老年慢性病患者出院准备服务的研究进展

doi:10.3761/j.issn.0254-1769.2021.09.024

摘要/Abstract

摘要：

目前在老年慢性病高发的趋势下,患者在疾病稳定期顺利转入下级医疗机构或家庭且仍能获得持续的护理服务面临极大的挑战,而出院准备服务是有效解决这一问题的途径之一。该文对老年慢性病患者疾病稳定期出院准备服务的概念、评估工具、计划、实施、质量评价及影响因素等进行综述,为制订适应于中国老年慢性病患者的出院准备服务模式提供依据,为更好地维护并促进老年慢性病患者的康复和健康提供借鉴。

关键词: 老年人, 出院准备服务, 慢性病, 评估工具, 综述, 护理

Abstract:

For the main group of the patients with chronic diseases,how to improve the quality of life of the patients during the stable period of the disease is one of the main focuses. This review synthesized the status quo of discharge planning services for hospitalized elderly patients with chronic diseases,including the conceptualization,assessment tools,intervention strategies,quality appraisal and influencing factors. To provide information bases for the development of discharge preparation service model for the elderly patients with chronic diseases in China,findings from this review can provide guidance for better maintenance and promotion of rehabilitation and health of elderly patients with chronic diseases.

Key words: Aged, Discharge Planning, Chronic Diseases, Assessment Tool, Review, Nursing Care

刘媛, 陈菲菲, 费文海, 徐红丽, 张家香, 林兴凤. 老年慢性病患者出院准备服务的研究进展[J]. 中华护理杂志, 2021, 56(9): 1420-1425.

LIU Yuan, CHEN Feifei, FEI Wenhai, XU Hongli, ZHANG Jiaxiang, LIN Xingfeng. Research progress on discharge planning for hospitalized elderly patients with chronic diseases[J]. Chinese Journal of Nursing, 2021, 56(9): 1420-1425.

参考文献 38

[1]	国家统计局. 中华人民共和国2019年国民经济和社会发展统计公报[EB/OL].( 2020- 02- 28)[2021-03-10]. http://www.stats.gov.cn/tjsj/zxfb/202002/t20200228_1728913.html .
	National Bureau of Statistics. The national economic and social development statistics announcement of the People’s Republic of China in 2019[EB/OL].( 2020- 02- 28)[2021-03-10]. http://www.stats.gov.cn/tjsj/zxfb/202002/t20200228_1728913.html .
[2]	丁春戈, 张振香. 国内外社区慢性病病人分类系统的研究进展[J]. 护理研究, 2019,33(17):2969-2972.
	Ding CG, Zhang ZX. Research progress on classification system of chronic disease patients in communities in China and abroad[J]. Chin Nurs Res, 2019,33(17):2969-2972.
[3]	国家卫生健康委员会. 中国疾病预防控制工作进展[EB/OL].( 2015- 04- 15)[2021-03-10]. http://www.nhfpc.gov.cn/zwgk/jdjd/201504/7f0916f264c84508850ac6e80d8dd267.shtml .
	National Health Commission of the People’s Republic of China. The work progress toward disease prevention and control in China[EB/OL].( 2015- 04- 15)[2021-03-10]. ttp://www.nhfpc.gov.cn/zwgk/jdjd/201504/7f0916f264c84508850ac6e80d8dd267.shtml .
[4]	Lilleheie I, Debesay J, Bye A, et al. Experiences of elderly patients regarding participation in their hospital discharge:a qualitative metasummary[J]. BMJ Open, 2019,9(11):1-16.
[5]	Provencher V, D’Amours M, Menear M, et al. Understanding the positive outcomes of discharge planning interventions for older adults hospitalized following a fall:a realist synjournal[J]. BMC Geriatrics, 2021,21(1):84.
[6]	Considine J, Berry D, Sprogis SK, et al. Understanding the patient experience of early unplanned hospital readmission following acute care discharge:a qualitative descriptive study[J]. BMJ Open, 2020,10(5):1-10.
[7]	Gunn S. Patient education and discharge planning to prevent functional decline in the older adult[J]. Gastroen Nurs, 2017,40(4):272-278.
[8]	Fenwick AM. An interdisciplinary tool for assessing patients’ readiness for discharge in the rehabilitation setting[J]. J Adv Nurs, 1979,4(1):9-21.
[9]	中国老年护理联盟. 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.
	China Gerontological Nursing Alliance. Expert consensus on the discharge planning for hospitalized elderly patients(version 2019)[J]. Chin J Nurs, 2020,55(2):220-227.
[10]	汪晖, 王颖, 刘于, 等. 住院患者出院计划关键任务的证据总结[J]. 中华护理杂志, 2020,55(9):1412-1419.
	Wang H, Wang Y, Liu Y, et al. Evidence summary for key tasks of discharge planning in hospitalized patients[J]. Chin J Nurs, 2020,55(9):1412-1419.
[11]	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.
[12]	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.
[13]	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.
[14]	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.
[15]	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 Nurs Train, 2015,30(23):2179-2180.
[16]	Agency for Healthcare Research and Quality. Strategy 4:care transitions from hospital to home:IDEAL discharge planning[EB/OL].(2017-12-01) [2021-03-10]. https://www.ahrq.gov/pro-fessionals/systems/hospital/engagingfamilies/strategy4/index.html.
[17]	Tah YV, Sherrod DR, Onsomu EO, et al. Utilizing the IDEAL discharge process to prevent 30-day readmissions[J]. Nurs manag, 2019,50(11):28-32.
[18]	Health Service Executive. Guidelines for nurse/midwife facilitated discharges planning[EB/OL].(2009-06-30)[2021-03-10]. https//www.hse.ie/eng/about/who/qid/quality-and-patient-safetydo-cuments/guidelines-for-nurse-facilitated-discharges-july-09.pdf.
[19]	Lin PC, Wang JL, Chang SY, et al. Effectiveness of a discharge-planning pilot program for orthopedic patients in Taiwan[J]. Intern J Nurs Stu, 2005,42(7):723-731.
[20]	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].( 2019 -03-01)[2021-03-10]. https://www.medicare.gov/pubs/pdf/11376-discharge-planning-checklist.pdf.
[21]	Mennuni M, Gulizia MM, Alunni G, et al. ANMCO position paper:hospital discharge planning:recommendations and standards[J]. J Eur Soc Cardio, 2017,19(suppl d):D244-D255.
[22]	Zhao H, Feng X, Yu R, et al. Validation of the Chinese version of the readiness for hospital discharge scale on patients who have undergone laryngectomy[J]. J Nurs Res, 2016,24(4):321-328.
[23]	Weiss ME, Piacentine LB, Lokken L, et al. Perceived readiness for hospital discharge in adult medical-surgical patients[J]. Clin Nurs Special, 2007,21(1):31-42.
[24]	Agency for Healthcare Research and Quality. Re-Engineered Discharge(RED) Toolkit[EB/OL].(2013-03-01)[2021-03-10]. https://www.ahrq.gov/hai/red/toolkit/postdischarge-doc.html.
[25]	浙江大学医学院附属第二医院, 中国医院协会, 中南大学湘雅医院, 等. 出院患者随访服务团体标准[J]. 中华护理杂志, 2020,55(增刊):39-42.
	The Second Affiliated Hospital of Zhejiang University School of Medicine, China Hospital Association, Xiangya Hospital of Central South University, et al. Group standard of follow-up service[J]. Chin J Nurs, 2020,55(suppl):39-42.
[26]	Galvin EC, Wills T, Coffey A. Readiness for hospital dischar-ge:a concept analysis[J]. J Adv Nurs, 2017,73(11):2547-2557.
[27]	国家卫生健康委员会. 国家卫生健康委办公厅关于进一步推进“互联网+护理服务”试点工作的通知[EB/OL].( 2020- 12- 14)[2021-03-10]. http://www.nhc.gov.cn/yzygj/s7653pd/202012/abdde45b8f1d4343ae41452d738dbf73.shtml
	National Health Commission of the People’s Republic of China. The opinions on promoting the pilot work of internet+ nursing service in China[EB/OL].(2020- 12- 14)[2021-03-10]. http://www.nhc.gov.cn/yzygj/s7653pd/202012/abdde45b8f1d434-3ae41452d738dbf73.shtml
[28]	乐霄, 汪晖, 王颖, 等. 出院计划实施质量评价指标的范围综述[J]. 中华护理杂志, 2021,56(4):611-617.
	Yue X, Wang H, Wang Y, et al. The quality evaluation indicators for discharge planning:a scoping review[J]. Chin J Nurs, 2021,56(4):611-617.
[29]	王冰花, 汪晖, 杨纯子. 中文版出院指导质量量表的信效度测评[J]. 中华护理杂志, 2016,51(6):752-755.
	Wang BH, Wang H, Yang CZ. Reliability and validity of the Chinese version of the quality of Discharge Teaching Scale[J]. Chin J Nurs, 2016,51(6):752-755.
[30]	Shepperd S, Cradduck-Bamford A, Butler C, et al. A multi-centre randomised trial to compare the effectiveness of geriatrician-led admission avoidance hospital at home versus inpatient admission[J]. Trials, 2017,18(1):491.
[31]	汪晖, 王冰花, 杨纯子, 等. 护患双方对患者出院准备度评估的差异性及其影响因素分析[J]. 护理研究, 2018,32(12):1911-1915.
	Wang H, Wang BH, Yang CZ. Analysis of discrepancy and influencing factors of patient discharge readiness assessment by both nurses and patients[J]. Chin Nurs Res, 2018,32(12):1911-1915.
[32]	Facchinetti G, Ianni A, Piredda M, et al. Discharge of older patients with chronic diseases:what nurses do and what they record. An observational study[J]. J Clin Nurs, 2019,28(9/10):1719-1727.
[33]	Hodgins MJ, Logan SM, Fraser JM, et al. Clinical utility of scores on the Blaylock Risk Assessment Screen(BRASS):an analysis of administrative data[J]. App Nurs Res, 2018,41:36-40.
[34]	Luther B, Wilson RD, Kranz C, et al. Discharge processes:what evidence tells us is most effective[J]. Ortho Nurs, 2019,38(5):328-333.
[35]	Eileen CG, Teresa W, Alice C. Readiness for hospital discharge:a concept analysis[J]. JAN, 2017,73(11):2547-2557.
[36]	刘丹丹, 段娟, 蔡田培, 等. 慢性阻塞性肺疾病患者居家管理平台的应用及效果评价[J]. 中华护理教育, 2020,17(5):406-410.
	Liu DD, Duan J, Cai TP, et al. The effects of a home-based management platform for patients with chronic obstructive pulmonary disease[J]. Chin J Nurs Edu, 2020,17(5):406-410.
[37]	王文娜, 林蓓蕾, 张振香, 等. 脑卒中患者远程康复体验质性研究的Meta整合[J]. 中华护理杂志, 2021,56(2):199-206.
	Wang WN, Lin BL, Zhang ZX, et al. Meta-synjournal of qualitative research on the real experience of telerehabilitation for stroke survivors[J]. Chin J Nurs, 2021,56(2):199-206.
[38]	康琳琳, 张清. 社区主导的COPD家庭—社区—医院优化管理路径的构建[J]. 中华护理教育, 2020,17(5):389-395.
	Kang LL, Zhang Q. Construction of a community based “family-community-hospital” management pathway for COPD[J]. Chin J Nurs Edu, 2020,17(5):389-395.