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

Study Overview
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Brief Summary
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The objective of this study is to compare the efficacy of two behavioral interventions at recalibrating physician heuristics.

Detailed Description
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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.

Official Title
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Testing the Efficacy of Two Behavioral Interventions at Recalibrating Physician Heuristics in Trauma Triage: a Randomized Clinical Trial

Conditions
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Wounds and Injuries

Intervention / Treatment
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* Behavioral: Night Shift
* Behavioral: Graveyard Shift
* Behavioral: Educational program
* Behavioral: Control


Participation Criteria
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Eligibility Criteria
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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.
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: 1:1:1:1 allocation
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Night Shift<br>Night Shift is an adventure video game with the transformational goal of teaching physicians key characteristics of patients with non-representative severe injuries - injuries classified by the American College of Surgeons as life-threatening or critical but that do not fit the archetype of injuries typically requiring treatment at a trauma center. Players take on the persona of Andy Jordan, a young emergency physician who moves home after the disappearance of his estranged grandfather (Robert Jordan) and takes up a job in the local Emergency Department (ED). In the preamble, players learn they have two explicit objectives. First, they must diagnose and treat patients who present to their ED. Second they must solve the mystery of Robert's disappearance: was he murdered or has he simply chosen to disappear? | Behavioral: Night Shift<br>* Physicians in this arm of the trial will be asked to play Night Shift, an adventure video game, for two hours.<br>|
| Experimental: Graveyard Shift<br>Graveyard Shift is a puzzle video game with the transformational goal of helping physicians derive key triage decision principles for themselves. They complete a three-step game loop to obtain case information, compare cases to determine similarities and differences between cases, and then explicitly state the decision principle that should drive decision making. | Behavioral: Graveyard Shift<br>* Physicians in this arm of the trial will be asked to play Graveyard Shift, a puzzle video game, for two hours.<br>|
| Active Comparator: Educational program<br>The educational module consists of two separate apps, both commercially available. myATLS includes a review of each chapter of the Advanced Trauma Life Support (ATLS) textbook, a series of videos demonstrating common trauma procedures, and clinical resources including checklists for use at the bedside. Trauma Life Support MCQ Review includes 550 multiple-choice questions with correct answers and explanations. The investigators will ask physicians to review the myATLS app and then com | Behavioral: Educational program<br>* 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.<br>|
| Placebo Comparator: Control<br>Physicians in this arm will not be asked to complete any intervention. | Behavioral: Control<br>* Physicians in this arm will serve as a no-contact control group.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Incidence rate of successful triage | 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). | One month after completion of the intervention |