社区糖尿病路径化干预与管理模式的探讨

The Intervention and Management of Prehospital Path of Diabetes Patients of comunity

目的为更好地落实对糖尿病患者的长期干预效果,探索路径化的干预管理模式。方法成立干预小组,对182例糖尿病患者按时间节点设定干预内容,依据路径推进式的管理模式强化宣教、自我管理、复查、评估、总结内容的落实。结果干预后患者空腹血糖、餐后2小时血糖和糖化血红蛋白水平均比干预前显著下降(P<0.05)。糖尿病患者急诊率、住院率、急性并发症发生率均显著降低(P<0.05)。结论对慢性病群体实施路径化长期管理,是确保标准化和规范化干预,稳定固化提高效果的有效模式。

Objective To better carry out the long-term intervention and management of patients with diabetes, we have explored the mode of path of intervention and management. Methods we have set up an intervention group which has established contents of intervention according to time mode for 182 cases of patients with diabetes and strengthened education, self-management, Re-examination, evaluation and summing-up of contents. Results The fasting glucose ,2h postprandial blood glucose and glycosylated hemoglobin levels have lowered significantly （P〈 0.05 ） after intervention than before and the emergency treatment, hospitalization and acute complication rates have decreased remarkably as well（P〈0.05 ）. Conclusions To conduct long-term path management of chronic disease group is an effective mode of ensuring standardization intervention and improving effects.