老年急诊网络进行过渡性护理以预防非计划性再入院（URGENT）：一项前瞻性前后对照研究。
Unplanned readmission prevention by a geriatric emergency network for transitional care (URGENT): a prospective before-after study.
机构信息
Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium.
Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
出版信息
BMC Geriatr. 2019 Aug 7;19(1):215. doi: 10.1186/s12877-019-1233-9.
BACKGROUND
URGENT is a comprehensive geriatric assessment (CGA) based nurse-led care model in the emergency department (ED) with geriatric follow-up after ED discharge aiming to prevent unplanned ED readmissions.
METHODS
A quasi-experimental study (sequential design with two cohorts) was conducted in the ED of University Hospitals Leuven (Belgium). Dutch-speaking, community-dwelling ED patients aged 70 years or older were eligible for enrolment. Patients in the control cohort received usual care. Patient in the intervention cohort received the URGENT care model. A geriatric emergency nurse conducted CGA and interdisciplinary care planning among older patients identified as at risk for adverse events (e.g. unplanned ED readmission, functional decline) with the interRAI ED Screener© and clinical judgement of ED staff. Case manager follow-up was offered to at risk patients without hospitalization after index ED visit. For inpatients, geriatric follow-up was guaranteed on an acute geriatric ward or by the inpatient geriatric consultation team on a non-geriatric ward if considered necessary. Primary outcome was unplanned 90-day ED readmission. Secondary outcomes were ED length of stay (LOS), hospitalization rate, in-hospital LOS, 90-day higher level of care, 90-day functional decline and 90-day post-hospitalization mortality.
RESULTS
Almost half of intervention patients (404/886 = 45.6%) were categorized at risk. These received on average seven advices. Adherence rate to advices on the ED, during hospitalization and in community care was 86.1, 74.6 and 34.1%, respectively. One out of four at risk patients without hospitalization after index ED visit accepted case manager follow-up. Unplanned ED readmission occurred in 170 of 768 (22.1%) control patients and in 205 of 857 (23.9%) intervention patients (p = .11). The intervention group had shorter ED LOS (12.7 h versus 19.1 h in the control group; p < .001), but higher rate of hospitalization (70.0% versus 67.0% in the control group; p = .003).
CONCLUSIONS
The URGENT care model shortened ED LOS and increased the hospitalization rate, but did not prevent unplanned ED readmissions. A geriatric emergency nurse could improve in-hospital patient management, but failed to introduce substantial out-hospital case-management.
TRIAL REGISTRATION
The protocol of this study was registered retrospectively with ISRCTN ( ISRCTN91449949 ; registered 20 June 2017).
背景
URGENT 是一种基于综合老年评估（CGA）的护士主导的护理模式，在急诊科（ED）中针对老年患者进行后续护理，旨在预防非计划性 ED 再入院。
方法
这是一项在鲁汶大学医院急诊科（比利时）进行的准实验研究（顺序设计，两个队列）。年龄在 70 岁或以上、讲荷兰语、居住在社区的 ED 患者有资格入组。对照组患者接受常规护理。干预组患者接受 URGENT 护理模式。老年急诊护士使用 interRAI ED Screener©和 ED 工作人员的临床判断，对被确定为有发生不良事件（如非计划性 ED 再入院、功能下降）风险的老年患者进行 CGA 和跨学科护理计划。在指数 ED 就诊后，为有风险的患者提供病例管理随访，无需住院。对于住院患者，如果需要，保证在急性老年病房或非老年病房的住院老年会诊团队进行老年后续护理。主要结局为 90 天内非计划性 ED 再入院。次要结局为 ED 住院时间（LOS）、住院率、住院 LOS、90 天内更高水平的护理、90 天内功能下降和 90 天内住院后死亡率。
结果
干预组近一半（404/886 = 45.6%）患者被归类为有风险。这些患者平均接受了 7 条建议。ED、住院期间和社区护理中建议的依从率分别为 86.1%、74.6%和 34.1%。在指数 ED 就诊后无需住院的有风险患者中，有 1/4 接受了病例管理随访。在对照组 768 例患者中，有 170 例（22.1%）发生非计划性 ED 再入院，在干预组 857 例患者中，有 205 例（23.9%）发生非计划性 ED 再入院（p = .11）。干预组 ED LOS 更短（12.7 h 与对照组 19.1 h；p < .001），但住院率更高（70.0%与对照组 67.0%；p = .003）。
结论
URGENT 护理模式缩短了 ED LOS，增加了住院率，但未能预防非计划性 ED 再入院。老年急诊护士可以改善住院患者的管理，但未能引入实质性的院外病例管理。
试验注册
本研究方案以回顾性方式在 ISRCTN（ISRCTN91449949；注册于 2017 年 6 月 20 日）注册。
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