Acher Alexandra W, Campbell-Flohr Stephanie A, Brenny-Fitzpatrick Maria, Leahy-Gross Kristine M, Fernandes-Taylor Sara, Fisher Alexander V, Agarwal Suresh, Kind Amy J, Greenberg Caprice C, Carayon Pascale, Weber Sharon M
Wisconsin Surgical Outcomes Research Program, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S Middleton Memorial Veterans Hospital, Shorewood Hills, WI.
J Am Coll Surg. 2017 Aug;225(2):259-265. doi: 10.1016/j.jamcollsurg.2017.04.008. Epub 2017 May 23.
Poor-quality transitions of care from hospital to home contribute to high rates of readmission after complex abdominal surgery. The Coordinated Transitional Care (C-TraC) program improved readmission rates in medical patients, but evidence-based surgical transitional care protocols are lacking. This pilot study evaluated the feasibility and preliminary effectiveness of an adapted surgical C-TraC protocol.
The intervention includes in-person enrollment of patients. Follow-up protocolized phone calls by specially trained surgical C-TraC nurses addressed medication management, clinic appointments, operation-specific concerns, and identification of red-flag symptoms. Enrollment criteria included pancreatectomy, gastrectomy, operative small bowel obstruction or perforation, ostomy, discharge with a drain, in-hospital complication, and clinician discretion. Engaged patients participated in the first phone call, which was within 48 to 72 hours of discharge and continued every 3 to 4 days. Patients completed the program once they and surgical C-TraC nurse agreed that no additional follow-up was needed or the patient was readmitted.
Two hundred and twelve patients were enrolled, October 2015 through April 2016, with a mean age of 56 years (range 19 to 89 years); 33% of patients were 65 years or older. Surgery sites included colon (46%), small bowel (16%), pancreas (12%), multivisceral (9%), liver (4.5%), retroperitoneum/soft tissue (4.5%), gastric (4%), biliary (2%), and appendix (1.5%). Refusal rate was 1% and engagement was 95%. At initial call, 47% of patients had at least 1 medication discrepancy (range 0 to 6). Mean number of calls from provider to patient was 3.2 (range 0 to 20, median 3).
A phone-based transitional care protocol for surgical patients is feasible, with <1% refusals and 95% engagement. Medication management is a prominent issue. Future studies are needed to assess the impact of surgical C-TraC on post-discharge healthcare use.
从医院到家庭的护理过渡质量不佳导致复杂腹部手术后再入院率较高。协调过渡护理（C-TraC）计划降低了内科患者的再入院率，但缺乏循证的外科过渡护理方案。这项前瞻性研究评估了一种经过调整的外科C-TraC方案的可行性和初步效果。
干预措施包括患者亲自登记。由经过专门培训的外科C-TraC护士按照协议进行随访电话，内容涉及药物管理、门诊预约、特定手术相关问题以及识别警示症状。入选标准包括胰腺切除术、胃切除术、手术性小肠梗阻或穿孔、造口术、带引流管出院、院内并发症以及临床医生的判断。参与的患者在出院后48至72小时内参加第一次电话随访，并每3至4天持续进行一次。一旦患者和外科C-TraC护士一致认为无需进一步随访或患者再次入院，患者即完成该计划。
2015年10月至2016年4月共纳入212例患者，平均年龄56岁（范围19至89岁）；33%的患者年龄在6岁及以上。手术部位包括结肠（46%）、小肠（16%）、胰腺（12%）、多脏器（9%）、肝脏（4.5%）、腹膜后/软组织（4.5%）、胃（4%）、胆道（2%）和阑尾（1.5%）。拒绝率为1%，参与率为95%。在首次电话随访时，47%的患者至少存在1种药物差异（范围0至6种）。医护人员给患者打电话的平均次数为3.2次（范围0至20次，中位数3次）。
针对外科患者的基于电话的过渡护理方案是可行的，拒绝率<1%，参与率为95%。药物管理是一个突出问题。未来需要开展研究以评估外科C-TraC对出院后医疗保健利用情况的影响。
