Emergency Medicine · Medical Literature
Using Serious Games to Increase the Implementation of Trauma Triage Guidelines: A Randomized Clinical Trial.
Abstract
Low-cost methods that improve physician adherence to clinical guidelines are lacking. Trauma triage exemplifies time-sensitive conditions where guideline adherence remains at 50% or less despite stakeholder efforts, particularly when treating older adults. To determine whether a theory-based serious game (a purpose-driven video game) improves emergency physician adherence to trauma triage guidelines for older adults. This randomized clinical trial recruited 800 emergency physicians responsible for the triage of Medicare fee-for-service injured patients (≥65 years of age) at emergency departments within nontrauma centers in the US. Physician enrollment began November 27, 2023, and concluded February 7, 2024. Data collection began January 1, 2024 (or the date of enrollment), and ended February 6, 2025. The patients were treated during the 1 year after physician enrollment. Game-based training on a tablet for an initial session of 2 hours and then a 20-minute session each quarter (4 doses; n = 400 physicians) vs usual education (n = 400 physicians). The primary outcome was undertriage (defined as the proportion of severely injured patients not transferred to trauma centers) during the year after randomization. The secondary outcomes were overtriage (defined as the proportion of transferred patients with minor injuries) and a composite clinical outcome of 30-day mortality or hospital readmission. Medicare fee-for-service claims were analyzed using mixed-effects regression models. Of the 800 physicians, the length of experience was a median of 10 (IQR, 6-17) years in practice, 71% were male (563/789), and 750 (94%) had completed Advanced Trauma Life Support. The physicians worked at 1147 hospitals and treated 41 073 injured Medicare patients, of whom 1738 (4.2%) had severe injuries. Of the physicians in the game-based training (intervention) group, 99% (397/399) received 1 dose and 67% (268/399) received 4 doses. Physicians in the game-based training group had a lower proportion of severely injured older adults who were undertriaged (49%; 402/819) compared with the usual education (control) group (57%; 527/919) (model-adjusted difference, -7% [95% CI, -13% to -0.8%]; P = .02). The model-adjusted difference did not differ for the outcomes of overtriage (-3% [95% CI, -6% to 1%]; P = .14) and the composite outcome (-0.4% [95% CI, -5% to 4%]; P = .87). Among physicians responsible for the triage of patients in emergency departments of nontrauma centers, use of a theory-based serious game decreased the proportion of severely injured patients who were undertriaged. ClinicalTrials.gov Identifier: NCT06063434.
Clinical relevance
Does a theory-based serious game (purpose-driven video game) intervention improve emergency physician adherence to trauma triage guidelines—specifically reducing undertriage of severely injured older adults (≥65 years) at non-trauma center emergency departments—compared with usual continuing education? __SNAPSHOT__ {"studyDesign":"Randomized clinical trial (physician-level randomization)","setting":"Emergency departments within non-trauma centers across the United States (multi-site); affiliated with University of Pittsburgh / UPMC research team","sampleSize":"n = 800 physicians (intervention: n = 400; control: n = 400)","population":"Emergency physicians responsible for triaging Medicare fee-for-service injured patients aged ≥65 years at U.S. non-trauma center EDs. Physician enrollment ran November 27, 2023 – February 7, 2024. Median experience 10 years (IQR 6–17); 71% male (563/789); 94% (750/800) had completed Advanced Trauma Life Support. Patient data were drawn from the 1-year post-enrollment period (January 1, 2024 – February 6, 2025).","intervention":"Game-based training ('Night Shift') on a tablet: initial 2-hour session followed by quarterly 20-minute booster sessions (4 total doses). The game places the physician in high-stakes emergency triage scenarios combining narrative storytelling, emotional feedback, and timed decision puzzles designed to reshape maladaptive heuristics.","comparator":"Usual education (standard continuing medical education as required for physician re-certification)","primaryOutcome":"Undertriage — defined as the proportion of severely injured patients NOT transferred to a trauma center — during the 1 year after physician randomization","followUp":"1 year of patient data collection per physician following enrollment","fundingSource":"Government (NIH/National Institutes of Health); no industry sponsorship reported"}
Key findings
Primary outcome — undertriage: Physicians in the game-based training group undertriaged 49% of severely injured older adult patients (402/819 patients), compared with 57% in the usual education group (527/919 patients), yielding a model-adjusted absolute difference of −7% (95% CI, −13% to −0.8%; p = 0.02). The absolute risk reduction of 8 percentage points (calculated) corresponds to a number needed to treat (NNT) of approximately 13 physicians (calculated) to prevent one undertriage event per year, though patient-level NNT is not directly derivable from physician-level data. Secondary outcomes — overtriage (proportion of transferred patients with minor injuries): model-adjusted difference −3% (95% CI, −6% to 1%; p = 0.14) — not statistically significant, indicating the game did not increase inappropriate transfers. Composite clinical outcome (30-day mortality or hospital readmission): model-adjusted difference −0.4% (95% CI, −5% to 4%; p = 0.87) — not statistically significant. Exploratory (non-randomized) dose-response analyses found that physicians who completed all four game sessions showed greater reductions in undertriage than those who completed only one or two sessions, and that the treatment effect was strongest within 30 days of gameplay, with gradual decay until the next session. Game engagement was high: 99% (397/399) of intervention physicians played at least once; 67% (268/399) completed all four sessions. No clinically important adverse events attributable to the intervention were reported.
Practice implications
This trial established that a low-cost, theory-based serious game delivered via tablet can reduce undertriage of severely injured older adults by emergency physicians working at non-trauma centers, with a statistically significant 7-percentage-point absolute reduction in undertriage (p = 0.02). Importantly, the reduction in undertriage was NOT accompanied by a corresponding increase in overtriage, suggesting the intervention may improve diagnostic accuracy rather than merely lower the threshold for transfer—a distinction with meaningful clinical and resource implications. The study did NOT establish a statistically significant improvement in hard clinical outcomes (30-day mortality or readmission), which remained unchanged between groups; whether the triage behavior change ultimately translates to survival benefit requires further study or a larger, outcomes-powered trial. The trial enrolled Medicare fee-for-service patients ≥65 years at non-trauma centers only; findings may not generalize to younger patients, trauma centers, or other time-sensitive clinical conditions. Exploratory dose-response findings are hypothesis-generating and should not be used to guide dosing decisions, as physicians were not randomized to different dose levels, introducing selection bias. Only abstract-level data are publicly available for this summary, which constrains assessment of randomization fidelity, allocation concealment, blinding procedures, and handling of missing data. Practice change may be warranted in settings with similarly high baseline undertriage rates, but the absence of a mortality signal argues for cautious, monitored implementation pending confirmatory data. __LIMITATIONS__ Only abstract-level data are publicly available; full methods, allocation concealment, and handling of missing data cannot be independently assessed.,Physician-level randomization with patient outcomes as the endpoint introduces a unit-of-analysis mismatch; the degree to which clustering was adequately accounted for in the model is not verifiable from the abstract.,The composite clinical outcome (30-day mortality or readmission) showed no statistically significant difference, meaning a patient-level survival benefit was not established.,Usual education comparator was not standardized or described in detail, limiting assessment of what the control arm actually received.,Exploratory dose-response findings are confounded by self-selection: physicians who completed all four sessions may differ systematically from those who did not, precluding causal attribution of greater effect to higher dose.,The treatment effect was strongest within 30 days of play and subsequently decayed, raising concerns about durability and the adequacy of the quarterly 20-minute booster schedule.,The trial was restricted to Medicare fee-for-service patients ≥65 years at non-trauma centers, limiting generalizability to younger populations, other payer types, and trauma center settings.,No blinding of physicians to intervention assignment was possible (inherent in a behavioral intervention), introducing performance bias risk.,Triage transfer rate serves as a process/surrogate endpoint; its relationship to hard patient outcomes (mortality, complications) was not demonstrated in this trial.,The game ('Night Shift') was developed by the same institutional research team conducting the trial, which may introduce investigator allegiance bias, even with government funding. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ In this NIH-funded RCT of 800 emergency physicians at U.S. non-trauma centers, a theory-based serious game ('Night Shift') reduced undertriage of severely injured older adults by an absolute 7 percentage points (49% vs. 57%; p = 0.02) without increasing overtriage. No statistically significant improvement in 30-day mortality or hospital readmission was demonstrated, so a direct patient survival benefit remains unestablished. This intervention represents a promising, scalable, low-cost strategy to improve guideline adherence, but broader implementation should be approached thoughtfully, with outcome-level confirmation as a priority.