Problem

Interactive teaching methods are increasingly used in lieu of, or as a supplement to, traditional didactic-based teaching. Simulation-based games and serious games are examples of an interactive teaching strategy that has yet to be fully harnessed in medical education.1 Because gaming is a relatively new teaching method in medicine, only a small body of literature about it is available, yet burgeoning evidence suggests the usefulness of educational games as teaching tools.1 Medical educators have described serious games—games that are developed with a defined learning outcome that players must voluntarily achieve, wherein the rules limit the players’ path toward a goal, and variable levels affect difficulty2—as a strategy for teaching focused knowledge and skills in emergency medicine.3,4

To date, the medical education community is only just beginning to explore how physicians manage multiple patients simultaneously.5 With increasing volume, complexity, and acuity of clinical care in multipatient environments, the likelihood that junior trainees will be entrusted to handle flow within emergency departments (EDs) is decreasing. A recent study has shown that junior residents tended to focus more on single patients within a multipatient system, with attendings entrusting them to manage multiple patients only when the residents have demonstrated competency handling individual cases.6 Without the experience of managing multiple patients, however, residents will not have the chance to learn the crucial skill of multipatient care6 until late in their training.

While other serious games, such as Friday Night at the ER, have been created to teach administrators and leaders (at a cost of $425/person) about hospital systems,7 we developed a serious education game that aims to provide junior learners with training about multipatient environments—at a much lower cost. Leveraging previous work, we worked to create a new, safe, teaching environment that exposes junior medical trainees to core ED systems. Here we detail the game development process, the structure of the game, the results of our initial play testing, and our ongoing plans for the game.

Approach

We created a peer-reviewed, collaborative, strategy game, which we have titled GridlockED. We have built the game around elements that emulate the multipatient environment of the ED, designing it to teach players about managing multiple patients over the course of an eight-hour shift while considering various factors that can hinder or enhance patient flow through the ED. In May 2016, a team of medical students (D.T., P.S., and J.R.) approached faculty members interested in multipatient environments (T.M.C., M.M., and A.P.) about working together on a scholarly project. The senior scientist (T.M.C.) on the team had recently completed her thesis on multipatient environments and was actively considering new teaching techniques to teach skills related to her work.6 After assembling a team of volunteer students, gamers, and attending emergency physicians interested in cocreating the game, we worked through three main development process components: (1) research, (2) initial development, and (3) quality improvement (see Figure 1).

Figure 1: The development process for the GridlockED gameplay loop, developed at McMaster University, Hamilton, Ontario, Canada, May 2016–August 2017.

Research

Just as any scholarly project begins with a survey of previous work, we began the development of the board game by investigating (in May and June 2016) existing serious games and collaborative games and by reviewing the literature about these. Specifically, we examined the core gameplay elements of the 2002 cooperative, entertainment-focused board game called Pandemic. Our game planning mirrored the development strategy of many medical educational games, which have used fundamental gameplay concepts from existing games such as Snakes and Ladders and Jeopardy.8,9

Initial development

After researching education games and gaming concepts, we began the initial development of the game (July and August 2016). We worked to incorporate five core gameplay elements into the game: (1) characters, (2) goals, (3) mechanics/resources, (4) feedback, and (5) challenges.10 This resulted in a game with five different types of characters (registered nurses, emergency doctors, resident doctor, consulting doctor, and radiologist); these medical “providers” are embodied by the players within the game. These characters are embedded within a gameplay loop proceeding as repeated cycles of a card-draw phase followed by an action phase. These cycles are what characterize core GridlockED gameplay (see Figure 2).

Figure 2: A general overview of the GridlockED gameplay loop, developed at McMaster University, Hamilton, Ontario, Canada, May 2016–August 2017.

Players randomly draw one of two types of cards during the card-draw phase. Most of the cards in the deck are “patient cards.” These cards have descriptions of simulated patients’ varying acuities and medical concerns, and include a list of tasks for the providers to perform. For example, one card will list a number of tasks that need to be done by nurses and doctors in a particular order (i.e., the doctor must assess and write orders before the nurse can fulfill those orders). This element of variation is what most differentiates our game from other serious games of the genre (such as Friday Night at the ER7). That is, GridlockED patients have varying degrees of illness severity, and providers have varying abilities. A smaller proportion of the cards are “event cards,” which describe various events that may occur over the course of an ED shift that affect gameplay in various ways. For example, the hospital might be full of admitted patients, and this “bed blocking” will prevent admitted patients from flowing upstairs, thereby creating a “gridlock” situation. During the card-draw phase, the “patients” that players draw from the deck (or who are waiting in the waiting room) are assigned to appropriate zones in the board on the basis of their acuity.

Gameplay during the subsequent action phase involves collaboration between the players (acting as “providers”) who must perform the necessary tasks for patients to be dispositioned (discharged or admitted) in the manner outlined on the card. Higher-acuity patients generally have more tasks to complete before they can be dispositioned than lower-acuity patients. Upon admission or discharge, players accrue points for successful coordination of care for multiple patients. The players may invest these points towards achieving the “win” condition for the game or redeem them to purchase more resources (e.g., hiring an extra nurse or doctor, purchasing an extra bed).

To complete tasks, players move pawns representing the various characters (e.g., nurse, emergency doctor) around the game board to appropriate patient zones. The number of actions is limited by the game rules, both to force rationing of time and to give players an understanding of how an individual acts within the health care team.

Players lose the game if they incur too many patient-safety violations (e.g., the ED is full or the providers cannot place a critical patient into the proper zone), and they win the game by reaching the end of the simulated eight-hour shift and collectively accruing a specified number of points. Figure 2 provides a general overview of gameplay. Our hope is that players will find the game to be an engaging and entertaining way to learn about the difficulties involved in managing patient flow in the ED.

Quality improvement

After we developed the game, we undertook a quality improvement effort via iterative rounds of gameplay (September 2016 through August 2017). Specifically, we conducted continuous quality improvement arcs in the style of plan–do–study–act cycles. We invited reviewers—from medical teachers to experienced gamers—to play and critique our game. After each round of gameplay, we solicited feedback and made changes to the game whenever applicable. Over a 20-month period, we further developed GridlockED through roughly 50 iterative cycles of gameplay. We made changes to optimize game mechanics, the level of difficulty, and player engagement. Supplemental Digital Appendix 1, available at http://links.lww.com/ACADMED/A572, provides a picture of our earlier prototypes.

Costs

To develop the prototype and initially manufacture the game, we required a total budget of around $200 for materials. We were lucky to have team members with extensive graphic design and layout experience (S.H., T.M.C.), so we did not need to outsource any of the designing tasks for our game board or cards. The game is published by a custom board game company (The Game Crafter, Madison, Wisconsin) and has been available for purchase since the summer of 2018. Interested parties can explore the board game website (www.gridlockedgame.com) for more details. The cost is about $90 (U.S. dollars) per unit before taxes and shipping.

Evaluation methods

To evaluate the game, we recruited practicing clinicians to play test the penultimate version of the game. We asked each of these play testers to complete a postgame survey, so we could gather information regarding their play experiences and their views of the educational value of GridlockED. We designed the survey to explore the usefulness of GridlockED as a tool for teaching and learning about patient flow through the ED. Specifically, we examined how participants viewed the game’s usability, fidelity, acceptability, and applicability. We received institutional review board approval for this study (HIREB: no. 2017-3130). We measured participants’ perspectives through a series of postintervention questions (see Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A573). The postintervention survey included yes/no questions about usability, fidelity, acceptability, and applicability, as well as a space for play testers to provide qualitative commentary to explain their gameplay experience. Data collection was conducted by trained research assistants currently involved in GridlockED development.

Outcomes

From June to August 2017, we conducted 18 gameplay sessions. A total of 32 play testers played the game (13 emergency physicians, 15 residents, and 4 nurses). The median number of years in practice of the practicing clinicians was 5 years (interquartile range = 2–14 years). We received a 100% response rate for our postgameplay survey. Of the 32 play testers, 24 (75%) reported that they had extensive experience or were familiar with board game principles, and the remaining 8 (25%) were inexperienced, uninterested, or did not describe their prior gaming experiences. Only 4 participants (12.5%) had played a serious board game (i.e., a game not intended purely for fun) before.

Overall responses to the postgameplay survey showed that a majority of play testers (n = 24; 75%) endorsed GridlockED as a useful potential teaching tool, and many (n = 18; 56%) felt that it had the potential to improve patient flow in the ED. Most participants (27 of 29; 93%) found the game easy to play, and the majority (n = 28; 87.5%) reported that the instructions were clear. According to the answers to the open-ended questions, the play testers viewed the game experience positively. For example, one resident stated: “I think the game is useful for clerks or very junior residents to increase their awareness about flow in the ED. For more senior residents or staff it wouldn’t add any additional information.” Another participant (also a resident) commented: “The interaction [among play testers] was very democratic. We were all trying to get to 500 points.”

In terms of fidelity, the majority of respondents (n = 18; 56%) felt that the game reflected real-life scenarios, and over three-quarters (n = 25; 78%) felt that cases reflected the types of patients that they saw in the ED. Almost half of the participants thought that the gameplay was similar to true ED flow processes (n = 13; 41%) and that the interactions between game characters (e.g., the nurses and doctors) and the simulated patients were similar to real life (n = 14; 44%). Only about a third of the participants (34%; n = 11) felt that they would have made the same decisions they made in the game in the real ED, which suggests that some abstractions may occur in the game, preventing it from being a fully immersive simulation. Table 1 provides quotations from participants from our exit survey describing their perceptions of the game’s fidelity.

Table 1: Exemplar Quotations From Early Players of GridlockEDa Describing Their Perceptions of the Game’s Fidelity to a Real-Life Emergency Department

Although our initial testing study is limited by its sample size and a single institution, we feel these results demonstrate that overall players have had positive to very positive experiences with the current iteration of GridlockED.

Next Steps

The game is available to trainees to play in their spare time, but we are currently developing dedicated lesson plans targeting students (orientation to the ED), junior residents (basic patient flow in the ED), and even senior residents (quality improvement in the ED). We have found that we can modify the game to challenge even senior, experienced clinicians. We believe the game presents an opportunity to develop curricula for individual contexts by designing “expansion packs” that can train medical learners to prepare for rare incidents (e.g., disaster scenarios).

In the future, we plan to conduct an additional qualitative study investigating what effect GridlockED gameplay sessions have on the experience of medical trainees entering their emergency medicine core clerkship rotations. Another possibility to consider is translating this board game into a video game or smartphone app to explore how the change in media might affect the gameplay experience. Finally, we feel that our game development process may be useful to others who are looking to diversify their teaching platforms in other specialties. Locally, we have been asked to consider developing a game about operating room rationing and prioritization, as well as intensive care unit bed management. These plans are at an early stage but show an interesting potential for future directions.

GridlockED presents an innovative way for players to engage and play with the dynamics of patient flow in the ED. We feel that by incorporating elements of educational games as well as simulation-based learning, we have created a safe simulated environment wherein educators can introduce and teach concepts of the multiprovider and multipatient environment.

Acknowledgments:

The authors would like to thank all of the McMaster Emergency Medicine (EM) residents, their Hamilton nursing colleagues, and their McMaster EM faculty colleagues who helped with pilot testing. Additionally, they would like to thank the Shad Valley Interns (Alain Lou, Annie Zou), the game-testing summer associates (Eric Y.S. Jeong, Rebecca Ngoc Dang), external gameplay reviewers (Dr. Wayne Choi and Dr. David Savage), and the residents and medical students who have continued to help the game development team (Chris Heyd, Saif Shamsoon, Chad Singh, Tanishq Suryavanshi, Sam Lambert, Varun Srivatsav, Nandini Nandeesha, and Jana Balakumaran).