“互联网+专项延续护理服务”在居家老年患者中的应用  

Application of "Internet+ specific transitional care" in older patients discharged home

作　　者：张怡 付阿丹[2] 黄盼盼 彭秋霞 黄婷 杨明顺 Zhang Yi;Fu Adan;Huang Panpan;Peng Qiuxia;Huang Ting;Yang Mingshun(Department of Respiratory and Critical Care Medicine,Wuhan Central Hospital,Tongji Medical College,Huazhong University of Science and Technology,Wuhan 430014,China)

机构地区：[1]华中科技大学同济医学院附属武汉中心医院呼吸与危重症医学科,湖北武汉430014 [2]华中科技大学同济医学院附属武汉中心医院护理部,湖北武汉430014 [3]华中科技大学同济医学院附属武汉中心医院延续护理服务中心,湖北武汉430014 [4]华中科技大学同济医学院附属武汉中心医院信息科,湖北武汉430014

出　　处：《护理学杂志》2025年第6期20-23,共4页Journal of Nursing Science

基　　金：武汉市卫健委科研项目(WX23B30);武汉市科技局知识创新专项项目(2023020201010188)。

摘　　要：目的 构建基于智能随访模块的“互联网+专项延续护理服务”模式,为出院后老年患者提供居家护理服务。方法 依托智能随访系统,基于老年出院患者居家服务需求构建管道护理、伤口造口护理2个智能随访模块,提供“互联网+专项延续护理服务”,包括上门护理、智能随访等。结果 2023年1-12月通过专项延续护理服务为老年出院患者提供上门管道护理632例次,伤口造口护理260例次;162例老年患者对延续护理服务的满意度评分为(5.00±0.03)分。结论 基于智能随访模块的“互联网+专项延续护理服务”模式,能早期识别有居家护理服务需求的患者,促进患者从医院到家庭的护理延续性。Objective To construct an "Internet + specific transitional care" model based on the intelligent follow-up module to provide home care services for older patients discharged to home.Methods Based on the intelligent follow-up system,two intelligent follow-up modules for catheter and wound/stoma were constructed based on the needs of older patients to provide home care and intelligent follow-up services.Results From January to December 2023,632 cases of catheter care and 260 cases of wound/stoma care were provided for older patients at their home.The satisfaction score reported by 162 older patients towards this transitional care model was(5.00±0.03).Conclusion The "Internet + specific transitional care" model based on the intelligent follow-up module,can identify patients who need home care service at an early stage,and promote the continuity of care for patients discharged from hospital to home.

关 键 词：老年患者 智能随访模块 互联网+ 延续护理服务 居家护理 社区护理 管道护理 伤口造口护理 

分 类 号：R473.2[医药卫生—护理学]