三级医院专科护士开设社区慢性病护理门诊的实践

Practice of setting up community chronic disease nursing clinic by specialist nurses from tertiary hospitals

目的:分析三级医院专科护士开设社区慢性病护理门诊实践效果。方法:由三级医院专科护士在社区卫生服务中心开设高血压护理门诊和糖尿病护理门诊,建立专科护士社区慢性病护理门诊工作机制,分析2017年9月至2018年2月的社区慢性病护理门诊一般工作指标及高血压、糖尿病患者在签约时、签约3个月、6个月后主要结局指标。结果:高血压护理门诊和糖尿病护理门诊分别签约患者86例和95例,在签约3个月、6个月后,高血压疾病主要指标控制达标率分别为70.93%和87.20%,糖尿病疾病主要指标控制达标率分别为23.15%和40.00%。结论:三级医院专科护士开设社区慢性病护理门诊有利于社区慢性病患者的疾病控制、分级就诊及提升患者满意度。三级医院专科护士开设社区慢性病护理门诊建设需要政策跟进及机制优化。

Objective:To analyze the effects of setting up chronic diseases nursing clinic in community health centers by specialist nurses from tertiary hospital.Methods:Established hypertension and diabetes nursing clinic in community health center,and established the working system for community chronic disease nursing clinic.The general working indicators of the community chronic disease nursing clinic from September 2017 to February 2018,and the outcomes of patients with hypertension and diabetes after 3 and 6 months of the intervention were collected.Results:There were 86 and 95 patients signed up for hypertension and diabetes nursing care clinic,respectively.After 3 months and 6 months of intervention,the achieved rate of the main indicators for hypertension management was 70.93%and 87.20%respectively,and 23.15%and 40.00%for diabetes respectively.Conclusion:Setting up chronic disease nursing clinic in community health centers is benefit to improve the chronic disease management level,the implementation of tiered medical consultation system and the patients'satisfaction.In the future,policy supports and scientific management system are needed for the long-term implementation of the community chronic disease nursing clinic.