Effect of Mixed Reality on Delivery of Emergency Medical Care in a Simulated Environment: A Pilot Randomized Crossover Trial

IMPORTANCE: Mixed-reality (MR) technology has the potential to enhance care delivery, but there remains a paucity of evidence for its efficacy and feasibility. OBJECTIVE: To assess the efficacy and feasibility of MR technology to enhance emergency care delivery in a simulated environment. DESIGN, SETTING, AND PARTICIPANTS: This pilot randomized crossover trial was conducted from September to November 2021 at a single center in a high-fidelity simulated environment with participants block randomized to standard care (SC) or MR-supported care (MR-SC) groups. Participants were 22 resident-grade physicians working in acute medical and surgical specialties prospectively recruited from a single UK Academic Health Sciences Centre. Data were analyzed from September to December 2022. INTERVENTION: Participants resuscitated a simulated patient who was acutely unwell, including undertaking invasive procedures. Participants completed 2 scenarios and were randomly assigned to SC or MR-SC for the first scenario prior to crossover. The HoloLens 2 MR device provided interactive holographic content and bidirectional audiovisual communication with senior physicians in the MR-SC group. MAIN OUTCOMES AND MEASURES: The primary outcome was error rate assessed via the Imperial College Error Capture (ICECAP) multidimensional error-capture tool. Secondary outcomes included teamwork (Observational Teamwork Assessment for Surgery [OTAS]; range, 0-6 and Teamwork Skills Assessment for Ward Care [T-SAW-C]; range, 1-5), scenario completion, stress and cognitive load (NASA Task Load Index [NASA-TLX; range 0-100]), and MR device user acceptability. RESULTS: A total of 22 physicians (15 males [68.2%]; median [range] age, 28 [25-34] years) were recruited. MR technology significantly reduced the mean (SD) number of errors per scenario compared with SC (5.16 [3.34] vs 8.30 [3.09] errors; P = .003), with substantial reductions in procedural (0.79 [0.75] vs 1.52 [1.20] errors; P = .02), technical (1.95 [1.40] vs 3.65 [2.03] errors; P = .01), and safety (0.37 [0.96] vs 0.96 [0.85] errors; P = .04) domains. MR resulted in significantly greater scenario completion rates vs SC (22 scenarios [100%] vs 14 scenarios [63.6%]; P = .003). It also led to significant improvements in the overall quality of teamwork and interactions vs SC as measured by mean (SD) OTAS (25.41 [6.30] vs 16.33 [5.49]; P < .001) and T-SAW-C (27.35 [6.89] vs 18.37 [6.09]; P < .001) scores. As reported via mean (range) NASA-TLX score, there were significant reductions for MR-SC vs SC in participant temporal demands (38 [20-50] vs 46 [30-70]; P = .03) and significant improvements in self-reported task performance (50 [30-60] vs 39 [10-70]; P = .01). Overall, 19 participants (86.4%) reported that they were more confident in making clinical decisions and undertaking clinical procedures with MR support. CONCLUSIONS AND RELEVANCE: This study found that the use of MR technology reduced error, improved teamwork, and enhanced practitioner confidence when used to support the delivery of simulated emergency medical care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05870137