中国全科医学 ›› 2020, Vol. 23 ›› Issue (4): 499-504.DOI: 10.12114/j.issn.1007-9572.2019.00.449
• 专题研究 • 上一篇
施晓柳,耿桂灵*,高晶,华佳宁
出版日期:
2020-02-05
发布日期:
2020-02-05
基金资助:
SHI Xiaoliu,GENG Guiling*,GAO Jing,HUA Jianing
Published:
2020-02-05
Online:
2020-02-05
摘要: 延续护理中的信息延续是近年来国内外的研究热点。信息延续通过促进患者关键信息在不同机构与个人之间准确传递,可减少患者不良结局的发生和医疗资源的浪费,促进医疗机构的良性运转。本文对老年慢性病患者延续护理中出院计划、出院计划中病史信息和用药信息的内容和形式、存在的问题与对策进行综述,旨在加强医护工作者对信息延续的认知,促进其方法创新,从而提高老年慢性病延续护理服务质量。
[1]COLEMAN E A,BOULT C,American Geriatrics Society Health Care Systems Committee.Improving the quality of transitional care for persons with complex care needs[J].J Am Geriatr Soc,2003,51(4):556-557.DOI:10.1111/j.1532-5415.2004.52230_15.x.
[2]黄茂盛,洪震,曾军,等.上海市城乡老年人慢性病现况调查[J].中华老年医学杂志,2001,20(4):287-289.DOI:10.3760/j.issn.0254-9026.2001.04.013. HUANG M S,HONG Z,ZENG J,et al.Survey on the prevalence of common chronic diseases in the elderly in rural and urban areas of Shanghai[J].Chinese Journal of Geriatrics,2001,20(4):287-289.DOI:10.3760/j.issn.0254-9026.2001.04.013. [3]刘永碧,刘永芳,刘萍,等.重庆市某社区城市老年人慢性病现况调查[J].中华老年医学杂志,2003,22(8):501.DOI:10.3760/j.issn.0254-9026.2003.08.021. LIU Y B,LIU Y F,LIU P,et al.Investigation on chronic diseases of the elderly in a community of Chongqing[J].Chinese Journal of Geriatrics,2003,22(8):501.DOI:10.3760/j.issn.0254-9026.2003.08.021. [4]唐聪,李檬妤,王斌,等.武汉市老年人慢性病患病现状及知信行调查[J].中国老年学杂志,2017,37(5):1231-1234.DOI:10.3969/j.issn.1005-9202.2017.05.091. TANG C,LI M Y,WANG B,et al.Prevalence of chronic disease among older people in Wuhan City and the knowledge,attitude,practice about chronic disease[J].Chinese Journal of Gerontology,2017,37(5):1231-1234.DOI:10.3969/j.issn.1005-9202.2017.05.091. [5]刘竟芳,陈哲,杨非柯,等.长沙市社区老年人慢性病现状[J].中国老年学杂志,2014,34(11):6112-6114.DOI:10.3969/j.issn.1005-9202.2014.11.095. LIU J F,CHEN Z,YANG F K,et al.Status of chronic diseases of the elderly in Changsha Community[J].Chinese Journal of Gerontology,2014,34(11):6112-6114.DOI:10.3969/j.issn.1005-9202.2014.11.095. [6]原国家卫生和计划生育委员会.中国疾病预防控制工作进展[EB/OL].(2015-04-15)[2018-02-12].http://www.nhf-pc.gov.cn/zwgk/jdjd/201504/7f0916f264c84508850ac6e80d8dd267.shtml. [7]KRIPALANI S,THEOBALD C N,ANCTIL B,et al.Reducing hospital readmission rates:current strategies and future directions[J].Annu Rev Med,2014,65(1):471-485.DOI:10.1146/annurev-med-022613-090415. [8]李峰,陶蕾,徐星,等.基于微信平台的延续护理对肿瘤患者居家口服化疗药物依从性的影响[J].安徽医学,2019,40(4):456-459.DOI:10.3969/j.issn.1000-0399.2019.04.030.http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=ahyx201904030. [9]LOW L L,TAN S Y,NG M J,et al.Applying the integrated practice unit concept to a modified virtual ward model of care for patients at highest risk of readmission:a randomized controlled trial[J].PLoS One,2017,12(1):e0168757.DOI:10.1371/journal.pone.0168757. [10]RUTTER P,RAMSBOTTOM H,FITZPATRICK R.Community pharmacist perceptions of delivering post-hospital discharge medicines use reviews for elderly patients[J].Int J Clin Pharm,2017,39(1):33-36.DOI:10.1007/s11096-016-0400-8. [11]JUSELA C,STRUBLE L,GALLAGHER N A,et al.Communication between acute care hospitals and skilled nursing facilities during care transitions:a retrospective chart review[J].J Gerontol Nurs,2017,43(3):19-28.DOI:10.3928/00989134-20161109-03. [12]陈曦,毕越英,陈海花.连续护理的国内外研究现状及展望[J].中华护理杂志,2012,47(8):758-760.DOI:10.3761/j.issn.0254-1769.2012.08.032. CHEN X,BI Y Y,CHEN H H.Research status and prospect of continuous nursing at home and abroad[J].Chinese Journal of Nursing,2012,47(8):758-760.DOI:10.3761/j.issn.0254-1769.2012.08.032. [13]ARBAJE A I,HUGHES A,WERNER N,et al.Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge:a multisite,qualitative study[J].BMJ Qual Saf,2019,28(2):111-120.DOI:10.1136/bmjqs-2018-008163. [14]SHEHAB N,LOVEGROVE M C,GELLER A L,et al.US emergency department visits for outpatient adverse drug events,2013—2014[J].JAMA,2016,316(20):2115-2125.DOI:10.1001/jama.2016.16201. [15]RAUSCH C,LAFLAMME L,BULTMANN U,et al.Number of medications and adverse drug events by unintentional poisoning among older adults in consideration of inappropriate drug use:a Swedish population-based matched case-control study[J].Eur J Clin Pharmacol,2017,73(6):743-749.DOI:10.1007/s00228-017-2220-8. [16]GILMORE-BYKOVSKYI A L,KENNELTY K A,DUGOFF E,et al.Hospital discharge documentation of a designated clinician for follow-up care and 30-day outcomes in hip fracture and stroke patients discharged to sub-acute care[J].BMC Health Serv Res,2018,18(1):103.DOI:10.1186/s12913-018- 2907-2. [17]GREYSEN S R,HARRISON J D,KRIPALANI S,et al.Understanding patient-centred readmission factors:a multi-site,mixed-methods study[J].BMJ Qual Saf,2017,26(1):33-41.DOI:10.1136/bmjqs-2015-004570. [18]卢珏,薛小玲.出院计划的研究进展[J].中华护理杂志,2014,49(6):709-711.DOI:10.3761/j.issn.0254-1769.2014.06.017. LU J,XUE X L.Research progress on discharge planning:a review[J].Chinese Journal of Nursing,2014,49(6):709-711.DOI:10.3761/j.issn.0254-1769.2014.06.017. [19]董广翠,杨霞.出院计划在我国慢性疾病患者护理中的应用研究现状[J].中国护理管理,2015,15(7):884-887.DOI:10.3969/j.issn.1672-1756.2015.07.032. DONG G C,YANG X.Discharge planning of chronic disease in China[J].Chinese Nursing Management,2015,15(7):884-887.DOI:10.3969/j.issn.1672-1756.2015.07.032. [20]胡永琼,邓云霞.出院计划在慢性心力衰竭患者护理中的应用及效果评价[J].中国护理管理,2016,16(4):531-534.DOI:10.3969/j.issn.1672-1756.2016.04.025. HU Y Q,DENG Y X.Application of discharge plan in nursing patients with chronic heart failure and its effect evaluation[J].Chinese Nursing Management,2016,16(4):531-534.DOI:10.3969/j.issn.1672-1756.2016.04.025. [21]赵秀君,刘丽华,周红,等.出院计划新模式对2型糖尿病患者代谢指标和低血糖事件的影响研究[J].中国全科医学,2014,17(13):1481-1485.DOI:10.3969/j.issn.1007-9572.2014.13.009. ZHAO X J,LIU L H,ZHOU H,et al.Effect of new discharge planning pattern on metabolic indices and hypoglycemic events in T2DM patients[J].Chinese General Practice,2014,17(13):1481-1485.DOI:10.3969/j.issn.1007-9572.2014.13.009. [22]NAYLOR M D,BROOTEN D,CAMPBELL R,et al.Comprehensive discharge planning and home follow-up of hospitalized elders:a randomized clinical trial[J].JAMA,1999,281(7):613-620.DOI:10.1001/jama.281.7.613. [23]MABIRE C,DWYER A,GARNIER A,et al.Effectiveness of nursing discharge planning interventions on health-related outcomes in discharged elderly inpatients:a systematic review[J].JBI Database System Rev Implement Rep,2016,14(9):217-260.DOI:10.11124/JBISRIR-2016-003085. [24]POPEJOY L L,VOGELSMEIER A A,WAKEFIELD B J,et al.Adapting project RED to skilled nursing facilities[J].Clin Nurs Res,2018.[Epub ahead of print].DOI:10.1177/1054773818819261. [25]赵秀君,何文英,张兴,等.2型糖尿病患者应用出院计划服务的效果评价[J].护理学杂志,2014,29(1):18-20.DOI:10.3870/hlxzz.2014.01.018. ZHAO X J,HE W Y,ZHANG X,et al.Evaluating hospital discharge planning for patients with type 2 diabetes[J].Journal of Nursing Science,2014,29(1):18-20.DOI:10.3870/hlxzz.2014.01.018. [26]陈琴,姜小鹰,钟清玲,等.慢性阻塞性肺疾病患者应用出院计划服务的效果评价[J].中华护理杂志,2012,47(9):790-794.DOI:10.3761/j.issn.0254-1769.2012.09.007. CHEN Q,JIANG X Y,ZHONG Q L,et al.Effect of discharge planning services in patients with chronic obstructive pulmonary disease[J].Chinese Journal of Nursing,2012,47(9):790-794.DOI:10.3761/j.issn.0254-1769.2012.09.007. [27]SODHI N,MONT M A,Cleveland Clinic Orthopaedic Arthroplasty.Does patient experience after a total knee arthroplasty predict readmission?[J].J Arthroplasty,2020,23(4):3!!-3!!.DOI:10.1016/j.arth.2019.04.044. [28]包已男,姜茹鑫,白姆,等.信息技术在结直肠癌患者延续护理中的应用进展[J].中华护理杂志,2017,52(3):280-284.DOI:10.3761/j.issn.0254-1769.2017.03.005. BAO Y N,JIANG R X,BAI M,et al.Progress in application of information technology in continuing nursing care of patients with colorectal cancer[J].Chinese Journal of Nursing,2017,52(3):280-284.DOI:10.3761/j.issn.0254-1769.2017.03.005. [29]马计,杭波.患者信息管理系统设计与开发[J].医学信息学杂志,2014,35(4):25-28.DOI:10.3969/j.issn.1673-6036.2014.04.005. MA J,HANG B.Design and development of patient information management system[J].Journal of Medical Informatics,2014,35(4):25-28.DOI:10.3969/j.issn.1673-6036.2014.04.005. [30]BAHOUS M C,SHADMI E.Health information exchange and information gaps in referrals to a pediatric emergency department[J].Int J Med Inform,2016,87:68-74.DOI:10.1016/j.ijmedinf.2015.12.011. [31]ISAACMAN D J,PURVIS K,GYURO J,et al.Standardized instructions:do they improve communication of discharge information from the emergency department?[J].Pediatrics,1992,89(6 Pt 2):1204-1208. [32]罗文基,陈鸿江,黄丽娟.门诊慢性病患者药物咨询情况分析[J].中国实用医药,2011,6(5):15-16.DOI:10.3969/j.issn.1673-7555.2011.05.008. LUO W J,CHEN H J,HUANG L J.The analysis of drug consultation in chronic patients[J].China Practical Medicine,2011,6(5):15-16.DOI:10.3969/j.issn.1673-7555.2011.05.008. [33]PETERSEN H V,FOGED S,MADSEN A L,et al.Nurses' perception of how an e-message system influences cross-sectoral communication:a qualitative study[J].J Nurs Manag,2018,26(5):509-517.DOI:10.1111/jonm.12575. [34]POLDERVAART J M,VAN MELLE M A,WILLEMSE S,et al.In-hospital prescription changes and documentation in the medical records of the primary care provider:results from a medical record review study[J].BMC Health Serv Res,2017,17(1):792.DOI:10.1186/s12913-017-2738-6. [35]SHADE M Y,BERGER A M,CHAPERON C,et al.Adverse drug events reported by rural older adults[J].Geriatr Nurs,2017,38(6):584-588.DOI:10.1016/j.gerinurse.2017.04.008. [36]LEGRAIN S,TUBACH F,BONNET-ZAMPONI D,et al.A new multimodal geriatric discharge-planning intervention to prevent emergency visits and rehospitalizations of older adults:the optimization of medication in AGEd multicenter randomized controlled trial[J].J Am Geriatr Soc,2011,59(11):2017-2028.DOI:10.1111/j.1532-5415.2011.03628.x. [37]ENSING H T,KOSTER E S,DUBERO D J,et al.Collaboration between hospital and community pharmacists to address drug-related problems:the HomeCoMe-program[J].Res Social Adm Pharm,2019,15(3):267-278.DOI:10.1016/j.sapharm.2018.05.001. [38]陈黎明,卞丽芳,冯志仙.基于护理电子病历的临床决策支持系统的设计与应用[J].中华护理杂志,2014,49(9):1075-1079.DOI:10.3761/j.issn.0254-1769.2014.09.011. CHEN L M,BIAN L F,FENG Z X.The design and application of clinical decision support system based on electronic nursing records[J].Chinese Journal of Nursing,2014,49(9):1075-1079.DOI:10.3761/j.issn.0254-1769.2014.09.011. [39]唐孟言,李晓玲.手机应用程序在疾病延续护理中的应用进展[J].中华护理杂志,2018,53(3):363-365.DOI:10.3761/j.issn.0254-1769.2018.03.024. TANG M Y,LI X L.Advances in the application of mobile phone applications in continuing care for diseases [J].Chinese Journal of Nursing,2018,53(3):363-365.DOI:10.3761/j.issn.0254-1769.2018.03.024. [40]BLOMBERG B A,MULLIGAN R C,STAUB S J,et al.Handing off the older patient:improved documentation of geriatric assessment in transitions of care[J].J Am Geriatr Soc,2018,66(2):401-406.DOI:10.1111/jgs.15237. [41]MAHFOUZ C,BONNEY A,MULLAN J,et al.An Australian discharge summary quality assessment tool:a pilot study[J].Aust Fam Physician,2017,46(1):57-63. [42]刘雪琴,谭晓青.奥马哈系统的发展及在护理领域中的应用[J].中华护理杂志,2010,45(4):369-371.DOI:10.3761/j.issn.0254-1769.2010.04.034. LIU X Q,TAN X Q.Development of the Omaha system and its application in nursing[J].Chinese Journal of Nursing,2010,45(4):369-371.DOI:10.3761/j.issn.0254-1769.2010.04.034. [43]唐颖,孙晓燕,温贤秀.延续护理信息平台的构建及应用[J].中国护理管理,2016,16(3):392-394.DOI:10.3969/j.issn.1672-1756.2016.03.027. TANG Y,SUN X Y,WEN X X.The construction and application of transitional care information platform[J].Chinese Nursing Management,2016,16(3):392-394.DOI:10.3969/j.issn.1672-1756.2016.03.027. [44]PARK H K,BRANCH L G,BULAT T,et al.Influence of a transitional care clinic on subsequent 30-day hospitalizations and emergency department visits in individuals discharged from a skilled nursing facility[J].J Am Geriatr Soc,2013,61(1):137-142.DOI:10.1111/jgs.12051. [45]WHITMAN A M,DEGREGORY K A,MORRIS A L,et al.A comprehensive look at polypharmacy and medication screening tools for the older cancer patient[J].Oncologist,2016,21(6):723-730.DOI:10.1634/theoncologist.2015-0492. [46]WENGER N K,DOHERTY C L,GURWITZ J H,et al.Optimization of drug prescription and medication management in older adults with cardiovascular disease[J].Drugs Aging,2017,34(11):803-810.DOI:10.1007/s40266-017-0494-2. [47]MARTIN B A,CHEWNING B A,MARGOLIS A R,et al.Med wise:a theory-based program to improve older adults' communication with pharmacists about their medicines[J].Res Social Adm Pharm,2016,12(4):569-577.DOI:10.1016/j.sapharm.2015.09.010. [48]HOHMEIER K C,SPIVEY C A,BODIN S,et al.Implementation of a health information exchange into community pharmacy workflow[J].J Am Pharm Assoc(2003),2017,57(5):608-615.DOI:10.1016/j.japh.2017.05.009. [49]SAAVEDRA-QUIRóS V,MONTERO-HERNáNDEZ E,MENCHéN-VISO B,et al.Medication reconciliation at admission and discharge.A consolidated experience[J].Rev Calid Asist,2016,31 Suppl 1:45-54.DOI:10.1016/j.cali.2016.02.002. [50]JURADO C,CALMELS V,LOBINET E,et al.The electronic pharmaceutical record:a new method for medication reconciliation[J].J Eval Clin Pract,2018,24(4):681-687.DOI:10.1111/jep.12942. [51]MURPHY S F,LENIHAN L,OREFUWA F,et al.Electronic discharge summary and prescription:improving communication between hospital and primary care[J].Ir J Med Sci,2017,186(2):455-459.DOI:10.1007/s11845-016-1397-7. [52]HORWITZ L I,JENQ G Y,BREWSTER U C,et al.Comprehensive quality of discharge summaries at an academic medical center[J].J Hosp Med,2013,8(8):436-443.DOI:10.1002/jhm.2021. [53]GILLIAM M,KREIN S L,BELANGER K,et al.Novel combined patient instruction and discharge summary tool improves timeliness of documentation and outpatient provider satisfaction[J].SAGE Open Med,2017,5:2050312117701053.DOI:10.1177/2050312117701053. [54]COLEMAN E A,MAHONEY E,PARRY C.Assessing the quality of preparation for posthospital care from the patient's perspective:the care transitions measure[J].Med Care,2005,43(3):246-255.DOI:10.1097/00005650-200503000-00007. [55]COLEMAN E A,SMITH J D,FRANK J C,et al.Development and testing of a measure designed to assess the quality of care transitions[J].Int J Integr Care,2002,2:e02.DOI:10.5334/ijic.60. [56]MASTERS S,GILES L,HALBERT J,et al.Development and testing of a questionnaire to measure older people's experience of the transition care program in Australia[J].Australas J Ageing,2010,29(4):172-178.DOI:10.1111/j.1741-6612.2010.00443.x. |
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