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首页> 外文期刊>Journal of cardiac failure >Multifaceted Interventions at Skilled Nursing and Long Term Care Facilities Reduce 30 day Heart failure Readmissions
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Multifaceted Interventions at Skilled Nursing and Long Term Care Facilities Reduce 30 day Heart failure Readmissions

机译：熟练护理和长期护理设施的多方面的干预减少了30天的心力衰竭入类

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Introduction: Preventing 30 day Heart Failure (HF) readmissions can improve morbidity and mortality, and the financial wellbeing of health care systems. One of the factors affecting readmissions is inconsistent quality of care and adverse outcomes at Skilled Nursing (SNF)/Long term Care (LTAC) facilities/ Home care (after discharge from hospitals).HypothesisIdentifying SNF/LTAC/Home care that are specifically appropriate for HF care and then ensure collaborating facilities undergo HF based training/education, and adhere to HF established protocol will reduce 30 day HF readmissions.MethodsAllegheny Health Network (AHN), PA piloted a comprehensive multifaceted centralized CRNP led program (with RN and Pharm D support and HF physician consultation) to ensure continuum of quality care after the transition from inpatient to SNF/LTAC/Home care. The network partnered exclusively with nine SNF's, one LTAC and a Home Care Agency after scrutinized review of following criteria: physician extender coverage, staffing ratios, clinical competency including dietary/clinical testing/treatment and availability of PT/OT. Education of Nurse practitioners from each facility included 32 hours of evidenced based curriculum training with the Advanced HF team. In addition to Nurse Practitioner training, Nursing Aides (3 hours) and Nurses (6 hours) were also required to undergo HF specific training at the AHN Simulation Teaching Center. Protocol establishment with central CRNP in charge of orchestrating the following:?Baseline Admission assessment and medication reconciliation, and completion of medical order for specific medical treatments during emergency.?Participating in daily fifteen minute phone huddle along with daily telehealth from the partnered facilities with daily reporting/monitoring of progress as follows:○CRNP/PA/RN daily clinical assessment of vitals, weights, symptoms, edema, lung sounds, pulse ox.○Review of low sodium diet.○Review of base line BNP/BMP and BMP 2x/week○Review progress of ambulation/activity○Discharge planning under the supervision of central CRNP○Physician follow-up < 7 days○Medication reconciliation/call Pharmacy○Referral to Cardiac RehabResults: The data reveals that the 2017 HF related 30 day readmission rate were significantly decreased from 10.7 % to 3.7% (see Table 1) after the program was instituted.Conclusion: Multifaceted multidisciplinary centralized interventions including education and monitoring may provide optimal quality/continuity of care during the continuum of care from the hospital to the SNF/LTAC setting and in turn reduces 30 day HF readmissions.
机译：简介：防止30天心力衰竭（HF）入类可以提高发病率和死亡率，以及医疗保健系统的金融福祉。影响入院的因素之一是技术护理（SNF）/长期护理（LTAC）设施/家庭护理/家庭护理（从医院排放后）。空白/ LTAC /家庭护理，特别适合HF Care，并确保合作设施接受基于HF的培训/教育，并遵守HF建立的协议将减少30天HF Readmissions.Methodsalgheny Health Network（AHN），PA举行了全面的多方面集中式CRNP LED程序（使用RN和PAMPL D支持和HF医师咨询）以确保从住院到SNF / LTAC /家庭护理后过渡后的高质量护理。该网络在审查审查以下标准的审查后，该网络专门与九个SNF，一个LTAC和家庭护理机构合作：医生扩展员覆盖范围，人员指定比率，临床能力，包括膳食/临床测试/治疗和PT / OT的可用性。从每个设施的护士从业者教育包括32小时证明基于先进的HF团队的课程培训。除护士从业者培训外，还需要在AHN仿真教学中心进行HF特定培训所需的护理助手（3小时）和护士（6小时）。与中央CRNP的协议建立负责结核以下内容：？基准入学评估和药物和解，并在紧急情况下完成特定医疗治疗的医疗秩序。在每日十五分钟手机中，每天都有每日电信的每日远程医疗报告/监测进展如下：○CRNP / PA / RN每日临床评估威胁，重量，症状，水肿，肺部声音，脉冲牛。○低钠饮食的回顾。○基线BNP / BMP和BMP 2X的回顾/周○审查救护车/活动的进展○中央CRNP监督下的排放规划○医生随访<7天○药物和解/呼叫药房○转诊到心脏康复：数据显示2017年HF相关30天的入院率在进行程序后，从10.7％下降到3.7％（参见表1）。结论：多方面的多学科集中干预措施，包括e在医院到SNF / LTAC设置期间，Ducation和Monitoring可以在关注的连续内提供最佳质量/连续性，然后减少30天的HF阅约。

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