Serious Gaming for Orthotopic Liver Transplantation Industry Track Demo Proposal

Orthotopic liver transplantation (OLT) is the definitive treatment for end-stage liver disease. Transplantation may be indicated when cirrhosis, drug-induced acute hepatic failure, malignancy, or metabolic diseases are present.[1] Although the procedure is life saving, the limited number of organs preclude performing the procedure in large numbers. For example, 5913 liver transplants were performed in 2013.[2] In contrast, approximately 750,000 laparoscopic cholecystectomies are performed annually.[3] Additionally, anesthesiology residents participated in liver transplantation-associated educational activities, such as a clinical rotation, in only 26% of institutions.[4] The low rates of OLTs and OLT-related activities result in uneven and relatively minimal first-hand operating room exposure among trainees, which is particularly troublesome considering the complexity of the procedure. The use of a serious game to teach anesthesia knowledge and skills has been explored by a previous study in which the use of a serious game improved central venous catheter (CVC) placement technique and safety.[5] We therefore set out to design a serious game aimed at improving anesthetic technique for orthotopic liver transplantation. Our serious game was designed for use on either the iPad, and android tablet, or an HTML5 compatible internet browser. We wanted the platform to be as universal as possible so that residents were not limited on ways to access the game. It was designed using the Gamesalad© engine which minimizes the amount of coding required and publishes games in all of the aforementioned platforms. The game begins with a brief patient summary and then takes the player through every stage of the procedure including: pre-operative assessment, invasive testing, blood product preparation, induction of anesthesia, placement of invasive monitoring lines, specimen dissection, anatomically anhepatic stage, reperfusion of the transplanted liver, and hepatobilliary reconstruction. (See Figure 1) Each phase is broken into integral components, with information gathered from the liver transplant literature and best practices seen at our institution. The player is asked to participate in each phase of the procedure and is given a sum of points on which to spend on tests and treatments. The player is also asked to answer knowledge-based questions in a more traditional format. All points that are spent are deducted from their point total, with the goal the end the procedure with the highest point total possible. This is done to minimize the interventions performed on the patient in order to save time and money. Each step is also tracked, with points deducted for either not gathering sufficient information, or for leaving the patient in a critical state during the procedure. When the player reaches 0 points, the patient expires and the game ends. The player then has the option of either returning to the prior stage to try again or returning to the main menu to restart the entire process. Each stage is followed by a feedback screen which lets the player know how to improve their practice for the next attempt, as well as provide explanations as to why points were deducted. Our game is currently being rolled out in the department of anesthesiology at the Icahn School of Medicine at Mount Sinai. It has thus far been well received. We intend to use this period to discover potential errors/bugs for its final release in the coming year.