三级医院老年患者出院延续护理转介单的设计及应用

Design and application of a referral form of transitional care for elderly patients discharged from tertiary hospitals

目的设计三级医院老年患者出院延续护理转介单,评价其应用效果。方法参考文献资料,采用焦点小组讨论法,设计老年患者出院延续护理转介单,嵌入医院电子病历信息系统,病区护士使用转介单对有延续护理需求的患者进行转介,延续护理服务部专职护士接收转介,到病区为患者提供出院计划服务及出院后上门护理。结果2021-2022年全院21个老年患者所在科室均应用老年患者出院延续护理转介单实施转介,转介患者386例,其中80岁及以上老年患者219例(56.7%),内科系统9个科室共转介患者267例(69.2%)。为386例患者出院后1个月内提供上门护理服务597例次,患者出院30 d内非计划性再入院率为5.2%。结论设计及应用老年患者出院延续护理转介单,有利于促进转介及提高不同部门工作人员之间合作协调性,从而满足出院老年患者延续护理服务需求及降低出院后非计划性再入院率。

Objective To design a referral form of transitional care for elderly patients discharged from tertiary hospitals,and to eva-luate its application effect.Methods Based on references and focus group discussion,a referral form of transitional care for elderly patients was designed and embedded in the hospital′s electronic medical record information system.Ward nurses used the referral form to refer patients that needing transitional care,then the full-time nurses in the transitional care department received the referral form and went to the wards to provide discharge planning services,and provided home care services after discharge.Results From 2021-2022,the referral form of transitional care for elderly patients was applied in 21 departments of the hospital.A total of 386 elderly patients were referred by using the form,among whom 219 patients were over 80 years old(56.7%),and 267 patients were referred from 9 departments of the internal medicine system(69.2%).All 386 patients were provided with home care services 597 times within 1 month after discharge,and the rate of unplanned readmission within 30 days of discharge was 5.2%.Conclusion Design and application of the referral form of transitional care for elderly patients is conducive to promoting the referral and improving the cooperation and coordination between staff in different departments,so as to meet the needs of discharged elderly patients for transitional care services and reduce the rate of unplanned readmission after discharge.