Escape the Simulation Room

Abstract

Background.

Healthcare simulations are used at most academic facilities to improve knowledge and performance on critical and key concepts and can also be used to enhance competency and teamwork. Group simulation scenarios often have individual team leaders, but these scenarios require a team to work together to efficiently care for the patient. Escape rooms can be utilized in healthcare as a fun educational activity to encourage teams to work together and think creatively to solve puzzles and challenges. One advantage of this type of activity in a healthcare setting is to dissolve any hierarchy amongst the team and build the confidence of novice or more passive participants. Escape rooms in a healthcare setting do not have to be medically themed to be effective, and rooms can be set up with minimal equipment.

Aim.

This article addresses the detailed steps required to set up a healthcare themed escape room that has been shown to work well. It is applicable to healthcare professionals and can be adapted for non-healthcare workers.

Method.

Based on the Escape Room video games and social activity phenomenon, teams compete to solve content-specific challenges to attain pieces of the final puzzle set forth by the instructors. Traditional quiz-type exercises, pictograms, and procedural based activities comprise the puzzles of the game. The first team to obtain all pieces of the final clue and put them together in the correct order in the shortest amount of time is deemed the winner. Gameplay is designed to conclude in approximately 20 minutes.

Results and Conclusion.

This game mimics interdisciplinary teamwork environments. Participating in interactive collaborative learning environments enhances the overall learning experience, allowing learners to apply knowledge.

Keywords

escape room health care teamwork communication emergency medicine

Background

Emergency medicine literature has shown a trend towards non-traditional, alternate approaches to education (Deiorio et al., 2012). The reason for this change is likely multifactorial, but includes a hypothesized theory that emergency medicine trainees have a relatively short attention span and prefer active learning. In addition, adult learners have an increased focus on problem solving, and in particular, millennial adult learners have an increased desire for interactive learning (Knowles, 1990).

Escape rooms in healthcare education have become increasingly popular over the past 3 years, with the number of peer reviewed articles tripling from 2017–2019. One of the advantages of this type of learning environment is to create a level playing field, by not depending on medical knowledge and using a non-clinical case (Kutzin, 2019, p. 478). Edutainment, or entertainment with an educational aspect, also allows for lower stress levels of the participants than what may be found in more traditional simulation experiences common in medicine, since the focus of the escape room is not on clinical knowledge. Escape rooms also provide opportunities for teams to gain a deeper understanding of team dynamics required to function at the highest level (AHRQ, 2014; Kutzin, 2019). With a properly executed debriefing, the lessons from the escape room can easily be translated to the clinical environment.

Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®), is an evidence-based curriculum developed by the Department of Defense and the Agency for Healthcare Research and Quality (AHRQ) to integrate teamwork into practice and is often used in the medical field (King et al., 2008). The main competencies of TeamSTEPPS® are team leadership, communication, situational monitoring, and mutual support, all of which can be taught through an escape room experience (Clancy & Tornberg, 2007, 2019). An escape room allows for groups of individuals to come together and practice TeamSTEPPS® tools. In addition, clinical training skills to be taught and reinforced in a fun, non-stressful, interactive manner.

The escape room discussed in this article was created for the Pediatric Emergency Medicine (PEM) Games, an annual competition between PEM faculty and fellows. Each year, teams face-off in a collegial, yet competitive set of games, of which the Escape Room is one component. The PEM Games serves as a way to teach important clinical and non-clinical concepts and build comradery among trainees and faculty. While other parts of the PEM Games session focus on clinical concepts such as resuscitation and procedures, the specific purpose of this escape room is to promote teamwork and communication and introduce new hires to each other in a fun, interactive manner.

The PEM Games Escape Room is designed to be a typical entertainment style escape room with multiple puzzles and simultaneous challenges occurring to keep the experience engaging for the whole team. Entertainment style escape rooms are what one would experience at a commercially available escape room, an experience designed to keep all participants having fun by presenting multiple puzzles at once, rather than one at a time. Many escape room experiences include some kind of entertaining theme or story to more fully immerse the participants, as is done in this experience. This room is not designed to teach or reinforce clinical concepts, though some medical knowledge is required to complete the puzzles in the room.

The development of an escape room includes creating puzzles that lead to the escape. The game creator must determine which types of puzzle pathways they want to create. Options include open paths, sequential paths, and linear paths (Nicholson, 2015). Open pathways allow clues to be solved in any order and when put together, they lead to the solution. This is in contrast to sequential and path-based games where teams have to solve clues in a specific order to unlock the next clue (Nicholson, 2015). The difference between a sequential game and a path-based game is that the path-based game has multiple sequential puzzles to solve simultaneously, which is common in larger rooms with more players (Nicholson, 2015). The PEM Games escape room begins with an open pathway, but encourages the team back together at certain points to force them to work together as a full team, to achieve the goal of escaping. In the PEM Games room, teams have the option of splitting up to survey different areas of the room to find clues versus staying together and solving one puzzle at a time.

Introduction to the Scenario

Prior to entering the room, participants were told that the simulation director, after spending too much time with the mannequins, goes mad and has turned into a serial killer with a plan to turn his victims into very realistic simulation mannequins. The scene opened with an abandoned simulation room, complete with a television playing static, lights dimmed, and creepy music. Once inside the room, the door was closed and locked.¹

Locking doors may be a violation of health and safety regulations. Instead of locking the door teams are advised the door cannot be opened until the final clue is solved.

Participants are advised that they have 20 minutes to escape before the simulation director returns for them. A game manager, an individual who introduced the scenario, explained the rules, and maintained a safe environment, stayed in the room with the participants to provide any clues that were needed or requested. The game manager may also lead the debriefing following the session as they likely have the most insight into the puzzles and the solutions.

The Flow of the Escape Room

Upon entering the room, the team saw a fully equipped simulation room, including a medical gas headwall, code cart, ultrasound machine, a high-technology patient simulator, and part-task trainers, including intubatable airway heads. A pediatric mannequin and two airway heads, one adult and one pediatric were available in the PEM Games. Although the lights were initially off, the team may choose to turn the lights on. As the team investigated the room, they found several locked bags and boxes throughout. Clues were scattered about the room. Some of the clues required a previous clue to be solved (linear pathway), while several could be opened at once by different team members (open path). Having multiple puzzles to solve simultaneously was preferred in this game so that all of the team members could be involved early in the experience. This also forced the team to communicate with each other about what they found as they did not all have the same information at the same time. Although the PEM Games room is medically themed and requires some basic medical knowledge, the puzzles can be easily modified to reduce the amount of medical knowledge needed to complete the game. This allowed fro team members from many disciplines and from multiple training levels to participate together.

Clues:

Overall Escape Puzzle: Clearly visible on a wall in the room, are small hook and loop tape tabs. The team should deduce that they are required to place items in a specific order on the tabs. In this room, pieces of paper with hook and loop tabs are the items that need to be found by the participants and then placed on the wall in the correct order. The team must work together to solve the final puzzle.

Clue 1: On a dry erase board there are a series of letters and spaces written vertically– M_D_I_ _S. The team should solve the clue with the missing letters to spell MUDPILES, a common mnemonic for an anion gap metabolic acidosis. The missing letters– UPLE open a 4-letter lockbox with a laminated piece of paper with a colored digit on it. On the back of the laminated paper is a piece of hook and loop tape indicating it should be hung on the wall.

Clue 2: A series of radiographs are located in a code cart. The five radiographs show a progression from a normal lung xray, to a pneumothorax, to a tension pneumothorax, to a chest tube, and finally a decompressed pneumothorax. On the back of each radiograph are numbers and when the images are arranged in the correct order, the numbers will be 43628 (any combination of digits can be used). This combination opens a lockbox that is disguised as a book (commercially available). Inside the lockbox, the team will find a laminated digit (to be hung on the wall) as well as a piece of paper with a 3-digit number on it.

Clue 3: The 3-digit combination located in the lockbox does not correspond to any lock in the room. The team will have to determine it refers to a page number in a procedure textbook located in the room. On the identified page, there is a discussion of how to place a chest tube, along with a series of underlined letters– DLLUU. These letters correspond to the directions required to open a directional lock that is attached to a bag in the room. Inside the bag, the team will find another laminated digit.

Clue 4: Inside a suction canister located in the room is a key. The key will open an airway box, in which a laminated piece of paper with a digit on it is located, as well as a laryngoscope blade and handle.

Clue 5: When the team attempts to test the laryngoscope handle to see if the light is functional, they will recognize that the light does not illuminate. If they unscrew the base of the handle, they will see there are no batteries in it, but there is a laminated digit located inside the handle.

Clue 6: Spare batteries are located in the code cart. The team can use the batteries to make the laryngoscope handle and blade function. Once they have a working laryngoscope, they can attempt to intubate the airway heads and/or mannequin. When attempting the intubation, they will find a key placed deep in the airway. They should retrieve the key with the ringed forceps that are located in the room. The key will open another lockbox which contains another laminated digit.

Clue 7: Located in the room are some small containers of an opaque substance (homemade ultrasound gel pads) with toxic labels on the containers (Figure 1) (SonoPath, 2013). Labels and or a pre-briefing should make it clear to the team that they should not touch the gel with their hands. Using an ultrasound machine in the room, the team will discover a key hidden in the gel pad. The team can use forceps to dig the key out without getting the "toxic substance" on their skin. The key will open a locked bag containing another laminated digit.

Final Puzzle: The team should now have all 7 laminated digits and will have to decide the final order. Upon examining the numbers, they will notice that they are each a different color. Each colored paper/digit corresponds to a color on the Broselow® tape, a colored-coded length based tape measure used for pediatric resuscitations, which is also available in the room (Luten et al., 2002; Wells, Goldstein, Bentley, Basnett, & Monteith, 2017). In our room, the Broselow® tape was located in the code cart, but it can be placed anywhere. Placing the numbers in the correct order unlocks the door, stops the clock, and wins the game. (See Figure 2).

Figure 1.

Example of homemade ultrasound gel pads.

Figure 2.

Final puzzle in Broselow Tape® color order.

Upon completion of the escape room, a debriefing should be facilitated by the game manager. The debriefing should begin with a walk-through of the room, a review of how the puzzles were supposed to be solved, and an opportunity for the participants to ask questions about the room and the puzzles. Following the walk-through, a more formal debriefing should be conducted. This is an opportunity to review TeamSTEPPS® concepts and any critical medical information that was trying to be reinforced during the escape room.

For example, in this room, the proper way to use the ringed forceps to retrieve an airway foreign body may be reviewed if the teams struggled with that skill. Next, a review of partially solved clues and a discussion of how improved communication between team members could help solve the puzzles is conducted. Finally, it is important to review how the concepts experienced during the escape room and discussed in the debriefing can be translated to the clinical environment. This helps the participants understand that the purpose of the activity is not only to have fun and build relationships, but also discover how working together can help them in their daily work lives.

Equipment

Table 1.

Required Equipment

Locks: Various locks including: 5 digit lock, travel locks, directional lock, two small locks

Laryngoscope handle and blade

Intubating airway heads and/or intubating mannequin

Lockable bags/boxes (can lock two zippers together)

Laminated, color-coded series of single digits

Dry erase board

Homemade ultrasound gel (See Figure 1) (SonoPath, 2013).

Ultrasound machine

Book of medical procedures

Airway cart or code cart

Ringed forceps

Other medical equipment to add to overall effect of room

Outcomes

Teams adopted different strategies to approach the room, with some strategies being more successful than others. Several differences were noted amongst teams in their approach to the room, which were particularly evident in teams comprised of more experienced clinicians, as described below.

In an informal, verbal group evaluation after the session, the PEM Games Escape Room was reviewed positively by the 17 participants who completed the room. Each group that has taken part in the event has requested for additional escape room activities in the future. It was noted that several of the more senior participants were more passive during the escape room, while junior participants had the opportunity to espouse leadership qualities and have a stronger voice than would be normally expected. This is likely due to more of the junior participants having prior experience with escape rooms and therefore having a better idea of how to methodically move about the room and the types of commonly used clues and puzzles used in commercial escape rooms.

The majority of groups who have participated in this experience escaped the room within 20 minutes. However, at times, clues could be provided by the game manager if needed to help facilitate the teams escape. Clues and hints were not necessary with any of the groups who participated in this escape room, but differing clinical backgrounds or limited experiences with escape rooms may make it necessary.

Prior research has shown that escape rooms are perceived as an engaging learning strategy by learners and educators (Toronto, 2019). Competition can also be a great motivator for teams. Immersion of clinical teams into a non-clinical environment that requires teamwork and communication amongst team members can increase the confidence of team members by challenging classic medical hierarchy (DiMenichi & Tricomi, 2015; Kutzin, 2019). Senior or attending level participants may not have any prior experience participating in escape rooms, thereby forcing more junior participants into a leadership role, and requiring senior clinicians to operate in a more supportive role. It was also noted that teams comprised of older participants tended to move about the room together, rather than splitting up to discover different aspects of the room simultaneously. This may be due to lack of experience in entertainment style or other escape room settings, or it may be that more senior clinicians have a stronger propensity for working in collaborative groups. This requires further investigation to uncover why certain groups acted the way they did. In addition, the more senior participants tended to focus on the medical aspects of the environment, rather than focusing on solving the puzzles in the room. A lack of experience with escape room games may lead to this difference.

This type of learning activity can lead to higher levels of engagement of the participants since escaping the room is directly related to the activities of all the team members in the room. No team members can sit idly by as they may be able to do in a typical healthcare simulation event. Because each member of the team brings a unique perspective and set of skills to the situation, recognizing early on that the success of the team truly depends on quickly forming of an ad-hoc team and subsequent collaboration of members is a key to the success or failure of the team.

Future Applications of the Room

The main concepts of this escape room should be easily used by others interested in hosting their own escape room. The exact puzzles used in this example can be modified to fit the available equipment and the expected knowledge level of the participants. Clues can be modified to test and teach more medical concepts or can be changed to eliminate the medical knowledge all together, so the focus is solely teamwork and communication.

If the room is recreated, future versions should include a clue on the wall to indicate to the participants what should be done with the hook and eye tabs. For example, a clue such as these seven will get you to your destination may help the participants recognize that they need to place items on the wall in order.

It was also found that if multiple teams are going to participate then having a leaderboard in the pre-brief/debrief room with the team names and time to completion adds a competitive element to the event. The competitive environment may increase the nervousness of the participants and cause them to rush and moved quickly through the room which may lead to mistakes. This provides additional opportunities to debrief as it may replicate some of the actions and feelings that may be felt in clinical or work situations.

Footnotes

Declaration of Conflicting Interests

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Jennifer E. Sanders, MD, is the assistant medical Director of Pediatric Emergency Medicine at the Mount Sinai Hospital in New York City. She also serves as the associate fellowship Director for the Pediatric Emergency Medicine fellowship.

Contact: jennifer.sanders@mountsinai.org

Jared Kutzin, DNP, is the Director of simulation at the Mount Sinai Hospital STAR Center and an assistant professor of Emergency Medicine at the Icahn School of Medicine at Mount Sinai. A well-regarded simulationist, Jared is well-published in the fields of simulation and health professionals education and a frequent presenter at simulation conferences. In addition, he is the associate editor responsible for simulation curriculums at MedEdPORTAL.

Contact: jared.kutzin@mountsinai.org

Christopher G. Strother, MD, is the Director of Pediatric Emergency Medicine at Mount Sinai Hospital in New York City. He also serves as the Director of Undergraduate Simulation for the Icahn School of Medicine at Mount Sinai and the Medical Director of the Emergency Department Simulation Teaching and Research Center.

Contact: christopher.strother@mountsinai.org