Collaboration Between the Government and Healthcare Professional Organizations for the Implementation of Geriatric Emergency Departments in Taiwan

Abstract

Background

Enhancing geriatric emergency care is important for the global aging society; however, the current state of collaboration between the government and healthcare professional organizations and its effect on this issue remain unclear. Therefore, this study was conducted for clarification.

Methods

The Taiwan Health Promotion Administration and the Taiwan Society of Emergency Medicine (TSEM) cooperated to lead 13 emergency departments (EDs) in implementing geriatric EDs based on the model of acute care for elders between January 1, 2021 and November 30, 2021. Experts from the Taiwan Association of Gerontology and Geriatrics and the Taiwan Association of Critical Care Nurses were also invited to set up a Taiwan Geriatric Emergency Department Guide (TGED) and individual goals for each ED. Education, benchmarking, regular joint and individual meetings, communication, and discussion were then performed via communication software, and intensive follow-up was conducted using a monthly checklist.

Results

Despite the impact of COVID-19, 10 of the 13 EDs accomplished the overall goals (76.9%). According to the TGED, the achievement rates for the seven domains were as follows: interdisciplinary team (100%), education (92.3%), equipment and supplies (100%), environment (92.3%), care protocol (100%), quality indicator (100%), and monitor indicator (92.3%). A practice guide and an education guide for the subsequent promotion of geriatric EDs were also established based on the experiences and results from the 13 EDs.

Conclusions

A new model for collaboration between the government and healthcare professional organizations was successfully implemented in Taiwan and thus could serve as an important reference for enhancing geriatric emergency care in the future.

Introduction

Aging is a critical public health issue globally.¹ In Taiwan, the older population (≥ 65 years) repre-sented 14.6% of the total population in 2018 and is projected to exceed 20% by 2025.² This demographic shift, along with the increasing proportion of the old-est-old (≥ 85 years), presents significant healthcare challenges due to the higher prevalence of chronic conditions and comorbidities, which impose a grow-ing burden on Taiwan's National Health Insurance.^3-5

Emergency departments (EDs) are a primary healthcare resource for older adults with urgent or emer-gency conditions and play a pivotal role in coordinating care between community, hospitalization, ambulatory, and long-term care.^6-8 However, geriatric care in EDs has been relatively neglected, particularly in Taiwan.^6,7

The Acute Care for Elders (ACE) model, which focuses on patient-centered care, prevention of func-tional decline, and early discharge planning, has been implemented in the U.S. since 2008, leading to the de-velopment of geriatric EDs to fill the care gap.^9,10 The American College of Emergency Physicians (ACEP) launched guidelines in 2014 and a Geriatric Emer-gency Department Accreditation (GEDA) program in 2018 to standardize geriatric emergency care.^6,7

The ACE model and geriatric ED were intro-duced into Taiwan by Health Promotion Administra-tion (HPA) in 2019.¹¹ In 2021, the HPA and Taiwan Society of Emergency Medicine (TSEM) cooperated to lead 13 EDs participating in the 2021 program to develop geriatric ED.¹² Under interdisciplinary collaboration, TSEM also invited experts from the Taiwan Association of Gerontology and Geriatrics (TAGG) and Taiwan Association of Critical Care Nurses (TACCN) for this program. Collaboration be-tween government entities and healthcare professional organizations is crucial in developing older care ser-vices. Successful examples, such as the Netherlands' long-term care reforms, demonstrate the potential for improved care outcomes through structured partner-ships.¹³ Effective collaboration requires clear com-munication, trust, and role clarification, particularly in interorganizational settings where differences in organizational cultures and formalization of processes present significant challenges. Addressing these as-pects will strengthen the partnership and enhance care delivery for older populations.¹⁴ However, the collab-oration between the government (i.e., HPA in Taiwan) and healthcare professional organizations (i.e., TSEM, TAGG, and TACCN) for implementing geriatric ED remains unclear. Therefore, this study aimed to pro-vide a deeper insight into the collaboration between the government and professional healthcare organiza-tions and its impact on the implementation of geriatric EDs in Taiwan.

Materials and Methods

Study Design, Setting, and Participants

A multidisciplinary team of experts from TSEM, TAGG, and TACCN collaboratively developed the Taiwan Geriatric Emergency Department Guide (TGED) (Appendix), based on established American guidelines such as the Geriatric ED Guidelines and GEDA (Fig. 1).^6,7 The guide focused on seven core domains critical to the implementation of geriatric emergency care: interdisciplinary team, education, equipment and supplies, environment, care protocol, quality indicators, and monitoring.

Fig. 1.

Flowchart of geriatric emergency department (ED) promotion by the collaboration between the government and healthcare professional organizations in Taiwan in 2021.

Setting the Individual Goal for Each ED

Each ED was categorized into one of three lev-els—elementary, advanced, or high-level—based on a consensus from the interdisciplinary experts, with specific requirements for each domain depending on the ED's category. In 2021, 13 EDs participated in the program: eight were first-time participants, while five had been involved in previous initiatives. The hospi-tals that participated in this study were selected on a voluntary basis and certified by the HPA to implement geriatric EDs following the TGED. The five hospitals that had participated in previous initiatives in 2020 were also selected on a voluntary basis and certified by the HPA. These 2020 initiatives focused on general geriatric care, rather than the specific implementation of geriatric EDs. This distinction is important, as the previous experience in geriatric care provided these hospitals with foundational knowledge but did not specifically involve the TGED or the focus on geri-atric EDs. Individual goals, including the selection of care protocols, were established for each of the 13 EDs in accordance with the TGED, taking into ac-count their differing experiences, medical resources, and patient recruitment accessibility.

Schedule of 2021 Program

The 2021 program for implementing geriatric ED was scheduled as follows:

1. Recruiting expert committees

2. Developing and revising TGED

3. Constructing the checklist for monthly progress of individual ED

4. Building the platforms of education and commu-nication

5. Closely monitoring the result of each ED every month

6. Creating an education program

7. Benchmarking

8. Building an education guide for geriatric emer-gency care

9. Creating a list of suggested lecturers for education of geriatric care

10. Regular joint meeting

11. Individual meeting for each ED

12. Counseling visit

13. Formulating a practice guide with questions and answers

14. Conducting a final joint meeting with geriatric care in hospitalization and ambulatory care

15. Building a continuous care model between ED and hospitalization

16. Publishing the progress in 2021

Members of Expert Committee

Sixteen emergency physicians with expertise in geriatric care from TSEM, two geriatricians from TAGG, one registered nurse from TACCN, and one clinical psychologist with expertise in hospice and palliative care were invited as members of the expert committee.

Emergency Response of the Program for the Impact of COVID-19

The COVID-19 pandemic in Taiwan has started since May 2021 and has a great impact on the partic-ipating EDs. All the scheduled programs were trans-formed to video conferences, including education and meetings. Given that the ED is the most important front door of infection control, many scheduled strat-egies of geriatric care were temporally stopped or modified during the COVID-19 pandemic.

Education Programs

A video education program including the fol-lowing eight aspects of geriatric emergency care was published on May 12, 2021: (1) screening and evalua-tion methods in geriatric emergency care, (2) atypical presentations and multi-comorbidities, (3) acute func-tional decline, (4) geriatric trauma, (5) cognitive and behavioral problems, (6) medication management, (7) care transition, and (8) hospice and palliative care. The program was also recorded as an online teaching course that provides another opportunity to health-care professionals who missed it. Pre-education and post-education tests were performed to evaluate the effect of education program on the participants.

Benchmarking

On August 5, 2021, video benchmarking was conducted on Chi Mei Medical Center (CMMC), which established a geriatric emergency care team in 2016 and initiated the first geriatric ED in Taiwan in 2019.¹⁵ Many protocols in the CMMC could serve as important reference for other geriatric EDs. Some ex-amples include computer-based and pharmacy-assist-ed medication reconciliation,¹⁶ hospice and palliative care,¹⁷ developing an emergency geriatric assessment tool,¹⁸ screening and referral model of geriatric syn-dromes and hospice and geriatric need,¹⁹ ED referral for home healthcare,²⁰ computer-assisted delirium screening and management,²¹ computer assisted tele-phone follow-up model after ED discharge,²² adverse outcome prediction by artificial intelligence for older patients with influenza,²³ combined care for older pa-tients with hip fracture, and volunteer care for older ED patients and their families.¹⁵

Regular Joint Meetings

Regular joint meetings were conducted to allow the 13 EDs report their progress on implementing geriatric ED. The experts from TSEM, TAGG, and TACCN provided comments to their reports. The four regular joint meetings were held on April 23, 2021, July 22, 2021, September 16, 2021, and November 17, 2021. Owing to the COVID-19 pandemic, each regular joint meeting was held by video conference for 130 minutes.

Individual Meetings

Individual ED meetings were held to monitor the progress and help solve the problems according to their monthly checklist. The staff of geriatric ED and experts could discuss the solutions for the obstacles they have encountered. These individual meetings were held for four EDs in July 2021, five EDs in Au-gust 2021, two EDs in September 2021, and two EDs in October 2021. Each individual meeting was held by video conference for 60 minutes.

Counseling Visit

The aim of counseling visit was to invite experts from TSEM, TAGG, and TACCN to check the prog-ress of the EDs of five regional hospitals and one dis-trict hospital because of their relatively few medical resources for geriatric care. In addition, the visiting experts might encourage the hospital leaders to pay attention and support for geriatric care. Each counsel-ing visit was also held by video conference for 100 minutes.

Communication and Discussion via Communication Software

For the promotion of geriatric emergency care, communication software was used to announce all the programs and their video linkages to all the emer-gency physicians and healthcare professions who are interested in this field. Information about geriatric emergency care was also shared via communication software.

Statistics

The achievements of each ED were analyzed in ac-cordance with the TGED, including the overall achieve-ments of three levels (i.e., level 1, level 2, and level 3) and the achievements of seven domains in 13 EDs. Overall achievement was attained when the participating ED accomplished all the seven domains of geriatric ED. Paired t-test was performed on May 12, 2021 to deter-mine the education effect among the 168 participants. Significance level was set at 0.05 (two-tailed).

Ethical Statement

This study was waived for the approval by the institutional review board because it did not involve humans.

Results

The participants showed significant improve-ment on their knowledge of the core content of geriat-ric emergency medicine after the education program on May 12, 2021 (Fig. 2). Despite the impact of COVID-19, 10 EDs achieved the overall goal (76.9%, 10/13) (Table 1). Among the first-time participants for geriatric ED program, 75% (6/8) achieved the overall goal. Among the continuous participants for geriatric ED program, 80% (4/5) achieved the overall goal. The achievement rates in seven domains according to the TGED were as follows: interdisciplinary team (100%), education (92.3%), equipment and supplies (100%), environment (92.3%), care protocol (100%), quality indicator (100%), and monitor indicator (92.3%).

Fig. 2.

Comparison of pre-test and post-test knowledge among the 168 participants who attended the education program on May 21, 2021.

Table 1.

Achievements according to TGED for the 13 EDs participating in the geriatric ED program

ED number	First-time participant for geriatric ED program								Continuous participant for geriatric ED program
	1	2	3	4	5	6	7	8	9	10	11	12	13
Overall achievementa	Yes	Yes	Yes	No	Yes	Yes	Yes	No	Yes	No	Yes	Yes	Yes
Achievement in 7 domains
Interdisciplinary team	Level 1	Level 3	Level 1	Level 2	Level 2	Level 2	Level 1	Level 1	Level 2	Level 1	Level 3	Level 2	Level 2
Education	Level 3	Level 3	Level 3	No	Level 3	Level 3	Level 3	Level 3	Level 3	Level 3	Level 3	Level 3	Level 3
Equipment and supplies	Level 1	Level 3	Level 1	Level 1	Level 1	Level 1	Level 2	Level 1	Level 2	Level 1	Level 3	Level 3	Level 2
Environment	Level 2	Level 3	Level 2	Level 3	Level 1	Level 2	Level 2	Level 1	Level 2	No	Level 3	Level 3	Level 3
Care protocol	Level 1	Level 2	Level 1	Level 1	Level 1	Level 1	Level 1	Level 1	Level 1	Level 2	Level 2	Level 3	Level 2
Quality indicator	NA	Level 2	NA	NA	NA	NA	NA	NA	NA	Level 2	Level 2	Level 3	Level 2
Monitor indicator	Level 1	Level 2	Level 1	Level 2	Level 2	Level 2	Level 1	No	Level 2	Level 1	Level 3	Level 2	Level 2

^aAchievement of all the 7 domains.

ED, emergency department; NA, not applicable; TGED, Taiwan Geriatric Emergency Department Guide.

Table 2 shows the geriatric care protocols and recruited patients in the eight first-timer EDs between January 1, 2021 and November 30, 2021. The most common care protocol for this group was "Evaluation, referral, and follow-up of functional decline.” For the five continuously participating EDs, the most com-mon care protocol was also "Evaluation, referral, and follow-up of functional decline" (Table 3), followed by "Evaluation, referral, and follow-up of dementia." Overall, the most common care protocol in the 13 EDs was "Evaluation, referral, and follow-up of func-tional decline" (n = 12), followed by “Collaboration with pharmacist for medication reconciliation” (n = 7), "Referral for geriatric clinic" (n = 7), “Evaluation, re-ferral, and follow-up of fall" (n = 6), and “Evaluation, referral, and follow-up of dementia" (n = 5) (Table 4).

Table 2.

Geriatric care protocols and recruited patients in the eight EDs participating in the geriatric ED program for the first time between January 1, 2021 and November 30, 2021

ED number	Care protocol	Number of recruited patients
1	Evaluation, referral, and follow-up of frailty	454
	Minimizing fasting time and enhancing food and water supply	1,010
	Access of transportation services for returning residence	55
2	Evaluation, referral, and follow-up of dementia	30
	Evaluation, referral, and follow-up of functional decline	38
	Evaluation, referral, and follow-up of fall	50
	Collaboration with pharmacist for medication reconciliation	79
	Referral for clinic of geriatric integrated care	4
	Follow-up after ED discharge	100
	Evaluation, referral, and follow-up of malnutrition	73
	Evaluation, referral, and follow-up of frailty	59
	Transitional care with long-term care facility	35
	Referral for home healthcare	1
3	Evaluation of frailty in the patients with sepsis	461
	Referral for nutrition clinic	17
	Referral for pharmacist clinic	12
	Referral for social worker	22
	Referral for home healthcare	31
4	Evaluation, referral, and follow-up of functional decline	2,538
	Evaluation, referral, and follow-up of delirium	2
	Minimizing fasting time and enhancing food and water supply	22
	Evaluation, referral, and follow-up of dementia	55
	Collaboration with pharmacist for medication reconciliation	63
	ED transferal for long-term care facility	5
	Geriatric psychiatric consultation	66
5	Evaluation, referral, and follow-up of functional decline	260
6	Evaluation, referral, and follow-up of fall	36
7	Evaluation, referral, and follow-up of functional decline	323
	Collaboration with pharmacist for medication reconciliation	2
8	Geriatric evaluation using 4Msa	74

^aMentation, mobility, medications, and what matters.

ED: emergency department.

Table 3.

Geriatric care protocols and recruited patients in the five EDs that continuously participated for geriatric ED program between January 1, 2021 and November 30, 2021

ED number	Care protocol	Number of recruited patients
9	Evaluation, referral, and follow-up of dementia	228
	Evaluation, referral, and follow-up of functional decline	110
	Evaluation, referral, and follow-up of fall	139
	Referral for geriatric clinic	54
	Hospice and palliative care	19
	Screening of sarcopenia	142
	Evaluation, referral, and follow-up of delirium	10
	Geriatric psychiatric consultation	1
	Minimizing potentially inappropriate medications	27
	Follow-up after ED discharge	225
10	Evaluation, referral, and follow-up of functional decline	217
	Collaboration with pharmacist for medication reconciliation	20
	Minimizing potentially inappropriate medications	20
	Referral of older adult living alone	25
	Hospice and palliative care	37
	At least three order sets for common geriatric ED presentations developed with particular attention to geriatric-appropriate medications and dosing and management plans	ED routine
	Referral for follow-up of elderly abuse, neglect, and abandonment	ED routine
11	Evaluation, referral, and follow-up of delirium	192
	Evaluation, referral, and follow-up of dementia	1,336
	Evaluation, referral, and follow-up of functional decline	1,336
	Evaluation, referral, and follow-up of fall	20,009
	Collaboration with pharmacist for medication reconciliation	8,195
	Minimizing potentially inappropriate medications	8,195
	Hospice and palliative care	1,336
	Minimizing fasting time and enhancing food and water supply	ED routine
	Enhancing early mobilization	ED routine
	Enhancing volunteer for caring older ED patient	ED routine
	Age-friendly discharge protocol	ED routine
	Referral for geriatric clinic	ED routine
	Follow-up after ED discharge	818
	Access of transportation services for returning residence	ED routine
	Available protocol for rehabilitation	1,336
	Evaluation of function and safety at home	818
12	Evaluation, referral, and follow-up of delirium	44
	Evaluation, referral, and follow-up of dementia	163
	Evaluation, referral, and follow-up of functional decline	163
	Evaluation, referral, and follow-up of fall	25
	Referral for follow-up of elderly abuse, neglect, and abandonment	1
	Collaboration with pharmacist for medication reconciliation	201
	Minimizing potentially inappropriate medications	225
	Pain control	11
	Hospice and palliative care	1
	Geriatric psychiatric consultation	4
	At least three order sets for common geriatric ED presentations developed with particular attention to geriatric-appropriate medications and dosing and management plans	225
	Standardization and minimizing use of urinary catheter	225
	Minimizing fasting time and enhancing food and water supply	225
	Enhancing early mobilization	225
	Enhancing volunteer for caring older ED patient	135
	Communication protocol with original care giver (foreign care giver)	ED routine
	ED transferal for long-term care facility	ED routine
	Minimizing physical restraints	225
	Referral for geriatric clinic	157
	Follow-up after ED discharge	165
	Access of transportation services for returning residence	ED routine
	Available protocol for rehabilitation	ED routine
	Evaluation of function and safety at home	ED routine
	Brief comprehensive geriatric assessment in the ED	225
	Triage handover in older patient	374
	Referral for the hub of community service	137
	Age-friendly care in the ED	22
13	Evaluation, referral, and follow-up of dementia	6
	Evaluation, referral, and follow-up of functional decline	74
	Evaluation, referral, and follow-up of fall	50
	Referral for follow-up of elderly abuse, neglect, and abandonment	7
	At least three order sets for common geriatric ED presentations developed with particular attention to geriatric-appropriate medications and dosing and management plans	74
	ED transferal for long-term care facility	4
	Referral for geriatric clinic	59
	Evaluation of function and safety at home	241
	Service of assisted medical care and follow-up in the community	4

ED: emergency department.

Table 4.

Classification of care protocols in the 13 EDs participating in geriatric ED program between January 1, 2021 and November 30, 2021

Care protocol	Number	Care protocol	Number
1. Evaluation, referral, and follow-up of delirium	4	20. Referral for geriatric clinic	7
2. Evaluation, referral, and follow-up of dementia	5	21. Follow-up after ED discharge	3
3. Evaluation, referral, and follow-up of functional decline	12	22. Access of transportation services for returning residence	4
4. Evaluation, referral, and follow-up of fall	6	23. Available protocol for rehabilitation	3
5. Referral for follow-up of elderly abuse, neglect, and abandonment	3	24. Evaluation of function and safety at home	3
6. Collaboration with pharmacist for medication reconciliation	7	25. Service of assisted medical care and follow-up in the community	3
7. Minimizing potentially inappropriate medications	4	26. Evaluation, referral, and follow-up of frailty	3
8. Pain control	1	27. Evaluation, referral, and follow-up of malnutrition	2
9. Hospice and palliative care	4	28. Referral for home healthcare	2
10. Geriatric psychiatric consultation	3	29. Geriatric evaluation using 4Msa	1
11. At least three order sets for common geriatric ED presentations developed with particular attention to geriatric-appropriate medications and dosing and management plans	2	30. Brief comprehensive geriatric assessment in the ED	1
12. Standardization and minimizing use of urinary catheter	1	31. Referral of older adult living alone	1
13. Minimizing fasting time and enhancing food and water supply	4	32. ED transferal for long-term care facility	1
14. Enhancing early mobilization	2	33. Triage handover in older patient	1
15. Enhancing volunteer for caring older ED patient	4	34. Referral for the hub of community service	1
16. Age-friendly discharge protocol	3	35. Screening of sarcopenia	1
17. Communication protocol with original care giver	1
18. ED transferal for long-term care facility	4
19. Minimizing physical restraints	2

^aMentation, mobility, medications, and what matters.

ED: emergency department.

All the 13 EDs showed progress on their achievement of the seven domains during the 5 months between July 1, 2021 and November 30, 2021 (Fig. 3). In the domain of “Education,” one ED did not reach the goal through the whole period. On July 1, 2021, five and two EDs failed in the domains of "Equipment and supplies” and “Care protocol," re-spectively; however, all of them achieved these goals on November 30, 2021.

Fig. 3.

Achievement in seven domains for all the 13 emergency departments (EDs) between June 1, 2021 and November 30, 2021.

The difficulties encountered by the 13 EDs in implementing geriatric ED were as follows: delayed recruitment of case manager, qualification of case manager, collaboration between team members, lack of teacher specialized in geriatric emergency medi-cine, criteria of recruitment of the case, selection of evaluation or screening tool, low success rate of refer-ral for transitional care, and doubt about the meaning of monitor indicator (Table 5).

Table 5.

Difficulties in achieving the seven domains as reported by the 13 EDs participating in geriatric ED program

Domain	Difficulty
Interdisciplinary team	Delayed recruitment of case manager; qualification of case manager; collaboration between team members
Education	Lack of teacher specialized in geriatric emergency medicine
Equipment and supplies	Nil.
Environment	Nil.
Care protocol	Criteria of recruitment of the case; selection of evaluation or screening tool
Quality indicator	Nil.
Monitor indicator	Low success rate of referral for transitional care; doubt about the meaning of monitor indicator

ED: emergency department.

Discussion

The collaboration program between the gov-ernment and healthcare professional organizations successfully promoted geriatric ED in the 13 EDs in Taiwan. The government, specifically through the HPA, provided significant assistance in addressing the challenges encountered during the implementation of geriatric EDs. The HPA played a central role by offering continuous support, including funding for the recruitment of case managers, education programs, necessary equipment, and supplies. Additionally, the government facilitated regular joint meetings, indi-vidual counseling visits, and intensive monitoring of each ED's progress through monthly checklists. These measures helped address key challenges such as de-layed recruitment, a lack of specialized geriatric emer-gency medicine educators, and coordination difficul-ties between team members. The collaborative effort between the HPA, the TSEM, and other healthcare organizations enabled the development and revision of the TGED, which was instrumental in overcoming the difficulties related to recruitment, education, and implementation.

The education program caused significant im-provement on the knowledge of the core content of geriatric emergency medicine among the participants. Despite the impact of COVID-19, 76.9% of the par-ticipating EDs achieved the overall goals. In the seven domains, the achievement rate was 100% in interdis-ciplinary team, equipment and supplies, care protocol, and quality indicator and 92.3% in education, envi-ronment, and monitor indicator. The results in Tables 2-4 primarily emphasize care protocols because this domain presented the most immediate challenges and was crucial for the success of the geriatric ED pro-gram. The focus on care protocols stemmed from the need to address the complex, acute health issues faced by the older population, which required immediate intervention. Other domains, such as interdisciplinary teams, equipment, and environment, while essential, were more straightforward to implement and monitor. Therefore, the care protocols were prioritized due to their direct impact on patient outcomes and the over-all success of the geriatric ED program.

Compared with the ACEP model of geriatric ED promotion, the model in Taiwan using the collaboration between the government and healthcare professional organizations has been proven effective in this new trial. The HPA promoted the healthy policies about older people in the community, clinics, health centers, long-term care facilities, and geriatric medicine of the hospitals.²⁴ According to the core strategy of the ACE model, the older people need continuous care, includ-ing community, ED, inpatient, and ambulatory cares.¹⁰ However, ED has always been omitted in the geriatric medicine in Taiwan. Therefore, the HPA cooperated with TSEM for the first time to build the geriatric ED to fill the gap of geriatric care. TSEM is the main organization of emergency medicine in Taiwan and consists of 2,065 board certified emergency physicians and 475 emergency medicine residency members as of January, 2022.¹² A sub-workgroup named “Geriatric Emergency Care Team," which consists of emergen-cy physicians specialized in geriatric medicine, was established in TSEM in 2018.²⁵ In addition to experts in geriatric emergency medicine, representatives from TAGG and TACCN were invited for professional sup-port and collaboration. The collaboration among HPA, TSEM, TAGG, and TACCN is a good reference for implementing geriatric ED. In addition to emergency physicians, geriatricians, and registered nurses, the recruitment of other experts for providing professional support, including pharmacists, social workers, phys-ical therapists, occupational therapists, and dieticians must be considered in the future.

The successful implementation can be attributed to the following: setting an individual goal according to TGED, monitoring the progress of each ED by following up their monthly checklist, and arranging individual meeting and counseling visit when the participating ED had encountered difficulty (Fig. 4). The American Geriatric ED Guidelines and GEDA by ACEP are good and important references for develop-ing geriatric ED programs. However, not all the con-tents in American Geriatric ED Guidelines and GEDA are suitable for Taiwan because of differences in cul-ture, medical resource, and insurance. Therefore, the American Geriatric ED Guidelines and GEDA were used as the major reference. A TGED was also de-veloped to guide the implementation of geriatric ED in Taiwan. The 1st edition of TGED was revised to 2nd edition of TGED after the experiences, data, and responses were collected from the participated EDs. This edition should be the new guide for the subse-quent implementation of geriatric ED.

Fig. 4.

Strategies for implementing geriatric ED in Taiwan. ED, emergency department; TGED, Taiwan Geriatric Emergency Department Guide.

The participants in the education program showed significant improvement on their knowledge of geriatric emergency care. This finding indicated the insufficient knowledge of most ED staff on this field and the effectiveness of the education program. Ac-cording to American Geriatric ED Guidelines, the suc-cess of geriatric ED relies mainly on the education of the ED staff regarding the need of the older people.⁷ However, on-scene education may not be applicable for the ED staff with shift work; online education may be a good solution for promoting geriatric emergency medicine. A good example for personalized E-learning in geriatric emergency medicine is the “Geri-EM" de-veloped by Dr. Don Melady.²⁶ This tool contains six modules, namely, cognitive impairments, medication management, trauma and falls, atypical presentations, functional assessment and discharge planning, and end of life issues and symptom management.²⁶ In the future, Taiwan must consider adopting online educa-tion.

The COVID-19 pandemic in Taiwan had neg-ative and positive impacts on the 2021 geriatric ED program. Between May 2021 and July 2021, the geri-atric care protocols in some participating EDs were stopped due to strict infection control. However, the COVID-19 pandemic rendered video conference as a useful tool for promoting the program. All the expert committees, education, benchmarking, regular joint meetings, and counseling visits were transitioned to video conferences. In addition, communication soft-ware was used to share the link of video conference to all the emergency physicians in Taiwan. With this link, healthcare professionals who are interested in geriatric emergency medicine were able to learn re-lated progress and knowledge. Video conference is a convenient way of attending the conference via web link. This method enhanced the progress of this pro-gram and introduced a new way for promoting geriat-ric ED.

Further analysis on the three EDs that failed to fully achieve the goals revealed the impact of COVID-19 pandemic as the major cause. Number 4 ED did not achieve the domain of "Education" due to the frequent resigning of the case managers affected by the COVID-19 pandemic. Number 8 ED did not achieve the domain of "Monitor indicator" for the same reason. Number 10 ED did not achieve the do-main “Environment" due to the lack of large analog clock. Possible solutions for the lack of case manag-ers include using part-time case manager and simpli-fying and internalizing the work of case manager into routine ED practice.

Although five of the participating hospitals had prior experience in geriatric care initiatives in 2020, no direct comparison was made between these hospi-tals and the eight hospitals participating for the first time. The reason for this is that the achievement goals were tailored to each hospital based on its individual resources, experience, and capacity. As a result, each hospital was evaluated according to its own goals, which were established in line with the TGED. This individualized goal-setting approach ensures that each hospital worked toward realistic and meaningful tar-gets within its specific context, rather than creating an artificial comparison between hospitals with varying levels of prior experience. By focusing on hospi-tal-specific achievements, the study aimed to provide a practical framework for the implementation of geri-atric EDs across diverse healthcare settings.

At the end of the 2021 geriatric ED program, a practice guide of continuous care model was built for ED, hospitalization, ambulatory care, and community. An education guide was also constructed for promot-ing geriatric ED in the future. The major strength of this study was being the first program to promote geri-atric ED through the collaboration between the gov-ernment and healthcare professional organizations. One limitation of this study is the sample size and the voluntary selection of 13 hospitals, which may limit the generalizability of the findings to other regions or hospital types. Additionally, the varying levels of prior experience among the hospitals, with five hospi-tals having participated in previous geriatric ED pro-grams, may have influenced the results and created a discrepancy in outcomes. The study's relatively short duration also limits the assessment of the long-term sustainability of the geriatric ED implementations. External factors, such as the ongoing COVID-19 pan-demic, may have affected hospital participation and the generalizability of the findings to non-pandemic contexts. Future research should address these limita-tions by including a larger and more diverse sample, employing advanced statistical methods, and conduct-ing longitudinal studies to assess long-term impacts.

Conclusions

The program successfully implemented a model for promoting geriatric EDs through collaboration between the government and healthcare professional organizations in Taiwan. This success can be attribut-ed to the use of the TGED for setting individualized goals for each ED, close collaboration between the government and healthcare organizations, intensive monitoring of progress via monthly checklists, and regular meetings to address challenges. While this program marks a significant first step toward pro-moting geriatric EDs in Taiwan, continued efforts are needed to sustain and expand these initiatives through ongoing support from the government, the TSEM, and other healthcare organizations. These efforts are essential to bridging the gap in continuous geriatric care, particularly as Taiwan's aging population grows rapidly.

We recommend that hospitals seeking to adopt geriatric EDs apply the findings of this study in alignment with their hospital level, available medical resources, and individual goals. Hospitals of similar levels should tailor the study's results to their institu-tional capacities and goals, ensuring that the findings are applicable across various healthcare settings. From an international perspective, Taiwan's experi-ence offers a valuable model for countries facing sim-ilar demographic and healthcare challenges.

A comparative analysis between the Taiwanese and foreign versions (e.g., GEDA) could provide valuable insights into the local need for developing geriatric EDs in Taiwan. The collaborative frame-work, interdisciplinary approach, and adaptability in the face of the COVID-19 pandemic underscore the resilience and effectiveness of the program. Taiwan's approach to integrating government support, expert collaboration, and tailored care protocols could serve as an important reference for enhancing geriatric emergency care systems globally.

Appendix. The Taiwan Geriatric Emergency Department Guide (2nd edition)

Table 1.

Seven domains of Taiwan Geriatric Emergency Department Guide^*

1. Interdisciplinary team

2. Education

3. Equipment and supplies

4. Environment

5. Care protocol

6. Quality indicator

7. Monitor indicator

^*Refer to the American College of Emergency Physicians Geriatric Emergency Department Accreditation https://www.acep.org/by-medical-focus/geriatrics/geriatric-emergency-department-guidelines

Table 2.

Interdisciplinary team^*

Grade	Level 1	Level 2	Level 3
	(Elementary)	(Advanced)	(High-level)
1. At least one physician who has received the training specialized in geriatric emergency medicine†‡		☑	☑
2. At least one nurse who has received the training specialized in geriatric emergency medicine†	☑	☑	☑
3. Physician champion/medical director		☑	☑
4. Case manager (or transitional care nurse) appear ≥ 40 hours a week		☑	☑
5. Interdisciplinary team members ≥ 2 types§	☑	☑	☑
6. Interdisciplinary team members ≥ 4 types§			☑
7. Team meeting once every 3 months at least	☑
8. Team meeting once every 1 month at least		☑	☑
9. At least one hospital chief (above the deputy superintendent level) supervises the geriatric emergency department		☑	☑
10. Participation of patients or their family members in quality improvement meetings			☑

^*Refer to the American College of Emergency Physicians Geriatric Emergency Department Accreditation https://www.acep.org/globalassets/sites/geda/documnets/geda-criteria.pdf

^†See Table 3 for the requirements for the 8 training aspects of geriatric emergency medicine.

^‡Those who have been board certified as geriatricians by Taiwan Association of Gerontology and Geriatrics meet the criteria of training of geriat-ric emergency medicine because their training course includes all the contents.

^§Interdisciplinary team members include geriatrician, geriatric psychiatrist, pharmacist, social worker, physical therapist, occupational therapist, dietitian, palliative hospice specialist, and volunteer.

Table 3.

Education^*

Grade	Level 1	Level 2	Level 3
	(Elementary)	(Advanced)	(High-level)
Physician, nurse, and case manager (or transitional care nurse) must have 8 aspects of training†
At least one physician, one nurse, and one case manager meet the training requirements	☑		☑
50% of team members meet the training requirements		☑
75% of team members meet the training requirements			☑

^*Refer to the American College of Emergency Physicians Geriatric Emergency Department Accreditation https://www.acep.org/by-medical-focus/geriatrics/geriatric-emergency-department-guidelines

^†The 8 aspects of training include: (1) screening and evaluation methods in geriatric emergency care (for example: 4Ms model^‡); (2) atypical pre-sentations and multi-comorbidities; (3) acute functional decline; (4)) geriatric trauma (including falls and fractures); (5) cognitive and behavioral problems (including delirium, depression, and dementia); (6) medication management (including polypharmacy and potentially inappropriate medications); (7) transition of care (including inpatient transfer, discharge transfer, health education, and follow-up); (8) hospice and palliative care.

^‡Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Documents/IHIAgeFriendlyHealthSystems_GuidetoUsing4MsCare.pdf

Table 4.

Equipment and supplies^*

Grade	Level 1	Level 2	Level 3
	(Elementary)	(Advanced)	(High-level)
Courtesy glasses		☑	☑
Hearing assist devices	☑	☑	☑
Mobility aids (crutches, wheelchair)	☑	☑	☑
The following equipment and supplies ≥ 3 types	☑
The following equipment and supplies ≥ 6 types		☑	☑
1. Seated or recumbent weight scale
2. Pressure-ulcer reducing mattresses and pillows
3. Bedside commodes
4. Disposable or condom catheters
5. Low bed
6. Reclining arm chair
7. Others (i.e., the geriatric emergency department may provide equipment and supplies not list above as needed)

^*Refer to the American College of Emergency Physicians Geriatric Emergency Department Accreditation https://www.acep.org/by-medical-focus/geriatrics/geriatric-emergency-department-guidelines

Table 5.

Environment^*

Grade	Level 1	Level 2	Level 3
	(Elementary)	(Advanced)	(High-level)
Available food and drink	☑	☑	☑
Large analog clock		☑	☑
Wheelchair accessible toilet	☑	☑	☑
The following aspects of environment ≥ 3 types	☑
The following aspects of environment ≥ 7 types		☑	☑
1. Adequate handrails (e.g., double handrails)
2. High quality signage and way-finding
3. Availability of raised toilet seats
4. Proper lighting
5. Efforts at noise reduction
6. Non-slip floors
7. Each bed can provide 2 chairs
8. Others (i.e., the geriatric emergency department may provide the aspect of environment does not list above as needed)

^*Refer to the American College of Emergency Physicians Geriatric Emergency Department Accreditation https://www.acep.org/by-medical-focus/geriatrics/geriatric-emergency-department-guidelines

Table 6.

Care protocol^*†

Grade	Level 1	Level 2	Level 3
	(Elementary)	(Advanced)	(High-level)
At least 1 care protocol	☑	☑	☑
The following care protocols ≥ 10 types		☑
The following care protocols ≥ 20 types			☑
1. Evaluation, referral, and follow-up of delirium (e.g., DTS, bCAM, and 4AT)
2. Evaluation, referral, and follow-up of dementia (e.g., Ottawa 3DY, Mini Cog, SIS, and Short Blessed Test)
3. Evaluation, referral, and follow-up of functional decline (e.g., ISAR, AUA, interRAI Screener, and EGA‡)
4. Evaluation, referral, and follow-up of fall (including activity assessment, such as Timed Up and Go Test)
5. Collaboration with pharmacist for medication reconciliation
6. Minimizing potentially inappropriate medications (using Beers' criteria or a plan based on hospital characteristics)
7. Hospice and palliative care
8. Discharge follow-up solutions (e.g., telephone follow-up and video follow-up)
9. Service of assisted medical care and follow-up in the community
10. Referral for geriatric clinic (e.g., comprehensive geriatric assessment clinics, fall clinics, and memory clinics)
11. Referral for follow-up of elderly abuse, neglect, and abandonment
12. Pain control
13. Geriatric psychiatric consultation
14. At least three order sets for common geriatric emergency department presentations developed with particular attention to geriatric-appropriate medications and dosing and management plans (e.g., delirium, hip fracture, sepsis, stroke, and acute coronary heart disease)
15. Standardization and minimizing use of urinary catheter
16. Minimizing fasting time and enhancing food and water supply
17. Enhancing early mobilization
18. Enhancing volunteer for caring older emergency department patient
19. Age-friendly discharge protocol (e.g., discharge information should be enlarged in fonts, language version of the caregiver should be available, and a clear tracking plan)
20. Communication protocol with original care giver
21. Emergency department transferal for long-term care facility
22. Minimizing physical restraints
23. Access of transportation services for returning residence
24. Available protocol for rehabilitation (including hospitalization)
25. Evaluation of function and safety at home
26. A plan to improve the quality of care in a residential long-term care institution
27. Others (i.e., the geriatric emergency department may provide the care protocol does not list above as needed)

^*Refer to the American College of Emergency Physicians Geriatric Emergency Department Accreditation https://www.acep.org/by-medical-focus/geriatrics/geriatric-emergency-department-guidelines

^†Refer to the Chinese version of American Geriatric Emergency Department Guideline of the Taiwan Society of Emergency Medicine https://www.sem.org.tw/News/11/Details/432 and the original version by the American College of Emergency Physicians https://www.acep.org/globalassets/sites/geda/documnets/geda-guidelines.pdf

^‡Ke YT, Peng AC, Shu YM, Chung MH, Tsai KT, Chen PJ, Weng TC, Hsu CC, Lin HJ, Huang CC. Emergency geriatric assessment: A novel comprehensive screen tool for geriatric patients in the emergency department. Am J Emerg Med. 2018 Jan;36(1):143-146.

Table 7.

Quality indicator^*

Grade	Level 1	Level 2	Level 3
	(Elementary)	(Advanced)	(High-level)
Content of the above 1 care protocol (screening rate, referral rate, and success rate) reached 75%	☑
Achievement rate of the above 10 care protocols >75%		☑
Achievement rate of the above 20 care protocols >75%			☑

^*Refer to the American College of Emergency Physicians Geriatric Emergency Department Accreditation https://www.acep.org/by-medical-focus/geriatrics/geriatric-emergency-department-guidelines

Table 8.

Monitoring indicator^*

Grade	Level 1	Level 2	Level 3
	(Elementary)	(Advanced)	(High-level)
Monitoring ≥1 process or outcome indicator	☑
Monitoring the following ≥ 5 process or outcome indicators		☑
Monitoring the following ≥ 10 process or outcome indicators			☑
1. Number and rate of evaluation
2. Number and rate of eligible referrals for evaluation
3. Number and rate of successful referrals
4. Outcome of eligible successful referrals
5. Number and rate of hospitalizations of older patients (including analysis of their main complaints and diagnosis)
6. Number and rate of discharged older patients (including analysis of their dispositions for home or long-term care institution, chief complaint, and diagnosis)
7. Number and rate of older patients revisiting emergency department
8. Number and rate of rehospitalization of older patients
9. Number and rate of older patients staying in emergency department for more than 8 hours
10. Others (i.e., the geriatric emergency department may provide the monitor indicator does not list above as needed)

^*Refer to the American College of Emergency Physicians Geriatric Emergency Department Accreditation https://www.acep.org/by-medical-focus/geriatrics/geriatric-emergency-department-guidelines

Ethics Approval and Consent to Participate

This study was conducted with the approval of the institutional review board of the CMMC. All pa-tient data were anonymized. Patient informed consent was waived due to the retrospective and observational nature of the study. The welfare of patients was not affected by the waiver.

Funding

This work was funded by the Health Promotion Administration, Ministry of Health and Welfare. The content of this research does not represent the opinion of the Health Promotion Administration, Ministry of Health and Welfare.

Authors' Contributions

CHL and CJY designed and conceived this study and wrote the manuscript. THT and CJN assisted the implementation and wrote the manuscript. CJY performed the statistical analysis and wrote the man-uscript. All authors read and approved the final manu-script.

Acknowledgments

We would like to extend our sincere gratitude to Prof. Chien-Cheng Huang for his valuable guidance and contributions to this program and manuscript. We also thank all the participating emergency depart-ments and the experts from the TSEM, TAGG, and TACCN for their collaboration and support through-out this project.