化疗患者延续护理模式的探索与实践

目的探讨以电话随访为主的延续护理对化疗后出院患者居家期间化疗并发症及护理服务满意度的影响。方法选取300例某三级甲等肿瘤专科医院接受化疗的肿瘤患者,对观察组150例肿瘤患者进行电话随访,对对照组150例肿瘤患者进行常规出院健康教育,比较两组患者的护理服务满意度、化疗并发症及应对方式的异同。结果两组患者门诊治疗率比较差异具有统计学意义（P〈0．01）;观察组患者对护理服务满意度高于对照组（P〈0．01）。结论以电话随访为主的延续护理有利于肿瘤患者居家期间积极应对化疗并发症。     

Nursing attitudes to the care of elderly patients at risk of continuing hospital care

This study assesses changes in nurses' attitudes to the process of decision-making regarding the care of elderly patients identified as being at risk of continuing (long-term) hospital care It was undertaken during the course of an evaluation of an intervention programme which involved a new approach to decision-making concerning the long-term care of dependent elderly patients Complementary components of the intervention programme were (a) an early discharge planning service, and (b) an extended home care programme The programme involved close liaison of specially trained community health nurses with staff members of the general medical wards of a large general hospital At the onset of the evaluation, it was perceived by management that the staff of the general medical wards favoured continuing hospital care for very dependent elderly patients rather than community care It was hypothesized that the intervention programme would result in a change in ward staffs' attitudes concerning the feasibility of home-based care and how decisions about care should be made To test this, attitude changes of community health nurses and ward nurses were assessed over the period of implementation of the programme Following the introduction of the programme, the study found that some of the ward nurses' attitudes became closer to those of community health nurses There was a shift in ward nurses' attitudes away from a professional approach to decisions about the care and placement of very dependent elderly patients to a 'patient choice' approach Nurses felt more strongly that they had an important role in patient care Implications of the research are considered in relation to the process of discharge planning     

持续性腹膜透析患者的延续护理

目的:对108例持续性腹膜透析患者的延续护理进行总结、分析,以进一步完善持续性腹膜透析患者的延续护理服务。方法:建立以腹膜透析专科护士为主导的延续护理团队,制定针对持续性腹膜透析患者的个性化健康教育及出院后的居家护理计划,对108例出院后的持续性腹膜透析患者采取电话随访、基于网络平台的健康教育、门诊随访及家庭访视等方式开展院外延续护理。结果:经2年实践,患者的治疗依从性由51.3%上升至91.4%,腹膜炎发生率由1/45病人月下降为1/61病人月;有89例患者不同程度地回归了社会;患者对延续护理服务的满意度为97.2%。结论:延续护理服务为持续性腹膜透析患者提供了持续、不间断的护理,提高了其治疗依从性及满意度,降低了其腹膜炎的发生率,促进了其病情转归,同时也提升了护理工作的职业价值。     

Promoting the efficacy of discharge planning through the case management model

Careful analysis has shown that case management in unit, has the potential to be improved in to reduce patient re-admission rates. The purposes of this project were to use case management to identify as early as possible the potential care problems and care needs of patients after discharge, to establish care programs, to arrange services and transfers, and facilitate efficient patient discharges. The project also provided sustainable care via telephone visiting. The project was divided into preparation, performance and evaluation phases. Our results showed that we not only improved the quality of nursing care, and the nursing-patient relationship, but that we also dramatically increased the number of patients following discharge planning (from 31 to 74, an increase of 138%), and telephone visiting (from 31 to 253, an increase of 716%). The rate of satisfactions with discharge planning increased from 2.8 to 4.4, and the re-admission rate decreased from 12.1% to 4.5%. Thus, we can see that discharge planning and telephone visiting are very important to improvements in service quality and the satisfaction of patients.     

The effects of a discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions.

This study was a secondary analysis of data collected on 202 patients hospitalized with common medical or surgical cardiac conditions who completed a 24-week postdischarge follow-up program as part of a large-scale randomized clinical trial. Subjects were age 65 years or older, admitted from their homes with one of the following diagnosis-related groups: heart failure, angina, myocardial infarction, coronary artery bypass graft surgery, or cardiac valve replacement. The intervention consisted of comprehensive discharge planning and home follow-up by an advanced practice nurse (APN) for 4 weeks after discharge. Control subjects received usual care. Findings indicated that medical patients in the intervention group had fewer multiple readmissions during the 24 weeks of follow-up and a reduced total number of days of rehospitalization. There were fewer hospital readmissions in the surgical group when measured from discharge to 6 weeks. There were no differences in functional status between intervention and control groups for either population. The findings of this study suggest that high-risk elders with significant cardiac problems may benefit from a care program that emphasizes collaborative, coordinated discharge planning and home follow-up that includes telephone and home visits by APNs.     

院外延续护理对精神分裂症患者康复和生活质量的影响

目的探讨院外延续护理对精神分裂症患者康复和生活质量的影响。方法对照组（n：58）患者给予常规出院指导,干预组（n：60）患者在此基础上实施院外延续护理,即成立院外延续护理小组,建立出院患者档案,采用电话随访、邮递信函、上门随访及开展主题活动等形式进行院外延续护理。两组患者采用简明精冲病量表、康复状态餐表、生活质量综合评定量表和服药依从性量表进行比较。结果出院12个月后干预组简明精神病量表评分、康复状态量表评分均低于对照组（P〈0．01或P〈0．05）;生活质量评分及服药依从性高于对照组（P〈0．01）。结论院外延续护理呵以提高精神分裂症患者的服药依从性,有助于进一步改善患者的精神症状,提高其生活质量。     

The discharge liaison nurse at the interface of hospital and community nursing services

The organization of nursing into hospital and community services makes the smooth transition of care between hospital and community difficult to establish. This paper describes the function of discharge liaison nurses as one facet of a study designed to determine how hospital and community nurses perceive their provision of continuing patient care. Semi-focused interviews were conducted with 12 hospital nurses and 12 community nurses to explore their perceptions of discharge planning related experiences. Hospital and community nurses both relied on discharge liaison nurse to provide a link between hospital and community services. The practice of discharge liaison nurses as facilitators and co-ordinators of discharge planning are discussed.     

Secondary prevention of hyperlipidemia after coronary artery bypass graft: from acute care to primary care.

BACKGROUND: Clinical trials have established that secondary prevention of hyperlipidemia in patients after coronary artery bypass graft (CABG) surgery prevents progression of atherosclerosis. A multidisciplinary team promotes secondary prevention by prescribing antihyperlipidemic agents, screening for risk factors, and providing education on disease, diet, and medications. Information is minimal on the number of patients who continue with antihyperlipidemic therapy or follow-up with a primary care provider for cholesterol management after antihyperlipidemic therapy is initiated in an acute surgical setting. OBJECTIVES: To determine (1) the frequency of use of antihyperlipidemic agents before CABG surgery, at hospital discharge, and approximately 9 months after discharge and (2) the occurrence of cholesterol monitoring by a primary care provider at least once between discharge and telephone follow-up. METHODS: Observational study of 135 patients undergoing CABG surgery at a regional medical center during a 4-month period. Patients were contacted by telephone between 5 and 12 months after discharge and asked about continued use of antihyperlipidemic agents and cholesterol monitoring since discharge. RESULTS: Before surgery, 56% of the patients were taking an antihyperlipidemic agent. At discharge, 95% were taking an antihyperlipidemic agent. At the time of study follow-up, 91% were still taking an antihyperlipidemic agent, and 84% had follow-up cholesterol monitoring by their primary care provider. CONCLUSION: Initiation of an antihyperlipidemic agent and provision of education during hospitalization for CABG surgery results in a high percentage of patients continuing antihyperlipidemic therapy and having cholesterol levels monitored by their primary care provider after discharge.     

The impact of follow-up telephone calls to patients after hospitalization

We studied whether pharmacists involved in discharge planning can improve patient satisfaction and outcomes by providing telephone follow-up after hospital discharge. We conducted a randomized trial at the General Medical Service of an academic teaching hospital. We enrolled General Medical Service patients who received pharmacy-facilitated discharge from the hospital to home. The intervention consisted of a follow-up phone call by a pharmacist 2 days after discharge. During the phone call, pharmacists asked patients about their medications, including whether they obtained and understood how to take them. Two weeks after discharge, we mailed all patients a questionnaire to assess satisfaction with hospitalization and reviewed hospital records. Of the 1,958 patients discharged from the General Medical Service from August 1, 1998 to March 31, 1999, 221 patients consented to participate. We randomized 110 to the intervention group (phone call) and 111 to the control group (no phone call). Patients returned 145 (66%) surveys. More patients in the phone call than the no phone call group were satisfied with discharge medication instructions (86% vs. 61%, P = 0.007). The phone call allowed pharmacists to identify and resolve medication-related problems for 15 patients (19%). Twelve patients (15%) contacted by telephone reported new medical problems requiring referral to their inpatient team. Fewer patients from the phone call group returned to the emergency department within 30 days (10% phone call vs. 24% no phone call, P = 0.005). A follow-up phone call by a pharmacist involved in the hospital care of patients was associated with increased patient satisfaction, resolution of medication-related problems, and fewer return visits to the emergency department.     

Standardized discharge planning assessments: impact on patient outcomes

The purpose of the study was to determine whether a difference exists in patient-reported problems and unmet needs after discharge when a standardized discharge planning assessment is added to usual care by staff nurses. Two groups of 130 adult patients were enrolled while hospitalized. The intervention group patients reported fewer unmet needs (P = .01) and had fewer problems complying with their discharge instructions (P = .04). Standardizing discharge planning assessments by staff nurses may improve identification of continuing care needs.     

Transitional care post TAVI: A pilot initiative focused on bridging gaps and improving outcomes

Interventions focused on ensuring safe transitions for patients from hospital to home can assist in providing continuity of care, preventing readmissions, and reducing duplication of services. Patients undergoing a Transcatheter Aortic Valve Implantation (TAVI) procedure are often frail, elderly, and have multiple co-morbidities. A pilot initiative evaluating transitional care strategies through telephone follow up was implemented in a tertiary centre with the aim to identify gaps and intervene, preventing re-admission and improving patient outcomes. TAVI patients or caregivers were contacted at 3 days and 30 days post discharge by an Advanced Practice Nurse (APN). Telephone follow up centered on best practices for transitional care. Outcomes revealed fluid balance monitoring, medication management, and feelings of anxiety and depression post TAVI were the most frequent areas requiring intervention. Findings from this initiative reinforce the need to establish consistent processes that support elderly patient populations during potentially vulnerable points in the care trajectory.     

Risks for unplanned hospital readmission in a teaching hospital in southern Taiwan

The purpose of this study was to assess and analyse hospital readmission and its risk factors for patients who were visited by a discharge planning coordinator during hospitalization in a teaching hospital located in southern Taiwan. Results found that 67 patients (5.7%) were readmitted within 14 days of discharge during the data collection period. Twenty-eight patients (41.8%) were readmitted because of complications. Patients' previous diagnoses and complications were two major reasons for patients to be re-hospitalized within 14 days of discharge. In addition, significant predictors for unplanned hospital readmission within 14 days of discharge were patients who received care from home health care nurses or hospice home health care nurses.     

某三级医院193例慢性病患者延续护理需求调查研究

目的探讨三级医院慢性病患者对延续护理的需求情况。方法研究者自行设计调查问卷,对某三级医院193例慢性病住院患者进行问卷调查,问卷内容包括延续护理的提供者、内容、形式、时限、频次、费用态度等。结果三级医院66.0%的慢性病患者希望出院后得到医院的延续护理;60.2%的慢性病患者希望责任医生提供延续护理;慢性病患者对延续护理内容需求排在首位的是药物知识(占57.0%),其次是康复知识(占53.9%);慢性病患者对延续护理形式需求排在首位的是电话随访(占74.2%),其次是咨询热线(占34.4%);50.8%的慢性病患者希望出院后1~2年内得到延续护理,42.2%的慢性病患者希望出院后每年得到10~12次延续护理;53.9%的慢性病患者认为根据延续护理的内容及形式,可以按照国家相关法规收取费用。结论三级医院慢性病患者对延续护理的需求较高,对延续护理的提供者、内容、形式、时限、频次、费用态度多样化,医院应组建多学科团队,根据慢性病患者的不同需求采取针对性强、形式丰富的延续护理,使延续护理不流于形式,而是真正地深入到社区,进入到每个家庭。     

电话干预对经皮经肝胆道外引流术患者康复及生活质量的影响

目的探讨电话干预对经皮经肝胆道外引流术治疗恶性梗阻性黄疸患者康复及生活质量的影响。方法将某三级甲等医院经皮经肝胆道外引流术治疗恶性梗阻性黄疸患者分为对照组48例和干预组51例。干预组在接受常规健康教育的基础上,出院后3个月内接受电话干预提供的个性化健康教育;出院后3个月对两组患者带管相关知识、带管相关并发症及生活质量进行调查比较。结果患者出院后3个月除引流袋更换外,电话干预组带管相关知识均优于对照组,生活质量优于对照组,带管相关并发症低于对照组(P<0.01或P<0.05)。结论电话干预可以提高经皮经肝胆道外引流术治疗梗阻性黄疸患者的自我护理能力及生活质量。     

To evaluate the effectiveness of a discharge‐planning programme for hip fracture patients

Aims and objectives. This study aimed to evaluate the effectiveness of a comprehensive discharge‐planning service for hip fracture patients, including length of stay, functional status, self‐care knowledge and quality of life (QOL). Background. Hip fractures are the most devastating result of osteoporosis. Care of these patients from the moment they enter the hospital until discharge and postdischarge is a challenging task, requiring a coordinated approach by an interdisciplinary team. Design. An experimental design was used. Methods. Fifty hip fracture patients were recruited from a medical centre in Taipei, Taiwan and randomly divided into two groups. The control group received routine discharge nursing care and the experimental group received comprehensive discharge planning. After patient admission, researchers assessed discharge‐planning needs, provided discharge nursing instruction, coordinated services and determined discharge placement based on assessment results. Results. (i) Mean age of 50 hip fracture patients was 78·75 (SD 6·99) years. Mean length of stay was 6·04 (SD 2·41) days for the experimental group and 6·29 (SD 2·17) for the control group. Difference between groups was not significant (t = ?0·394, p = 0·696). (ii) The self‐care knowledge of the experimental group was higher than that of the control group (F = 11·569, p = 0·001). (iii) Significant improvements were observed in functional status of both groups at three months postdischarge, with no significant differences observed between groups. However, the functional status of experimental group patients showed a slightly better trend than that of the control group. (iv) At three months postdischarge, QOL of experimental group patients was better than control group patients. Conclusions. A comprehensive discharge‐planning service can improve hip fracture patients’ self‐care knowledge and QOL. Relevance to clinical practice. Results of this study can be used clinically as a basis for practical implementation of discharge‐planning services in fracture patients.     

The Public Health Nurse as a Discharge Planner: Patients'' Perceptions of the Discharge Process

The trend toward earlier patient discharges from hospitals has provided new incentives for hospitals and public health nurses to work together to ensure that patients receive uninterrupted quality care after discharge. This study investigated perceptions of the discharge process using a structured telephone interview to survey a sample of 30 adult patients who had been hospitalized for at least 24 hours in a small, rural community, hospital in the upper Midwest. The county public health nursing agency contracted with the hospital to provide discharge planning services. Patients identified discharge needs in 15 different areas, with a mean of 5.8 needs per patient. Twenty-seven percent of the patients received referrals for the services of a public health nurse, homemaker, or both before discharge. One week after discharge 37 percent of the patients continued to need assistance appropriate for referral back to the professionals or agencies with whom they had had initial contact. Elderly patients with chronic illnesses were more likely to have received referrals at the time of discharge than younger patients with acute illnesses. Family and friends were heavily involved in providing support services in the postdischarge period.     

Liaison nursing for stroke patients: results of a Dutch evaluation study

Liaison nurses, employed by a home care organization, were introduced into two Dutch hospitals to improve discharge planning for stroke patients. The main aim of the study presented was to gain insight into the effects of liaison nursing on the quality of the discharge process and related outcomes. After the introduction of liaison nursing, hospital nurses completed a questionnaire on satisfaction with the liaison nurse. In addition, both before and after the introduction of liaison nursing, two groups of discharged stroke patients were interviewed by telephone. The records of these patients were also studied with respect to background characteristics and duration of hospital stays. The hospital nurses were, generally, positive about the liaison nurse and the job she did (e.g. they found that home care was better organized). Further, after the introduction of liaison nursing, more patients stated that their post-discharge needs had been discussed not later than 48 hours prior to discharge, and more patients said their aftercare had been discussed with community nurses. However, the number of patients whose medication had arrived at home on time had decreased. The results also indicated that there was no significant difference in the duration of stay between the before and after group. The overall conclusion is that the liaison nurses have been moderately successful in their jobs. However, since the study was conducted in only two Dutch hospitals, findings may not be representative of other settings. Future research on liaison nursing is therefore recommended.     

Randomized trial of an intensive care unit-based early discharge planning intervention for critically ill elderly patients.

BACKGROUND: Few investigators have targeted elderly patients and monitored outcomes of care in studies on discharge planning interventions after critical illness. OBJECTIVES: To pilot test an intensive care unit-based nursing screening intervention to assist in determining the discharge needs and outcomes of critically ill elderly patients. METHOD: A randomized clinical trial with in-hospital and mailed questionnaires was used. Patients 65 years and older who were hospitalized in 1 of 2 intensive care units at 2 midwestern university-affiliated medical centers were recruited for the study. Control patients (n = 53) received usual discharge planning, experimental patients (n = 47) were screened in the intensive care unit by using the Discharge Planning Questionnaire. Both groups were assessed for readiness for discharge when discharged from the hospital and were followed up 2 weeks later with a survey completed at home. RESULTS: One hundred patients 65 to 90 years old (mean 73, SD 5.78) completed the study. Sixty-six percent were men. The 2 groups did not differ with regard to age, race, sex, severity of illness, lengths of stay in the intensive care unit or hospital, education level, or income. Patients in the experimental group were more ready than patients in the control group for discharge (P =.06). Patients in the experimental group were also more likely to report they had adequate information, had less concern about managing their care at home, knew their medicines, and knew danger signals indicating potential complications. CONCLUSION: Intensive care unit-based early discharge planning can affect elderly patients' preparation for discharge.     

Discovery of the discharge process: a study of patient discharge from a care unit for elderly people

Patient discharge is not a new research topic Numerous studies have shown patients do not always receive the services they need on leaving hospital The purpose of this study was to examine the process of discharge and move away from the snapshot study of discharge outcomes Interviews were undertaken with elderly patients, their carers and the hospital and community staff involved in their care A content analysis of the data revealed a distinctive discharge process which started with admission and ended with the patient leaving hospital Discharge planning was highlighted as a separate component of this process A number of examples are examined of how vulnerable to breakdown patient discharge can be     

Discharge planning of elderly patients in need of care

The following article is based on a survey about the perception of elderly patients concerning their discharge from hospital. This includes all activities carried out at the hospital to prepare the patients for further treatment and care after discharge if necessary. 63 elderly patients from the department of internal medicine of a general hospital in Lower Saxony were interviewed using a standardized questionnaire. The results of this survey show that many patients interviewed were neither feeling informed nor did they learn how to cope with the situation after discharge from hospital. A quarter of all interviewed patients realized neither their involvement nor the involvement of their family in planning the essential steps required for the time of discharge from hospital. We found out that being involved in discharge planning has a great influence not only on the satisfaction with the preparation for discharge from hospital but with the entire hospital care.