60 seconds to survival: A pilot study of a disaster triage video game for prehospital providers


  • Mark X. Cicero, MD
  • Travis Whitfill, MPH
  • Kevin Munjal, MD
  • Manu Madhok, MD, MPH
  • Maria Carmen G. Diaz, MD
  • Daniel J. Scherzer, MD
  • Barbara M. Walsh, MD
  • Angela Bowen, RN, BSN, CPEN, NREMT-P
  • Michael Redlener, MD
  • Scott A. Goldberg, MD, MPH
  • Nadine Symons, MD
  • James Burkett, DHSc, PA-C, DFAAPA
  • Joseph C. Santos, MPH, NREMT
  • David Kessler, MD, MSc, RDMS
  • Ryan N. Barnicle, MD, MEd
  • Geno Paesano, NREMT-P
  • Marc A. Auerbach, MD, MSc




serious video games, disaster triage, pediatrics, paramedics, emergency medical technicians, curriculum evaluation


Introduction: Disaster triage training for emergency medical service (EMS) providers is not standardized. Simulation training is costly and time-consuming. In contrast, educational video games enable low-cost and more time-efficient standardized training. We hypothesized that players of the video game “60 Seconds to Survival” (60S) would have greater improvements in disaster triage accuracy compared to control subjects who did not play 60S.

Methods: Participants recorded their demographics and highest EMS training level and were randomized to play 60S (intervention) or serve as controls. At baseline, all participants completed a live school-shooting simulation in which manikins and standardized patients depicted 10 adult and pediatric victims. The intervention group then played 60S at least three times over the course of 13 weeks (time 2). Players triaged 12 patients in three scenarios (school shooting, house fire, tornado), and received in-game performance feedback. At time 2, the same live simulation was conducted for all participants. Controls had no disaster training during the study. The main outcome was improvement in triage accuracy in live simulations from baseline to time 2. Physicians and EMS providers predetermined expected triage level (RED/YELLOW/GREEN/BLACK) via modified Delphi method.

Results: There were 26 participants in the intervention group and 21 in the control group. There was no difference in gender, level of training, or years of EMS experience (median 5.5 years intervention, 3.5 years control, p = 0.49) between the groups. At baseline, both groups demonstrated median triage accuracy of 80 percent (IQR 70-90 percent, p = 0.457). At time 2, the intervention group had a significant improvement from baseline (median accuracy = 90 percent [IQR: 80-90 percent], p = 0.005), while the control group did not (median accuracy = 80 percent [IQR:80-95], p = 0.174). However, the mean improvement from baseline was not significant between the two groups (difference = 6.5, p = 0.335).

Conclusion: The intervention demonstrated a significant improvement in accuracy from baseline to time 2 while the control did not. However, there was no significant difference in the improvement between the intervention and control groups. These results may be due to small sample size. Future directions include assessment of the game's effect on triage accuracy with a larger, multisite site cohort and iterative development to improve 60S.

Author Biographies

Mark X. Cicero, MD

Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut

Travis Whitfill, MPH

Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut

Kevin Munjal, MD

Emergency Medicine, Mount Sinai Medical Center, New York, New York

Manu Madhok, MD, MPH

Pediatrics, Children's Minnesota Minneapolis Hospital, Saint Paul, Minnesota

Maria Carmen G. Diaz, MD

Pediatrics, A. I. DuPont Hospital for Children, Wilmington, Delaware

Daniel J. Scherzer, MD

Pediatrics, Nationwide Children's Hospital, Columbus, Ohio

Barbara M. Walsh, MD

Associate Professor of Pediatrics, Division of Pediatric Emergency Medicine; Director, Pediatric Emergency Medicine Simulation Program, Hofstra School of Medicine, Cohen’s Children’s Medical Center, New Hyde Park, New York

Angela Bowen, RN, BSN, CPEN, NREMT-P

Radiation Emergency Assistance Center/Training Site (REAC/TS), Oak Ridge, Tennessee

Michael Redlener, MD

Department of Emergency Medicine, Mount Sinai St. Luke's, New York, New York

Scott A. Goldberg, MD, MPH

Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts

Nadine Symons, MD

Pediatrics, Le Bonheur Children's Hospital, Memphis, Tennessee

James Burkett, DHSc, PA-C, DFAAPA

Director, Advanced Physician Assistant Degree Program, Arizona School of Health Sciences, Mesa, Arizona

Joseph C. Santos, MPH, NREMT

Emergency Medical Services for Children, Baylor College of Medicine, Houston, Texas

David Kessler, MD, MSc, RDMS

Pediatrics, Columbia School of Medicine, New York, New York

Ryan N. Barnicle, MD, MEd

Medical School, Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, Connecticut

Geno Paesano, NREMT-P

Sponsor Hospital Program, Yale New Haven Hospital, New Haven, Connecticut

Marc A. Auerbach, MD, MSc

Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut


Romig L: Pediatric triage. A system to JumpSTART your triage of young patients at MCIs. JEMS. 2002; 27(7): 52-58, 60-53.

Cone D, Serra J, Burns K, et al.: Pilot test of the SALT mass casualty triage system. Prehosp Emerg Care. 2009; 13(4): 536-540.

Cross KP, Cicero MX: Head-to-head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann Emerg Med. 2013; 61(6): 668-676.e667.

Toltzis P, Soto-Campos G, Shelton C, et al.: Evidence-based pediatric outcome predictors to guide the allocation of critical care resources in a mass casualty event. Pediatr Crit Care Med. 2015; 16(7): e207-e216.

North CS, Pfefferbaum B: Mental health response to community disasters: A systematic review. JAMA. 2013; 310(5): 507-518.

SALT mass casualty triage: Concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association. Disaster Med Public Health Prep. 2008; 2(4): 245-246.

Nadeau NL, Cicero MX: Pediatric disaster triage system utilization across the United States. Pediatr Emerg Care. 2016.

Arshad FH, Williams A, Asaeda G, et al.: A modified simple triage and rapid treatment algorithm from the New York City (USA) fire department. Prehosp Disaster Med. 2015; 30(2): 199-204.

Eyal N, Firth P, Group MDRE.: Repeat triage in disaster relief: Questions from haiti. PLoS Curr. 2012; 4: e4fbbdec6279ec.

Gall C, Wetzel R, Kolker A, et al.: Pediatric triage in a severe pandemic: Maximizing survival by establishing triage thresholds. Crit Care Med. 2016; 44(9): 1762-1768. 11. Cone DC, MacMillan DS, Parwani V, et al.: Pilot test of a proposed chemical/biological/radiation/ nuclear-capable mass casualty triage system. Prehosp Emerg Care. 2008; 12(2): 236-240.

Cross KP, Petry MJ, Cicero MX. A better START for low-acuity victims: Data-driven refinement of mass casualty triage. Prehosp Emerg Care. 2015; 19(2): 272-278.

Kleber C, Cwojdzinski D, Strehl M, et al.: Results of in-hospital triage in 17 mass casualty trainings: Underestimation of life-threatening injuries and need for re-triage. Am J Disaster Med. 2013; 8(1): 5-11.

Koziel JR, Meckler G, Brown L, et al.: Barriers to pediatric disaster triage: A qualitative investigation. Prehosp Emerg Care. 2015; 19(2): 279-286.

Schulz CM, Skrzypczak M, Raith S, et al.: High-fidelity human patient simulators compared with human actors in an unannounced mass-casualty exercise. Prehosp Disaster Med. 2014; 29(2): 176-182.

Claudius I, Kaji A, Santillanes G, et al.: Comparison of computerized patients versus live moulaged actors for a mass-casualty drill. Prehosp Disaster Med. 2015; 30(5): 438-442.

Lee WH, Kuan JT, Shiau YW, et al.: Designation of a new training model of a local disaster medical system with tabletop exercises. Chang Gung Med J. 2003; 26(12): 879-888.

Whitney RE, Burke RV, Lehman-Huskamp K, et al.: On shaky ground: Learner response and confidence after tabletop earthquake simulation. Pediatr Emerg Care. 2016; 32(8): 520-524.

Zapko KA, Ferranto ML, Brady C, et al.: Interdisciplinary disaster drill simulation: Laying the groundwork for further research. Nurs Educ Perspect. 2015; 36(6): 379-382.

Ngo J, Schertzer K, Harter P, et al.: Disaster medicine: A multimodality curriculum designed and implemented for emergency medicine residents. Disaster Med Public Health Prep. 2016; 10(4): 611-614.

Ahn J, Yashar MD, Novack J, et al.: Mastery learning of video laryngoscopy using the glidescope in the emergency department. Simul Healthc. 2016; 11(5): 309-315.

Braun L, Sawyer T, Smith K, et al.: Retention of pediatric resuscitation performance after a simulation-based mastery learning session: a multicenter randomized trial. Pediatr Crit Care Med. 2015; 16(2): 131-138.

Jalink MB, Goris J, Heineman E, et al.: Construct and concurrent validity of a Nintendo Wii video game made for training basic laparoscopic skills. Surg Endosc. 2014; 28(2): 537-542.

Fiellin LE, Kyriakides TC, Hieftje KD, et al.: The design and implementation of a randomized controlled trial of a risk reduction and human immunodeficiency virus prevention videogame intervention in minority adolescents: Playforward: Elm city stories. Clin Trials. 2016; 13(4): 400-408.

Ferrero NA, Bortsov AV, Arora H, et al.: Simulator training enhances resident performance in transesophageal echocardiography. Anesthesiology. 2014; 120(1): 149-159.

Adams BJ, Margaron F, Kaplan BJ: Comparing video games and laparoscopic simulators in the development of laparoscopic skills in surgical residents. J Surg Educ. 2012; 69(6): 714-717.

Diehl LA, de Souza RM, Gordan PA, et al.: User assessment of "InsuOnLine," a game to fight clinical inertia in diabetes: A pilot study. Games Health J. 2015; 4(5): 335-343.

Hogle NJ, Widmann WD, Ude AO, et al.: Does training novices to criteria and does rapid acquisition of skills on laparoscopic simulators have predictive validity or are we just playing video games? J Surg Educ. 2008; 65(6): 431-435.

Knight JF, Carley S, Tregunna B, et al.: Serious gaming technology in major incident triage training: A pragmatic controlled trial. Resuscitation. 2010; 81(9): 1175-1179.

Cicero MX, Overly F, Brown L, et al.: Comparing the accuracy of three pediatric disaster triage strategies: A simulation-based investigation. Disaster Med Public Health Prep. 2016; 10(2): 253-260.

Huang C, Gao Z: Associations between students' situational interest, #mastery |experiences, and physical activity levels in an interactive dance game. Psychol Health Med. 2013; 18(2): 233-241.

Starkweather AR, Kardong-Edgren S: Diffusion of innovation: Embedding simulation into nursing curricula. Int J Nurs Educ Scholarsh. 2008; 5: Article13.

Curtin MM, Dupuis MD: Development of human patient simulation programs: achieving big results with a small budget. J Nurs Educ. 2008; 47(11): 522-523.

Johnsen HM, Fossum M, Vivekananda-Schmidt P, et al.: Teaching clinical reasoning and decision-making skills to nursing students: Design, development, and usability evaluation of a serious game. Int J Med Inform. 2016; 94: 39-48.

Kleinert R, Heiermann N, Wahba R, et al.: Design, realization, and first validation of an immersive web-based virtual patient simulator for training clinical decisions. Surgery. J Surg Educ. 2015; 72(6): 1131-1138.



How to Cite

Cicero, MD, M. X., T. Whitfill, MPH, K. Munjal, MD, M. Madhok, MD, MPH, M. C. G. Diaz, MD, D. J. Scherzer, MD, B. M. Walsh, MD, A. Bowen, RN, BSN, CPEN, NREMT-P, M. Redlener, MD, S. A. Goldberg, MD, MPH, N. Symons, MD, J. Burkett, DHSc, PA-C, DFAAPA, J. C. Santos, MPH, NREMT, D. Kessler, MD, MSc, RDMS, R. N. Barnicle, MD, MEd, G. Paesano, NREMT-P, and M. A. Auerbach, MD, MSc. “60 Seconds to Survival: A Pilot Study of a Disaster Triage Video Game for Prehospital Providers”. American Journal of Disaster Medicine, vol. 12, no. 2, Apr. 2017, pp. 75-83, doi:10.5055/ajdm.2017.0263.




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