CAJ | 학술논문

目的：构建专科延伸护理服务流程并评价其实施效果。方法组建专科延伸护理服务组织架构，明确各成员的岗位职责；制定专科延伸护理服务流程。自制调查问卷，主要从延伸护理服务内容、就医成本（包括费用成本和时间成本）、患者满意度、护士满意度等方面进行调查。结果专业小组所提供的专科延伸护理服务项目频次由高到低排序为：导管护理（包括PICC 维护、胃管、导尿管等，27．3％）、伤口护理（包括造口护理，25．5％）、压疮护理（21．8％）、腹膜透析指导（16．4％）、功能锻炼指导（包括手术后、卒中后偏瘫、糖尿病足、产后乳房按摩指导等，9．0％）。专科延伸护理服务流程运作后，出院患者每次就医费用成本为（95．11±25．68）元、每次就医时间成本为（3．95±1．68） h，运作前分别为（195．73±114．77）元，（195．73±12．00）h，差异具有统计学意义（t值分别为69．71，80．93；P＜0．05）。结论构建专科延伸护理服务流程有利于减低就医费用和时间成本，有利于提高患者对护理服务的满意度。今后将基于医院社区家庭三元联动进一步优化延伸护理服务流程。
목적：구건전과연신호리복무류정병평개기실시효과。방법조건전과연신호리복무조직가구，명학각성원적강위직책；제정전과연신호리복무류정。자제조사문권，주요종연신호리복무내용、취의성본（포괄비용성본화시간성본）、환자만의도、호사만의도등방면진행조사。결과전업소조소제공적전과연신호리복무항목빈차유고도저배서위：도관호리（포괄PICC 유호、위관、도뇨관등，27．3％）、상구호리（포괄조구호리，25．5％）、압창호리（21．8％）、복막투석지도（16．4％）、공능단련지도（포괄수술후、졸중후편탄、당뇨병족、산후유방안마지도등，9．0％）。전과연신호리복무류정운작후，출원환자매차취의비용성본위（95．11±25．68）원、매차취의시간성본위（3．95±1．68） h，운작전분별위（195．73±114．77）원，（195．73±12．00）h，차이구유통계학의의（t치분별위69．71，80．93；P＜0．05）。결론구건전과연신호리복무류정유리우감저취의비용화시간성본，유리우제고환자대호리복무적만의도。금후장기우의원사구가정삼원련동진일보우화연신호리복무류정。
Objective To build the specialized transitional care process and evaluate its effect . Methods Firstly,the specialized transitional care organization structure was constructed , to make clear the responsibility of the member;to develop the specialized transitional care process .The transitional care content , medical costs including expense and time cost , patients’ satisfaction, and nurses’ satisfaction were investigated through self-made questionnaire .Results The main transitional care programs provided by the professional team were ordered from high to low: catheter care ( including PICC maintenance , stomach tube, catheter, etc., 27.3%), wound care (including colostomy care, 25.5%), pressure ulcers care(21.8%), peritoneal dialysis care ( 16.4%), function exercise guidance ( including surgery, hemiplegia after stroke, diabetic foot, postpartum breast massage guidance , etc., 9.0%).There were statistically significant differences about medical expense [(195.73 ±114.77) vs (95.11 ±25.68)] and time cost [(195.73 ±12.00)h vs (3.95 ± 1.68)h] before and after the operation of specialized transitional care process (t=69.71,80.93,respectively;P<0.05).Conclusions Building the specialized transitional care process is helpful to reduce the medical expense and time cost ,and to improve patients ’ satisfaction to nursing service .In the future it is necessary to optimize transitional care process based on the hospital-community-family ternary linkage .