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. Author manuscript; available in PMC: 2022 Nov 15.
Published in final edited form as: Proc Int Symp Hum Factors Ergon Healthc. 2021 Nov 12;65(1):267–271. doi: 10.1177/1071181321651108

FUN AND GAMES: DESIGNING A GAMIFIED CENTRAL VENOUS CATHETERIZATION TRAINING SIMULATOR

Haroula M Tzamaras 1, Jason Martinez 2, Dailen C Brown 1, Jessica M Gonzalez-Vargas 1, Jason Z Moore 1, Scarlett R Miller 1
PMCID: PMC8830596  NIHMSID: NIHMS1711650  PMID: 35155712

Abstract

Gamification, or adding elements of games to training systems, has the potential to increase learner engagement and information retention. However, the use of gamification has yet to be explored in Central Venous Catheterization (CVC) trainers which teach a commonly performed medical procedure with high incidence rates. In order to combat these errors, a Dynamic Haptic Robotic Trainer (DHRT) was developed, which focuses on vessel identification and access. A DHRT+ system is currently under development that focuses on whole procedure training (e.g. sterilization and catheter insertion), including a gamified Graphical User Interface. The goal of this paper was to (1) develop a game-like, patient-centered interface to foster personalized learning and (2) understand the perceived utility of gamification for CVC skill development with expert doctors. This paper outlines some of the potential benefits and deficits of the use of gamification in medical trainers that can be used to drive simulation design.

INTRODUCTION

Gamification, or “the use of elements of game design to increase user engagement” (Nevin et al., 2014, p.685) has been integrated in a variety of contexts from classroom education to tourism, to healthcare (Faiella & Ricciadri, 2015; McCoy et al., 2016; Xu et al., 2014). The most used elements in gamification are points systems, competition, leaderboards, and progress tracking (Garett & Young, 2019; Xu et al., 2014). Though some research on gamification is mixed, from an educational perspective, gamification increases learning gains compared to non-gamified learning by positively affecting the overall retention of knowledge (Putz et al., 2020). In a healthcare context, gamification increases learning retention when framed and implemented around specific learning objectives (van Gaalen et al., 2020). In addition to increases in retention, gamification has also been linked to increases in engagement among medical residents as observed from both self-reports as well as increases in voluntary simulator usage (Kerfoot & Kissane, 2014; Lobo et al., 2017). While the use of gamification has yet to be applied across all areas of medical education, there are areas that could benefit from its deployment.

One such area is Central Venous Catheterization (CVC). CVC is used to provide medication and other necessary fluids to the heart quickly and efficiently via direct access from a vein (Taylor & Palagiri, 2007). CVC is a common medical procedure with more than 5 million patients undergoing it annually (McGee & Gould, 2003). Due to the complexity of the procedure, complications occur at high rates (Hamilton & Foxcroft, 2007). Central venous catheters are generally placed in one of three sites, the subclavian vein, the femoral vein or the internal jugular (IJ) vein (Hamilton & Foxcroft, 2007). IJCVC is the most recommended of the three sites and as such is the focus of hands-on CVC medical education (Ishizuka et al., 2010). When residents are improperly trained on CVC skills, the instances of procedure- related complications can increase, causing risks or even fatalities to patients (Barsuk et al., 2009).

Current residency programs teach CVC using manikin trainers (Soffler et al., 2018) because they can train physical skills that engage multiple senses in a low-stress environment without putting an actual patient at risk (Kunkler, 2006), see Figure 1. However, these manikins are limited in their durability and their ability to train residents on the complex patient scenarios they may experience in a clinical environment. To better train medical residents on the mechanical skills needed to properly insert an IJCVC, the Dynamic Haptic Robotic Trainer (DHRT) was developed (Pepley et al., 2016), see Figure 1. The DHRT uses a combination of haptic forces and ultrasound images to mimic the anatomy of multiple patient profiles, allowing the medical resident to gain experience on a wider variety of patient anatomies (Pepley et al., 2017). This system has been proven to be as effective as a manikin trainer in both skills training and self-efficacy (Yovanoff et al., 2016; Yovanoff et al., 2018). The system focuses on minimizing errors associated with mechanical complications, and as such trains only the first step of the CVC procedure, needle insertion. The system also includes a graphical user-interface (GUI) that focuses on feedback related to needle insertion specifically and lacks gamification elements (Yovanoff et al., 2017). To improve the DHRT system, a holistic simulator that trains the entire CVC procedure is currently in development, which creates the DHRT+ from the original DHRT system, see Figure 1. This system will provide an engaging interface and will tailor feedback to specifically meet the trainee’s needs.

Figure 1:

Figure 1:

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Standard Manikin (Left); DHRT system (Middle); DHRT+ System (Right)

One way to improve the interface of the DHRT+ over the existing DHRT interface is to add gamification. This type of gamification can help residency programs focus their CVC education on following a patient-centered approach and empowering medical practitioners to effectively manage patient care at any critical state (Di Bitonto et al., 2014). By using simulation as a tool for teaching rather than just evaluation and using gamification elements to facilitate patient feedback, the focus can be shifted from trainee performance to patient outcomes (Clark & Hammond, 2017). The focus in medical simulation training should be designing around a patient-specific model that creates a more knowledgeable clinician equipped with the tools to analyze and incorporate patient needs into their care (Arnold et al., 2018). As such, CVC simulators should deploy a gamification approach.

The goal of the current study was to: (1) develop a GUI for the DHRT+ system that integrated game design, and (2) understand through qualitative interviews the perceived utility of gamification for CVC skill development. We use these insights to develop recommendations for the design of gamified CVC medical simulator.

PHASE 1: GAMIFIED GUI DEVELOPMENT

The first goal of this study was to develop a user interface for a holistic CVC simulator incorporating elements of game design. This is important because gamification is proven to increase learner engagement (Kerfoot & Kissane, 2014; Lobo et al., 2017). A new GUI that focuses on feedback for the post needle insertion steps of CVC was developed. The system includes a patient status indicator (Figure 2), summary screen that is seen both at the start and end of the simulation (Figure 3), and multiple training scenarios (Figure 4).

Figure 2:

Figure 2:

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(left) a full patient indicator and a happy face; (right) a decreased patient indicator and a sad face

Figure 3:

Figure 3:

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Summary screen of the interface for an experienced user including: (A) performance over time, (B) tips for the procedure, (C) badges earned (happy patient, stay sterile, complication crusher, needle angle), and (D) progress bar showing how close a user is to verification of proficiency (VOP)

Figure 4:

Figure 4:

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Example scenarios included in the interface; (left) the last step of the simulation which tests proficiency in X-ray reading; (right) the automatic failure situation which results from improper handling and/or disposal of sharps

Game Elements.

The first step in developing a gamified interface for personalized medical simulation was to determine what game elements should be included. There are 12–14 game mechanics elements that are defined as having been used in healthcare simulation (Garett & Young, 2019). Two of the most common are points systems and progress tracking (Garett & Young, 2019). As one of the common pitfalls of gamification is trying to implement too many gameplay methods at once, we chose to focus on badges, progress tracking, adaptive game mechanics, immediate feedback and points system (Singhal et al., 2019).

Patient Status Indicator.

As the user goes through the simulation, they are shown the status of the patient via a patient status indicator seen in Figure 2. This is modeled after a video game health bar in combination with an emoji and satisfies the game elements of immediate feedback and adaptive game mechanics. As the user performs the steps incorrectly, the level of the health bar as well as the emoji change. This provides immediate feedback to the user as well as adaptive game mechanics by modifying the simulation based on direct performance. This also teaches the trainee to focus on the wellbeing of the patient rather than just the steps of the procedure. As an example, Figure 2 (left) shows when the patient indicator is full and the patient is happy, and Figure 2 (right) shows when the patient indicator has decreased, and the patient is not happy.

Summary Screen.

Figure 3 showcases the summary screen which includes badges and several other elements. The top left of the figure shows the user performance over time which tracks the date the user performed the simulation as well as their score (Figure 3A). The top right shows the user personalized tips based on items that they got wrong on previous uses (Figure 3B).

Badges.

Badges were implemented into the interface as seen in Figure 3C. The goal of the badges is to help users track the development of several key skills. While the original DHRT system focused primarily on needle insertion and associated metrics, the newly developed interface provides holistic metrics that train the entire procedure with a clinical mindset by focusing on patient needs and potential problems that could occur. The happy patient badge focuses on ensuring the patient is safe and comfortable. The stay sterile badge focuses on maintaining the sterile field. The complication crusher focuses on ensuring users understand how to handle various complications that can arise during CVC placement. The needle angle badge focuses on ensuring that residents are entering the IJ at an appropriate angle.

Progress Bar.

Verification of proficiency (VOP) is a metric for surgical training that helps residents identify when they have gained an appropriate amount of experience in a specific skillset (Sanfey & Dunnington, 2010). Figure 3D is labeled “VOP Progress” and measures how close a user is to reaching proficiency in CVC insertion. This bar is not eligible to be filled until after the user has earned all the badges. Once this bar is full, the user is verified as proficient in the procedure.

Scenario Development.

To properly showcase the GUI, medical scenarios were developed to program into the system. These scenarios were based on common mistakes that residents make, actions that are inherently dangerous to the patient, and complications that can arise during CVC placement.

Scenario 1 was a general walkthrough of the system and how the interface and patient status indicator change when the user performs a step incorrectly. Scenario 2 showed what happens if the user commits an atrocious breach of safety, in this case disposing of sharp instruments (sharps) on the patient surface rather than in the safe sharps disposal area. Scenario 3 showcased a venous air embolism and the series of questions a resident would have to answer to appropriately navigate through this complication. Scenario 4 showcased how to end the simulation by the ordering and reading of an X-ray. Scenario 5 was a walkthrough of the summary screen and the performance metrics included on it. Scenarios 4 and 2 can be seen in Figure 4 left and right respectively.

PHASE 2: PRELIMINARY FEEDBACK

Once the system had been designed, we sought to understand through qualitative interviews the perceived utility of gamification for CVC skill development. A pilot study was run with two CVC experts and one novice to get feedback. An expert in this case was defined as a doctor who has inserted at least 100 central lines. The experts spoken to were a surgeon (E1) and an anesthesiologist (E2) with similar levels of medical experience. The novice was a surgical resident (N1).

Methods

Due to the Covid-19 pandemic, these 1-hour interviews were conducted via Zoom. The flow of the interview was to present one scenario video at a time showcasing a specific feature of the interface and then ask questions about it. At the end, final questions were asked to participants about general impressions, likes, and dislikes of the system.

Scenario 1.

Experts were asked several questions regarding their overall opinion of the patient health bar and general flow of the system. This included questions like “Are there other important vitals that you think should be shown on the patient status screen? What are they and why?”

Scenario 2.

The experts were asked questions surrounding if the resident should fail the simulation for mishandling their sharps. Examples questions included “Are there any other extreme breaches of safety that should be automatic failures?”

Scenario 3.

The interview questions on this scenario focused on the accuracy of the complication description as well as other complications to include in the system. An example of a question asked about this scenario was “What other complications should the system include to best prepare residents for a clinical environment?”

Scenario 4.

The interview questions about this scenario focused on the validity of ending the procedure with an X-ray. Participants were asked questions such as “Do you think that showing the x-ray and asking a multiple-choice question provides evidence that the resident understands this process?”

Scenario 5.

The interview questions about the summary screen focused on gathering impressions on what kind of feedback is the most useful for residents. To facilitate this, the doctors were asked questions about each portion of the feedback screen and what is useful or useless about it. The last question asked for this scenario was “Is there any other feedback we have not addressed that should be included?”

General Feedback.

After all the scenarios were shown, a few general questions were asked regarding the interviewees’ favorite parts of the system, biggest concerns, and any other not mentioned items that should be included.

Results

Once the interviews were complete, they were transcribed using the online platform Rev.com. This section details a summary of the interviews in 4 main categories: overall impressions, system flow, scenario development and feedback. We then use these findings to provide recommendations for how the system can be improved in future iterations.

Overall Impressions.

General feedback to the design was positive. According to N1, it hit “all the salient points as far as the overall steps and performance of the procedure in a safe manner.” According to E2, the system focuses on “objective feedback” and embodies the belief that “self-learning is more important than guided learning” in a medical setting. In addition to the positive feedback, N1 reiterated that it is the most important with a medical simulator to “verify that the simulation is at least correct in recreating the experience and doing the procedure for real.”

System Flow.

This feedback included suggestions from N1 such as utilizing “different values of patient status decline depending on what happens” to represent differences more accurately in outcomes that would happen in a real scenario. E1 suggested to “make the whole [patient health bar] green” rather than having it be multicolored because the current multi-color scheme may be confusing for the user. E2 indicated that patient feedback may be “more of a distraction” and that it may be better to only show the patient status at the beginning and the end rather than throughout the procedure. Additionally, sometimes for CVC the patient is under anesthesia and not awake during the procedure, meaning they will likely not be providing any indicators regarding how they feel to the doctor performing the procedure. In this case, important feedback mentioned by all interviewees was to add vital signs to the indicator screen such as a fake ECG tracing to monitor the patient’s heart rate.

Scenario Development.

Scenario 2 showcased a breach of safety by the user where they discarded a sharp object on the patient drape instead of in the proper sharp disposal area. The feedback for this scenario was positive as N1 mentioned “it’s good to encourage best patient practices,” but E2 warned that it would be important to inform trainees to take the scenarios seriously and attempt to mimic how they would act in an actual clinic prior to beginning the simulation. Scenario 3 showcased what would happen if a complication arose during the simulation. Though venous air embolism is not a common complication that arises, the feedback was positive overall. E1 said that the way the complication was presented was “really good” and provided suggestions of how to make it more realistic. E1 and E2 both suggested including complications such as pneumothorax or heart-related problems in future iterations. Scenario 4 depicted how an X-ray would be used to end the procedure and test X-ray reading proficiency. The feedback to this was positive, E1 said that they thought it “would be really good” and N1 said it was useful because a resident should “know how to look for [the] line and how to tell that it’s in the right position.”

Summary Screen.

The feedback regarding the summary screen was positive. E1 felt that personalized learning in this environment was useful because it “really give[s] the learner the opportunity to do so much of this on their own” rather than having to be supervised by a trainer. N2 appreciated the tips portion of the summary screen because it is useful to provide “corrective feedback from previous attempts,” but recommended that the feedback be more specific in the future. Badges were viewed as helpful because they are data-driven, provide users with exact measures of how they are doing, and according to N1 “add a little element of fun” to the training. E1 thought that the happy patient badge was useful because it helps with the idea of “basing all of [the] metrics on the patient happiness and safety,” while E2 liked the badge but warned that the name should be changed because “happy” is a subjective descriptor and it could be more beneficial to call the badge something more quantitative. E1 and N1 recommended revisiting the idea behind the needle angle badge.

CONCLUSION

Gamification has proven to be an effective method for increasing the information retention and engagement of learners. However, it has yet to be integrated throughout medical education, and is specifically lacking in CVC training. CVC is a complex medical procedure that needs more robust training methods due to the high complication rates associated with it. This paper outlines the development of an interface intended to train residents in the entirety of the CVC procedure. The interface was developed using gamification strategies and presented to two expert doctors and one novice doctor to gather preliminary feedback. This pilot study provided crucial and necessary information that will help further the development of this interface, as well as initial data to validate the potential use of gamification in CVC education. Items from the interviews that will be implemented in the next design iteration include the addition of vital signs to the patient monitor, a modification of the patient health bar, and renaming of some of the badges in order to improve the overall quality of the training. Future work on this interface will include a 10-doctor study on the perceived usability to help inform the final design. This study will include doctors from a variety of specialties who have inserted at least 50 central lines and have various years of medical experience.

ACKNOWLEDGEMENTS

This work was supported by the national Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) under Award Number RO1HL127316. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Coauthors Dr. Moore and Miller owns equity in Medulate, which may have a future interest in this project. Company ownership has been reviewed by the University’s Individual Conflict of Interest Committee.

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