Distractions Hospital: A High-Fidelity Simulation to Train Prioritization, Triage, and Task Switching for Emergency Medicine Residents

Emergency medicine as a field requires rapid prioritization, task-switching, and cognitive overload management, all of which are skills now emphasized in ABEM’s new Certifying Exam (under “Prioritization Cases"). To address this need, a “Distractions Hospital” simulation was created to mirror real ED complexity. This scenario uses deliberate distraction, multi-patient demands, and timed, escalating interruptions to train residents in managing high cognitive load while maintaining situational awareness and effective team communication.

The primary objective was to design and evaluate a high-complexity and high-fidelity simulation that trains EM residents in prioritization, task-switching, and cognitive overload management while aligning with ABEM's “Prioritization Case” assessment standards. A secondary objective was to assess the impact of this scenario and its applicability to real-world EM practice through the perception of residents. A tertiary objective was to create an easily reproducible model for enhancing complexity across simulations to engage learners.

Residents participated in a high-fidelity simulation involving a 60-year-old with acute coronary syndrome who deteriorated into ventricular fibrillation. While resuscitation is ongoing, embedded simulation participants (EM faculty or nursing staff) delivered timed interruptions from five additional patients, each requiring prioritization and delegation. Scenario design emphasized realism, communication challenges, and psychological safety. Debriefing employed PEARLS and advocacy-inquiry techniques to explore help-seeking, overload management, and task-delegation. Learners (PGY 1–3, n=30) completed voluntary, anonymous post-session surveys.

Two EM residencies participated in the simulation. Quantitative survey results were summarized using descriptive statistics and free-text comments were reviewed for common themes. Results showed strong educational impact: 100% agreed the scenario helped manage cognitive overload, 93% reported improved task-switching confidence, and 100% would recommend it. Learners valued realism, escalating interruptions, and structured debriefing. Our findings support this scenario as an effective model for teaching complex cognitive skills aligned with EM practice and ABEM priorities.

The field of emergency medicine (EM) is heavily characterized by constant interruptions, simultaneous crises, and rapidly evolving situations, all of which demand strong cognitive flexibility. As the American Board of Emergency Medicine (ABEM) introduces new “Prioritization Cases” on the Certifying Exam to formally assess skills such as prioritization and task-switching, EM educators must consider designing tools that prepare residents for both real-world and examination-based challenges. In response, the “Distraction Hospital” simulation scenario was developed as an innovative, high-cognitive-load training tool designed to authentically replicate the chaotic and multitasking nature of emergency care. “Distraction Hospital” centers on a high-acuity index case: a 60-year-old patient presenting with acute coronary syndrome who rapidly deteriorates into ventricular fibrillation and cardiac arrest. While the resident team initiates CPR and advanced resuscitation, embedded simulation participants (ESPs, often EM faculty or nursing staff) portray roles such as nurses, technicians, and consultants who arrive with urgent updates (in the form of EKGs, phone calls, or critical results) from five additional ED patients. These interruptions are intentionally timed to coincide with key decision points in the resuscitation, escalating cognitive demand and forcing residents to continually re-assess priorities, delegate tasks, and maintain a shared mental model under stress. The scenario’s design emphasizes psychological safety while still keeping learners within a zone of proximal development. Realism is enhanced through scripted interruptions that mimic the unpredictability of ED workflow and communication challenges inherent in managing a busy ED. The instructional goal is not to overwhelm the learner, but to cultivate adaptive expertise and help residents recognize cognitive strain and manage multiple competing demands effectively. Following the simulation, debriefing is conducted using PEARLS and advocacy-inquiry techniques to help residents reflect deeply on their performance. Facilitators guide learners in identifying self-limiting behaviors, recognizing thresholds for asking for help, managing information overload, and applying practical strategies (such as task-delegation, cognitive-offloading, checklists, and structured team communication). The debriefing process serves as a critical scaffold, converting a high-intensity simulation into actionable learning. Preliminary evaluation data from 30 EM residents (PGY-1 to PGY-3) across two EM residencies demonstrate strong acceptance and perceived educational value. All participants (100%) strongly agreed that the session equipped them with tools to combat cognitive overload, and 93% strongly agreed that it improved their confidence in task switching. Every participant reported they would recommend the session to peers. Qualitative comments further highlighted the realism of the escalating interruptions and the proximity of this experience to a real-world ED attending experience.