住院患者出院计划实践工具的范围综述

doi:10.3761/j.issn.0254-1769.2020.12.021

摘要/Abstract

摘要：

目的系统综述国内外住院患者出院计划实践工具相关研究及指南、政府文件。方法聚焦出院计划实践工具,系统检索中英文数据库和相关指南、政府网站,各类工具提取的信息包括：作者/发布机构、年份、国家/地区、工具名称、适用对象、工具内容简介和使用时机。结果沿患者入院至出院时间轴,将出院计划实践工具分为入院时-评估、住院期间-实施、出院前24 h-核查、出院时-转介和出院后-随访5个类别、共29个促进出院计划顺利实施的工具。结论建议卫生保健人员在综合和了解国外出院计划实践工具的基础上,制订和发展适合本国国情和医疗环境的出院计划实践工具,以标准化的工具有效推进出院计划的实施,优化患者结局,提升患者医疗护理服务的延续性。

关键词: 住院患者, 出院计划, 工具, 范围综述, 护理评估

Abstract:

Objective To integrate the relevant research,guidelines and government documents on the practice tools of discharge planning in inpatients by taking scoping reviews. Methods Focusing on the practical tools of discharge planning,we systematically searched the relevant databases,guidelines and government websites,extracted the information including author,year,country,name,applicable object,content introduction,using time and the purpose of the tools. Results Along the time line from admission to discharge of a patient,the discharge planning practice tools were divided into 5 categories：admission - evaluation,hospitalization - implementation,24 hours before discharge - verification,on discharge - referral,and after discharge - follow-up,with a total of 29 tools to promote the smooth implementation of the discharge plan. Conclusion Health care personnel should formulate and develop suitable practice tools of discharge planning based on national conditions and medical environment,so as to effectively promote the implementation of discharge plans with standardized tools,optimize the outcomes of patients,and promote the continuity of medical care services for patients.

Key words: Inpatients, Discharge Planning, Tools, Scoping Review, Nursing Assessment

柯键,汪晖,王颖,刘于,乐霄,王冰花,胡凯利,杨纯子,黄海珊. 住院患者出院计划实践工具的范围综述[J]. 中华护理杂志, 2020, 55(12): 1876-1883.

KE Jian,WANG Hui,WANG Ying,LIU Yu,YUE Xiao,WANG Binghua,HU Kaili,YANG Chunzi,HUANG Haishan. A scoping review of discharge planning practice tools in hospitalized patients[J]. Chinese Journal of Nursing, 2020, 55(12): 1876-1883.

图/表 7

图1 文献筛选流程图

Figure 1 Flow chart of literature screening

表1 住院患者出院计划实践工具总体情况

Table 1 General distribution of researches on discarge planning practice tools for hospitalized patients

表2 住院患者出院计划评估工具（n=12）

Table 2 Discharge planning assessment tools for hospitalized patients（n=12）

表3 出院计划任务清单(n=3)

Table 3 List of discharge planning tasks(n=3)

表4 住院患者出院计划核查工具(n=7)

Table 4 Discharge planning checking tools for hospitalized patients(n=7)

表5 出院计划转介工具(n=4)

Table 5 Referral assessment tools for discharge planning(n=4)

表6 出院计划随访工具(n=3)

Table 6 Follow-up tools for discharge planning(n=3)

参考文献 34

[1]	孙超, 奚桓, 李峥, 等. 老年患者出院准备服务专家共识(2019版)[J]. 中华护理杂志, 2020,55(2):220-227.
	Sun C, Xi H, Li Z, et al. Expert consensus on the discharge planning for hospitalized elderly patients(version 2019)[J]. Chin J Nurs, 2020,55(2):220-227.
[2]	Gonçalves-Bradley DC, Lannin NA, Clemson LM, et al. Dischar-ge planning from hospital[J]. Cochrane Database Syst Rev, 2016: 1-87.
[3]	Shahsavari H, Zarei M, Aliheydari Mamaghani J. Transitional care:concept analysis using Rodgers’ evolutionary approach[J]. Int J Nurs Stud, 2019,99:103387.
[4]	Gonçalves-Bradley DC, Iliffe S, Doll HA, et al. Early discharge hospital at home[J]. Cochrane Database Syst Rev, 2017: 1-105. DOI URL PMID
[5]	Santana MJ, Manalili K, Jolley RJ, et al. How to practice person-centred care:a conceptual framework[J]. Health Expect, 2018,21(2):429-440. DOI URL PMID
[6]	Adams CJ, Stephens K, Whiteman K, et al. Implementation of the Re-Engineered Discharge(RED) toolkit to decrease all-cause readmission rates at a rural community hospital[J]. Qual Manag Health Care, 2014,23(3):169-177. DOI URL PMID
[7]	Holland DE, Harris MR, Leibson CL, et al. Development and validation of a screen for specialized discharge planning services[J]. Nurs Res, 2006,55(1):62-71. URL PMID
[8]	Moppett IK, Wiles MD, Moran CG, et al. The Nottingham Hip Fracture Score as a predictor of early discharge following fractured neck of femur[J]. Age Ageing, 2012,41(3):322-326. URL PMID
[9]	Boult C, Dowd B, McCaffrey D, et al. Screening elders for risk of hospital admission[J]. J Am Geriatr Soc, 1993,41(8):811-817.
[10]	Lin PC, Wang JL, Chang SY, et al. Effectiveness of a discharge-planning pilot program for orthopedic patients in Taiwan[J]. Int J Nurs Stud, 2005,42(7):723-731. URL PMID
[11]	丁玲, 芦鸿雁, 路露. 老年患者出院计划风险筛查指标的构建[J]. 护理学杂志, 2018,33(21):5-8.
	Ding L, Lu HY, Lu L. Development of a risk screening tool for discharge planning for elderly patients[J]. J Nurs Sci, 2018,33(21):5-8.
[12]	Sager MA, Rudberg MA, Jalaluddin M, et al. Hospital admission risk profile(HARP):identifying older patients at risk for functional decline following acute medical illness and hospitalization[J]. J Am Geriatr Soc, 1996,44(3):251-257. URL PMID
[13]	Blaylock A, Cason CL. Discharge planning predicting patients’ needs[J]. J Gerontol Nurs, 1992,18(7):5-10. URL PMID
[14]	Holland DE, Hansen DC, Matt-Hensrud NN, et al. Continuity of care:a nursing needs assessment instrument[J]. Geriatr Nurs, 1998,19(6):331-334. URL PMID
[15]	陈琴. 出院计划模式在慢性阻塞性肺疾病患者中应用的效果评价[D]. 福州:福建医科大学, 2011.
	Chen Q. Impact evaluation to the application of discharge planning model in patients with chronic obstructive pulmonary disease[D]. Fuzhou:Fujian Medical University, 2011.
[16]	易银萍. 基于聚焦解决模式的出院计划在慢性心力衰竭患者中的应用研究[D]. 成都:成都中医药大学, 2018.
	Yi YP. A study of application on discharge planning based on solution focused approach for the patients with chronic heart failure[D]. Chengdu:Chengdu University of TCM, 2018.
[17]	楊伶惠, 黃子庭. 出院準備服務病患需求等級評估量表修訂專案[J]. 護理雜誌, 2007,54(2):55-61.
	Yang LH, Huang ZT. A project to revise the Patient Needs Rank Assessment Scale for discharge planning[J]. The Journal of Nursing, 2007,54(2):55-61.
[18]	刘华华, 蒋红, 戈娜, 等. 急性脑梗死患者出院计划需求调查问卷的可行性研究[J] 护士进修杂志, 2015,30(23):2179-2180.
	Liu HH, Jiang H, Ge N, et al. Feasibility study on the questionnaire of discharge planning needs of patients with acute cerebral infarction[J]. J Nurses Train, 2015,30(23):2179-2180.
[19]	Soong C, Daub S, Lee J, et al. Development of a checklist of safe discharge practices for hospital patients[J]. J Hosp Med, 2013,8(8):444-449. DOI URL PMID
[20]	Agency for Healthcare Research and Quality. Strategy 4：care transitions from hospital to home：IDEAL discharge planning[EB/OL]. （2017-12-01） [2019-11-15]. https://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy4/index.html.
[21]	Health Service Executive. Guidelines for nurse/midwife facilitated discharges planning[EB/OL]. （2009-06-30） [2019-11-15]. https://www.hse.ie/eng/about/who/qid/quality-and-patient-safety-documents/guidelines-for-nurse-facilitated-discharges-july-09.pdf.
[22]	Mennuni M, Gulizia MM, Alunni G, et al. ANMCO Position Paper:hospital discharge planning:recommendations and standards[J]. Eur Heart J Suppl, 2017,19(suppl d):D244-D255. DOI URL PMID
[23]	Centers for Medicare & Medicaid Services. Your discharge planning checklist:for patients and their caregivers preparing to leave a hospital, nursing home, or other care setting[EB/OL]. （2009-03-01） [2019-11-15]. https://www.medicare.gov/pubs/pdf/11376-discharge-planning-checklist.pdf.
[24]	Coleman EA. Charting a course for high quality care transitions[M]. London:Routledge, 2007.
[25]	Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients:development of a discharge checklist for hospitalists[J]. J Hosp Med, 2006,1(6):354-360. DOI URL PMID
[26]	Tyler A, Boyer A, Martin S, et al. Development of a discharge readiness report within the electronic health record-a discharge planning tool[J]. J Hosp Med, 2014,9(8):533-539. URL PMID
[27]	汤维娟. 上海市癌症病人连续性照护模式的构建[D]. 上海:第二军医大学, 2011.
	Tang WJ. Study on construction of a model of continity of cancer care in Shanghai[D]. Shanghai:Second Military Medical University, 2011.
[28]	Society of Hospital Medicine. BOOSTing care transitions resource room[EB/OL]. （2017-11-28） [2019-12-01]. http://www.hospitalmedicine.org.
[29]	林碧珠, 王靜慧, 許秀珠, 等. 骨科病人出院準備服務模式之建立[J]. 榮總護理, 2007,24(3):210-218.
	Lin BZ, Wang JH, Xu XZ, et al. Discharge planning service for orthopedic patients[J]. VGH Nursing,24(3), 2007,24(3):210-218.
[30]	Agency for Healthcare Research and Quality. Re-Engineered Discharge（RED） Toolkit[EB/OL]. （2013-03-01） [2019-11-15]. https://www.ahrq.gov/hai/red/toolkit/postdischarge-doc.html.
[31]	Kang E, Gillespie BM, Tobiano G, et al. Discharge education delivered to general surgical patients in their management of recovery post discharge:a systematic mixed studies review[J]. Int J Nurs Stud, 2018,87:1-13. DOI URL PMID
[32]	王冰花, 汪晖, 杨纯子, 等. 冠心病患者出院准备度现状及其影响因素的研究[J]. 中华护理杂志, 2017,52(2):138-143.
	Wang BH, Wang H, Yang CZ, et al. Survey of the readiness for hospital discharge and its influencing factors among coronary heart disease patients[J]. Chin J Nurs, 2017,52(2):138-143.
[33]	Weetman K, Dale J, Scott E, et al. The discharge communication study:research protocol for a mixed methods study to investigate and triangulate discharge communication experiences of patients,GPs,and hospital professionals,alongside a corresponding discharge letter sample[J]. BMC Heal Serv Res, 2019,19(1):1-12.
[34]	Rodakowski J, Rocco PB, Ortiz M, et al. Caregiver integration during discharge planning for older adults to reduce resource use:a Meta-analysis[J]. J Am Geriatr Soc, 2017,65:1748-1755. URL PMID