Serious Game Training Lowered Undertriage In Trauma Triage Trial

Key Takeaways

• The serious game was associated with lower undertriage than usual education during the year after randomization.
• Differences in overtriage and in 30-day mortality or hospital readmission were not statistically significant.
• Nearly all physicians received at least 1 intervention dose, and about two-thirds received all 4 doses.

Emergency physicians assigned to a tablet-based, theory-based serious game had lower undertriage of severely injured older adults than physicians receiving usual education in a JAMA randomized clinical trial, with undertriage during the year after randomization occurring in 49% of severely injured patients in intervention physicians' care and 57% in control physicians' care. The comparison involved US nontrauma-center emergency departments caring for injured Medicare fee-for-service patients aged 65 years or older. The difference during follow-up centered on undertriage in this older-adult trauma triage setting.

The trial randomized 800 emergency physicians responsible for triage decisions for injured Medicare fee-for-service patients aged 65 years or older. The study took place in US emergency departments within nontrauma centers. The intervention used tablet-based game training with an initial 2-hour session and 20-minute quarterly sessions for 4 total doses, compared with usual education. The primary outcome was undertriage during the year after randomization, with overtriage and a 30-day composite as secondary outcomes.

Physicians had a median 10 years in practice, 71% were male, and 94% had completed Advanced Trauma Life Support. They practiced across 1147 hospitals and treated 41,073 injured Medicare patients during the follow-up period. Among those patients, 1,738 had severe injuries and contributed to the trial's undertriage assessment. The trial examined physician triage behavior in routine nontrauma-center care.

Undertriage meant severely injured patients were not transferred to trauma centers, whereas overtriage meant transferred patients had minor injuries. The model-adjusted undertriage difference was -7%, with a 95% CI of -13% to -0.8% and P = .02. The adjusted difference for overtriage was -3%, with a 95% CI of -6% to 1% and P = .14. The adjusted difference for 30-day mortality or hospital readmission was -0.4%, with a 95% CI of -5% to 4% and P = .87. Only undertriage differed between groups; the 2 secondary outcomes did not.

Intervention exposure was high, with 99% of physicians in the serious-game group receiving at least 1 dose and 67% receiving all 4 doses. Enrollment ran from November 27, 2023, through February 7, 2024, and data collection continued through February 6, 2025. Patients were followed for 1 year after physician enrollment, and the trial was published online April 20, 2026. The composite outcome did not differ statistically, and the findings were limited to nontrauma centers and older Medicare fee-for-service patients. Overall, the serious game was associated with lower undertriage in this trial.