About the Game
OutSMA℞T Agitation is an educational serious game being developed by the CRoME Lab at the University of Kentucky to train emergency department nursing staff to get ahead of agitation in older adult patients — recognizing the early signs, preventing escalation, and de-escalating safely when it does occur. The game gives learners a safe, low-pressure space to practice the clinical judgment that makes the biggest difference at the bedside.
Who It Is For
The game is designed first for practicing emergency department nurses caring for geriatric patients, who are at unique risk of agitation and restlessness. It is also built to serve the wider bedside team: nursing students in clinical education programs, patient care technicians, allied health students in patient-contact roles, and the volunteers who rotate through the emergency department each semester.
Developed with the UK HealthCare Emergency Department Team
OutSMA℞T Agitation is being developed in partnership with the UK HealthCare Emergency Department Team. The concept grew out of collaboration with Dr. Jessica Houck, who leads the Geriatric Emergency Department team at UK HealthCare, and is being shaped alongside emergency department nursing staff and clinical experts to ensure the training reflects real bedside practice.
Why Agitation in Older ED Patients?
Agitation in older emergency department patients is common, distressing, and often driven by causes that staff can actually fix — unrelieved pain, a full bladder, thirst or hunger, hearing aids left in a drawer, a long night under bright lights. Prolonged boarding in the emergency department compounds every one of them. The most meaningful clinical lever is early recognition followed by swift, protocol-driven intervention, before behavior escalates to the point where safety — the patient's and the team's — is at stake.
OutSMA℞T Agitation is grounded in evidence-based geriatric emergency care and uses game-based learning to build the observation, assessment, and decision-making skills that help nursing staff catch agitation sooner, treat the cause rather than the behavior, and keep physical restraints as a last resort.
Learning Objectives
On completion of OutSMA℞T Agitation, the learner will be better able to:
Get ahead of agitation in geriatric emergency department patients — recognize it early and act before it escalates.
Supporting objectives
- Identify the verbal and conversational indicators of early, moderate, and escalating agitation.
- Describe non-pharmacological and pharmacological pathways for both prevention and intervention.
- Recognize environmental risk factors — including prolonged emergency department boarding times — alongside patient history cues.
- Reserve physical restraints for situations where they are absolutely necessary for immediate safety.
How It Works
OutSMA℞T Agitation borrows the escape-room genre's emphasis on puzzle-solving and discovery, but strips away the timers and locked doors. Instead of racing a clock, the player is racing a patient's deterioration — while managing more than one patient at a time. The tension comes from clinical stakes, not artificial pressure.
Each scenario is a self-contained puzzle, and the “room” you have to escape is diagnostic ambiguity. You start uncertain about the patient's state and have to gather enough evidence to reach a sound assessment and act on it.
Orient
Review the patient chart summary, the room, and whatever history is available. No diagnosis yet — only context.
Converse
Engage the patient through structured dialogue. Choose your questions, listen to the answers, and watch the tone and coherence of the response.
Assess
Identify which agitation risk factors are actually present in front of you, and judge how far along the patient is.
Decide
Choose a prevention action or intervention pathway from the options available at the bedside.
Debrief
Get immediate feedback on each decision with the clinical rationale behind it — and the option to retry the ones that were off.
Conversation is the diagnostic medium
Rather than reading vital-sign charts, the player learns to notice what a patient says — and what they fail to say — the same way they would at a real bedside. Four signals sit at the center of the game:
- Topic driftThe patient starts answering a focused question, then veers off and never notices.
- Delayed processingAn abnormally long pause before a simple answer, or losing the thread mid-sentence.
- Inappropriate affect or contentWorry about things that are not there, people or events that do not fit the room, clarity that comes and goes.
- Agitation without a clear causeResistance, a short temper, pulling at equipment or trying to leave — with no obvious physical trigger.
There is no time pressure and no failure state. When a judgment or intervention is off, the game explains what was missed and returns the learner to the decision point to try again with that added context — an approach designed to reduce anxiety for newer clinicians while actively correcting misunderstandings rather than letting them pass.
Clinical Focus
The game is built around three things a nurse does in sequence at the bedside, and the clinical content is organized the same way:
- RecognizeSpot agitation through conversational and subtle physical cues.
- PreventApply ABCDEF bundle protocols and address the causes you can fix.
- InterveneRespond to agitation safely — and de-escalate without reaching for restraints.
Three Levels of Agitation
Scenarios are built across a severity ladder, scored with the Behavioral Activity Rating Scale (BARS), so learners practice matching the response to the stage rather than treating every agitated patient the same way.
What it looks likeRestlessness and inattention rather than resistance: repeating the same question, losing track of the time of day, eating little, quietly setting aside hearing aids. Still pleasant and easily redirected.
What the learner practicesCover the basics — pain, thirst, hunger, toileting. Get glasses and hearing aids back on and working. Lower the noise, restore a day/night rhythm, remove lines that are no longer needed, reorient gently and bring family in when possible.
What it looks likeRepeated attempts to get out of bed to go home or to work, forgetting what just happened, unable to follow multi-step instructions, pulling off telemetry leads — yet calm and cooperative each time someone comes to the bedside.
What the learner practicesSimplify to one-step instructions with frequent reorientation. Put fall precautions and bed alarms in place. Work the reversible causes: point-of-care glucose, pain, hypoxia, infection, urinary retention, constipation. Escalate to the provider for a bedside evaluation of the underlying medical cause.
What it looks likeParanoia and hallucinations, refusing medication, swatting at staff, trying to climb out of bed despite injury, pulling at IV lines and oxygen tubing, unable to follow commands.
What the learner practicesImmediate provider notification and pain intervention, continuous observation, and the fall bundle in place. Verbal de-escalation with a calm presence, low light and noise, and familiar caregivers present. Rule out medical triggers. Physical restraints only if strictly required for immediate safety — and if sedation is given, continuous monitoring with restraints removed as soon as safety is restored.
Risk Factors the Player Has to Weigh
Before any diagnosis, the player reads the chart and the room. Some risk factors can be acted on directly; others shape how closely the patient needs to be watched.
Causes you can fix at the bedside
- Pain that has not been relieved
- Hunger and thirst
- A full bladder or unmet toileting need
- Hearing aids and glasses that are absent or not working
- Sleep deprivation and disrupted day/night rhythm
- Immobility — and physical restraint itself
- IV lines, monitoring leads, and urinary catheters that are no longer needed
Context that raises the risk
- Advanced age, particularly over 85
- Cognitive baseline: dementia or mild cognitive impairment
- Acute illness, severity of illness, surgery, or trauma
- Comorbid chronic disease and frailty
- Polypharmacy and high-risk medications — benzodiazepines, opioids, anticholinergics
- The emergency department environment: noise, light, an unfamiliar setting
- Prolonged boarding — the longer the stay, the higher the risk
How We're Building It
OutSMA℞T Agitation is being built with a new, AI-accelerated development approach — the same one behind the CRoME Lab's Crossroads game. Instead of building slowly from scratch, our developer uses AI tools to prototype and iterate rapidly.
Crucially, this is not an “all-AI” process. We practice human-in-the-loop development: by giving the AI precise information and a strong creative foundation up front, we dramatically speed up development while keeping the reliability of the content and the power of human decision-making firmly in people's hands.
Speed of AI, judgment of people.
- Clinical experts & stakeholdersReview the game and give feedback at every stage, so the content stays accurate and clinically sound.
- An artist’s hand-drawn artOriginal illustrations give the AI accurate visual reference and ready-to-use starting assets — including the illustrated patient avatars — not generic, generated imagery.
- Our project teamMakes the final calls on direction, content, and design — people stay in charge of every decision.
Designed for the way nurses actually learn
The interface is conversation-first: the patient dialogue stays the largest thing on the screen, with the chart, the BARS scale, and the bundle checklist available on demand rather than crowding the view. It is meant to feel like a modern healthcare tool, not a textbook.
Accessibility is built in from the start — all patient dialogue is screen-reader accessible, nothing counts down or auto-advances, and color is never the only way a patient's state is communicated.
Team & Partners
OutSMA℞T Agitation brings together expertise in pharmacy practice, geriatric emergency care, delirium and agitation research, educational game development, and health professions education:
- CRoME Lab
- University of Kentucky College of Pharmacy
- UK HealthCare Emergency Department Team
- Geriatric Emergency Medicine collaborators
Development Status
OutSMA℞T Agitation is currently under active development, with the game design document under review and scenarios being built out. Our team is working closely with UK HealthCare Emergency Department nursing staff and clinical experts to build a meaningful, evidence-based learning experience. Initial testing will run in the browser, and a playable version will be shared here as it becomes available — please check back soon.
Contact
For questions about OutSMA℞T Agitation or this research, please contact the Principal Investigator, Dr. Olufunmilola Abraham, by email: Olufunmilola.Abraham@uky.edu.
For questions about the CRoME Lab, our studies, becoming a participant, or joining the team, please contact the Research Coordinator by email: crome.lab@uky.edu.