多学科合作团队延续护理在慢性心力衰竭易损期患者中的应用及效果评价  

Application and effect evaluation of multi-disciplinary team continuous nursing in the vulnerable period of chroni cheart failure

作　　者：严莉[1] 李筠[1] 耿丽[2] 李红丽[1] 胡柳[2] YAN Li;LI Yun;GENG Li;LI Hongli;HU Liu(Heart Failure Center,Wuhan Asia Heart Hospital,Wuhan,430022,China)

机构地区：[1]武汉亚洲心脏病医院心衰治疗中心,430022 [2]武汉亚洲心脏病医院护理部,430022

出　　处：《中国护理管理》2019年第12期1865-1872,共8页Chinese Nursing Management

基　　金：武汉市卫生计生科研基金资助（WX18B13）

摘　　要：目的:将多学科合作团队延续护理模式应用于慢性心力衰竭易损期患者并评价其效果。方法:采用便利抽样法,选取武汉市某三级甲等医院心力衰竭治疗中心2017年6—12月治疗后出院的100例患者作为对照组,2018年1—6月治疗后出院的100例患者作为观察组。对照组实施常规的延续护理模式,观察组则实施以心力衰竭专病医师和心力衰竭专病护士为核心,包含药剂师、营养师、康复师、社会工作者等成员的多学科团队延续护理模式,多学科团队在患者出院前行出院准备服务,居家时进行电话、微信随访,在患者病情稳定后进行转诊和联谊服务。实施6个月后比较两组患者心功能、疾病自我管理能力、向社区医院转诊率、满意度、再住院情况等数据。结果:观察组患者心功能和疾病自我管理能力明显高于对照组,差异有统计学意义(P<0.001),观察组患者社区转诊率为41.0%,明显高于对照组的14.0%,差异有统计学意义(P<0.05),观察组患者满意度为94.0%,高于对照组的83.0%,差异有统计学意义(P<0.05),观察组再住院率为12.0%,低于对照组的25.0%,差异有统计学意义(P<0.05)。结论:多学科合作团队延续护理模式可以明显提高延续护理效果,改善患者的临床结局和就医体验。Objective:To evaluate the effects of continuous nursing model of multi-disciplinary team in the vulnerable period of chronic heart failure.Methods:The study was conducted in a heart failure center of a tertiary hospital in Wuhan and a convenient sampling method was used.A total of 100 patients discharged from June to December 2017 were recruited and assigned to the control group by a convenient sampling method.Another 100 patients discharged from January to June 2018 were assigned to the experimental group.Patients in the control group received the routine continuous nursing and followed up by the heart failure specialized nurses.Patients in the experimental group received the continuous nursing provided by the multidisciplinary team including heart failure specialized physican,heart failure specialized nurse,pharmacist,dietitian,physical therapist,and social worker.The continuous nursing provided by the team included preparation before the discharge,follow up by Wechat and telephone when at home,and referral service when station was stable.Six months later,information of cardiac function,self-care ability,referrals to the community health center,re-hospitalization,and satisfaction between the two groups were compared.Results:Cardiac function and self-careability of patients in the experimental group were significantly higher than those of patients in the control group(P<0.001).The rate of community referrals in the experimental group was 41.0%which was significantly higher than 14.0%in the control group(P<0.05).The satisfaction rate of patients in the experimental group was 94.0%and it was also significantly higher than 83.0%in the control group(P<0.05).Besides,the re-hospitalization rate in the experimental group was 12.0%which was significantly lower than 25.0%in the control group(P<0.05).Conclusion:The continuous nursing provided by the multi-disciplinary team can obviously improve the clinical outcomes and medical experience of patients.

关 键 词：多学科合作团队 慢性心力衰竭 延续护理 易损期 

分 类 号：R47[医药卫生—护理学]