【摘要】 目的 建立老年共病患者出院准备服务方案，探讨其在临床实践中的应用效果。方法 通过小组讨论，建立老年共病患者出院准备服务方案。采用便利抽样法，选取2019年6月至12月于本科室就诊的138例老年共病患者为对照组，给予常规护理及出院宣教指导；选取2020年6月至12月就诊的128例老年共病患者为干预组，根据综合评估结果，由多学科团队共同制定干预措施，责任护士于患者入院后即开展出院准备服务方案。结果 干预组出院前1d时的出院准备度量表总分以及各维度得分均高于对照组，住院时间明显少于对照组，出院后30d、6个月、12个月内再入院率与出院后30d、6个月跌倒发生率均明显低于对照组（均P<0.001）。出院后30d干预组照护者的家庭照护能力明显高于对照组（P<0.001），两组均处于较高水平。结论 出院准备服务方案的建立及应用，有利于缩短老年共病患者的平均住院日，降低出院后再入院率和居家负性事件发生率，同时提升患者的出院准备度和照护者的家庭照护能力，从而提高患者生活质量。更多还原

【Abstract】 Objective The goal for the study is to establish a scheme of discharge preparation service for elderly comorbidity patients and then evaluate the effect on application of the scheme in clinical practice. Methods The scheme of discharge preparation service for elderly comorbidity patients was developed through group discussions. Convenience sampling method was applied to recruit elderly comorbidity patients. A group of 138 patients admitted into the hospital between June and December 2019 was assigned as the control group,treated by routine nursing and discharge education. Another group of 128 patients admitted into the hospital between June and December 2020 was assigned into the intervention group,and treated under the scheme of discharge preparation service that was customer developed by a multidisciplinary team according to the results of comprehensive evaluation. The responsible nurse carried out the process right after the patient was admitted to the hospital. Results The scores of readiness for hospital discharge sale and its dimensions in the intervention group at day 1 before the discharge were higher than those in the control group,and the hospital stay was significantly shorter than that of the control group(P<0.001). Compared with the control group,the readmission rate within 30 days,6months and 12 months after discharge and the incidence of falls at 30 days and 6 months were significantly lower(all P<0.001). In addition,the care ability of family caregivers in the intervention group was significantly higher(P<0.001),at a high level. Conclusions The establishment and application of the scheme of discharge preparation service is conducive in terms of shortening the average hospital stay of elderly comorbidity patients,reduction of the readmission rate after discharge and the incidence of negative events at home. It improves the discharge preparation of patients as well as the care ability of family caregivers,thereby improves the quality of life of the elderly comorbidity patients.更多还原