Neuropsychiatric symptoms (NPS) of dementia and delirium, including confusion, disorientation, refusal of care, and agitation, are common among older adults presenting to the emergency department (ED) 1. A salient patient case was observed by a geriatrician, in which an older woman, who appeared scared, made timid efforts to leave her assigned space. This resulted in a “take-down” and utilization of an antipsychotic to mitigate the patient's actions. The woman had a known diagnosis of dementia and for the prior 12 h had been assigned to a space adjacent to an individual with active psychiatric symptoms. Possibly out of fear, this patient was attempting to find a safer space. However, there was no framework for identifying or managing these NPS. Such symptoms are often associated with delays in care, safety concerns, and increased use of physical and pharmacologic restraints 2, 3. In addition, as in our index case, NPS may not be noticed in a timely manner, as there is no established protocol to notify teams of NPS or structured responses to NPS. Delayed recognition may lead to unnecessary escalation of NPS. ED staff are not always prepared to respond to NPS of dementia and delirium 4. Silwanowicz, et al. noted significant differences in how NPS were handled in the ED and called for the development of methods to manage NPS in the ED 5. In the ED environment, other rapid response models (e.g., Code 99, Code 100) are used to bring resources and attention to a developing situation. We noted there was no corresponding process for NPS. To address the recognition of and responses to NPS in outpatient long-term care settings, especially for dementia, The DICE Approach (Describe, Investigate, Create, Evaluate) was developed 6, but to our knowledge, no established behavioral modification protocols have been adapted for the acute care setting. To address this gap, we developed Code DICE, an interprofessional rapid-response intervention tailored to the ED environment, and we tested it for feasibility. In January 2023, we convened an interprofessional team of emergency medicine, geriatrics, psychiatry, and pharmacy clinicians to design a structured, patient-centered protocol for responding to NPS. The team adapted the DICE Approach to the acute care setting, integrating behavioral strategies with pharmacologic interventions when necessary. Code DICE was implemented as a rapid-response model in which an interprofessional team rapidly observes and describes the patient situation in order to identify the etiology of the behavior and thus develop de-escalation techniques (e.g., providing a commode, addressing pain, or obtaining hearing aids) and medications were used judiciously to minimize reliance on physical restraints. A Code DICE event is typically initiated by a nurse or other care team member in response to observed changes in a patient's behavior, identified risks, or concerns about potential behavioral changes that could pose safety issues or require adjustments to the patient's management plan. Code DICE leads to an overhead page in the ED signaling the need for an in-person, bedside huddle to rapidly describe the situation, investigate potential causes of the behavioral change, and create new, specific plans to address the situation. The interprofessional huddle may include RNs, physicians, pharmacists, physical therapists, geriatrics clinicians, patient care attendants, caregivers, and others. Examples include: (1) A patient with Alzheimer's became angry and physically combative; evaluation revealed 6 h of urinary retention. After Foley placement, neuropsychiatric symptoms rapidly resolved. (2) A patient with dementia wanted to urinate utilizing a commode, but none was available and alternatives were not accepted and the patient became combative, until urinary urgency was relieved. Even when pharmaceutical interventions are chosen to address NPS of dementia or delirium, simultaneous consideration of environmental modifications may reduce the doses of medication utilized or reduce the risks of delirium development. However, medication dosing was not assessed in this study. Training for Code DICE included education at departmental conferences and faculty meetings, and was augmented by including the nurse practitioners and social workers from the Age Friendly Emergency Department (AFED) program consult service. Many patients subsequently had AFED consults, which utilized a modified comprehensive geriatric assessment and development of a care plan for NPS and geriatric syndromes. To support the intervention, a nursing documentation tool was created within the electronic medical record (EMR) to record activations and interventions. A retrospective chart review was conducted to assess utilization and patient outcomes between January 2023 and February 2024 during the launch of the novel program. During the 13-month study period, Code DICE was activated at least 55 times as documented by nurses in the EMR. We conducted a retrospective analysis of 17 cases, selected randomly, over a 6-month period (January 2023–July 2023) where Code DICE was activated. The limited sample size reflects constrained researcher availability during this timeframe. In all cases, behavioral strategies were prioritized (17/17), with pharmacologic treatments used only as adjuncts (9/17). This approach appeared to reduce reliance on physical restraints (3/17), though complete outcome data were limited by inconsistent documentation. Documentation of Code DICE activations within the EMR was often incomplete, making it difficult to fully evaluate the range of interventions applied or their effectiveness. Our initial experience suggests that a structured, team-based approach to addressing NPS in the ED is both feasible and beneficial. Code DICE offers a framework that promotes early recognition and standardized management of NPS while prioritizing patient and staff safety. A central challenge has been ensuring consistent documentation, which limits the ability to measure outcomes and refine interventions. To address this, we recently relocated the documentation fields within the EMR from the “behavioral health” section to the “suggested screenings” area, improving visibility for nursing staff. In addition to structured team-based interventions, we observed promising results from patient-specific distraction strategies, such as personalized music delivered with noise-canceling headphones. This initiative was started after noticing sometimes significant responses to offering personalized music from a mobile phone. Also, due to the observation of patient needs during AFED and Code DICE evaluations, the equipment available in the ED has been augmented, such as increased availability of bedside commodes, audio amplification devices, and activity aprons. Much like hypoactive delirium, recognition of NPS is often subtle and may be missed until more overt NPS interfere with care plans. Staffing levels, training opportunities, and adverse conditions, such as high levels of ED boarding, strain the ability to recognize and respond to early NPS. Earlier recognition of NPS and utilization of Code DICE may make non-pharmacologic environmental modifications and care plan modifications more effective, leading to lower utilization of physical and pharmacologic restraints with their risks and side effects. In addition, we notice that the earlier initiation of the Code DICE intervention may frequently be useful and might lead to increased effectiveness. However, there is a theoretical risk of alarm fatigue if Code DICE is utilized too often and too soon or if meaningful environmental changes appear impossible. Further evaluation of the most effective triggers for Code DICE and the most useful interprofessional training is an important priority for future development. This study was conducted in a single emergency medicine department at an urban academic medical center, and the conclusions may not be applicable to other settings. Not all clinicians and staff received training for Code DICE rapid response interventions. The simultaneous development and ongoing implementation of an Age-Friendly Emergency Department program consult service influenced the awareness of modified approaches to the medical care of older adults. Geriatric Emergency Department programs may not be available at other EDs. Documentation of Code DICE activations within the EMR was often incomplete, and the researcher's limited availability to review charts made it difficult to fully evaluate the range of interventions applied or their effectiveness. Ongoing staff education was difficult to sustain with increased staff turnover and competing priorities. Nonetheless, Code DICE education remains essential for effective utilization of the protocol. Future work will also focus on evaluating outcomes such as restraint use, staff perceptions, length of stay, and patient safety events. Code DICE represents a novel adaptation of an outpatient behavioral model for the ED setting. Early results demonstrate feasibility, interprofessional collaboration, and the potential to reduce reliance on physical restraints through the prioritization of behavioral strategies. With continued refinement of protocols, documentation, educational initiatives, and systematic outcome evaluation Figure 1, Code DICE has the potential to serve as a replicable model for improving care for older adults with NPS in the acute care environment. Helen Kales, MD, for her permission to adapt the DICE Approach. Anna Harris, MA, for designing the Code DICE protocol figure. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.
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