Simulation in healthcare

OBJECTIVES Advanced cardiac life support (ACLS) skills tend to degrade over time. There is mounting evidence that high-fidelity simulation (HFS) is advantageous to teaching ACLS. The
aspects of HFS that enhance learning are not entirely clear, but the anxiety generated by a scenario may enhance retention through well-established learning pathways. We sought to
determinewhether anHFS withaddedemotional stress could provoke anxiety and, if so, whether or not participants learning ACLS would demonstrate better written and applied knowledge retention 6 months after their initial course.

METHODS Twenty-five student volunteers from Year 1 and 2 at Mount Sinai School of Medicine were randomly assigned to a control group or an emotional content (EC) group for a sudden cardiac death management course. All subjects were monitored for heart rate and were assessed using the State-Trait Anxiety
Inventory. Control group participants experienced an HFS in which actors were not scripted to add stress, whereas EC group participants were exposed to an emotionally charged environment
using the same actors.

RESULTS Participants across the two groups were well matched by resting heart rates, baseline anxiety and prior ACLS knowledge. The EC group participants experienced greater anxiety than controls (mean state anxiety score: 35.0 versus 28.2 [p < 0.05]; average heart rate [HR]: 94.6 bpm versus 72.9 bpm [p < 0.05]; maximum HR: 120.8 bpm versus 95.3 bpm [p < 0.05]). Six months later, written test scores were similar,
but the EC group participants achieved higher practical competency examination (‘mega code’) scores than controls (32.5 versus 25.0; p < 0.05). Independent t-tests and
Spearman rank coefficients were employed where applicable.

CONCLUSIONS Simulation with added emotional stressors led to greater anxiety during ACLS instruction but correlated with
enhanced performance of ACLS skills after this course. The quantitative and qualitative values of added stressors need further
exploration, but these values represent important variables in simulation-based education.

Communication is an essential element of the relationship between patient and dentist. Dental schools are required to ensure that undergraduates are adequately trained in communication skills yet little evidence exists to suggest what constitutes appropriate training and how competency can be assessed. This review aimed to explore the scope and quality of evidence relating to communication skills training for dental students. Eleven papers fitted the inclusion criteria. The review found extensive use amongst studies of didactic learning and clinical role-play using simulated patients. Reported assessment methods focus mainly on observer evaluation of student interactions at consultation. Patient involvement in training appears to be minimal. This review recommends that several areas of methodology be addressed in future studies, the scope of research extended to include intra-operative communication, and that the role of real patients in the development of communication skills be active rather than passive.

"Background: Theconcept of simulation as an educational tool in Emergency Medicine is becoming commonly used.
Aims: Developing a simulation-based course appears to be the best way for EM learning and improving patient safety. Teachers should know why simulation techniques are useful in adult learning and at what stage they should be included in the curriculum. This highlights the need for a clear statement of benefits and limitations of medical simulation.
Method: This paper is the outcome of the medical simulation and education workshop that was designed for the 1st Global Network in EM Conference held in Dubai in January 2012.
Results: This paper presents a clear classification of educational scheme in adult medical learning and its benefits in understanding the need for EM in training using teamwork for risk reduction and better health care. There are different ways to teach in simulated environment and it should be in combination with traditional methods. Essential factors for the success of simulation-based education in- clude providing feedback and staff training, integrating simulation into beginning and continuing training and providing repeated practical situations with variable levels of difficulty and setting.
Conclusion: In emergency medicine context, Simulation is helpful for guiding educators and trainees to realize the po- tential learning outcomes in professional development. Simulation improves EM quality of care."

Interprofessional simulation-based education (IPSE) is becoming an increasingly popular educational strategy worldwide within undergraduate healthcare curricular. The purpose of the literature review was to examine qualitative, quantitative and mixed/multi-method research studies featuring undergraduate IPSE.

From humble beginnings in an "emergency room" in the USA and a "casualty station" in the UK, SAMU in France and other models of care around the globe, the modern specialty of emergency medicine has come of age. Over 50 years of evolution have resulted in a specialty that is recognised internationally with a unique domain of skills and knowledge and a critical role in the provision of emergency clinical services in many countries. The development of treatments that are time sensitivesuch as treating AMI, trauma and sepsis -have necessitated a different way of managing emergency patients. The old paradigm of consultant rounds on a hospital ward on a daily or weekly basis, simply does not work. Patients need access to treatments within minutes or hours -not days or weeks… In addition, patient/community expectations have risen and the concept of being managed in a haphazard way by junior doctors on presentation to a hospital with a serious illness is simply not acceptable. The cross fertilisation of management processes from industrial models, such as "lean thinking" have also contributed to the changes in emergency care. Ensuring that patients get the right treatments early in their hospital journey or even prior to arrival in hospital and that a coordinated management plan is instituted requires senior clinical decision making "at the front door". The only feasible way of doing this across multiple subspecialties is by having specialists with emergency training available 24 hours/7days per week. In the past, there has been an argument that emergency medicine is only useful in rich countries -as the marginal benefit compared with cost, for providing this care is less than for other specialties such as public health, infectious diseases or obstetrics. This seems a spurious argument, when the limiting factor in reducing preventable death and morbidity in most low income countries is an organised approach to delivering good emergency care. This often extends to an organised system of medical care in general. Thus, access to any medical care is often as an emergency. Children dying of gastroenteritis need early assessment and good fluid management (not high technology), mothers dying of maternal haemorrhage need access to basic resuscitation and obstetric skills -again not expensive. Trauma care can be massively improved by analgesia, splinting and haemorrhage control -without necessarily having access to a level one trauma centre. Creating an integrated emergency system that ensures access to simple emergency care for the majority of the community should be seen as a basic right globally. This should not be seen as a luxury for rich countries. Even in rich countries, good emergency care is frequently difficult (or impossible) to access because of cost or lack of organisation. The International Federation for Emergency Medicine (IFEM) is the global "umbrella" for emergency medicine societies. Its role is to promote the development of emergency medicine and support countries with developed emergency systems. Through full and affiliate membership, it represents more than 60 countries internationally. There is a lot to learn from each other in improving emergency care and there is much to gain by collectively lobbying governments and other agencies to improve outcomes for emergency patients. I welcome you to join our efforts in improving emergency care internationally.

Excerpts:
"The ‘5 whys’ technique is one of the most widely taught approaches to root-cause analysis (RCA) in healthcare. Its use is promoted by the WHO,1 the English National Health Service, [2] the Institute for Healthcare Improvement, [3] the Joint Commission [4] and many other organisations in the field of healthcare quality and safety. Like most such tools, though, its popularity is not the result of any evidence that it is effective. [5–8]"
....
"But the real problem with ‘5 whys’ is not how it is used in RCA, but rather that it so grossly oversimplifies the process of problem exploration that it should not be used at all. It forces users down a single analytical pathway for any given problem,[13] insists on a single root cause as the target for solutions [9 ,13 ,20] and assumes that the most distal link on the causal pathway (the fifth ‘why’) is inherently the most effective and efficient place to intervene."

"Simulation is becoming more and more popular in the field of healthcare education. The main concern for some faculty is knowing how to organise simulation training sessions when there is no simulation centre as they are not yet widely available and their cost is often prohibitive. In medical education, the pedagogic objectives are mainly aimed at improving the quality of care as well as patient safety. To that effect, a mobile training approach whereby simulation-based education is done at the point of care, outside simulation centres, is particularly appropriate. It is usually called “in-situ simulation”. This is an approach that allows training of care providers as a team in their normal working environment. It is particularly useful to observe human factors and train team members in a context that is their real working environment. This immersive training approach can be relatively low cost and enables to identify strengths and weaknesses of a healthcare system. This article reminds readers of the principle of « context specific learning » that is needed for the good implementation of simulation-based education in healthcare while highlighting the advantages, obstacles, and challenges to the development of in-situ simulation in hospitals. The objective is to make clinical simulation accessible to all clinicians for the best interests of the patient.

La simulation en santé gagne en popularité dans le champ de l’éducation médicale. La préoccupation des formateurs en simulation est de savoir comment proposer des séances de simulation en santé alors que les centres de simulation ne sont pas encore répandus et que leur coût paraît prohibitif. Or, en formation médicale, les objectifs pédagogiques s’orientent principalement vers l’amélioration de qualité des soins et la sécurité du patient. Par sa mobilité, la simulation in-situ est une simulation réalisée « au pied du lit » (point of care), en dehors des laboratoires de simulation. Elle apparaît donc comme une méthode originale qui permet d’entrainer les soignants, en équipe, dans leurs conditions de travail habituelles, afin de mettre en jeu les facteurs humains et faire évoluer les apprenants dans un contexte proche du réel. Tout en identifiant les forces et les faiblesses d’un système de soin, cet entrainement en immersion permet également de réaliser une simulation de haute fidélité à moindre coût. Cet article rappelle le principe de « contextualisation » nécessaire au bon déroulement de la simulation et met l’accent sur les avantages, les obstacles et les défis au développement de la simulation in-situ dans les hôpitaux. Le but est de rendre accessible la simulation en santé à tous pour le bien des patients."

Can the cybernetic communication theories of Norbert Wiener, MIT mathematician and author of the seminal The Human Use of Human Beings, help us answer the question: Do digital interactive games or so-called ‘serious games’ designed to educate or train, help to enhance message delivery, and improve learning and training in a healthcare context? In this paper, we will apply the Norbert Wiener’s cybernetic communication theory to a virtual, online simulation game designed to help control the spread of Methicillin-Resistant Staphylococcus Aureus (MRSA) in hospitals in the UK, as explored in the peer-reviewed “A Virtual Infection Control Simulation: The Development of a Serious Game in Healthcare Sector” written by Andy Pulman and Mark Shufflebottom, in the book Serious Games on the Move.

Specifically, we will look at the use of video or digital online games designed to help healthcare professionals, in this case nurses, deliver safer more effective patient care through a cybernetic communications theory lens. We will apply Wiener’s theory to the question of whether gamified digital content could be used effectively to help reinforce healthcare safety and care-giving procedures. We will briefly explore whether the use of ‘always on’ digitally accessible eLearning games, ones that allow replayability whenever and wherever the user finds herself or himself, help to enhance skills-based learning. We will test the assumption that this serious game, with its reinforcing feedback, and step-wise approach, and ability for users to engage in low-risk trial and error, is not only a strong example of cybernetic principles in action, but a tool for effective learning.

We have developed a NetLogo agent-based model showing the interactions between Organizational Culture, Intellectual Capital and Organizational Performance.  This explains the model, a screencast of which is at: https://www.youtube.com/watch?v=_uUmHj6B1Yc

An application of Artificial Intelligence is computational simulation which reproduces the behavior of a system, such as an organization. Simulations provide benefits into business process management, also by combining scenarios and what-if analysis. This study explores the adoption of agent-based modeling technique, in addition to traditional discrete event simulations. The focus is on a real case study of an hospital emergency department. Following the construction of a new hospital , managers are interested in simulating the actual flows in the new configuration before the moving. In our model, patients and operators are agents, acting due to simple behavioral rules in the environment. The different activities are placed on the map of the department, to provide immediate understanding of bottlenecks and queues. While first results were validated from managers, next steps include the comparison of resulting flows between the new and the old department. Logistics analysis includes the time for moving agents between different wards. Agent based modeling and simulation · Emergency Department

The Modeling and Simulation Community successfully developed and applied interoperability standards like the Distributed Interactive Simulation (DIS) protocol (IEEE 1278) and the High Level Architecture (HLA) (IEEE 1516). These standards were applied for world-wide distributed simulation events for several years. However, this paper shows that some of the assumptions and constraints underlying the philosophy of these current standards are not valid for Medical Simulation Systems. The paper describes the standards, the philosophy, and the limits for medical applications and recommends necessary extensions of the standards to support medical simulation.

Non-medical expertise has a major role in emergency treatment. To examine its real time flow, we propose a method that tracks use of a mannequin to ‘reach a diagnosis’ and ‘alleviate suffering’. Instead of relying on cognitive psychology, interaction analysis or human-computer interaction, we identify events that contribute to real-time decision making. In the Simulation Centre, doctors use a simulated patient, technical devices and each other and, as they do so, trigger events that enable them to identify and meet the ‘patient’s’ needs. By definition, events are changes in the affordance layout that matter to how the scenario is expected to unfold. All parties connect many kinds of expertise: if biosemiotics are central to discovering the patient’s ‘condition’, later events draw more heavily on medical expertise. Since the early phase of the simulation depends on non-medical events, we claim that the method can help us understand how medical knowledge is integrated with non-medical and, specifically, biosemiotic expertise.

The importance of non-technical skills among healthcare professionals is gaining a widespread recognition as critical elements complementing the technical skills used for improving patients' safety. These skills are typically acquired through simulation training, which emerged as an effective way to complement clinical training. Non-technical skills frequently use high-fidelity simulation followed by a facilitated discussion known as debriefing. Debriefing by a skilled facilitator is thought to be essential for effective learning through reflective processes. Unfortunately, evidence to support the elements which contributes towards the effectiveness of debriefing remains sparse. We review the studies where elements of debriefing that have been manipulated and its effectiveness on the acquisition of non-technical skills among healthcare professionals through eight publications across four different databases. Non-technical skills performance improved after manipulated debriefing such as multimedia debrief, self-led debrief or no debrief. Besides, there was no added performance when video recording was added to facilitator-led debriefing. The application of learning theory on specific elements together with the application of selected debriefing models is highly encouraging for effective debriefing.

The evolution of simulation from an educational tool to an emerging evaluative tool has been rapid. Physician certification has a long history and serves an important role in assuring that practicing physicians are competent and capable of providing a high level of safe care to patients. Traditional assessment methods have relied mostly on multiple-choice exams or continuing medical education exercises. These methods may not be adequate to assess all competencies necessary for excellence in medical practice. Simulation enables assessment of physician competencies in real time and represents the next step in physician certification in the modern age of healthcare.

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Objective. The aim of the study is to analyse correlations between age-related cataract (ARC), serum selenium levels and glutathione peroxidase gene 1 and 4 (GPX-1 and GPX-4). Materials and method. A total sample of 275 participants were enrolled into the study: group A, 94 subjects elligible for ARC surgery, and group B, 181 volunteers without ocular symptoms, gender-, age-, and smoking-status and volume-matched at 1:2 with subjects in group A. All participants (n=275) were divided according to the Lens Opacities Classification System III (LOCS III) into: 1) study group (subjects with clinically significant cataract; N≥3 or C≥3 or P≥2), 2) control group (controls with clinically non-significant cataract; N<3 and C<3 and P<2). The single nucleotide polymorphisms of GPX-1 and GPX-4 were assessed using Real Time PCR. Serum selenium levels were assayed using Inductively Coupled Plasma Mass Spectrometry. Results. Low selenium levels significantly predicted any age-related cataract (OR 7.969; p<.01), nuclear cataract (OR 12.823; p<.01) and cortical cataract (OR 3.31; p<.01). There was no significant effect of gender, age, SNP GPX-1 and SNP GPX-4 on the prevalence of age-related nuclear, cortical and posterior sub-capsular cataract. Serum selenium levels of 75-85 µg/L were associated with the lowest prevalence of ARC. Conclusions. Due to a confirmed association between serum selenium levels and age-related cataract, low serum selenium levels may constitute a potential risk factor of age-related cataract.

The objective of this research was to design a 2.4 GHz class AB Power Amplifier (PA), with 0.18um Semiconductor Manufacturing International Corporation (SMIC) CMOS technology by using Cadence software, for health care applications. The ultimate goal for such application is to minimize the trade-offs between performance and cost, and between performance and low power consumption design. This paper introduces the design of a 2.4GHz class AB power amplifier which consists of two stage amplifiers. This power amplifier can transmit 10dBm output power to a 50 load. The power added efficiency is 7.5% at 1dB compression point and the power gain is 10dB, the total power consumption is 0.135W. The performance of the power amplifier meets the specification requirements of the desired.

Simulation modeling is increasingly being used to address a variety of issues in several disciplines including but not limited to healthcare, manufacturing, service and supply chain systems. As a pivotal decision making tool, simulation determines the attractive configurations and alternatives to provide sufficient justification to convince managers to adopt improvements. However, there are some activities in real-world systems which simulation software packages are not enable to address them properly. These type of activities are primarily decision making toolboxes which are developed in order to improve the system performance. For instance, in manufacturing systems, scheduling techniques are widely used to provide the optimal scheduling of the shop floor activities. Therefore, with the aim of long-term strategic planning of the system via simulation, it’s crucial to bring these decision making activities into simulation model. This capability makes the simulation smarter and more accurate since it provides more realistic perspective of the system and what really happens in there.

Embedding this exceptional logic into a simulation model is quite challenging; however, with the advance of current simulation packages like SIMIO, its attainable. One of the advantageous of SIMIO among many, is its “Application Programmers Interface” (API) capability, which allows users to customize or extend their desired model properly. The extension could be adding new steps, elements and rules, importing and exporting data, enhancing experimentation with external algorithms, or interfacing from external programs. By leveraging the API capability, this study presents a new user defined step instance which incorporates MATLAB as an integral part of the SIMIO. This step is called “CallMatlab” and requires the folder address that the MATLAB file is located plus the MATLAB function’s name. Similar to the existing step instances in SIMIO, the user could easily drag-and-drop CallMatlab while building processes.

La simulation en santé gagne en popularité dans le champ de l’éducation médicale. La préoccupation des formateurs en simulation est de savoir comment proposer des séances de simulation en santé alors que les centres de simulation ne sont pas encore répandus et que leur coût paraît prohibitif. Or, en formation médicale, les objectifs pédagogiques s’orientent principalement vers l’amélioration de qualité des soins et la sécurité du patient. Par sa mobilité, la simulation in-situ est une simulation réalisée « au pied du malade » (point of care), en dehors des laboratoires de simulation. Elle apparaît donc comme une méthode originale qui permet d’entrainer les soignants, en équipe, dans leurs conditions de travail habituelles, afin de mettre en jeu les facteurs humains et faire évoluer les apprenants dans un contexte proche du réel. Tout en identifiant les forces et les faiblesses d’un système de soin, cet entrainement en immersion permet également de réaliser une simulation de haute fidélité à moindre coût. Cet article rappelle le principe de « contextualisation » nécessaire au bon déroulement de la simulation et met l’accent sur les avantages, les obstacles et les défis au développement de la simulation in-situ dans les hôpitaux. Le but est de rendre accessible la simulation en santé à tous, pour le bien des patients.

Malaysian healthcare landscape is changing rapidly and facing drastic transformation in relation to drivers of change in the healthcare system. The objective of this study is to analyze the impact of healthcare resources interventions on accessibility and affordability of healthcare. The Malaysian Healthcare Resources Model (MHRM) is developed to provide a wide-ranging view of the complex interactions between demand and supply of healthcare resources and provide potential future scenarios of healthcare provision to achieve the country's target. The scenario analysis' findings suggest that increasing healthcare resources through medical workforce supply and productivity of hospital beds (bed turnover ratio) will assist to achieve healthcare accessibility and this in turn will improve the quality of healthcare along with moderate increase in budget allocation to public healthcare. Meanwhile, reducing the proportion of out-of-pocket expenditure is more valuable than having higher income in fostering healthcare affordability among Malaysians.

Simulating healthcare processes is a sophisticated endeavor. Treatment processes and patient arrival patterns differ significantly in their statistical attributes and implicate a high degree of variability. In addition, there are several types of interconnected processes of medical staff involved that accompany a patient's journey through the healthcare facility. Replicating this behavior with process flow models in a discrete event simulation model is highly complex and therefore difficult to create while maintaining a high degree of precision.

Today’s healthcare professionals face many challenges.
Preparing the next generation for these challenges requires
innovative and daring new ways of thinking. Globally,
healthcare faculty are aging and find themselves in an
increasingly complex healthcare system compared to when
they were educated. The patient population includes frail
elderly, physical comorbidities, and mental health issues
to name a few. An explosion of information provides
new research and best practice standards, including new
pharmaceutical options, complex technological medical
treatments, and nursing care must evolve and include
a multiprofessional approach. Healthcare professionals
recognize the need to collaborate interprofessionally with the
multiple allied health professionals emerging, and yet they
face challenges daily trying to make this practice a reality.
What options exist for education of healthcare students and
how can we manage professional development of healthcare
faculty to accommodate these changes?
http://scholar.google.ca/scholar_url?url=https://www.revistas.ufg.br/fen/article/download/57250/33729&hl=en&sa=X&d=6455783703820394227&scisig=AAGBfm3Z1FGSbV45RX8pTeuTWA-6g0Y1rg&nossl=1&oi=scholaralrt

Kristie Holmes, PhD, LCSW
University of Southern California
USC Suzanne Dworak-Peck School of Social Work
323-459-5685

Cardiac issues will end our lives as females 33% of the time- more than breast cancer ever will, despite incredible awareness campaigns that have convinced us otherwise. Symptoms like fatigue, frequent urination, shortness of breath and headaches are easily ignored by patients as well as providers.

Educational objectives:
1. Increase knowledge of cardiac issues pre, during, and post birth.
2. Increase knowledge of signs and symptoms to refer immediately as a mental health provider, including "impending doom".
3. Increase knowledge of clear action items to raise awareness in participant's network that will save lives.
4. Increase knowledge of maternal mortality rate in the US as compared to other countries in the world and how California has reversed the national trend.

Medical schools and residencies are currently facing a shift in their teaching paradigm. The increasing amount of medical information and research makes it difficult for medical education to stay current in its curriculum. As patients become increasingly concerned that students and residents are ''practicing'' on them, clinical medicine is becoming focused more on patient safety and quality than on bedside teaching and education. Educators have faced these challenges by restructuring curricula, developing small-group sessions, and increasing self-directed learning and independent research. Nevertheless, a disconnect still exists between the classroom and the clinical environment. Many students feel that they are inadequately trained in history taking, physical examination, diagnosis, and management. Medical simulation has been proposed as a technique to bridge this educational gap. This article reviews the evidence for the utility of simulation in medical education. We conducted a MEDLINE search of original articles and review articles related to simulation in education with key words such as simulation, mannequin simulator, partial task simulator, graduate medical education, undergraduate medical education, and continuing medical education. Articles, related to undergraduate medical education, graduate medical education, and continuing medical education were used in the review. One hundred thirteen articles were included in this review. Simulation-based

Health is one of the sustainable development areas in all of the countries. Internet of Things has a variety of use in this sector which was not studied yet. The aim of this research is to prioritize IoT usage in the healthcare sector to achieve sustainable development. The study is an applied descriptive research according to data collection. As per the research methodology which is FAHP, it is a single cross-sectional survey research. After data collection, the agreed paired comparison matrices, allocated to weighted criteria and the priority of IoT usage were determined. Based on the research findings, the two criteria of "Economic Prosperity" and "Quality of Life" achieved the highest priority for IoT sustainable development in the healthcare sector. Moreover, the top priorities for IoT in the area of health, according to the usage, were identified as "Ultraviolet Radiation", "Dental Health" and "Fall Detection".

Purpose: Although simulation technology in nursing education is becoming increasingly commonplace, a review of the literature reveals a paucity of rigorous, high-level research comparing the effectiveness of simulation with other traditional education methods in the acquisition of clinical knowledge and skills. This research aimed to investigate the impact of three learning interventions on graduate nurse health assessment knowledge and skills. It was hypothesized that the patient assessment skills of graduate nurses who completed a simulation learning activity would be superior to those who completed traditional education activities. Methods: Graduate nurses (n ϭ 74) were randomly allocated to three groups (1: self-directed learning package [SDLP] only; 2: SDLP plus two scenario-based PowerPoint workshops; and 3: SDLP plus two simulation education sessions using a manikin with lowfidelity capabilities. Following the education activities, graduates completed an individual test involving a systematic patient assessment upon a manikin. They were scored using a checklist of relevant responses. Results: Analysis of variance results suggest that the mean test score for nurses in the simulation group (mean ϭ 135.52, SD ϭ 26.63) was significantly higher (P Ͻ 0.001) than those in the learning package group (mean ϭ 107.42, SD ϭ 29.82) and the PowerPoint group (mean ϭ 102.77, SD ϭ 31.68).

The evolution of simulation from an educational tool to an emerging evaluative tool has been rapid. Physician certification has a long history and serves an important role in assuring that practicing physicians are competent and capable of providing a high level of safe care to patients. Traditional assessment methods have relied mostly on multiple-choice exams or continuing medical education exercises. These methods may not be adequate to assess all competencies necessary for excellence in medical practice. Simulation enables assessment of physician competencies in real time and represents the next step in physician certification in the modern age of healthcare. Mt Sinai J Med 79:140-153, 2012.  2012 Mount Sinai School of Medicine

background: Based on the guidelines 2010 and regarding the next version 2015, this article shows the new possibilities to care about the cardiac arrest casualties, is there any increase of return of spontaneous circulation (ROSC), survival rate and neurological outcome? Do we need to adapt our emergency care for the future?
Methods: Using a simulation case, the CCR pathway brings the new techniques and devices on the front of the scene. The association between them was a critical point to get a positive alchemy.
Results: Based on studies, evidence based-medicine and field experiences in different companies around the world, we can note a good outcome between all this new supports for our patients.
Conclusion: This pathway shows, with a good survival chain, an important improvement to the cardiac arrest care and gives a new vision for the reanimation pre and in-hospital.

The research goal is to develop tools for bridging participant’s abstraction gap within healthcare facilities projects. Tools that help participants create and manipulate representations of abstract concepts like space use and time management based on participant’s concrete experience. It’s important that these tools can be used both in group meetings and individual contexts for enabling constant concrete reevaluation of abstractions being produced. Distributed collaboration can overcome participant’s limited scheduled availability for meetings and encourage participation from people that feel constrained to talk in group meetings.