• Deepika Mohan, Matthew R Rosengart, Baruch Fischhoff, Derek C Angus, Coreen Farris, Donald M Yealy, David J Wallace, and Amber E Barnato.
• Department of Critical Care Medicine, University of Pittsburgh, Room 638 Scaife Hall, 3550 Terrace Street, Pittsburgh, 15261, PA, USA. mohand@upmc.edu.
• BMC Emerg Med. 2016 Nov 11; 16 (1): 44.

BackgroundBetween 30 and 40 % of patients with severe injuries receive treatment at non-trauma centers (under-triage), largely because of physician decision making. Existing interventions to improve triage by physicians ignore the role that intuition (heuristics) plays in these decisions. One such heuristic is to form an initial impression based on representativeness (how typical does a patient appear of one with severe injuries). We created a video game (Night Shift) to recalibrate physician's representativeness heuristic in trauma triage.MethodsWe developed Night Shift in collaboration with emergency medicine physicians, trauma surgeons, behavioral scientists, and game designers. Players take on the persona of Andy Jordan, an emergency medicine physician, who accepts a new job in a small town. Through a series of cases that go awry, they gain experience with the contextual cues that distinguish patients with minor and severe injuries (based on the theory of analogical encoding) and receive emotionally-laden feedback on their performance (based on the theory of narrative engagement). The planned study will compare the effect of Night Shift with that of an educational program on physician triage decisions and on physician heuristics. Psychological theory predicts that cognitive load increases reliance on heuristics, thereby increasing the under-triage rate when heuristics are poorly calibrated. We will randomize physicians (n = 366) either to play the game or to review an educational program, and will assess performance using a validated virtual simulation. The validated simulation includes both control and cognitive load conditions. We will compare rates of under-triage after exposure to the two interventions (primary outcome) and will compare the effect of cognitive load on physicians' under-triage rates (secondary outcome). We hypothesize that: a) physicians exposed to Night Shift will have lower rates of under-triage compared to those exposed to the educational program, and b) cognitive load will not degrade triage performance among physicians exposed to Night Shift as much as it will among those exposed to the educational program.DiscussionSerious games offer a new approach to the problem of poorly-calibrated heuristics in trauma triage. The results of this trial will contribute to the understanding of physician quality improvement and the efficacy of video games as behavioral interventions.Trial Registrationclinicaltrials.gov; NCT02857348 ; August 2, 2016.

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