城市社区冠心病临床路径的研制及双向转诊机制的建立

目的开发研制适合我国城市社区人群冠心病的临床路径。方法采用文献法、专家会议法、现场考察和预试验的方法，研制中国城市社区人群的冠心病临床路径。结果建立了冠心病的社区照顾路径、冠心病的专科诊疗流程、急性心肌梗死专科诊疗路径、不稳定型心绞痛专科诊疗路径、冠心病社区一专科双向转诊技术路径和社区一专科双向转诊管理路径。结论冠心病的临床路径是以社区慢性病照顾为切入点，以循证医学为指导，突出以病人为中心和以照顾的连续性为方向的一组环行路径。

Development of Clinical Pathway and Clinical Two-way Referral Pathway for Coronary Heart Disease in Urban Community

Objective The aim of this study was to develop the clinical pathways in urban community for the patients with coronary heart disease.Methods The clinical pathways in urban community for coronary heart disease was developed by literature retrieval and review, expert discussion, field observation and preliminary test.Results The clinical pathways for coronary heart disease was developed, including the clinical pathway for coronary heart disease in community, the clinical pathway for coronary heart disease in hospital ,the clinical pathway for acute myocardial infarction in hospital, the clinical pathway for unstable angina in hospital, the clinical two-way referral technical pathway and the clinical two-way referral management pathway between community health care service centers and hospitals for coronary heart disease.Conclusion The clinical pathways for coronary heart disease may be a set of loop pathways, cut in from the community care for chronic disease, directed by evidence based medicine, with patients as a center, with continuity care as a direction.