Department of Medical Sciences, Geriatric-Orthogeriatric Unit S. Anna Hospital, University of Ferrara, Via A. Moro 8, 44124, Ferrara, Italy.
Department of Medical Sciences, University of Ferrara, Ferrara, Italy.
Aging Clin Exp Res. 2018 Mar;30(3):263-270. doi: 10.1007/s40520-017-0885-6. Epub 2018 Jan 8.
Current demographic and epidemiological trends highlight a growing task in surgical departments by elderly patients, characterized by high prevalence of comorbidity, complexity, and functional disability. Of consequence, discharge of an elderly patient must be considered in a new cultural perspective and should be imagined as a well-structured process starting from admission to surgical department and finishing with the patient discharge in a setting able to support her/him in the best possible way. The lack of a suitable discharge planning and of a proper transition program in the elderly subjects increases the risk of quick re-admission and may negatively affect the functional and the status quality of life of patients and caregivers. To reduce the risk of negative outcome it is essential a hospital organization dedicated to the discharge of frail older patients considering: (1) adequate attention to assess the comprehensive clinical/social/care conditions; (2) respect of the expectations of the patient and her/his relatives; (3) formalization of institutional roles or teams designated to the planning and coordination of discharge; (4) good knowledge of management programs of transitional care, and (5) strong communication/information ability in patients transition between hospital, home care and community settings.
当前人口和流行病学趋势凸显了老年患者在外科部门的任务不断增加，其特点是合并症、复杂性和功能障碍的高发率。因此，必须从新的文化角度考虑老年患者的出院问题，将其想象为一个从外科部门入院到以能够以最佳方式支持患者的环境中出院的结构化过程。老年患者缺乏适当的出院计划和适当的过渡计划会增加快速再次入院的风险，并可能对患者和护理人员的功能和生活质量状况产生负面影响。为了降低不良后果的风险，医院组织必须专门为体弱的老年患者出院考虑以下因素：（1）充分关注评估全面的临床/社会/护理状况；（2）尊重患者及其亲属的期望；（3）正式确定负责规划和协调出院的机构角色或团队；（4）对过渡护理管理计划有很好的了解，以及（5）在患者从医院、家庭护理和社区环境过渡期间具有强大的沟通/信息能力。
