腦中風是造成失能的原因之一,近年來政府積極推展腦中風病人急性後期整合照護計劃(Post-Acute Care,以下簡稱PAC),期於治療黃金期內給予積極整合性照護,以減少病人失能與醫療社會成本。本單位2016年腦中風病人PAC下轉率僅30.7%,經調查發現原因為政策宣導不足、缺乏執行標準流程及輔助工具、無專責人員等。因此,2017年8月成立專案小組,其後以製作PAC海報與單張,建立執行PAC作業流程、舉辦說明會、調整腦中風個管師職務內容等方式執行專案策略。於2018年1-12月執行後,腦中風病人PAC下轉率由30.7%提升至72.0%,成功達標,病人平均住院天數也從16.2天降至12.8天。本專案經驗可提供他科執行PAC參考,共謀病人福利。
Stroke is a major cause of disability. Our government has worked hard to improve postacute care (PAC) in patients with stroke. PAC aims to prevent disability and reduce medical costs using integrated care in patients with stroke. However, the transfer rate of PAC in 2016 was 30.7%. Our investigation revealed several reasons, including inadequate policy advocacy, lack of standard operating procedure (SOP) and tools for nurses, and lack of management of the PAC plan. Therefore, we established an SOP, held conferences to explain the PAC plan, and assigned a manager for PAC. Implementation of these plans from January 2018 to December 2018, led to an increase in the transfer rate from 30.7% to 72.0% and reduced the average length of stay from 16.2 d to 12.8 d. Other departments can follow our example in patient care.