心衰患者的长期管理——心衰中心的临床实践

Long-term management of patients with heart failure——clinical practice of heart failure center

建立心力衰竭(心衰)患者的长期管理模式对于改善患者的预后和提高其生活质量具有重要意义。我国心衰防控形势严峻,整体管理水平相对落后,普遍存在重"治疗"轻"管理"、重"院内"轻"院外"的情况,建立符合我国国情和医疗现状的心衰长期管理模式势在必行,需要积极争取政府、社会、医疗机构和患者的共同参与。深圳市孙逸仙心血管医院心衰中心在积极参与中国心衰中心建设和认证项目的临床实践过程中,充分结合本院自身和深圳地区的实际情况,初步建立了一套心衰患者的长期管理模式。该模式以心衰病房为基础,组建多学科的心衰管理团队,构建以健康档案管理、家庭自我管理、随访管理及区域协同管理为主要内容的心衰患者管理体系。笔者将在今后工作中对其不断地评估和完善,使之能在改善本区域心衰患者预后方面切实发挥积极作用。

Establishing long-term management model of heart failure is considered to be important for improving the prognosis and quality of life for patients with heart failure. The situation of heart failure control in our country is severe, and the overall management level is relatively backward. There is widespread emphasis on ＂in-hospital treatment＂ and ignoring ＂out of hospital management＂. It is imperative to establish a long-term heart failure management model consistent with the medical conditions of our country, which requires the joint participation of the government, society, medical institutions, and patients. In the process of participating in the clinical practice of the construction and accreditation project of the heart failure center in China, the heart failure center of Shenzhen Sun Yat-sen Cardiovascular Hospital integrated the actual conditions of the hospital and the region, and initially established a set of long-term management model for patients with heart failure. Based on the heart failure ward, we established a multi-disciplinary heart failure management team and built a management system with the main content of health records management, patient family selfcare, follow-up management, regional cooperative management system. We will continue to evaluate and improve this management model in the future so that it can play a positive role in improving the prognosis of patients with heart failure in the region.