Research Department, Murcia Health Service, Spain.
J Adv Nurs. 2010 Jun;66(6):1365-70. doi: 10.1111/j.1365-2648.2010.05284.x.
To evaluate the effectiveness of a protocolized intervention for hospital discharge and follow-up planning for primary care patients with chronic obstructive pulmonary disease.
Chronic obstructive pulmonary disease is one of the main causes of morbidity and mortality internationally. These patients suffer from high rates of exacerbation and hospital readmission due to active problems at the time of hospital discharge.
A quasi-experimental design will be adopted, with a control group and pseudo-randomized by services (protocol approved in 2006). Patients with pulmonary disease admitted to two tertiary-level public hospitals in Spain and their local healthcare centres will be recruited. The outcome variables will be readmission rate and patient satisfaction with nursing care provided. 48 hours after admission, both groups will be evaluated by specialist coordinating nurses, using validated scales. At the hospital, a coordinating nurse will visit each patient in the experimental group every 24 hours to identify the main caregiver, provide information about the disease, and explain treatment. In addition, the visits will be used to identify care problems and needs, and to facilitate communication between professionals. 24 hours after discharge, the coordinating nurses will inform the primary care nurses about patient discharge and nursing care planning. The two nurses will make the first home visit together. There will be follow-up phone calls at 2, 6, 12 and 24 weeks after discharge.
The characteristics of patients with this pulmonary disease make it necessary to include them in hospital discharge planning programmes using coordinating nurses.
评估针对慢性阻塞性肺疾病（COPD）患者出院和后续计划的方案化干预的效果。
COPD 是全球发病率和死亡率的主要原因之一。这些患者由于出院时存在活跃的问题，因此经常出现恶化和再次住院的情况。
采用准实验设计，设有对照组和服务伪随机分组（2006 年批准的方案）。将招募来自西班牙两家三级公立医院及其当地医疗中心的肺病患者。主要观察指标是再入院率和患者对护理服务的满意度。入院后 48 小时，将由专科协调护士使用经过验证的量表对两组患者进行评估。在医院，实验组成员的协调护士将每 24 小时访问每位患者，以确定主要照顾者，提供有关疾病的信息，并解释治疗方案。此外，这些访问还将用于识别护理问题和需求，并促进专业人员之间的沟通。出院后 24 小时，协调护士将向初级保健护士通报患者出院和护理计划情况。两位护士将一起进行首次家访。在出院后 2、6、12 和 24 周进行电话随访。
这种肺病患者的特点使得有必要使用协调护士为他们制定出院计划方案。
