专科护士主导的慢性心力衰竭患者三级联动全程管理模式的构建及应用

Establishment and application of a three-stage linkage management model for chronic heart failure patients led by specialized nurses

目的构建专科护士主导的慢性心力衰竭患者三级联动全程管理模式,并观察应用效果。方法选取2018年7月1日至2018年12月31日渝东北片区12家医院心血管内科收治的慢性心力衰竭患者200例作为研究对象。利用随机数字表法将患者分为观察组和对照组,每组100例。观察组和对照组患者在医院均接受心内科常规治疗和护理。出院后对照组按照常规社区疾病管理模式进行干预,观察组根据"医院-社区-家庭"联动的全程管理模式进行干预,干预6个月后比较两组患者再住院率、死亡率、药疗能力评估表评分和生活满意度指数量表(LSIA)评分以及明尼芬达心力衰竭生活质量问卷(MLHFQ)和疾病相关知识掌握调查表评分。结果干预后观察组患者再住院率、死亡率均显著低于对照组,药疗能力合格率及生活满意率均明显高于对照组,差异有统计学意义(P<0.05),干预后观察组MLHFQ评分和相关知识掌握情况评分均高于对照组,差异有统计学意义(P<0.05)。结论专科护士主导的慢性心力衰竭患者三级联动全程管理模式可提高患者生活质量、药疗能力、生活质量、相关知识掌握情况及生活满意率,降低再住院率、死亡率。

Objective To construct a three-level linkage whole process management mode for patients with chronic heart failure(CHF)led by specialist nurses and observe its application effect.Methods From July 1,2018 to December 31,2018,200 CHF patients were selected as the research objects.Random number table method was used to divide them into the observation group and the control group,100 cases in each group.Both the observation group and the control group received routine treatment and nursing in the hospital.After discharge,the control group was intervened according to the conventional community disease management mode,and the observation group was intervened according to the whole process management mode of"hospital-community-family"linkage.After 6 months of intervention,the rehospitalization rate,mortality rate,medication ability assessment scale,life satisfaction index(LSIA)score,Minnefanda Heart Failure Quality of Life Questionnaire(MLHFQ)scores,and Disease Related Knowledge Mastery Questionnaire scores were compared between the two groups.Results After the intervention,the rehospitalization rate and mortality rate of the experimental group were significantly lower than those of the control group(P<0.05);the qualified rate of medication ability and life satisfaction rate of the observation group were significantly higher than those of the control group(P<0.05).After the intervention,the MLHFQ score and related knowledge mastery score of the observation group were higher than those of the control group(P<0.05).Conclusion Using in CHF patients,the three-level linkage whole process management mode led by specialist nurses can improve their quality of life,medication ability,quality of life,mastery of relevant knowledge and life satisfaction,and reduce the readmission rate and mortality rate.