| Purpose:To establish hospital and community integrated Transitional Care in orthopedic discharged patients to suitable for our national conditions.And to evaluate the effect of the application of this transitional care model in orthopedic discharged patients.Methods:This study was divided into three parts.The first part was to create the questionnaire of evaluating nursing problems of orthopedic discharged patients based on Omaha question classification system.A total of 150 orthopedics patients were enrolled to evaluate the transitional care needs and nursing problems.To investigate the influencing factors of transitional care of orthopedic nurses,a total of 67 nurses in a top hospital and 14 community hospitals were investigated by a questionnaire of influencing factors of transitional care.The second part was to establish hospital and community integrated Transitional Care in orthopedic discharged patients based on studies.The third part was to test the model by the controlled cluster prospective trial.By convenient sampling,the patients in orthopedic ward of a hospital were selected from February 2016 to August 2016 and then randomized into the intervention group and control group.The sample contained 126 patients who in orthopedic Ⅰ and Ⅱ were divided into two subgroups.The control group(n=61)only received normal discharged care.The intervention group(n=60)were given the hospital and community integrated Transitional Care interventions for 6 months.The Mos 36-item Short Form Health Survey(SF-36)was used to measure patients’ health condition.The Exercise of Self-Care Agency Scale(ESCA)was measured their self-care ability.At the same time,their utilization of health service and nursing satisfaction were recorded.All date were collected at discharge,1 month,3 month and 6 month,in order to evaluate the effectiveness and feasibility of TC.Results:1.The result of expert consultation was showed that I-CVI was 0.78-1.00,S-CVI/UA was 0.89,S-CVI/Ave was 0.97.There were 73.33%patients needed TC.The telephone follow-up,home visit and internet follow-up were common.46%patients thought TC interventions should be charged,and mostly patients agreed 30-50 yuan is suitable.There werefive main nursingproblems during the period of discharged,included neuro-musculo-skeletal function(80.67%),pain(68.67%),cognition(62%),residence(54%),mental health(51.33%).The main factors included lack of charging standard,lack of nursing human resources,lack of national policies.2.The hospital and community integrated Transitional Care in orthopedic discharged patients included 3 parts:①hospital:The hospital nurses established the information records of orthopedics discharged patients,evaluated the needs of transitional care and the nursing problems,and made transitional care plans.They also supervised and trained the community nurses.②the connection between hospital and community hospitals:The nurses built an effective network-based communicating platform,delivered the information records and transitional care plans to the community nurses.③community hospitals:The community nurses received the information records and transitional care plans and implemented the transitional care plans.3.Compared with the health condition between intervention group and control group,there were no statistical difference between the two groups regarding the scores of SF-36 before discharged(P>0.05).1 month after discharged,the total,GH,BP,VT,MH scores of intervention group were higher than those of control group(P<0.05).At 3 and 6 month,the total,GH,PF,RP,BP,VT,SF,MH scores of intervention group were higher than those of control group(P<0.05),except the RE scores(P>0.05).Compared with the self-care ability between intervention group and control group,there were no statistical difference between the two groups regarding the scores of ESCA before discharged(P>0.05).1,3,6 month after discharged,the total and each items scores were significantly higher than those of control group(P<0.05).Compared with the utilization of health service between intervention group and control group,there were no statistical difference between the two groups regarding emergency-visit times(P>0.05).But the community-visit times,outpatients-visit times and readmission times of intervention group were significantly better than that of control group(P<0.05).Compared with the nursing satisfaction between intervention group and control group,there were no statistical difference between the two groups before discharged(P>0.05).At 1,3,6 month,the patients’ nursing satisfaction of intervention group were better than that of control group(P<0.05).Conclusions:1.The questionnaire of evaluating nursing problems of orthopedic discharged patients can be more useful to react the nursing requirements and nursing problems of the orthopedics discharged patients.2.The hospital and community integrated transitional care in orthopedics discharged patients we established is better suited the orthopedic patients.It could effectively improve the health condition and self-care ability of orthopedic patients.Transitional care has some effect on improving the utilization of health service and nursing satisfaction. |
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