提升腦中風病人急性後期整合照護計畫轉銜率之專案

腦中風病人急性醫療處置後，轉銜至急性後期照護（PAC）承作醫院復健，為政府之重要政策，本院2018年1-6月腦中風PAC轉銜率僅為3.2%，故運用專案分析轉銜率低的原因，包括相關政策及流程不明確、醫護人員對於腦中風PAC認知不足、缺乏衛教單張及相關資訊系統。經由擴大出院準備小組為專責團隊，取得院方支持指派各科部醫師代表參與推動會議，重新制定轉介流程、舉辦在職教育、製作衛教單張、運用跨團隊合作與資訊系統，建置潛在收案名單及線上協同編輯系統等措施後，腦中風PAC轉銜率於2018年7月至2019年6月提升至10.7%，此經驗亦推廣至其他類別PAC，建議未來推動時，加強專業人員諮商能力輔以資訊系統與訊息連結的部份，可有更完善的規劃以提升轉介效能。

關鍵字

急性後期照護；腦中風；跨團隊合作；護理專案

並列摘要

After acute treatment of stroke patients, it is an important policy to transfer patients to Post-Acute Care (PAC) for hospital rehabilitation. However, our hospital Post-Acute Care-Cerebrovascular Diseases (PAC-CVD) transferring rate was only 3.2% from January to June 2018. Improvement was thus necessary. The possible reasons for the low transfer rate included complex application processes, insufficient knowledge of PAC-CVD among medical personnel, and lack of adequate propaganda and information systems. To improve the transfer rate, our Discharge Planning Department (DPD), which is exclusively responsible for the project, recruited doctors in each department to join the team meeting. We re-designed the referral process, organized on-the-job education, developed a health education campaign, and established a potential candidate list and online collaborative editing system with the help of cross-team discussion and information system. The transfer rate of PAC-CVD increased to 10.7% from July 2018 to June 2019. This experience can also be extended to other types of PACs. It is recommended to supplement professional consultation with information systems and linkages, as to improve discharge plans and their efficiency.