门诊腹膜透析患者分层分级管理的实践

目的:探索门诊腹膜透析患者管理的新方法。方法:在门诊腹膜透析责任制护士随访管理模式基础上,探索性地提出分层分级管理门诊腹膜透析患者的方法,该方法是以KaiserTriangle慢性疾病管理模型和分级护理方式为理论框架,将门诊随访的腹膜透析患者分为重患者、高危患者和平稳患者3个层次进行管理,并提供相应的个案护理、疾病管理及人群自我管理3个级别的护理。结果:在2006-2009年腹透门诊患者数从196人增长至437人的过程中,尽管每位腹膜透析责任护士管理患者人数从30人增至60～70人,但是患者的管理质量没有下降。结论:分层分级管理方法增加了门诊腹膜透析责任制护士随访患者进行管理内容,在一定程度上节省了护理人力,提高了工作效率,同时也提高了患者的管理质量。

Implementing hierarchical management approach to manage outpatients with peritoneal dialysis

Objective： To explore a new management approach among outpatients with peritoneal dialysis. Methods： Based on the primary nurse follow-up management model, the hierarchical management approach （HMA） used Kaiser Triangle and grading nursing system as its framework. Every group of patients were graded into one of three levels , stable patients, patients with risk of co-morbidities and sick patients, according to hierarchical management criteria. Then they were given population management, disease management and case management according to hierarchical nursing criteria respectively. Results： During 2006 to 2009, patients＇ number for each primary nurse increased from 30 to 60-70, while patients＇ care quality did not decline. Conclusion： HMA could increase PD nurse＇s work efficiency and ensure care quality at the same time. It would work as an effective way to save human resources for PD program.