At present, the "Elderly Care Strategy" carried out by our hospital has 10 facets:

1. Geriatric emergency patients are screened and admitted to the "integrated ward" (including dementia screening referrals, functional deterioration assessment referrals, fall assessment referrals, hospice and palliative care referrals, specialized geriatric outpatient referrals, and rehabilitation referrals when needed)
2. Computer-assisted medication integration for geriatric emergency patients (including cooperation with pharmacists for medication optimization)      
3. Emergency computer-assisted delirium screening and treatment
4.  Joint care model for elderly patients with fractures in the emergency department
5. Emergency and discharge home medical care (including in-home functional and safety assessment)
6. Emergency "Discharge Follow-up Service"
7. Reducing fasting time and promoting adequate access to food and water
8. Promoting volunteers to participate in the care of elderly patients
9. Elder-friendly Discharge Program
10. Elderly fall risk assessment

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1. Geriatric emergency patients are screened and admitted to the "integrated ward" (including dementia screening referrals, functional deterioration assessment referrals, fall assessment referrals, hospice and palliative care referrals, specialized geriatric outpatient referrals, and rehabilitation referrals when needed).
   

   In response to the advent of the super-aged society in Taiwan and the rapid increase in the elderly population, in order to delay elderly disability, improve the quality of medical care, and reduce medical waste and burdens on family members, the team adopted the strategies recommended by the American Emergency Medical Standards for the Elderly, the American Emergency Medical Certification for the Elderly, ICOPE and 4Ms. Geriatric emergency patients with "comorbidities, physical and mental disabilities, and hospice needs" are screened and admitted to the "integrated ward" to facilitate further comprehensive elderly assessment and interdisciplinary team care and to delay the onset of elderly disability. Chi Mei's senior emergency team has close cooperation and connection with the integrated ward, allowing patients to receive holistic and continuous care from emergency, inpatient, outpatient and at-home care.

    

   The emergency department cooperates with the integrated ward, and screens for "comorbidities, physical and mental disabilities, and hospice needs". 4 checkpoints are used to screen patients for admission to the integrated ward, where further comprehensive geriatric evaluations are performed. Interdisciplinary team aims to resolve various problems of geriatric patients, including dementia screening, functional deterioration assessment, fall assessment, hospice care, specialized outpatient follow-up, and rehabilitation. The 4 levels are as follows:

   The first checkpoint: After emergency physician evaluation, if geriatric emergency patient do not need to be hospitalized, but they meet the requirements of "comorbidities (more than three chronic diseases) or physical and mental disabilities (dementia, delirium, functional deterioration, falls, weakness, etc.)," they are recommended for transfer to a specialized geriatric outpatient clinic for follow-up or referral for home medical care

   The second checkpoint: If geriatric emergency patients need to be hospitalized for treatment and meet any of the conditions of "comorbidities, physical and mental disabilities, and hospice needs," they will be admitted to the "integrated ward" first. If none of these conditions exists and an specific disease requires treatment, the patient is admitted to the sub-specialty ward.

   The third checkpoint: If geriatric emergency patients need to be hospitalized for treatment but are not admitted to the "integrated ward," patients that temporarily remain in the emergency observation area will undergo re-evaluation by holistic emergency physicians and specialist nurses.  If the patient meets any of the conditions of "comorbidities, physical and mental disabilities, and hospice needs," they are recommended for transfer to the "integrated ward".

   The fourth checkpoint: The emergency department case manager will conduct a re-screening of the boarded patients in the emergency observation area during normal working hours. If the patient meets any of the conditions of "comorbidities, physical and mental disabilities, and hospice needs," they are recommended for transfer to the "integrated ward".

    

    

2. Computer-assisted medication integration for geriatric emergency patients (including cooperation with pharmacists for medication optimization)

   Because elderly patients often have multiple chronic diseases, they are prone to multiple medications and potentially inappropriate medications, which greatly increases the chance of adverse drug reactions. The American Academy of Emergency Physicians believes that elderly patients rarely have the opportunity to undergo drug integration, and that the best time for drug integration is when they come to the emergency department. This is also helpful to explore whether the patient visits the emergency department due to a possible adverse drug reaction. The American College of Emergency Physicians (ACEP) recommends the use of "computer-assisted medication integration" and pharmacists to assist in the integration of medications. However, due to the extreme difficulty in implementation, our team searched through PubMed and Google Scholar, but currently found no research published in the literature on the integration of computer-assisted emergency medications. Therefore, we established our own in-house screening model by using the "cloud healthcare medical record" as the basis for computer-assisted integration of medication. Our goals are to assist emergency pharmacists in reducing “serious polypharmacy" and "potentially inappropriate drug use", thereby reducing adverse drug events, improving the quality of medical care, and reducing medical expenses and family burdens. Our implementation process of drug integration is as follows:

    

    

3. Emergency computer-assisted delirium screening and treatment

   The occurrence of delirium in geratric patients in the emergency department increases mortality by 62% and the length of hospitalization by 2.3 times. The incidence of delirium in geriatric emergency patients is estimated to be about 8%-17%, but only 16-35% of these are diagnosed, indicating that medical staff vastly under diagnose this disease. Therefore, to improve the diagnosis rate of delirium in the emergency department, we provide personnel education, the application of evaluation tools and the integration of information systems. At the same time, we use interdisciplinary interventions to reduce the mortality and disability of these patients.

   We adopted and computerized the DTS (Delirium Triage Screen) and bCAM (brief Confusion Assessment Method) recommended by the ACEP Geriatric Emergency Department Guidelines to assist in the diagnosis of delirium. We collaborate with the pharmacy department and information systems staff to screen and provide warnings when prescribing drugs that can easily cause delirium. We also cooperate with the integrated ward in the treatment of geriatric patients diagnosed with delirium.

   
   

    

4. Joint care model for elderly patients with fractures in the emergency department

   Because elderly patients often have multiple comorbidities and debilitating symptoms, complications often occur after fracture surgery, including pneumonia, urinary tract infection, gastrointestinal bleeding, bedsores and other medical problems. Orthopedic doctors need the assistance of the geriatric medicine interdisciplinary team in order to better care for these patients. Therefore, our hospital has launched the “Emergency Geriatric Fracture Common Care Model” to provide elder patients with fractures with continuity of care from hospitalization, postoperative care and discharge.

   Admission criteria: Geriatric emergency patients (aged ≥65 years old) who have been diagnosed with hip fractures requiring surgery, and the emergency physician and orthopedic physician jointly agree that the patient requires integrated ward care after surgery.

   Admission process: For those patients who meet admission criteria, emergency physicians consult integrated ward physicians for ward admission. They will be first operated on by orthopedics then transferred to the integrated ward for hospitalization after operation.

    

    

5. Emergency and discharge home medical care (including in-home functional and safety assessment)

   It is inconvenient for many elderly people to visit the hospital for treatment due to immobility, illness or family factors. In these cases, "home medical care" provides great help. However, in the past, home-based medical care was only implemented for inpatients after discharge. Thus patients discharged from the emergency department could not utilize this resource. Therefore, we established "Home Medical Care and Home Rehabilitation Services for Emergency Discharged Patients". For elderly patients who do not need to be hospitalized, cannot wait for a bed, or cannot return to the outpatient clinic for follow-up, home-based medical care is provided by emergency physicians and home care nurses. The team visits the patient at home soon after emergency discharge to provide home medical services. According to the patient's rehabilitation and long-term needs, they are referred to appropriate subsequent services, including the government’s National Ten-Year Long-Term Care Plan 2.0 and other related services.

   Acceptance criteria: Geriatric emergency patients (aged ≥ 65 years old) who meet the following 4 conditions: stable condition or self-discharge from the hospital, non-facility care patients, disability or mobility impairment, location within a 30-minute drive.

   Acceptance process: For those who meet the conditions, the emergency physician can use the hospital information system to refer the patient for home medical care. After the consultation is made, the home medical doctor will contact the patient or family member to confirm whether they wish to receive home medical care.
   

    

    

6. Emergency "Discharge Follow-up Service"

   There are many uncertainties after the discharge of geriatric emergency patients. Also, in response to the COVID-19 pandemic, our hospital has established an emergency "discharge follow-up service".

   Acceptance criteria: Geriatric emergency patients (aged ≥ 65 years old) discharged from the hospital but that require close follow-up.

   Acceptance process: For those who meet these conditions, the emergency physician can use the emergency hospital information system and simply click on "Discharge Follow-up". After receiving the referral, the emergency department case manager will contact the patient or family member by phone or video for follow-up at 3 days after the patient discharge, 7 days after patient discharge, and 30 days after discharge.
   

    

    

   Referral button of "Follow-up Visit" on the Hospital Information System

   Video tracking mode description

7. Reducing fasting time and promoting adequate access to food and water

   In order to prevent caregivers from leaving the bedside and reduce the risk of patient falls, the emergency department and the nutrition department jointly set up a "bedside meal sales service", which can provide food and beverages, and provide services such as "hourly attendants".

8. Promoting volunteers to participate in the care of elderly patients

   The emergency department and the department of social services jointly established the "Geriatric Emergency Friendly Volunteer Group". After professional training, they accompany and chat with geriatric emergency patients, displaying the core culture of "Caring" at Chi Mei Hospital.

    
   

    

9. Elder-friendly Discharge Program

   In order to allow elderly patients to have clear health education information when they are discharged from the hospital, the original all-text health education pamphlets have been revised to be suitable for reading by elderly patients and their families. Currently, two education sheets have been completely revised, including ones for urinary tract infections and delirium.

    

   Both pictures and texts are suitable for elderly patients and their families to read a leaflet on health education

    

10. Elderly fall risk assessment

    All geriatric emergency patients that come to the emergency department undergo STRATIFY assessment by the nursing staff to determine if the patient has a high risk of falling. If the patient is assessed as having a high risk of falling, the following nursing treatments will be performed:

    （1）Yellow or red-colored “high-risk for fall” cards are placed at the head of the bed

    （2）High fall risk health education is performed

    （3）Continuous reassessment by nursing staff for the risk of falls every shift

     

    Yellow & Red "High-Risk for Fall" Cards	"High-Risk for Fall" Patient Education Sheet
    Hospital Information System Nursing Assessment of Fall Risk