Abdul Aziz Aznida Firzah, Mohd Nordin Nor Azlin, Ali Mohd Fairuz, Abd Aziz Noor Azah, Sulong Saperi, Aljunid Syed Mohamed
Department of Family Medicine, 14th Floor, Preclinical Block, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000, Kuala Lumpur, Malaysia.
School of Rehabilitation Sciences, Faculty of Health Sciences, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
BMC Health Serv Res. 2017 Jan 13;17(1):35. doi: 10.1186/s12913-016-1963-8.
Lack of intersectoral collaboration within public health sectors compound efforts to promote effective multidisciplinary post stroke care after discharge following acute phase. A coordinated, primary care-led care pathway to manage post stroke patients residing at home in the community was designed by an expert panel of specialist stroke care providers to help overcome fragmented post stroke care in areas where access is limited or lacking.
Expert panel discussions comprising Family Medicine Specialists, Neurologists, Rehabilitation Physicians and Therapists, and Nurse Managers from Ministry of Health and acadaemia were conducted. In Phase One, experts chartered current care processes in public healthcare facilities, from acute stroke till discharge and also patients who presented late with stroke symptoms to public primary care health centres. In Phase Two, modified Delphi technique was employed to obtain consensus on recommendations, based on current evidence and best care practices. Care algorithms were designed around existing work schedules at public health centres.
Indication for patients eligible for monitoring by primary care at public health centres were identified. Gaps in transfer of care occurred either at post discharge from acute care or primary care patients diagnosed at or beyond subacute phase at health centres. Essential information required during transfer of care from tertiary care to primary care providers was identified. Care algorithms including appropriate tools were summarised to guide primary care teams to identify patients requiring further multidisciplinary interventions. Shared care approaches with Specialist Stroke care team were outlined. Components of the iCaPPS were developed simultaneously: (i) iCaPPS-Rehab© for rehabilitation of stroke patients at community level (ii) iCaPPS-Swallow© guided the primary care team to screen and manage stroke related swallowing problems.
Coordinated post stroke care monitoring service for patients at community level is achievable using the iCaPPS and its components as a guide. The iCaPPS may be used for post stroke care monitoring of patients in similar fragmented healthcare delivery systems or areas with limited access to specialist stroke care services.
No.: ACTRN12616001322426 (Registration Date: 21st September 2016).
公共卫生部门之间缺乏跨部门合作，这加大了在急性期后出院时促进有效的多学科中风后护理的难度。由中风护理专家组成的专家小组设计了一条以初级保健为主导的协调护理路径，用于管理社区中居家的中风患者，以帮助克服在医疗服务获取有限或缺乏的地区中风后护理碎片化的问题。
开展了专家小组讨论，成员包括家庭医学专家、神经科医生、康复医生和治疗师，以及来自卫生部和学术界的护士长。在第一阶段，专家们梳理了公共医疗机构中从急性中风到出院的当前护理流程，以及那些中风症状出现较晚并前往公共初级保健健康中心就诊的患者的护理流程。在第二阶段，采用改良德尔菲技术，根据当前证据和最佳护理实践，就各项建议达成共识。护理算法围绕公共卫生中心现有的工作时间表进行设计。
确定了适合在公共卫生中心接受初级保健监测的患者指征。在急性护理出院后或在健康中心被诊断为亚急性期及以后的初级保健患者中，出现了护理交接方面的差距。确定了从三级护理向初级保健提供者进行护理交接时所需的基本信息。总结了包括适当工具在内的护理算法，以指导初级保健团队识别需要进一步多学科干预的患者。概述了与中风专科护理团队的共享护理方法。同时开发了iCaPPS的组成部分：(i) iCaPPS-Rehab©用于社区层面中风患者的康复；(ii) iCaPPS-Swallow©指导初级保健团队筛查和管理与中风相关的吞咽问题。
以iCaPPS及其组成部分为指导，在社区层面为患者提供协调的中风后护理监测服务是可行的。iCaPPS可用于在类似的医疗服务碎片化系统或获取专科中风护理服务有限的地区对中风患者进行中风后护理监测。
编号：ACTRN12616001322426（注册日期：2016年9月21日）。
