Landefeld C S, Palmer R M, Kresevic D M, Fortinsky R H, Kowal J
Division of General Internal Medicine and Health Care Research, Case Western Reserve University, Cleveland, OH, USA.
N Engl J Med. 1995 May 18;332(20):1338-44. doi: 10.1056/NEJM199505183322006.
Older persons who re hospitalized for acute illnesses often lose their independence and are discharged to institutions for long-term care.
We studied 651 patients 70 years of age or older who were admitted for general medical care at a teaching hospital; these patients were randomly assigned to receive usual care or to be cared for in a special unit designed to help older persons maintain or achieve independence in self-care activities. The key elements of this program were a specially prepared environment (with, for example, uncluttered hallways, large clocks and calendars, and handrails); patient-centered care emphasizing independence, including specific protocols for prevention of disability and for rehabilitation; discharge planning with the goal of returning the patient to his or her home; and intensive review of medical care to minimize the adverse effects of procedures and medications. The main outcome we measured ws the change from admission to discharge in the number of five basic activities of daily living (bathing, getting dressed, using the toilet, moving from a bed to a chair, and eating) that the patient could perform independently.
Twenty-four patients in each group died in the hospital. At the time of discharge, 65 (21 percent) of the 303 surviving patients in the intervention group were classified as much better in terms of their ability to perform basic activities of daily living, 39 (13 percent) as better, 151 (50 percent) as unchanged, 22 (7 percent) as worse, and 26 (9 percent) as much worse. In the usual care group, 40 (13 percent) of the 300 surviving patients were classified as much better, 33 (11 percent) as better, 163 (54 percent) as unchanged, 39 (13 percent) as worse, and 25 (8 percent) as much worse (P = 0.009). The difference between the groups remained significant (P = 0.04) in a multivariable model in which we controlled for potentially confounding base-line characteristics of the patients. Lengths of stay and hospital charges were similar in the two groups. Fewer patients assigned to the intervention group were discharged to long-term care institutions (43 patients [14 percent], as compared with 67 patients [22 percent] in the usual-care group; P = 0.01). Among the 493 patients discharged to private homes, similar proportions (about 10 percent) in the two groups were admitted to long-term care institutions during the three months after discharge.
Specific changes in the provision of acute hospital care can improve the ability of a heterogeneous group of acutely ill older patients to perform basic activities of daily living at the time of discharge from the hospital and can reduce the frequency of discharge to institutions for long-term care.
因急性病再次住院的老年人常常失去自理能力，出院后被送往长期护理机构。
我们研究了651名70岁及以上在一家教学医院接受普通医疗护理的患者；这些患者被随机分配接受常规护理或在一个旨在帮助老年人在自我护理活动中维持或实现自理能力的特殊病房接受护理。该项目的关键要素包括一个经过特别布置的环境（例如，走廊整洁、有大时钟和日历以及扶手）；以患者为中心、强调自理能力的护理，包括预防残疾和康复的具体方案；以让患者回家为目标的出院计划；以及对医疗护理进行深入审查以尽量减少诊疗操作和药物的不良影响。我们测量的主要结果是患者从入院到出院能够独立进行的五项基本日常生活活动（洗澡、穿衣、使用厕所、从床上移至椅子上以及进食）数量的变化。
每组各有24名患者在医院死亡。出院时，干预组303名存活患者中，65名（21%）在进行基本日常生活活动的能力方面被归类为改善很多，39名（13%）为有所改善，151名（50%）无变化，22名（7%）变差，26名（9%）变差很多。在常规护理组中，300名存活患者中，40名（13%）被归类为改善很多，33名（11%）为有所改善，163名（54%）无变化，39名（13%）变差，25名（8%）变差很多（P = 0.009）。在一个对患者潜在的混杂基线特征进行控制的多变量模型中，两组之间的差异仍然显著（P = 0.04）。两组的住院时间和住院费用相似。被分配到干预组的患者出院后被送往长期护理机构的较少（43名患者[14%]，而常规护理组为67名患者[22%]；P = 0.01）。在493名出院回家的患者中，两组中相似比例（约10%）在出院后的三个月内被送往长期护理机构。
急性医院护理的特定改变可以提高一组异质性急性病老年患者出院时进行基本日常生活活动的能力，并可以减少出院后被送往长期护理机构的频率。
