治疗老年共病患者的重要模式：多学科整合团队

Interdisciplinary team： a new model for treatment of multimorbid elderly patients

目的总结老年科住院患者对多学科团队查房的需求及其解决的问题，推广适合我国国情的多学科团队医疗模式。方法建立多学科整合团队查房的制度和流程，对2011至2012年北京协和医院老年示范病房的住院患者的团队查房情况进行统计，分析团队查房的使用情况。结果时间段内共收治患者274例，其中65岁以上老年患者198例（72．3％），年龄（75．4±7．0）岁。134例（67．7％）超过65岁的老年患者接受过团队查房。这些患者均有共病，涉及营养问题96例（71．6％），精神心理问题55例（41％），康复医疗52例（38．8％），调整用药13例（9．7％）。经过团队医护后，好转出院130例（97．O％），死亡4例（30％）。结论老年住院患者对团队查房有较高需求。多学科整合团队是为老年共病患者提供全方位处理的重要工作模式。

Objective To sum up the demands of inpatients from geriatric department where the ward round is made by a interdisciplinary team, and the problems that the team can solve, in order to popularize the interdisciplinary care model suitable for Chinese patients. Methods A policy and procedures of ward round for geriatric inpatients made by a interdisciplinary team were established. The data of this model for the inpatients in geriatric ward of our hospital from 2011-09-01 to 2012-08-31 were collected and statistically analyzed. Results There were totally 274 patients hospitalized in the geriatric ward during that period, including 198 （72.3%） over 65 years old with a age of （75.4 ± 7.0） years. Among those older than 65 years, 134 （67.7%） elderly inpatients received the interdisciplinary care. They all had multimorbidities, and 96 （71.6%）, 55 （41%）, 52 （38.8%）, and 13（9.7%） got adviees and treatments on nutrition, psychiatric disorder, rehabilitation therapy, and medication and/or dose adjustment, respectively. After interdisciplinary care, 130 eases（97.0%） recovered and were discharged from hospital, and four cases （3.0%） died. Conclusion Elderly inpatients with multimorbidities have a high demand for interdisciplinary care. Our new model of interdisciplinary team is an important working pattern for multimorbid elderly patients.