Scarponi Dorella, Cangini Gabriella, Pasini Andrea, La Scola Claudio, Mencarelli Francesca, Bertulli Cristina, Amabile Domenico, Busutti Marco, La Manna Gaetano, Pession Andrea
Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
Department of Specialist, Diagnostic and Experimental Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy.
Front Pediatr. 2022 Aug 23;10:954641. doi: 10.3389/fped.2022.954641. eCollection 2022.
Transitional care is an essential step for patients with kidney disease, and it is supported by policy documents in the United Kingdom and United States. We have previously described the heterogeneous situation currently found in Europe regarding certain aspects of transitional care: the written transition plan, the educational program, the timing of transfer to adult services, the presence of a coordinator and a dedicated off-site transition clinic. In line with the transition protocol "RISE to transition," the objective of this paper is to describe the experience of the Bologna center in defining a protocol for the management of chronic kidney disease and the difficulties encountered in implementing it. We apply this model to various chronic diseases along the process of transfer to adult services. It begins when the patient is 14 years old and is complete by the time they reach 18. The family is continuously involved and all the patients in transitional care receive continuous medical care and psychological support. We identified a series of tests designed to measure various criteria: medical condition, psychological state, quality of life, and degree of patient satisfaction, which are repeated at set intervals during the transition process. The organization of the service provided an adequate setting for taking charge of the patients in the long term. The transition program implemented by the adult and pediatric nephrology services of the Bologna center has lowered the risk of discontinuity of care and greatly improved the patients' awareness of responsibility for their own healthy lifestyle choices.
过渡性护理是肾病患者的重要环节，在英国和美国的政策文件中都有相关支持。我们之前曾描述过目前欧洲在过渡性护理某些方面存在的异质性情况：书面过渡计划、教育项目、转至成人服务的时机、协调员的配备以及专门的院外过渡诊所。按照“RISE to transition”过渡方案，本文旨在描述博洛尼亚中心在制定慢性肾病管理方案方面的经验以及实施过程中遇到的困难。我们将该模式应用于转至成人服务过程中的各种慢性病。该模式从患者14岁时开始，到患者18岁时完成。患者家庭持续参与其中，所有接受过渡性护理的患者都能获得持续的医疗护理和心理支持。我们确定了一系列旨在衡量各种标准的测试：医疗状况、心理状态、生活质量和患者满意度，这些测试在过渡过程中按设定的间隔重复进行。服务的组织为长期照料患者提供了适当的环境。博洛尼亚中心成人和儿科肾病服务部门实施的过渡项目降低了护理中断的风险，并极大地提高了患者对自身健康生活方式选择责任的认识。
