Serious Games Reduce Geriatric Trauma Undertriage in Nontrauma Centers

Digital Simulation and Geriatric Trauma Triage

Adherence to trauma triage algorithms remains a persistent challenge in emergency medicine, particularly when managing time-sensitive injuries in non-specialized centers. Current clinical practice guidelines emphasize that regular in-house exercises or virtual training are necessary to improve the quality of triage decisions [1]. While traditional didactic methods often fail to bridge the gap between knowledge and practice, serious games (purpose-driven digital simulations designed to reinforce clinical decision-making through interactive scenarios) have emerged as a potential resource for embedding evidence-based design elements like feedback and storylines into medical education [2]. Preliminary evidence suggests that these virtual patient simulations can improve clinical reasoning and procedural skills at least as effectively as traditional education [3]. However, before these interactive learning tools can be integrated into standard emergency curricula, they require rigorous validation through randomized trials to prove their impact on objective clinical outcomes [4]. A new study now evaluates whether this digital approach can specifically address the high rates of undertriage seen in geriatric trauma care.

Trial Design and Physician Demographics

The researchers conducted a randomized clinical trial that recruited 800 emergency physicians responsible for the triage of Medicare fee-for-service injured patients who were 65 years of age or older. These clinicians practiced within emergency departments at 1147 nontrauma centers across the United States, representing a broad cross-section of the frontline workforce managing geriatric trauma in settings without immediate access to specialized trauma resources. Physician enrollment for the study occurred between November 27, 2023, and February 7, 2024, establishing a robust cohort for evaluating the impact of digital simulation on clinical decision-making. The participating physicians represented an experienced clinical group, with a median of 10 years in practice (interquartile range, 6 to 17 years). Demographic data indicated that 71% (563 of 789) of the participating physicians were male. Notably, the baseline level of trauma-specific training was high among the participants, as 94% (750 of 800) of the physicians had completed Advanced Trauma Life Support (a standardized training program for the initial management of acute trauma). This high rate of prior certification suggests that the study findings reflect the intervention effect on clinicians who were already well-versed in standard trauma protocols. Data collection for the trial spanned from January 1, 2024, to February 6, 2025, covering patients treated during the one year following each physician enrollment. During this period, the participating physicians treated a total of 41,073 injured Medicare patients. By utilizing Medicare fee-for-service claims data, the researchers were able to track longitudinal outcomes and triage accuracy for a substantial geriatric population across a full year of clinical practice, ensuring the results accounted for seasonal variations in patient volume and injury patterns.

Digital Intervention vs. Standard Education

The researchers randomized the 800 participating emergency physicians into two distinct study arms to compare the efficacy of digital simulation against traditional learning methods. The intervention group (n = 400 physicians) received game-based training delivered via a tablet, which utilized a theory-based serious game. This digital curriculum began with an initial 2-hour session to establish core triage competencies, followed by a 20-minute session each quarter, totaling four doses of training over the study year. In contrast, the control group (n = 400 physicians) received usual education, representing the standard continuing medical education and institutional protocols typically available to clinicians in nontrauma centers. Adherence to the digital intervention was high among the clinicians, suggesting that the game-based format was accessible and integrated well into the busy schedules of emergency department staff. Within the intervention group, 99% (397 of 399) of physicians received at least 1 dose of the game-based training. Engagement remained relatively stable throughout the longitudinal study period, as 67% (268 of 399) of the physicians completed all 4 doses of the training. This high level of participation allowed the researchers to evaluate the impact of repeated, low-burden booster sessions on long-term clinical decision-making and the reduction of geriatric trauma undertriage.

Impact on Triage Accuracy and Clinical Outcomes

The researchers focused on undertriage as the primary outcome, which they defined as the proportion of severely injured patients who were not transferred to specialized trauma centers during the year following physician randomization. Within the total patient cohort, 1738 individuals (4.2%) presented with severe injuries requiring high-level trauma care. The study found that the proportion of severely injured older adults who were undertriaged was 49% (402 of 819) in the game-based training group, compared to 57% (527 of 919) in the usual education group. This resulted in a model-adjusted difference in undertriage of -7% (95% CI, -13% to -0.8%; P = .02), indicating that the digital intervention significantly improved the identification and appropriate transfer of high-risk geriatric patients. To ensure that improved triage for severe cases did not lead to an inefficient surge in unnecessary transfers, the authors evaluated overtriage as a secondary outcome, defined as the proportion of transferred patients who actually had only minor injuries. They also tracked a composite clinical outcome consisting of 30-day mortality or hospital readmission. These metrics were calculated by analyzing Medicare fee-for-service claims using mixed-effects regression models (statistical tools that account for both fixed variables and random variations across different clinical settings, such as differences in hospital volume or patient demographics). The model-adjusted difference for overtriage was -3% (95% CI, -6% to 1%; P = .14), and the model-adjusted difference for the composite outcome was -0.4% (95% CI, -5% to 4%; P = .87). These results suggest that while the game-based training reduced the failure to transfer severely injured patients, it did not significantly increase the rate of unnecessary transfers or alter short-term mortality and readmission rates. For the practicing clinician, these findings suggest that low-dose, high-frequency digital simulation may serve as a scalable method to improve adherence to complex triage protocols without increasing the burden of overtriage in resource-constrained environments.

References

1. Suda AJ, Franke A, Hertwig M, Gooßen K. Management of mass casualty incidents: a systematic review and clinical practice guideline update. European Journal of Trauma and Emergency Surgery. 2025. doi:10.1007/s00068-024-02727-0

2. Aster A, Laupichler MC, Zimmer S, Raupach T. Game design elements of serious games in the education of medical and healthcare professions: a mixed-methods systematic review of underlying theories and teaching effectiveness. Advances in Health Sciences Education. 2024. doi:10.1007/s10459-024-10327-1

3. Kononowicz AA, Woodham L, Edelbring S, et al. Virtual Patient Simulations in Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. Journal of Medical Internet Research. 2019. doi:10.2196/14676

4. Graafland M, Schraagen JM, Schijven MP. Systematic review of serious games for medical education and surgical skills training. British journal of surgery. 2012. doi:10.1002/bjs.8819