Bloemen-Vrencken J H A, de Witte L P, Post M W M, Pons C, van Asbeck F W A, van der Woude L H V, van den Heuvel W J A
Rehabilitation Centre Hoensbroeck, Hoensbroek, The Netherlands.
Clin Rehabil. 2007 Nov;21(11):997-1006. doi: 10.1177/0269215507079835.
To evaluate whether transmural care for people with spinal cord injury living in the community has more impact on health outcomes than traditional follow-up care within the Netherlands.
Quasi-experiment with 12 months of follow-up.
Eight Dutch rehabilitation centres.
Thirty-one patients who received transmural care in two ;experimental' rehabilitation centres were compared with a matched sample of 31 patients having received ;usual follow-up care' in six other rehabilitation centres.
The core component of the transmural care consists of a transmural nurse, who 'liaises' between former patients living in the community, primary care professionals and the rehabilitation team. The transmural care model provides activities to support patients and their family/partners and activities to promote continuity of care.
The prevalence of pressure sores and urinary tract infections; the number and duration of re-admissions to hospital and rehabilitation centre due to pressure sores, bladder and bowel problems; and the experienced quality of follow-up care.
The transmural care, as implemented, did not influence the health outcomes. The prevalence of pressure sores, urinary tract infections and the number of re-admissions (due to pressure sores, bladder and bowel problems) was respectively 13, 13 and 4 in the intervention group versus 14, 15 and 6 in the usual follow-up care group. Since the transmural care had been incompletely implemented and there were methodological and practical limitations, we formulated no final conclusions regarding its effectiveness.
Implementing the transmural care model strictly according to protocol may improve its effectiveness.
评估在荷兰，为社区脊髓损伤患者提供的跨部门护理对健康结局的影响是否大于传统的后续护理。
为期12个月随访的准实验。
八家荷兰康复中心。
在两家“实验性”康复中心接受跨部门护理的31名患者与在其他六家康复中心接受“常规后续护理”的31名匹配患者进行比较。
跨部门护理的核心组成部分包括一名跨部门护士，其在社区中的 former patients、初级保健专业人员和康复团队之间“联络”。跨部门护理模式提供支持患者及其家人/伴侣的活动以及促进护理连续性的活动。
压疮和尿路感染的患病率；因压疮、膀胱和肠道问题再次入院至医院和康复中心的次数及持续时间；以及所体验到的后续护理质量。
实施的跨部门护理并未影响健康结局。干预组的压疮患病率、尿路感染患病率以及再次入院次数（因压疮、膀胱和肠道问题）分别为13、13和4，而常规后续护理组分别为14、15和6。由于跨部门护理实施不完全且存在方法学和实际限制，我们未就其有效性得出最终结论。
严格按照方案实施跨部门护理模式可能会提高其有效性。
