Video Game Improves Emergency Doctor Trauma Triage Decision Making

Older adults are under-triaged as much as 70% of the time.

Mohan became interested in improving appropriate triage practices after a frustrating night at work consulting on patients who didn’t need to be there. She then saw a patient who was under-triaged and had a long delay in transferring to her trauma center for appropriate care.

She was witnessing the outcome of ingrained decision-making behaviors, sometimes called mental shortcuts or heuristics, which are notoriously hard to change. After talking with decision scientist Baruch Fischhoff, Ph.D., at Carnegie Mellon University, Mohan hit on the idea to build a video game that could let emergency physicians subconsciously learn from their decisions without impacting real patients.

In 2016 she created the first version of the game Night Shift with Schell Games, a Pittsburgh-based educational and entertainment game development company. The game features a young emergency physician triaging trauma patients in a high-stakes, emotional setting. The player’s decisions garner reinforcing praise or admonishment. The game also has puzzles that the player must solve in under 90 seconds with limited clinical information.

For a year starting in 2024, Mohan and her colleagues followed 800 physicians who staffed the emergency departments of non-trauma centers in the U.S. Half were randomized to play the game for two hours and then quarterly for 20 minutes, and the other half simply attended regularly scheduled continuing education, which physicians are required to receive to maintain certification.

Physicians who played the game had lower rates of under-triaging severely injured older patients, at 49%, compared to a 57% under-triage rate in those who did not play the game. Conversely, playing the game was not associated with over-triaging; both groups over-triaged at the same rate.

Mohan said this provides some reassurance that playing the game didn’t just increase physician willingness to transfer injured patients – rather, it may have improved diagnostic abilities. This indicates that the way the game leverages storytelling to tap into emotions or uses puzzles to shape decision rules may be rewiring heuristics and effectively changing behavior.

Interestingly, Mohan noted that physicians assigned to the game had the best adherence to the trauma triage guidelines within 30 days of playing it, with the effect fading until they played the game again.

“Quarterly exposure for 20 minutes may not be the best ‘dose,’” she said. “Perhaps playing the game more frequently and for less time would be better – maybe even a ‘microdose’ of 90 seconds each week.”

Next steps involve testing that hypothesis, along with an ambitious project to tackle decision making across the spectrum of trauma care, from emergency medical services to non-trauma hospitals to clinical teams at top level trauma centers.

“It would be a multi-component behavioral intervention at multiple levels,” she said. “With the ultimate objective of saving lives.”

Additional authors on this research are co-senior authors Douglas B. White, M.D., M.A.S., and Derek C. Angus, M.D., M.P.H., as well as Chung-Chou H. Chang, Ph.D., Jonathan Elmber, M.D., M.S., Kimberly J. Rak, Ph.D., Jacqueline L. Barnes, Ph.D., Andrew B. Peitzman, M.D., Raquel M. Forsythe, M.D., and Frank X. Guyette, M.D., M.P.H., all of Pitt; Baruch Fischhoff, Ph.D., of Carnegie Mellon University; Brad Bendesky, M.D., of Drexel College of Medicine and Trinity Health System; Casey Carr, M.D., of INTEGRIS Baptist Medical Center; Allyson C. Chapman, M.D., the University of California San Francisco; Jonathan J. Oskvarek, M.D., M.B.A., of US Acute Care Solutions and Summa Health System; Scott D. Weingart, M.D., of Nassau University Medical Center; and Michael B. Weinstock, M.D., of Adena Regional Medical Center and the Wexner Medical Center at The Ohio State University.

This research was funded by the National Institutes of Health (R01 AG 076499, K23 NS097629 and K24 HL148314).