Using Serious Games to Increase the Implementation of Trauma Triage Guidelines

Importance: 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. Objective: To determine whether a theory-based serious game (a purpose-driven video game) improves emergency physician adherence to trauma triage guidelines for older adults. Design, Setting, and Participants: 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. Interventions: 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). Main Outcomes and Measures: 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. Results: 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). Conclusions and Relevance: 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. Trial Registration: ClinicalTrials.gov Identifier: NCT06063434.