Journal of Education and Teaching in Emergency Medicine

Audience: This is an in-person escape room and procedure simulation activity based on complications of human immunodeficiency virus (HIV) in India, which was created by using local HIV management guidelines. Emergency Medicine (EM) trainees of all post-graduate levels are the target audience. This may also be used by trainees in other specialties, such as infectious disease or internal medicine, who require an understanding of HIV and its complications. This escape room can be completed in teams of varying sizes and is designed to be adaptable to local resource availability.

Background: Patients with HIV present to the Emergency Department (ED) for a variety of reasons such as initial viral syndrome, medication side effects, and opportunistic infections. While the widespread use of antiretroviral therapy (ART) has significantly increased the life expectancy of patients living with HIV and decreased the incidence of classical opportunistic infections, EM providers should still be vigilant and competent in diagnosing and managing these pathologies. This is particularly critical in India, where the prevalence of HIV was most recently estimated at 0.22% (2.2 million people older than 15 years) in 2020.1 This patient population, primarily infected through unprotected heterosexual contact, is at high risk for interruptions in ART and development of opportunistic infections for a variety of reasons including migration for work, low social status of women, and significant social stigma against HIV.2 Simulation is an educational opportunity to review these high-acuity low-occurrence presentations to prepare EM trainees for independent practice.

Educational Objectives: By the end of the escape room, learners should be able to: 1) describe the mechanism of action of antiretroviral therapies available in India, 2) prescribe initial antiretroviral therapy to

a patient presenting to the emergency department with a new diagnosis of HIV, 3) develop a differential diagnosis for a patient with HIV presenting to the ED with chest pain, 4) identify common dermatologic manifestations of opportunistic infections in patients with HIV, 5) identify computerized tomography scan and lumbar puncture features for central nervous system infections seen in patients with Acquired Immunodeficiency Syndrome (AIDS), 6) identify red flag features and appropriate workup for a patient with HIV presenting with a headache to the ED, 7) interpret images obtained during a Rapid Ultrasound for Shock and Hemorrhage (RUSH) exam, 8) identify cardiac tamponade and perform a pericardiocentesis, and 9) communicate and collaborate as a team to manage a complex, unstable patient with HIV in the ED.

Educational Methods: We sought to create and implement an educational tool that could meet the complex education needs of EM trainees while being low cost, easily adapted to local resources, and engaging for trainees. Hospitals participating in the Masters in Emergency Medicine (MEM) program, a global partnership between the Ronald Reagan Institute for Emergency Medicine at the George Washington University and 18 hospitals in India, have resource variability for traditional simulation. The escape room created combines simulation, content review specific to the contextual practice of EM in India focused on HIV and its complications, and critical procedure teaching on pericardiocentesis. This innovation framework is based on Kolb’s experiential learning cycle and incorporates the gamification principles of a sense of autonomy, perception of competitiveness, and learner-relatedness.3-4 Escape rooms have been shown to engage learners, and low-fidelity procedure models could further maximize the experience for learners in resource variable settings.5 A pericardiocentesis model was adapted from Lord et al.’s low-fidelity model, ensuring it could be assembled with materials readily available in-country.6

Research Methods: We adapted the escape room format to combine simulation, content review, and procedural training in a cost-effective, contextually relevant, and scalable way. The escape room was trialed using a case of chest pain and altered mental status caused by a pericardial effusion due to tuberculosis in a patient with HIV. Local practice patterns and guidelines were used to develop puzzles and clinical clues. A pericardiocentesis model was constructed using materials readily available in India. Pre- and post-surveys were developed to assess baseline trainee experience with escape rooms, self-reported knowledge of the differential diagnosis and management for altered mental status, and ways to incorporate escape room content into daily practice.

Results: A total of 47 trainees participated; 41 of 47 participants completed both pre- and post-surveys (87% response rate). Participants represented all program trainee levels: 49% (n = 20) PGY-1, 27% (n = 11) PGY-2, and 24% (n = 10) PGY-3. Based on a score greater than seven on a 1-10 Likert scale, the escape room was rated as “highly effective” by 93.5% of respondents in reviewing medical knowledge. The trainees were allotted 60 minutes to escape the room; the median time for escape room completion was 57 minutes. The escape room and pericardiocentesis model cost under $100 USD, were repeated up to six times in one day, and could be recycled for future use.

Discussion: Utilizing simulation in the escape room format that can be adaptable to variable resource settings is a valuable educational tool. The integrated escape room and procedure training proved to be an effective educational tool that was scalable and maintained efficacy across variable hospital resource levels. The next step includes adapting this format for other disease pathologies. This is a useful way to meet the education needs of MEM program trainees, regardless of hospital resource availability, that could be replicable in other EM training programs.