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We have previously published the study protocol for this trial.28 We developed a video game (Night Shift) in collaboration with Schell Games (Pittsburgh, PA) and conducted a randomized controlled trial of the effect of the game compared with traditional didactic education, administered through commercially available applications, on triage by US emergency physicians practicing at non-trauma centers.

We hypothesized that physicians exposed to game based education would under-triage fewer patients on a virtual simulation than those exposed to the didactic education program (primary trial outcome) and that experimentally induced cognitive load would degrade triage performance less among physicians exposed to the game than among those exposed to the didactic program (secondary trial outcome).

Narrative engagement is defined as the use of compelling stories to communicate and encode principles of best practice decision.

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High levels of under-triage (the failure to transfer severely injured patients to trauma centers) persist, despite efforts to improve best practice.

The problem is particularly acute at non-trauma centers, where fewer than 30% of severely injured patients are transferred as recommended by clinical practice guidelines.2122232425 Our prior experimental and observational work suggests that heuristics play an important role in under-triage.2627 We selected one promising method of recalibrating heuristics—narrative engagement—and developed a theoretically grounded intervention delivered through the platform of a video game.

Decisions to admit, discharge, or transfer were measured.

The proportion of patients under-triaged (patients with severe injuries not transferred to a trauma center) was calculated then (primary outcome) and again six months later, with a different set of cases (primary outcome of follow-up study).

Physicians were randomized with a 2×2 factorial design to intervention (game Main outcome measures Outcomes of a virtual simulation that included 10 cases; in four of these the patients had severe injuries.

Participants completed the simulation within four weeks of their intervention.

Our intervention sought to modify system one processes so as to improve heuristic thinking in decision making in trauma triage.

Our specific strategy was based on clinical experience and experimental observations.27 For example, we observed that patients with gunshot wounds were far more likely to be transferred to a trauma center than patients who had fallen, even when they had similar injury severity scores.

Physicians exposed to the game under-triaged fewer severely injured patients than those exposed to didactic education (316/596 (0.53) Conclusions Compared with apps based on traditional didactic education, exposure of physicians to a theoretically grounded video game improved triage decision making in a validated virtual simulation.

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