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Introduction: Disaster triage training for emergency medical service (EMS) providers is not standardized. Simulation training is costly and time-consuming. In contrast, educational video games enable low-cost and more time-efficient standardized training. We hypothesized that players of the video game "60 Seconds to Survival" (60S) would have greater improvements in disaster triage accuracy compared to control subjects who did not play 60S. Methods: Participants recorded their demographics and highest EMS training level and were randomized to play 60S (intervention) or serve as controls. At baseline, all participants completed a live school-shooting simulation in which manikins and standardized patients depicted 10 adult and pediatric victims. The intervention group then played 60S at least three times over the course of 13 weeks (time 2). Players triaged 12 patients in three scenarios (school shooting, house fire, tornado), and received in-game performance feedback. At time 2, the same live simulation was conducted for all participants. Controls had no disaster training during the study. The main outcome was improvement in triage accuracy in live simulations from baseline to time 2. Physicians and EMS providers predetermined expected triage level (RED/YELLOW/GREEN/BLACK) via modified Delphi method. Results: There were 26 participants in the intervention group and 21 in the control group. There was no difference in gender, level of training, or years of EMS experience (median 5.5 years intervention, 3.5 years control, p = 0.49) between the groups. At baseline, both groups demonstrated median triage accuracy of 80 percent (IQR 70-90 percent, p = 0.457). At time 2, the intervention group had a significant improvement from baseline (median accuracy = 90 percent [IQR: 80-90 percent], p = 0.005), while the control group did not (median accuracy = 80 percent [IQR:80-95], p = 0.174). However, the mean improvement from baseline was not significant between the two groups (difference = 6.5, p = 0.335). Conclusion: The intervention demonstrated a significant improvement in accuracy from baseline to time 2 while the control did not. However, there was no significant difference in the improvement between the intervention and control groups. These results may be due to small sample size. Future directions include assessment of the game's effect on triage accuracy with a larger, multisite site cohort and iterative development to improve 60S.
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www.disastermedicinejournal.com 75
DM
Abstract
Introduction: Disaster triage training for emer-
gency medical service (EMS) providers is not standard-
ized. Simulation training is costly and time-consuming.
In contrast, educational video games enable low-cost
and more time-efficient standardized training. We
hypothesized that players of the video game “60 Seconds
to Survival” (60S) would have greater improvements in
disaster triage accuracy compared to control subjects
who did not play 60S.
Methods: Participants recorded their demograph-
ics and highest EMS training level and were rand-
omized to play 60S (intervention) or serve as controls. At
baseline, all participants completed a live school-shoot-
ing simulation in which manikins and standardized
patients depicted 10 adult and pediatric victims. The
intervention group then played 60S at least three times
over the course of 13 weeks (time 2). Players triaged 12
patients in three scenarios (school shooting, house fire,
tornado), and received in-game performance feedback.
At time 2, the same live simulation was conducted for
all participants. Controls had no disaster training dur-
ing the study. The main outcome was improvement in
triage accuracy in live simulations from baseline to
time 2. Physicians and EMS providers predetermined
expected triage level (RED/YELLOW/GREEN/BLACK)
via modified Delphi method.
Results: There were 26 participants in the inter-
vention group and 21 in the control group. There was
no difference in gender, level of training, or years of
EMS experience (median 5.5 years intervention, 3.5
years control, p = 0.49) between the groups. At baseline,
both groups demonstrated median triage accuracy of
80 percent (IQR 70-90 percent, p = 0.457). At time 2, the
intervention group had a significant improvement from
baseline (median accuracy = 90 percent [IQR: 80-90
percent], p = 0.005), while the control group did not
(median accuracy = 80 percent [IQR:80-95], p = 0.174).
However, the mean improvement from baseline was not
significant between the two groups (difference = 6.5,
p = 0.335).
Conclusion: The intervention demonstrated a
significant improvement in accuracy from baseline to
time 2 while the control did not. However, there was
no significant difference in the improvement between
the intervention and control groups. These results may
be due to small sample size. Future directions include
assessment of the game's effect on triage accuracy with
a larger, multisite site cohort and iterative development
to improve 60S.
Key words: serious video games, disaster triage,
pediatrics, paramedics, emergency medical techni-
cians, curriculum evaluation
Introduction
In mass casualty incidents (MCIs), prehospital
care providers, specifically paramedics and emergency
medical technicians (EMTs), are called upon to perform
disaster triage.1,2 These incidents are infrequent and
thus most EMTs have little experience with disaster
ORIGINAL ARTICLE
60 seconds to survival: A pilot study of a disaster triage video game
for prehospital providers
Mark X. Cicero, MD; Travis Whitfill, MPH; Kevin Munjal, MD; Manu Madhok, MD, MPH; Maria Carmen G. Diaz, MD;
Daniel J. Scherzer, MD; Barbara M. Walsh, MD; Angela Bowen, RN, BSN, CPEN, NREMT-P;
Michael Redlener, MD; Scott A. Goldberg, MD, MPH; Nadine Symons, MD; James Burkett, DHSc, PA-C, DFAAPA;
Joseph C. Santos, MPH, NREMT; David Kessler, MD, MSc, RDMS; Ryan N. Barnicle, MD, MEd;
Geno Paesano, NREMT-P; Marc A. Auerbach, MD, MSc
DOI:10.5055/ajdm.2017.0263
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76 American Journal of Disaster Medicine, Vol. 12, No. 2
triage. Triage impacts outcomes for the individual
patient, outcomes for the whole population of victims,
and the communities in which the MCIs occur.3-5
Regardless of what triage strategy prehospital
care providers use,1,6,7 errors in triage are possible.
The consequences of triage errors can include delayed
field treatment for critically ill or injured patients,
inefficient use of field resources, and use of hospital
resources best used for more critical patients for lower
priority patients instead. Triage errors may be divided
into over- and under-triage.
Over-triage can occur in two ways and leads to
the allocation of more resources than are necessary or
indicated for a particular patient. It can occur as the
erroneous assignment of a higher triage category (eg,
Red) to a patient who is not critically ill or injured.8
When a physiologically stable patient with minor
injuries consumes healthcare resources for which a
more acute patient has a greater need (eg, field stabi-
lization, transport to a hospital, the operating room),
outcomes for the more injured individual will worsen.9
Over-triage also occurs when deceased patients and
patients whose injuries or illness are incompat-
ible with survival are triaged a category other than
deceased or expectant (eg, Black).4,10
Under-triage, in contrast, is the failure to rec-
ognize a nonambulatory (Yellow), or critically ill or
injured (Red) patient as needing delayed or immedi-
ate medical care.11,12 Consequences of under-triage
can include delayed treatment, worsening of clinical
status, or patient demise.13
Disaster triage occurs in a hectic and time-con-
strained environment. It is a difficult task, particu-
larly when children are among the victims14: children
are more vulnerable than able-bodied adults, may not
communicate with EMS providers, and the manage-
ment of their illness and injuries are less familiar to
EMS providers. Despite this, training for disaster tri-
age is not standardized, and often brief or absent.
Training modalities such as live simulation,15,16
and tabletop exercises17,18 have been shown to improve
triage accuracy. There are several advantages to live
simulation with manikins and standardized patients.
These advantages include opportunities for hands-on
skill practice (eg, airway repositioning and tourniquet
application), debriefing with a facilitator,19,20 and
opportunities to master skills and knowledge with mul-
tiple simulations over time.21,22 There are limitations
to simulation-based disaster training, however, includ-
ing potential cost of the equipment and instructor time,
and schedule constraints for busy EMS providers.
In the aviation industry and in other healthcare
disciplines, serious video games overcome these limi-
tations23 while standardizing training24 and improv-
ing learner performance.25 Though previous work has
examined and supported video game education in
healthcare,26-28 the use of video games in disaster edu-
cation, especially for paramedics and EMTs, has been
the subject of infrequent rigorous investigation.29
In this work, we aimed to assess the efficacy of
the serious video game “60 Seconds to Survival” (60S)
for EMS disaster triage learning. We hypothesized
that participants who played 60S would demonstrate
greater improvement in triage accuracy over time
than EMS providers who had no formal disaster tri-
age training during the study period. Secondary out-
comes included associations between the game and
decreased instances of over- and under-triage for 60S
playing EMS providers.
Methods
Participants
Participants were EMS providers including para-
medics, paramedic students, and EMTs at a single EMS
training facility affiliated with a medical school. All
participants completed a survey of their demographics,
highest level of EMS training, and years of EMS expe-
rience. The institutional review board of the sponsoring
medical school determined this study was exempt from
formal review, as it occurred in an educational context.
Video game design and rationale
The video game 60S was iteratively developed
with input from EMS providers and educators and
emphasizes the triage of pediatric MCI victims. A
team of software designers and graphic designers
worked with the investigators to develop 60S.
In the game, players completed a practice level to
gain familiarity with play. After the practice level, game
play was divided into three levels, each portraying a
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www.disastermedicinejournal.com 77
different kind of MCI (school shooting, multiple-family
house fire, tornado). Each level consisted of three views,
for example, gymnasium, hallway, and classroom for the
school shooting scenario (Figure 1), and each view had
three to five victims, for a total of 12 victims per level.
The victim screens (Figure 2) allowed players to perform
assessments (eg, check pulse, assess mental status),
select appropriate interventions (eg, apply a tourniquet,
Figure 1. In the view screen, players view a portion of the disaster scenario, assess which patients can walk and
move, and decide the order in which to evaluate patients.
Figure 2. In the patient screen, players may make assessments, such as checking pulse or mental status, take
actions, such as placing a tourniquet, and assign triage levels.
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78 American Journal of Disaster Medicine, Vol. 12, No. 2
reposition the airway, provide rescue breaths), and finally
assign a color-coded triage tag (Red-Immediate, Yellow-
Delayed, Green-Minor, or Black-Deceased/Expectant).
START/JumpSTART triage is employed in 60S, as it is
the most commonly used pediatric triage system in the
United States7 and has compared favorably to other tri-
age modalities.30
Game elements were included to encourage play
and enhance replay value. These elements included
a countdown clock, a minimum score required to
advance to the next level, a soundtrack selected to
promote a sense of urgency, and a leaderboard that
displayed the 10 highest player scores.
The 60S feedback system of 60S was personalized
to the participant's performance during each instance
of gameplay and displayed gaps between actual and
ideal triage performance. Participants received a
numerical score, representing percentages of overall
triage accuracy and efficiency (ideal efficiency defined
as triage of an individual victim in <30 seconds,
acceptable as triage in 30-59 seconds, and needing
improvement if triage took 60 + seconds).
Study design
We conducted a randomized controlled study of
the impact of playing 60S on EMS provider's triage
accuracy. At the onset of the study (baseline), all par-
ticipants completed the same live simulation, a school
shooting with 10 victims, six children and four adults.
One of the victims was a nursery caregiver, portrayed
by a standardized patient. The other nine victims were
played by a uniform group of low-, mid-, and high-fidel-
ity manikins. Injuries included minor, serious, and
fatal gunshot wounds and blunt trauma. Participants
individually assessed and triaged the patients.
Facilitators introduced the scenario and directed the
participants to triage each of the victims. Facilitators
used a standardized set of responses and vital signs
that were offered when requested. Facilitators did
not provide any guidance, hints, or feedback to par-
ticipants. Participants were video recorded for later
analysis of triage accuracy, and videos were stored in
a secure, password-protected repository.
Participants were randomized in blocks of three, 2:1
Intervention: Control. Control subjects had no formal
disaster triage training offered for the remainder of the
study. Participants randomized to the intervention group
were encouraged to play the game weekly for 13 weeks
and received weekly email reminders to play. If a par-
ticipant did not play the game for 14 days, they received
personal communication encouraging gameplay.
At the conclusion of the study (time 2), 13 weeks
after the onset, all participants returned to the same
simulation center and completed the same live simu-
lation as at the onset of the study. At the conclusion of
the second live simulation, the expected triage level
of each victim was revealed to the participant, as well
as expected assessments and actions. Control subjects
were granted access to 60S after completing the sec-
ond simulation. All participants who completed the
study were granted a continuing education certificate
and a $50 gift card.
Data management and statistical analysis
A SQL-based relational database was automati-
cally populated from 60S. Captured data included
players’ demographics and registration information,
instances of play, assessments, actions, and triage deci-
sions, and time spent per patient and game level. Data
were extracted from the relational database using
Tableau v. 9.0.2 (Tableau Software, Seattle, WA) and
analyzed using SPSS v. 22 (IBM Inc., Armonk, NY).
Descriptive statistics were conducted with Mann-
Whitney U tests for nonparametric continuous data,
independent, two-sided t tests for normal continuous
data, and chi-square tests for proportions. Wilcoxon
signed-rank tests were conducted to determine any
significant improvements to baseline to the end of the
study. Pearson's correlations were used to examine
any possible relationships between game play and live
simulation performance. Last, a mixed-effects linear
regression controlling for site and modeling improve-
ment was performed to evaluate potential confounders
and their effect on improvement between the control
and intervention groups.
Results
A total of 68 participants were recruited for
the study, and 62 were enrolled and randomized. Of
the 62 that were enrolled, 23 were randomized to the
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www.disastermedicinejournal.com 79
control group and 39 were randomized to the inter-
vention group. Of these, two controls were excluded
from analysis because they did not complete the
second session, and 13 were excluded from analyses
because eight did not complete the second session
and five did not play the game at least three times
(Figure 3). There was no difference between the
groups regarding gender (p = 0.53), level of training
(p = 0.55), or years of experience (median 3.5 years
intervention, 5.5 years control, p = 0.49). Participant
characteristics are presented in Table 1.
At the onset of the study, median triage accu-
racy in the live simulation was 80 percent in both
groups (IQR 60-90 percent control, 70-80 percent
intervention). There was no difference between
groups (p = 0.457). At the end of the study, after
the intervention group had played the game for 13
weeks, the intervention group had median triage
accuracy of 90 percent (IQR 80-90 percent) with a
median improvement of 10 percent (IQR:0,20) and
mean improvement of 13 percent (p = 0.005 between
baseline and time 2), while the control group saw
no difference between the start and end of the
study (median improvement = 0 [IRQ: −5,20], mean
improvement = 6 percent; p = 174 between baseline
and time 2). The median difference between the two
groups was 10 percent (p = 0.335) and the mean dif-
ference was 6.5 (p = 0.279). Improvement in both
groups is represented in Figure 4. A mixed-effects
linear regression revealed that a higher number of
years of experience was negatively associated with
simulation improvement (Table 2). There was no
correlation between either number of game plays
or triage accuracy in the game and improvement in
live simulation triage accuracy.
Discussion
Between the onset and the conclusion of the study,
there was a significant improvement in triage accu-
racy for the intervention group but not for the control
group. This finding supports our hypothesis; however,
the difference in triage accuracy between the control
and intervention groups at the end of the study was
not significant in unadjusted and adjusted analyses.
This is most likely due to a small sample size, as our
study was under-enrolled due to a number of partici-
pants not completing the study.
Video game based factors are another potential
explanation for the lack of difference in the triage accu-
racy between the intervention and control groups. The
median number of times (8) that players interacted with
the game may have been too few for learners to reach
maximal learning. A game-based barrier to more inter-
actions with the game was the lack of novelty in replay-
ing the game: each patient behaved exactly the same
way each time participants played the game. Previous
work has shown that maintaining novelty31 is associated
with increased video game play to the point of mastery.
Figure 3. Participant flow diagram, including randomization and inclusion in analysis.
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80 American Journal of Disaster Medicine, Vol. 12, No. 2
Video games in healthcare education are increas-
ingly recognized as valid and efficacious means for
imparting skills23,26 and knowledge.27 Video games have
faced the same barriers to acceptance in healthcare
education seen at the onset of healthcare simula-
tion.32,33 Recent work by Mohan et al has shown that
video game education can be rigorously designed and
used to evaluate changes in clinical work behaviors.
Table 1. Participant characteristics
Group
p-value
Control
N = 21 (%)
Intervention
N = 26 (%)
Gender 0.526
Male 17 (81) 19 (73)
Female 4 (19) 7 (27)
Profession 0.549
First responder or student 6 (29) 6 (27)
EMT 6 (29) 11 (42)
Paramedic 7 (33) 6 (23)
Other 3 (13) 4 (12)
Race 0.501
White 17 (81) 23 (89)
Other 3 (14) 3 (12)
Median years of experience (IQR) 5.5 (0, 10.5) 3.5 (0, 9.3) 0.486
Median number of game plays 8.0 (2.8, 11.5)
Median final game-based triage accuracy 50 (50, 100)
Table 2. Linear regression modeling
improvement from baseline
to second simulation
βSE p-value
Intervention
group vs. control
group
2.3 6.2 0.710
Number of years
of experience −0.8 0.4 0.038
Gender (males
vs. females) −2.6 7.7 0.736
Training (EMT/
Paramedic vs.
others)
−9.1 8.9 0.316
Figure 4. Improvement in triage accuracy for video
game participants and controls.
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www.disastermedicinejournal.com 81
Parallels may be drawn between that work and ours,
as both studies involved adherence to algorithms and
guidelines in the triage of trauma victims. Game-based
curricula for clinical reasoning and decision-making for
nursing students34 and medical students35 have further
strengthened the argument that video games are effi-
cacious, serious modes of education.
Participant factors may have contributed to the
lack of difference between the intervention and con-
trol groups. As noted above, there were no significant
differences in the demographics of the two groups.
Additionally, this study was conducted at a single EMS
training facility. During the time of the study, there
was no formal MCI or disaster training offered at the
training site, nor, to our knowledge, was there an MCI
to which our participants responded. No feedback
was given after the first live simulation to any par-
ticipants. However, media coverage of MCI and/or
community events during the study period could have
triggered self-study by EMS providers. It is also pos-
sible that members of the control group independently
studied disaster triage in the interval between the
two live simulations or that the first live simulation
served as an educational experience for the control
group, even without feedback or formal instruction.
The Hawthorne effect, by which the participants knew
they would be observed and therefore altered their
behavior, may also have influenced performance in the
second simulation.
Limitations
Our study is subject to several limitations. It is
possible that the study was underpowered to detect
a significant difference in improvement between
the intervention and control groups. The difference
between the two groups was 6.5 but was not signifi-
cant. Possibly with a larger cohort, a significant dif-
ference would have emerged. Additionally, we did not
evaluate for the association between individual par-
ticipant demographics and interaction with 60S. For
example, an assessment by participant age and self-
reported experience with video game play could assist
in targeting subgroups that are more likely to ben-
efit from 60S as an educational intervention. A fur-
ther limitation is the relative small size of the MCIs
depicted in 60S. Each game level had 12 victims. It
is unknown how performance in 60S would be associ-
ated with triage accuracy in a video game, live simu-
lation, or real MCI with a greater number of victims.
Future directions
This investigation suggests several directions for
future inquiry. First, from participant feedback and
the results of the study, it is likely that variety in
the presentation of each patient (eg, changes in vital
signs, injuries, and responses to triage interventions,
or combination of the assessment and intervention
game interface panels, as suggested by some partici-
pants) will improve player engagement. Next, a com-
parison of learner improvement in which intervention
participants with the lowest initial live simulation
accuracy are compared to intervention participants
with the highest initial accuracy might help target
characteristics of learners most likely to benefit from
the video game as a learning intervention. In other
words, an assessment of players’ baseline accuracy
and amount if improvement could reveal whether the
game is helpful for all learners or just those with the
biggest gaps between actual and ideal performance.
Additionally, comparisons of future participant base-
line triage accuracy and triage accuracy after the
video game intervention by population density (eg,
urban vs. rural), and EMS agency model (fire, free-
standing EMS, hospital, or aeromedical-based) may
guide the design of targeted video game education.
Finally, the linear regression analysis showed a nega-
tive association with improvement in the live simula-
tions. An intervention targeting junior, and possibly
younger, EMS providers could reveal that 60S has the
greatest effect for that group.
Additional future investigations can include a mul-
ticenter study with a greater number of EMS providers
will provide greater power for detecting associations
between 60S game play and improved triage accuracy
and efficiency. Finally, a cost-benefit analysis compar-
ing triage accuracy and efficiency among EMS provid-
ers who participate in a live simulation curriculum to
those who complete a video game such as 60S would be
important for guiding disaster triage training decisions.
A final, possibly most intriguing, future direction is a
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82 American Journal of Disaster Medicine, Vol. 12, No. 2
non-inferiority study comparing triage outcomes when
EMS providers learn disaster triage with live-simula-
tion versus a video game educational intervention.
Conclusion
Participants who played 60S demonstrated
improved triage accuracy from the beginning to
the end of the study, and the control group did not.
However, there was no significant difference in tri-
age performance at the end of the study between the
intervention and control groups. These results may
be due to small sample size, the Hawthorne effect or
lack of variation in patient presentation in this itera-
tion of 60S. Future studies can determine why the null
hypothesis was accepted, and result in a more effica-
cious version of the 60S disaster triage video game.
Acknowledgment
This study was supported by the Agency for Healthcare Research
and Quality grant 1R18HS022837-01.
Mark X. Cicero, MD; Departments of Pediatrics and Emergency
Medicine, Yale School of Medicine, New Haven, Connecticut.
Travis Whitfill, MPH, Department of Pediatrics, Yale School of
Medicine, New Haven, Connecticut.
Kevin Munjal, MD, Emergency Medicine, Mount Sinai Medical
Center, New York, New York.
Manu Madhok, MD, MPH, Pediatrics, Children's Minnesota
Minneapolis Hospital, Saint Paul, Minnesota.
Maria Carmen G. Diaz, MD, Pediatrics, A. I. DuPont Hospital for
Children, Wilmington, Delaware.
Daniel J. Scherzer, MD, Pediatrics, Nationwide Children's Hospital,
Columbus, Ohio.
Barbara M. Walsh, MD, Associate Professor of Pediatrics, Division
of Pediatric Emergency Medicine; Director, Pediatric Emergency
Medicine Simulation Program, Hofstra School of Medicine,
Cohen’s Children’s Medical Center, New Hyde Park, New York.
Angela Bowen, RN, BSN, CPEN, NREMT-P, Radiation Emergency
Assistance Center/Training Site (REAC/TS), Oak Ridge, Tennessee.
Michael Redlener, MD, Department of Emergency Medicine,
Mount Sinai St. Luke's, New York, New York.
Scott A. Goldberg, MD, MPH, Emergency Medicine, Brigham and
Women's Hospital, Boston, Massachusetts.
Nadine Symons, MD, Pediatrics, Le Bonheur Children's Hospital,
Memphis, Tennessee.
James Burkett, DHSc, PA-C, DFAAPA, Director, Advanced
Physician Assistant Degree Program, Arizona School of Health
Sciences, Mesa, Arizona.
Joseph C. Santos, MPH, NREMT, Emergency Medical Services for
Children, Baylor College of Medicine, Houston, Texas.
David Kessler, MD, MSc, RDMS, Pediatrics, Columbia School of
Medicine, New York, New York.
Ryan N. Barnicle, MD, MEd, Medical School, Frank H. Netter MD School
of Medicine, Quinnipiac University, North Haven, Connecticut.
Geno Paesano, NREMT-P, Sponsor Hospital Program, Yale New
Haven Hospital, New Haven, Connecticut.
Marc A. Auerbach, MD, MSc, Departments of Pediatrics and Emer-
gency Medicine, Yale School of Medicine, New Haven, Connecticut.
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... We used data from two published studies for these cost-effectiveness analyses: (1) The video game data were synthesised from the intervention arm of a previously published randomised control trial that compared triage accuracy in a live simulation scenario of paramedics and EMTs exposed versus unexposed to 60S. 24 (2) The live simulation data were from one site in a previously published prospective cohort study evaluating live simulation and feedback for improving disaster triage skills. 25 We hypothesised that a video gamebased disaster triage programme would be more cost-effective than a live simulation and feedbackbased disaster triage programme for EMS providers. ...
... This cost-effectiveness analysis used data from a previously conducted randomised controlled trial (RCT) 24 and a prospective cohort study. 25 The study design is outlined in figure 1A. ...
... The disaster triage video game 60S was developed iteratively by a team of PDTexperts, paramedics, software engineers and graphic designers. 24 26 27 The game uses simple triage and rapid treatment (START) and JumpSTART (a variation of START) triage, the predominant system used in USA. 28 29 Software was designed by the firm Sound Web Solutions (Coventry, Connecticut, USA). ...
Full-text available
Article
Introduction Disaster triage training for emergency medical service (EMS) providers is unstandardised. We hypothesised that disaster triage training with the paediatric disaster triage (PDT) video game ‘60 s to Survival’ would be a cost-effective alternative to live simulation-based PDT training. Methods We synthesised data for a cost-effectiveness analysis from two previous studies. The video game data were from the intervention arm of a randomised controlled trial that compared triage accuracy in a live simulation scenario of exposed vs unexposed groups to the video game. The live simulation and feedback data were from a prospective cohort study evaluating live simulation and feedback for improving disaster triage skills. Postintervention scores of triage accuracy were measured for participants via live simulations and compared between both groups. Cost-effectiveness between the live simulation and video game groups was assessed using (1) A net benefit regression model at various willingness-to-pay (WTP) values. (2) A cost-effectiveness acceptability curve (CEAC). Results The total cost for the live simulation and feedback training programme was $81 313.50 and the cost for the video game was $67 822. Incremental net benefit values at various WTP values revealed positive incremental net benefit values, indicating that the video game is more cost-effective compared with live simulation and feedback. Moreover, the CEAC revealed a high probability (>0.6) at various WTP values that the video game is more cost-effective. Conclusions A video game-based simulation disaster triage training programme was more cost-effective than a live simulation and feedback-based programme. Video game-based training could be a simple, scalable and sustainable solution to training EMS providers.
... Another way of improving EMS triage practices includes the use of virtual simulations. A videogame intervention, titled "60 Seconds to Survival," was shown to have some success in improving triaging knowledge of EMS providers (Cicero et al., 2017). In this game, players have to triage 12 victims in three scenarios, one which includes a school shooting. ...
... In this randomized control trial, the intervention group, those who played the game, had a significant improvement from their baseline score, whereas the control group did not. Thus, the video-game intervention could have value in improving triage among EMS providers (Cicero et al., 2017). ...
Article
Research Summary We conducted a scoping review of literature indexed in the National Library of Medicine's journal citation database, MEDLINE, and Scopus to identify articles in which the rapid response of hospital staff, emergency medical services personnel, the police, and the public to mass shootings is covered. Sixty‐five articles were included, and critical themes related to reducing the harm from a mass shooting were summarized. Policy Implications According to our findings, when mass shootings occur in the United States, several evidence‐informed steps can be taken from the moment the first bullet is fired until the last injured individual is transported to the hospital to promote a rapid response that can reduce death and disability. Ten recommendations are made ranging from recognition of the need for rapid response and bystander training to triage and transport training of police and avoidance of over‐response.
... The disaster triage SBS game 60 Seconds to Survival # (60S) was developed iteratively by a team of disaster triage experts, paramedics, software engineers, and graphic designers (17). The game uses Simple Triage and Rapid Treatment (START)/Pediatric version of Simple Triage and Rapid Treatment (JumpSTART) triage algorithms, the predominant system used in the United States (3,18). ...
Article
Background: Disaster triage is an infrequent, high-stakes skill set used by emergency medical services (EMS) personnel. Screen-based simulation (SBS) provides easy access to asynchronous disaster triage education. However, it is unclear if the performance during a SBS correlates with immersive simulation performance. Methods: This was a nested cohort study within a randomized controlled trial (RCT). The RCT compared triage accuracy of paramedics and emergency medical technicians (EMTs) who completed an immersive simulation of a school shooting, interacted with an SBS for 13 weeks, and then completed the immersive simulation again. The participants were divided into two groups: those exposed vs. those not exposed to 60 Seconds to Survival© (60S), a disaster triage SBS. The aim of the study was to measure the correlation between SBS triage accuracy and immersive simulation triage accuracy. Improvements in triage accuracy were compared among participants in the nested study before and after interacting with 60S, and with improvements in triage accuracy in a previous study in which immersive simulations were used as an educational intervention. Results: Thirty-nine participants completed the SBS; 26 (67%) completed at least three game plays and were included in the evaluation of outcomes of interest. The mean number of plays was 8.5 (SD =7.4). Subjects correctly triaged 12.4% more patients in the immersive simulation at study completion (73.1% before, 85.8% after, P = 0.004). There was no correlation between the amount of improvement in overall SBS triage accuracy, instances of overtriage (P = 0.101), instances of undertriage (P = 0.523), and improvement in the second immersive simulation. A comparison of the pooled data from a previous immersive simulation study with the nested cohort data showed similar improvement in triage accuracy (P = 0.079). Conclusions: SBS education was associated with a significant increase in triage accuracy in an immersive simulation, although triage accuracy demonstrated in the SBS did not correlate with the performance in the immersive simulation. This improvement in accuracy was similar to the improvement seen when immersive simulation was used as the educational intervention in a previous study.
Summary statement: Disaster medicine (DM) training aims to recreate stressful, mass casualty scenarios faced by medical professionals in the field with high fidelity. Virtual (VR) and augmented reality (AR) are well suited to disaster training as it can provide a safe, socially distant simulation with a high degree of realism. The purpose of this literature review was to summarize the current use of VR or AR for simulation training of healthcare providers in DM education. A systematic review of peer-reviewed articles was performed from January 1, 2000, to November 21, 2020, on PubMed, Embase, and OVID. Exclusion criteria included non-English articles, computer-generated models without human participants, or articles not relating to DM, VR or AR. Thirty-two articles were included. Triage accuracy was evaluated in 17 studies. Participants reported improved confidence and positive satisfaction after the simulations. The studies suggest VR or AR can be considered for disaster training in addition to other, more traditional simulation methods. More research is needed to create a standardized educational model to incorporate VR and AR into DM training and to understand the relationship between disaster simulation and improved patient care.
Summary statement: Pediatric disaster triage (PDT) is challenging for healthcare personnel. Mistriage can lead to poor resource utilization. In contrast to live simulation, screen-based simulation is more reproducible and less costly. We hypothesized that the screen-based simulation "60 Seconds to Survival" (60S) to learning PDT will be associated with improved triage accuracy for pediatric emergency nursing personnel.During this prospective observational study, 138 nurse participants at 2 tertiary care emergency departments were required to play 60S at least 5 times over 13 weeks. Efficacy was assessed by measuring the learners' triage accuracy, mistriage, and simulated patient outcomes using JumpStart.Triage accuracy improved from a median of 61.1 [interquartile range (IQR) = 48.5-72.0] to 91.7 (IQR = 60.4-95.8, P < 0.0001), whereas mistriage decreased from 38.9 (IQR = 28.0-51.5) to 8.3 (IQR = 4.2-39.6, P < 0.0001), demonstrating a significant improvement in accuracy and decrease in mistriage. Screen-based simulation 60S is an effective modality for learning PDT by pediatric emergency nurses.
Chapter
The need for mass casualty preparedness has become increasing recognized by the medical community and by regulatory organizations. Due to the cost and scheduling constraints of full-scale live drills, many institutions have chosen to do minimal or no planning for a disaster. While live drills provide the most realistic simulation of a mass casualty event, there are other more economical modalities such as computer or tabletop exercises. Rapid advances in the field of computer science and the gaming industry make the ability to prepare for mass casualties available to institutions that were previously unable to participate.
Chapter
Serious Games and Virtual Reality (VR) have been accelerating in their quality and ubiquity within healthcare simulation, and the variety of technological innovations is outpacing the healthcare research community’s ability to evaluate their effects as an intervention or their utility in simulating an environment for research. This chapter seeks to highlight unique advantages and challenges when using serious games or VR for healthcare research that are different than those encountered with other simulation modalities such as manikins, simulated/standardized patients etc. First, we define the terminology surrounding the concept of serious games and VR, including the advantages and disadvantages for their utility in answering important healthcare research questions. Second, we provide insight into optimal models of research that are suited for serious games or VR. Finally, we describe the development process for researchers to integrate research methodologies during the development phase.
Full-text available
Article
Background: It is unclear which pediatric disaster triage (PDT) strategy yields the best accuracy or best patient outcomes. Methods: We conducted a cross-sectional analysis on a sample of emergency medical services providers from a prospective cohort study comparing the accuracy and triage outcomes for 2 PDT strategies (Smart and JumpSTART) and clinical decision-making (CDM) with no algorithm. Participants were divided into cohorts by triage strategy. We presented 10-victim, multi-modal disaster simulations. A Delphi method determined patients' expected triage levels. We compared triage accuracy overall and for each triage level (RED/Immediate, YELLOW/Delayed, GREEN/Ambulatory, BLACK/Deceased). Results: There were 273 participants (71 JumpSTART, 122 Smart, and 81 CDM). There was no significant difference between Smart triage and CDM. When JumpSTART triage was used, there was greater accuracy than with either Smart (P<0.001; OR [odds ratio]: 2.03; interquartile range [IQR]: 1.30, 3.17) or CDM (P=0.02; OR: 1.76; IQR: 1.10, 2.82). JumpSTART outperformed Smart for RED patients (P=0.05; OR: 1.48; IQR: 1.01,2.17), and outperformed both Smart (P<0.001; OR: 3.22; IQR: 1.78,5.88) and CDM (P<0.001; OR: 2.86; IQR: 1.53,5.26) for YELLOW patients. Furthermore, JumpSTART outperformed CDM for BLACK patients (P=0.01; OR: 5.55; IQR: 1.47, 20.0). Conclusion: Our simulation-based comparison suggested that JumpSTART triage outperforms both Smart and CDM. JumpSTART outperformed Smart for RED patients and CDM for BLACK patients. For YELLOW patients, JumpSTART yielded more accurate triage results than did Smart triage or CDM. (Disaster Med Public Health Preparedness. 2016;1-8).
Introduction: According to the Accreditation Council for Graduate Medical Education emergency medicine requirements established before the popularity of video laryngoscopy (VL) use, 35 intubations are necessary for graduation. Our study aimed to establish a mastery-learning model for a skill set very different (VL) from direct laryngoscopy and to determine the attempts to achieve mastery with VL. Methods: With the use of a randomized, controlled crossover study design, 2 learner groups underwent baseline testing intubating a mannequin using VL. Afterward, the intervention group received mastery training intervention. After training, learners were required to repeat the procedure until achievement of 100% on the checklist for 2 consecutive attempts was achieved. After 3 months, both groups returned for retesting, and the control group received the same mastery training as the intervention group. Both groups returned for final testing after another 3 months. Results: The intervention arm had an improvement in performance versus the control arm at 3 months of total time (P < 0.05). Both groups had an improvement within their groups' checklist scores at 3 months after training (P < 0.05), and within the intervention arm, this effect was sustained at 6 months (P < 0.05). There was no significant difference in the mean required attempts to demonstrate mastery (overall, 2.5; intervention, 2.75; control 2.25; P = 0.28). Conclusions: Simulation-based mastery-learning produces skill enhancement with VL that is resistant to decay across 6 months. Furthermore, although a small number of attempts are needed to achieve mastery, clinical experience did not substitute as a proxy for skill acquisition. This mastery-learning model provides skill sets that are not otherwise obtained in the clinical curriculum in a 3-month period.
Article
Background: Serious games (SGs) are a type of simulation technology that may provide nursing students with the opportunity to practice their clinical reasoning and decision-making skills in a safe and authentic environment. Despite the growing number of SGs developed for healthcare professionals, few SGs are video based or address the domain of home health care. Aims: This paper aims to describe the design, development, and usability evaluation of a video based SG for teaching clinical reasoning and decision-making skills to nursing students who care for patients with chronic obstructive pulmonary disease (COPD) in home healthcare settings. Methods: A prototype SG was developed. A unified framework of usability called TURF (Task, User, Representation, and Function) and SG theory were employed to ensure a user-centered design. The educational content was based on the clinical decision-making model, Bloom's taxonomy, and a Bachelor of Nursing curriculum. A purposeful sample of six participants evaluated the SG prototype in a usability laboratory. Cognitive walkthrough evaluations, a questionnaire, and individual interviews were used for the usability evaluation. The data were analyzed using qualitative deductive content analysis based on the TURF framework elements and related usability heuristics. Results: The SG was perceived as being realistic, clinically relevant, and at an adequate level of complexity for the intended users. Usability issues regarding functionality and the user-computer interface design were identified. However, the SG was perceived as being easy to learn, and participants suggested that the SG could serve as a supplement to traditional training in laboratory and clinical settings. Conclusions: Using video based scenarios with an authentic COPD patient and a home healthcare registered nurse as actors contributed to increased realism. Using different theoretical approaches in the SG design was considered an advantage of the design process. The SG was perceived as being useful, usable, and satisfying. The achievement of the desired functionality and the minimization of user-computer interface issues emphasize the importance of conducting a usability evaluation during the SG development process.
Article
http://journals.lww.com/ccmjournal/Citation/2016/09000/Pediatric_Triage_in_a_Severe_Pandemic___Maximizing.16.aspx Objectives: To develop and validate an algorithm to guide selection of patients for pediatric critical care admission during a severe pandemic when Crisis Standards of Care are implemented. Design: Retrospective observational study using secondary data. Patients: Children admitted to VPS-participating PICUs between 2009-2012. Interventions: A total of 111,174 randomly selected nonelective cases from the Virtual PICU Systems database were used to estimate each patient's probability of death and duration of ventilation employing previously derived predictive equations. Using real and projected statistics for the State of Ohio as an example, triage thresholds were established for casualty volumes ranging from 5,000 to 10,000 for a modeled pandemic with peak duration of 6 weeks and 280 pediatric intensive care beds. The goal was to simultaneously maximize casualty survival and bed occupancy. Discrete Event Simulation was used to determine triage thresholds for probability of death and duration of ventilation as a function of casualty volume and the total number of available beds. Simulation was employed to compare survival between the proposed triage algorithm and a first come first served distribution of scarce resources. Measurements and main results: Population survival was greater using the triage thresholds compared with a first come first served strategy. In this model, for five, six, seven, eight, and 10 thousand casualties, the triage algorithm increased the number of lives saved by 284, 386, 547, 746, and 1,089, respectively, compared with first come first served (all p < 0.001). Conclusions: Use of triage thresholds based on probability of death and duration of mechanical ventilation determined from actual critically ill children's data demonstrated superior population survival during a simulated overwhelming pandemic.
Article
Objectives: The study goal was to determine which pediatric disaster triage (PDT) systems are used in US states/territories and whether there is standardization to their use. Secondary goals were to understand user satisfaction with each system, user preferences, and the nature and magnitude of incidents for which the systems are activated. Methods: A survey was developed regarding PDT systems used in each state/territory, satisfaction with those used, preference for specific systems, and type and magnitude of incidents prompting system activation. The survey was distributed to emergency medical services for children leads in each state/territory. Results: Eighty-six percent of states/territories responded. Eighty-eight percent of respondents used some formal PDT system, 50% of whom reported utilization of multiple systems. JumpSTART was most commonly used, most often in conjunction with other systems. Of formal systems, JumpSTART has been in use the longest. JumpSTART was also preferred by 71% of those stating a preference; it tied with Smart for median satisfaction level. Although types of incidents prompting system activation was similar across responding states/territories, number of patients prompting activation varied from 1 to 3 to greater than 20, median range of 4 to 7. Conclusions: Most states/territories use some formal PDT system; few have 1 standardized approach. JumpSTART is predominantly used and is preferred by most respondents. With all systems, there is marked variation in number of patients prompting activation although the reported nature of incidents prompting activation is similar.
Article
Objective: Few established curricula are available for teaching disaster medicine. We describe a comprehensive, multi-modality approach focused on simulation to teach disaster medicine to emergency medicine residents in a 3-year curriculum. Methods: Residents underwent a 3-year disaster medicine curriculum incorporating a variety of venues, personnel, and roles. The curriculum included classroom lectures, tabletop exercises, virtual reality simulation, high-fidelity simulation, hospital disaster drills, and journal club discussion. All aspects were supervised by specialty emergency medicine faculty and followed a structured debriefing. Residents rated the high-fidelity simulations by using a 10-point Likert scale. Results: Three classes of emergency medicine residents participated in the 3-year training program. Residents found the exercise to be realistic, educational, and relevant to their practice. After participating in the program, residents felt better prepared for future disasters. Conclusions: Given the large scope of impact that disasters potentiate, it is understandably difficult to teach these skills effectively. Training programs can utilize this simulation-based curriculum to better prepare the nation's emergency medicine physicians for future disasters. (Disaster Med Public Health Preparedness. 2016;0:1-4).
Article
Background: To address the need for risk behavior reduction and human immunodeficiency virus prevention interventions that capture adolescents "where they live," we created a tablet-based videogame to teach skills and knowledge and influence psychosocial antecedents for decreasing risk and preventing human immunodeficiency virus infection in minority youth in schools, after-school programs, and summer camps. Methods: We developed PlayForward: Elm City Stories over a 2-year period, working with researchers, commercial game designers, and staff and teens from community programs. The videogame PlayForward provides an interactive world where players, using an avatar, "travel" through time, facing challenges such as peer pressure to drink alcohol or engage in risky sexual behaviors. Players experience how their choices affect their future and then are able to go back in time and change their choices, creating different outcomes. A randomized controlled trial was designed to evaluate the efficacy of PlayForward. Participants were randomly assigned to play PlayForward or a set of attention/time control games on a tablet at their community-based program. Assessment data were collected during face-to-face study visits and entered into a web-based platform and unique real-time "in-game" PlayForward data were collected as players engaged in the game. The innovative methods of this randomized controlled trial are described. We highlight the logistical issues of conducting a large-scale trial using mobile technology such as the iPad(®), and collecting, transferring, and storing large amounts of in-game data. We outline the methods used to analyze the in-game data alone and in conjunction with standardized assessment data to establish correlations between behaviors during gameplay and those reported in real life. We also describe the use of the in-game data as a measure of fidelity to the intervention. Results: In total, 333 boys and girls, aged 11-14 years, were randomized over a 14-month period: 166 were assigned to play PlayForward and 167 to play the control games. To date (as of 1 March 2016), 18 have withdrawn from the study; the following have completed the protocol-defined assessments: 6 weeks: 271 (83%), 3 months: 269 (84%), 6 months: 254 (79%), 12 months: 259 (82%), and 24 months: is ongoing with 152 having completed out of the 199 participants (76%) who were eligible to date (assessment windows were still open). Conclusion: Videogames can be developed to address complex behaviors and can be subject to empiric testing using community-based randomized controlled trials. Although mobile technologies pose challenges in their use as interventions and in the collection and storage of data they produce, they provide unique opportunities as new sources of potentially valid data and novel methods to measure the fidelity of digitally delivered behavioral interventions.
Article
Aim: The aim of this study was to examine the effect of using serial simulations with progression through the nursing curriculum. Background: Simulation provides a way to learn without fear of failure and increase critical thinking and clinical decision-making skills. Learning in an interdisciplinary simulation provides a greater understanding of teamwork and communication skills. Method: The NLN/Jeffries Simulation Framework was used in an interactive disaster drill with role-playing patient actors and manikins. In a debriefing session, nursing and radiology students co-presented scenarios. Results: Students displayed critical thinking and clinical decision-making skills. They reported an increase in self-confidence in caring for patients during a disaster, an increase in empathy, and learning by observing others. Conclusion: This pilot study revealed that an interdisciplinary disaster drill simulation experience was a positive learning experience for both nursing and radiology students.
Article
Introduction Multiple modalities for simulating mass-casualty scenarios exist; however, the ideal modality for education and drilling of mass-casualty incident (MCI) triage is not established. Hypothesis/Problem Medical student triage accuracy and time to triage for computer-based simulated victims and live moulaged actors using the pediatric version of the Simple Triage and Rapid Treatment (JumpSTART) mass-casualty triage tool were compared, anticipating that student performance and experience would be equivalent. The victim scenarios were created from actual trauma records from pediatric high-mechanism trauma presenting to a participating Level 1 trauma center. The student-reported fidelity of the two modalities was also measured. Comparisons were done using nonparametric statistics and regression analysis using generalized estimating equations. Thirty-three students triaged four live patients and seven computerized patients representing a spectrum of minor, immediate, delayed, and expectant victims. Of the live simulated patients, 92.4% were given accurate triage designations versus 81.8% for the computerized scenarios (P=.005). The median time to triage of live actors was 57 seconds (IQR=45-66) versus 80 seconds (IQR=58-106) for the computerized patients (P<.0001). The moulaged actors were felt to offer a more realistic encounter by 88% of the participants, with a higher associated stress level. While potentially easier and more convenient to accomplish, computerized scenarios offered less fidelity than live moulaged actors for the purposes of MCI drilling. Medical students triaged live actors more accurately and more quickly than victims shown in a computerized simulation. Claudius I , Kaji A , Santillanes G , Cicero M , Donofrio JJ , Gausche-Hill M , Srinivasan S , Chang TP . Comparison of computerized patients versus live moulaged actors for a mass-casualty drill. Prehosp Disaster Med. 2015; 30(5): 1-5.
Article
Immersive patient simulators (IPS) allow an illusionary immersion into a synthetic world where the user can freely navigate through a 3-dimensional environment similar to computer games. Playful learning with IPS allows internalization of medical workflows without harming real patients. Ideally, IPS show high student acceptance and can have positive effect on knowledge gain. Development of IPS with high technical quality is resource intensive. Therefore most of the "high-fidelity" IPS are commercially driven. Usage of IPS in the daily curriculum is still rare. There is no academic-driven simulator that is freely accessible to every student and combines high immersion grade with a profound amount of medical content. Therefore it was our aim to develop an academic-driven IPS prototype that is free to use and combines a high immersion grade with profound medical content. In addition, a first validation of the prototype was conducted. The conceptual design included definition of the following parameters: amount of curricular content, grade of technical quality, availability, and level of validation. A preliminary validation was done with 25 students. Students' opinion about acceptance was evaluated by a Likert-scale questionnaire. Effect on knowledge gain was determined by testing concordance and predictive validity. A custom-made simulator prototype (Artificial learning interface for clinical education [ALICE]) displays a virtual clinic environment that can be explored from a first-person view similar to a video game. By controlling an avatar, the user navigates through the environment, is able to treat virtual patients, and faces the consequence of different decisions. ALICE showed high students' acceptance. There was positive correlation for concordance validity and predictive validity. Simulator usage had positive effect on reproduction of trained content and declarative knowledge. We successfully developed a university-based, IPS prototype (ALICE) with profound medical content. ALICE is a nonprofit simulator, easy to use, and showed high students' acceptance; thus it potentially provides an additional tool for supporting student teaching in the daily clinical curriculum. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.