BACKGROUND:Coronary artery disease is a major cause of morbidity and mortality among adults worldwide, including China. After a hospital stay, transitional care could help to ensure improved patient care and outcomes, and reduce Medicare costs. Nevertheless, the results of the existing transitional care are not always satisfactory and our knowledge of how to perform effective transitional care for patients with coronary artery disease is limited in mainland China. OBJECTIVES:To examine the effectiveness of a nurse-led transitional care program on clinical outcomes, health-related knowledge, and physical and mental health status among Chinese patients with coronary artery disease. DESIGN:Randomized controlled trial. METHODS:The Omaha system and Pender's health promoting model were employed in planning and implementing this nurse-led transitional care program. The sample was comprised of 199 Chinese patients with coronary artery disease. The experimental group (n=100) received nurse-led transitional care intervention in addition to routine care. The nurse-led transitional care intervention included a structured assessment and health education, followed by 7 months of individual teaching and coaching (home visits, telephone follow-up and group activity). The control group (n=99) received a comparable length routine care and follow-up contacts. Evaluations were conducted at baseline and completion of the interventions using the perceived knowledge scale for coronary heart disease, the medical outcomes study 36-item short-form health survey and clinical measures (blood pressure, blood glucose, lipids, body mass index). Data were collected between March and October 2014. RESULTS:Compared with the control group, participants in the experimental group showed significant better clinical outcomes (systolic blood pressure, t=5.762, P=0.000; diastolic blood pressure, t=4.250, P=0.000; fasting blood glucose, t=2.249, P=0.027; total cholesterol, t=4.362, P=0.000; triglyceride, t=3.147, P=0.002; low density lipoprotein cholesterol, t=2.399, P=0.018; and body mass index, t=3.166, P=0.002), higher knowledge scores for coronary artery disease (total knowledge score, t=-7.099, P=0.000), better physical health status (t=-2.503, P=0.014) and mental health status (t=-2.950, P=0.004). CONCLUSIONS:This study provides evidence for the value of a nurse-led transitional care program using both the Omaha system and Pender's health promoting model as its theoretical framework. The structured interventions in this nurse-led transitional care program facilitate the use of this program in other settings.

译文

背景:冠状动脉疾病是包括中国在内的世界各地成年人发病和死亡的主要原因。住院后,过渡护理可以帮助确保改善患者护理和结局,并降低医疗保险成本。然而,现有的过渡治疗的结果并不总是令人满意的,在中国大陆,我们对如何为冠心病患者进行有效的过渡治疗的知识是有限的。
目的:探讨由护士主导的过渡护理计划对中国冠心病患者的临床结局,健康相关知识以及身心健康状况的有效性。
设计:随机对照试验。
方法:奥马哈系统和Pender的健康促进模型被用于计划和实施由护士主导的过渡护理计划。样本包括199名中国冠心病患者。除常规护理外,实验组(n = 100)还接受了护士主导的过渡护理干预。由护士主导的过渡护理干预包括结构化评估和健康教育,然后是7个月的个人教学和辅导(上门拜访,电话随访和小组活动)。对照组(n = 99)接受了相当长度的常规护理和随访。在基线和干预措施完成时使用已知的冠心病知识量表,医学成果研究36个项目的简短健康调查和临床指标(血压,血糖,血脂,体重指数)进行评估。数据是在2014年3月至2014年10月之间收集的。
结果:与对照组相比,实验组参与者表现出明显更好的临床结局(收缩压,t = 5.762,P = 0.000;舒张压,t = 4.250,P = 0.000;空腹血糖,t = 2.249 ,P = 0.027;总胆固醇,t = 4.362,P = 0.000;甘油三酸酯,t = 3.147,P = 0.002;低密度脂蛋白胆固醇,t = 2.399,P = 0.018;体重指数,t = 3.166,P = 0.002),对冠心病的知识得分更高(总知识得分,t = -7.099,P = 0.000),更好的身体健康状况(t = -2.503,P = 0.014)和心理健康状况(t = -2.950,P = 0.004)。
结论:本研究提供了以奥马哈体系和彭德健康促进模型为理论框架的护士主导的过渡护理计划的价值的证据。该由护士主导的过渡护理计划中的结构化干预措施有助于在其他环境中使用该计划。

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