Testing the Efficacy of Two Behavioral Interventions at Recalibrating Physician Heuristics in Trauma Triage

Treatment at trauma centers improves outcomes for patients with moderate-to-severe injuries. Accordingly, professional organizations, state authorities, and the federal government have endorsed the systematic triage and transfer of these patients to trauma centers either directly from the field or after evaluation at a non-trauma center. Nonetheless, between 30 to 40% of patients with moderate-to-severe injuries still only receive treatment at non-trauma centers, so-called under-triage. Most of this under-triage occurs because of physician decisions (rather than first-responder decisions). Existing efforts to change physician decision making focus primarily on knowledge of clinical practice guidelines and attitudes towards the guidelines. These strategies ignores the growing consensus that decision making reflects both knowledge as well as intuitive judgments (heuristics). Heuristics, mental short cuts based on pattern recognition, drive the majority of decision making. The investigators have developed two separate behavioral interventions to recalibrate physician heuristics in trauma triage, and will compare the effect of these interventions, an educational program, and no intervention on physician performance on a virtual simulation.

• Night Shift (Behavioral): Physicians in this arm of the trial will be asked to play Night Shift, an adventure video game, for two hours.
• Graveyard Shift (Behavioral): Physicians in this arm of the trial will be asked to play Graveyard Shift, a puzzle video game, for two hours.
• Educational program (Behavioral): Physicians in this arm of the trial will be asked to use myATLS, an app designed by the American College of Surgeons to serve as an adjunct to the ATLS course, and Trauma Life Support MCQ Review, an app designed to help students prepare for the ATLS exam. They will be asked to spend at least two hours on the combined tasks.
• Control (Behavioral): Physicians in this arm will serve as a no-contact control group.

Primary outcomes

• Incidence rate of successful triage [One month after completion of the intervention]: Physicians in all arms of the study will be asked to complete a virtual simulation, upon completion of the intervention, ideally within one month of enrollment. The virtual simulation replicates the environment of the ED. Physicians have to manage 10 patients that appear concurrently, while also responding to a series of audio-visual distractors. Specifically, they must provide information on whether they will admit, transfer, or discharge the patients home. The investigators will categorize severely injured patients as successfully transferred (transferred to a trauma center or died in the ED) or not (admitted). We will use a Poisson regression to estimate the association between successful transfer and exposure to the different interventions (Night Shift v. Graveyard Shift v. educational program v. control).

Sex: All

Inclusion Criteria:

* Emergency medicine physicians who work at a non-trauma center.
* Emergency medicine physicians who work at a Level III/IV trauma center.

Exclusion Criteria:

* Emergency medicine physicians who work only at a Level I/II trauma center.
* Emergency medicine physicians who do not practice in the US.

• Results publication: Mohan D, Fischhoff B, Angus DC, Rosengart MR, Wallace DJ, Yealy DM, Farris C, Chang CH, Kerti S, Barnato AE. Serious games may improve physician heuristics in trauma triage. Proc Natl Acad Sci U S A. 2018 Sep 11;115(37):9204-9209. doi: 10.1073/pnas.1805450115. Epub 2018 Aug 27. PMID 30150397