.
Nallamothu BK, Guetterman TC, Harrod M, Kellenberg JE, Lehrich JL, Kronick SL, Krein SL, Iwashyna TJ, Saint S, Chan PS. How Do Resuscitation Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest Succeed? A Qualitative Study. Circulation. 2018 Jul 10;138(2):154-163. doi: 10.1161/CIRCULATIONAHA.118.033674. PMID: 29986959; PMCID: PMC6245659.
Chan PS, Krein SL, Tang F, Iwashyna TJ, Harrod M, Kennedy M, Lehrich J, Kronick S, Nallamothu BK; American Heart Association's Get With the Guidelines–Resuscitation Investigators. Resuscitation Practices Associated With Survival After In-Hospital Cardiac Arrest: A Nationwide Survey. JAMA Cardiol. 2016 May 1;1(2):189-97. doi: 10.1001/jamacardio.2016.0073. Erratum in: JAMA Cardiol. 2018 Sep 1;3(9):898. PMID: 27437890; PMCID: PMC5745254.
Guskuma EM, Lopes MCBT, Piacezzi LHV, Okuno MFP, Batista REA, Campanharo CRV. Conhecimento da equipe de enfermagem sobre ressuscitação cardiopulmonar em um hospital universitário. Rev. Eletr. Enferm.. 31º de dezembro de 2019 [citado 18º de junho de 2022]; 21:52253. Disponível em: https://revistas.ufg.br/fen/article/view/52253
Gravesteijn, B.Y., Schluep, M., Lingsma, H.F. et al. Between-centre differences in care for in-hospital cardiac arrest: a prospective cohort study. Crit Care 25, 329 (2021). https://doi.org/10.1186/s13054-021-03754-8
Anderson TM, Secrest K, Krein SL, Schildhouse R, Guetterman TC, Harrod M, Trumpower B, Kronick SL, Pribble J, Chan PS, Nallamothu BK. Best Practices for Education and Training of Resuscitation Teams for In-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes. 2021 Dec;14(12):e008587. doi: 10.1161/CIRCOUTCOMES.121.008587. Epub 2021 Nov 15. PMID: 34779653; PMCID: PMC8759032.
Kim, C. W., & Oh, J. H. (2020). Advantage and limitation of using a visual feedback device during cardiopulmonary resuscitation training.Prehospital and Disaster Medicine, 35(1), 104-108.doi:http://dx.doi.org.bd.univalle.edu.co/10.
Smereka, J., Szarpak, L., Czekajlo, M., Abelson, A., Zwolinski, P., Plusa, T., Dunder, D., Dabrowski, M., Wiesniewska, Z., Robak, O., Frass, M., Sivrikaya G, U., & Ruetzler, K. (2019). The TrueCPR device in the process of teaching cardiopulmonary resuscitation: A randomized simulation trial. Medicine, 98(27), e15995. https://doi.org/10.1097/MD.0000000000015995
Ahn C, Lee S, Lee J, Oh J, Song Y, Kim IY, Kang H. Impact of a Smart-Ring-Based Feedback System on the Quality of Chest Compressions in Adult Cardiac Arrest: A Randomized Preliminary Study. Int J Environ Res Public Health. 2021 May 19;18(10):5408. doi: 10.3390/ijerph18105408. PMID: 34069369; PMCID: PMC8158714.
Chelladurai G, Noor Azhar AM, Mohd Isa R, Bustam A, Ahmad R, Munisamy M. Improving cardiopulmonary resuscitation (CPR) performance using an audio-visual feedback device for healthcare providers in an emergency department setting in Malaysia: a quasi-experimental study. Med J Malaysia. 2020 Sep;75(5):514-518. PMID: 32918419.
Pritchard J, Roberge J, Bacani J, Welsford M, Mondoux S. Implementation of Chest Compression Feedback Technology to Improve the Quality of Cardiopulmonary Resuscitation in the Emergency Department: A Quality Initiative Test-of-change Study. Cureus. 2019 Aug 29;11(8):e5523. doi: 10.7759/cureus.5523. PMID: 31687298; PMCID: PMC6819076.
Carlos Jesús Ortegón Cetina, Moisés Natanael de los Santos Rodríguez, Gilberto Sierra Basto, Calidad de reanimación cardiopulmonar avanzada efectuada por residentes de primer año en un hospital de segundo nivel, Investigación en Educación Médica, Volume 6, Issue 21, 2017, Pages 47-51, ISSN 2007-5057, https://doi.org/10.1016/j.riem.2016.05.009.
van Dawen J, Vogt L, Schröder H, Rossaint R, Henze L, Beckers SK, Sopka S. The role of a checklist for assessing the quality of basic life support performance: an observational cohort study. Scand J Trauma Resusc Emerg Med. 2018 Nov 16;26(1):96. doi: 10.1186/s13049-018-0564-4. PMID: 30445986; PMCID: PMC6240285.
Karen Josey, Marshall L. Smith, Arooj S. Kayani, Geoff Young, Michael D. Kasperski, Patrick Farrer, Richard Gerkin, Andreas Theodorou, Robert A. Raschke, Hospitals with more-active participation in conducting standardized in-situ mock codes have improved survival after in-hospital cardiopulmonary arrest, Resuscitation, Volume 133, 2018, Pages 47-52, ISSN 0300-9572, https://doi.org/10.1016/j.resuscitation.2018.09.020.
Luna-Villanueva Edgar, Santos-Rodríguez Moisés de los, Sierra Basto Gilberto, González-Arriaga Carlos R., Zamora-Graniel Fanny G. Retroalimentación integral (debriefing) oral y asistida por video en simulación de reanimación cardiopulmonar avanzada: estudio piloto. 2015 Abr [citado 2021 Oct 04]; 18(2): 139-147. Disponible en: http://scielo.isciii.es/scielo.php? script=sci_arttext&pid=S2014-98322015000200010&lng=es. https://dx.doi.org/10.4321/S2014-98322015000200010.
Fan H-J, You S-H, Huang C-H, et al. Effectiveness of hands-on cardiopulmonary resuscitation practice with self-debriefing for healthcare providers: A simulation-based controlled trial. Hong Kong Journal of Emergency Medicine. 2017;24(6):268-274. doi:10.1177/1024907917735086
Lorna Rozanski Dudzik, Debra G. Heard, Russell E. Griffin, Mary Vercellino, Amanda Hunt, Adam Cates, Maureen Rebholz, Implementation of a Low-Dose, High-Frequency Cardiac Resuscitation Quality Improvement Program in a Community Hospital, The Joint Commission Journal on Quality and Patient Safety, Volume 45, Issue 12, 2019, Pages 789-797, ISSN 1553-7250, https://doi.org/10.1016/j.jcjq.2019.08.010.
Urushibata N, Murata K, Endo H, Yoshiyuki A, Otomo Y. Evaluation of manual chest compressions according to the updated cardiopulmonary resuscitation guidelines and the impact of feedback devices in an educational resuscitation course. BMC Emerg Med. 2020 Jun 16;20(1):49. doi: 10.1186/s12873-020-00345-8. PMID: 32546142; PMCID: PMC7298753.
Wyllie JP, Yeung J, Nolan JP, Berg KM; COVID-19 Working Group. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life
Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group. Resuscitation. 2021 Dec; 169:229-311. doi: 10.1016/j.resuscitation.2021.10.040. Epub 2021 Nov 11. PMID: 34933747; PMCID: PMC8581280.
Olasveengen TM, Semeraro F, Ristagno G, Castren M, Handley A, Kuzovlev A, Monsieurs KG, Raffay V, Smyth M, Soar J, et al. European Resuscitation Council guidelines 2021: basic life support. Resuscitation. 2021; 161:98–114.
Eshel R, Wacht O, Schwartz D. Real-Time Audiovisual Feedback Training Improves Cardiopulmonary Resuscitation Performance: A Controlled Study. Simul Healthc. 2019 Dec;14(6):359-365. doi: 10.1097/SIH.0000000000000390. PMID: 31743309.
Fuchs, A., Käser, D., Theiler, L., Greif, R., Knapp, J., & Berger-Estilita, J. (2021). Survival and long-term outcomes following in-hospital cardiac arrest in a Swiss university hospital: a prospective observational study. Scandinavian journal of trauma, resuscitation and emergency medicine, 29(1), 115.
https://doi.org/10.1186/s13049-021-00931-0
Committee on the Treatment of Cardiac Arrest: Current Status and Future Directions; Board on Health Sciences Policy; Institute of Medicine; Graham R, McCoy MA, Schultz AM, editors. Strategies to Improve Cardiac Arrest Survival: A Time to Act. Washington (DC): National Academies Press (US); 2015 Sep 29. 2, Understanding the Public Health Burden of Cardiac Arrest: The Need for National Surveillance. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK321501/
Andersen LW, Holmberg MJ, Berg KM, Donnino MW, Granfeldt A. In-Hospital Cardiac Arrest: A Review. JAMA. 2019 Mar 26;321(12):1200-1210. doi: 10.1001/jama.2019.1696. PMID: 30912843; PMCID: PMC6482460.
Ofoma UR, Basnet S, Berger A, Kirchner HL, Girotra S; American Heart Association Get With the Guidelines – Resuscitation Investigators. Trends in Survival After In-Hospital Cardiac Arrest During Nights and Weekends. J Am Coll Cardiol. 2018 Jan 30;71(4):402-411. doi: 10.1016/j.jacc.2017.11.043. PMID: 29389356; PMCID: PMC5858924
Matilda Jerkeman, Pedram Sultanian, Peter Lundgren, Niklas Nielsen, Edvin Helleryd, Christian Dworeck, Elmir Omerovic, Per Nordberg, Annika Rosengren, Jacob Hollenberg, Andreas Claesson, Solveig Aune, Anneli Strömsöe, Annica Ravn-Fischer, Hans Friberg, Johan Herlitz, Araz Rawshani, Trends in survival after cardiac arrest: a Swedish nationwide study over 30 years, European Heart Journal, 2022;, ehac414, https://doi.org/10.1093/eurheartj/ehac414
Malik, A. O., Nallamothu, B. K., Trumpower, B., Kennedy, M., Krein, S. L., Chinnakondepalli, K. M., Hejjaji, V., & Chan, P. S. (2020). Association Between Hospital Debriefing Practices With Adherence to Resuscitation Process Measures and Outcomes for In-Hospital Cardiac Arrest. Circulation. Cardiovascular quality and outcomes, 13(11), e006695. https://doi.org/10.1161/CIRCOUTCOMES.120.006695
Pritchard J, Roberge J, Bacani J, et al. Implementation of Chest Compression Feedback Technology to Improve the Quality of Cardiopulmonary Resuscitation in the Emergency Department: A Quality Initiative Test-of-change Study. Cureus (August 29, 2019)11(8): e5523. doi:10.7759/cureus.5523
Gilmartin S, Martin L, Kenny S, et alPromoting hot debriefing in an emergency departmentBMJ Open Quality 2020: e000913. doi: 10.1136/bmjoq-2020-000913
Clemency, B. M., Innes, J. C., Waldrop, M., White, L. J., Dievendorf, E., Orlowski, R., Wang, K., Lindstrom, H. A., Canty, J. M., Jr, & Hostler, D. (2021). Changes in Field Termination of Resuscitation and Survival Rates After an Educational Intervention to Promote on Scene Resuscitation for Out-of-Hospital Cardiac Arrest. The Journal of emergency medicine, 60(3), 349–354. https://doi.org/10.1016/j.jemermed.2020.10.003
Nas, J., Thannhauser, J., van Geuns, R. M., van Royen, N., Bonnes, J. L., & Brouwer, M. A. (2021). Optimal Combination of Chest Compression Depth and Rate in Virtual Reality Resuscitation Training: A Post Hoc Analysis of the Randomized Lowlands Saves Lives Trial. Journal of the American Heart Association, 10(2), e017367. https://doi.org/10.1161/JAHA.120.017367
Pintos, M. M. (2022). La responsabilidad social de los abogados. Estudios Y Perspectivas Revista Científica Y Académica , 2(2), 92–114. https://doi.org/10.61384/r.c.a.v2i2.23
Da Silva Santos , F., & López Vargas , R. (2020). Efecto del Estrés en la Función Inmune en Pacientes con Enfermedades Autoinmunes: una Revisión de Estudios Latinoamericanos. Revista Científica De Salud Y Desarrollo Humano, 1(1), 46-59. https://doi.org/10.61368/r.s.d.h.v1i1.9
Machuca-Sepúlveda, J., López M., M., & Vargas L., E. (2021). Equilibrio ambiental precario en humedales áridos de altura en Chile. Emergentes - Revista Científica, 1(1), 33-57. Recuperado a partir de https://revistaemergentes.org/index.php/cts/article/view/3
Boza Calvo , R., & Solano Mena , S. (2021). Effectiveness Analysis of The Implementation of The Strategy of Simulation in Education According to The Perception of The Facilitators Involved in The Process as Of the Second Quarter Of 2016. Sapiencia Revista Científica Y Académica , 1(1), 61-77. Recuperado a partir de https://revistasapiencia.org/index.php/Sapiencia/article/view/14
European Commission. (2023). Ethical Guidelines on the Use of Artificial Intelligence (AI) and Data in Teaching and Learning for Educators. Available online: https://op.europa.eu/en/publication-detail/-/publication/d81a0d54-5348-11ed-92ed-01aa75ed71a1/language-en (accessed on 18 November 2023)
Derechos de autor 2023 Jose Pinilla Escobar , Julián Andrés Monroy García , Jhan Deivid Durán Ramírez, Consuelo Burbano López
Esta obra está bajo licencia internacional Creative Commons Reconocimiento 4.0.
.jpg)
