Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: randomized controlled trial

Abstract

ObjectiveTo determine whether a behavioral intervention delivered through a video game can improve the appropriateness of trauma triage decisions in the emergency department of non-trauma centers.DesignRandomized clinical trial.SettingOnline intervention in national sample of emergency medicine physicians who make triage decisions at US hospitals.Participants368 emergency medicine physicians primarily working at non-trauma centers. A random sample (n=200) of those with primary outcome data was reassessed at six months.InterventionsPhysicians were randomized in a 1:1 ratio to one hour of exposure to an adventure video game (Night Shift) or apps based on traditional didactic education (myATLS and Trauma Life Support MCQ Review), both on iPads. Night Shift was developed to recalibrate the process of using pattern recognition to recognize moderate-severe injuries (representativeness heuristics) through the use of stories to promote behavior change (narrative engagement). Physicians were randomized with a 2×2 factorial design to intervention (game v traditional education apps) and then to the experimental condition under which they completed the outcome assessment tool (low v high cognitive load). Blinding could not be maintained after allocation but group assignment was masked during the analysis phase.Main outcome measuresOutcomes of a virtual simulation that included 10 cases; in four of these the patients had severe injuries. Participants completed the simulation within four weeks of their intervention. Decisions to admit, discharge, or transfer were measured. The proportion of patients under-triaged (patients with severe injuries not transferred to a trauma center) was calculated then (primary outcome) and again six months later, with a different set of cases (primary outcome of follow-up study). The secondary outcome was effect of cognitive load on under-triage.Results149 (81%) physicians in the game arm and 148 (80%) in the traditional education arm completed the trial. Of these, 64/100 (64%) and 58/100 (58%), respectively, completed reassessment at six months. The mean age was 40 (SD 8.9), 283 (96%) were trained in emergency medicine, and 207 (70%) were ATLS (advanced trauma life support) certified. Physicians exposed to the game under-triaged fewer severely injured patients than those exposed to didactic education (316/596 (0.53) v 377/592 (0.64), estimated difference 0.11, 95% confidence interval 0.05 to 0.16; P<0.001). Cognitive load did not influence under-triage (161/308 (0.53) v 155/288 (0.54) in the game arm; 197/300 (0.66) v 180/292 (0.62) in the traditional educational apps arm; P=0.66). At six months, physicians exposed to the game remained less likely to under-triage patients (146/256 (0.57) v 172/232 (0.74), estimated difference 0.17, 0.09 to 0.25; P<0.001). No physician reported side effects. The sample might not reflect all emergency medicine physicians, and a small set of cases was used to assess performance.ConclusionsCompared with apps based on traditional didactic education, exposure ...

Simulation and Modeling Applications in Global Health Security

“…Similar to aviation simulators which train pilots in emergency procedures, serious games have been used to train surgeons in situational awareness for addressing crises and their ability to anticipate nonroutine adverse events during surgery [108A]. Serious games have been used to train forward combat casualty care medical personnel in a hostile remote environment advanced lifesaving procedures and trauma triage to non-trauma specialists [109][110][111].…”

Does Preexisting Practice Modify How Video Games Recalibrate Physician Heuristics in Trauma Triage?

“…The second, Shift: The Next Generation, used analogical reasoning delivered via a puzzle video game. 13,14 Both games included cases of representative and nonrepresentative patients and incorporated mechanisms to provide feedback based on triage decisions.…”

“…The main results from these studies have been previously reported. 13,14 In the current effort, we performed a post hoc secondary analysis by linking physician data from our previous trials to claims records acquired from the Centers for Medicare and Medicaid Services (CMS). The elderly experience high undertriage and mortality after injury, allowing insight into the determinants of variation in triage practices.…”

“…Enrollment occurred at two separate meetings of the American College of Emergency Physicians in 2016 (Study 1) and 2017 (Study 2). 13,14 We obtained information about physicians including age, sex, race, years of experience, and work environment. Subjects received a wage-based incentive ($100/ h) for participating.…”

“…11 We previously developed two video game interventions to recalibrate heuristics for triage decisions and found that game-based training improved physician decision-making compared with exposure to traditional text-based training or nothing at all. [12][13][14] However, little is known about whether individual differences exist in how physicians respond to behavioral or educational interventions. Better understanding of those differences would ensure the most effective dissemination of training programs.…”