医联体内"全专联合"的心房颤动一体化管理模式建设  

Management of atrial fibrillation with integrated general-specialty model within medical consortium

作　　者：王莉斐 廖晓阳[1] 刘长明 李志超[2] 王磊 崔凯军[4] 王伟文 Wang Lifei;Liao Xiaoyang;Liu Changming;Li Zhichao;Wang Lei;Cui Kaijun;Wang Weiwen(International Medical Center,General Practice Unit,West China Hospital,Sichuan University,Chengdu 610041,China;Day Surgery Ward,West China Hospital,Sichuan University,Sichuan University,Chengdu 610041,China;Shuangliu District Xihanggang Community Hospital,Chengdu 610041,China;Department of Cardiology,West China Hospital,Sichuan University,Chengdu 610041,China;Department of Neurology,the Sixth People's Hospital of Chengdu,Chengdu 610041,China)

机构地区：[1]四川大学华西医院特需医疗中心•全科医学病房,成都610041 [2]四川大学华西医院日间手术病房,成都610041 [3]四川省成都市双流区西航港社区卫生服务中心,610041 [4]四川大学华西医院心脏内科,成都610041 [5]成都市第六人民医院神经内科,610041

出　　处：《中华全科医师杂志》2020年第10期957-961,共5页Chinese Journal of General Practitioners

基　　金：四川大学华西医院临床研究孵化项目(2018HXFH005);四川省科技厅软科学研究(2019JDR0277);四川省卫生健康委员会普及应用项目(19PJ244)。

摘　　要：为有效管理心房颤动患者,四川大学华西医院建立了有地方特色的心房颤动管理模式,该模式以"心房颤动-卒中一体化管理"门诊为载体,联动全科和专科进行心房颤动规范化管理,形成"基层首诊、双向转诊、上下联动、急慢分治"的心房颤动一体化管理模式。本文重点介绍团队内三级综合医院专科医师、全科医师、社区医院全科医师开展特色心房颤动一体化管理的措施及初步实施效果,为其他地区开展心房颤动长程管理提供参考。In order to effectively manage the atrial fibrillation patients,West China Hospital has established an integrated general-specialty management model within medical consortium.This model takes the atrial fibrillation-stroke integrated management outpatient clinic as the platform,combines general practice and specialty to provide standardized care for atrial fibrillation patients.The model was characterized by primary diagnosis,two-way referral,up and down linkage,and differential management for acute and chronic conditions.This article,taking West China Hospital as an example,introduces the integrated team of cardiologists and general practitioners in the tertiary hospital with general practitioners in the community,and the preliminary accomplishment in the management of atrial fibrillation within the medical consortium.It would provide a reference for the long-range management of atrial fibrillation in other provinces and cities.

关 键 词：心房颤动 医联体 全专联合 模式 

分 类 号：R541.75[医药卫生—心血管疾病] R197.1[医药卫生—内科学]