ABSTRACT
Objetivo. Evaluar el programa de enfermera de enlace a los 2 años de funcionamiento. Diseño. Estudio descriptivo. Emplazamiento. Atención primaria de los municipios de Sant Boi de Llobregat y Sant Vicenç dels Horts (Barcelona) y el Hospital Comarcal de Sant Boi. Pacientes. Pacientes dados de alta del hospital (entre octubre de 2000 y octubre 2002) y que necesitaban cuidados de continuidad en el equipo de atención primaria o domicilio. Intervenciones. Visitas conjuntas entre la enfermera de enlace y la supervisora de la unidad hospitalaria para elaborar el plan de cuidados previo al alta hospitalaria. Se comunica al equipo de atención primaria del traspaso del enfermo y su plan de cuidados. Las visitas posteriores al domicilio las realiza la enfermera de enlace, el equipo de atención primaria, o conjuntamente. Resultados. Se ha estudiado a 854 pacientes (57,6% mujeres); media de edad en mujeres 69,82 ± 14,7 años y en varones de 61,7 ± 19,6 años (p < 0,0001). La enfermera de enlace ha realizado 2.241 visitas hospitalarias, 81 domiciliarias y 434 llamadas telefónicas. También se han hecho 636 coordinaciones. El diagnóstico de enfermería más frecuente ha sido trastorno de la movilidad física (61% de los pacientes). Conclusiones. Se ha creado un mecanismo que mejora la continuidad desde el alta hospitalaria hasta el contacto con el equipo de atención primaria. La enfermera de enlace coordina y gestiona los casos antes de que el paciente sea traspasado al ámbito de la atención primaria
Objective. To evaluate the link nurse programme after 2 years of operation. Design. Descriptive study. Setting. Primary vare in the towns of Sant Boi de Llobregat and Sant Vicenç dels Horts (Barcelona) and the County Hospital of Sant Boi, Spain. Patients. Patients discharged from the hospital (October 2000-October 2002) and who needed ongoing care in the primary care centre or at home. Interventions. Joint visits of the link nurse and the hospital unit's supervisor to work out the care plan before discharge. The PC team was informed of the transfer of the patient and his/her care plan. Subsequent home visits were by the link nurse, the primary care team or both together. Results. 854 patients (57.6% women) were studied. Women's mean age was 69.82 (SD, 4.7) and men's was 61.7 (SD, 9.6) (P<.0001). The link nurse made 2241 hospital visits, 81 home visits, and 434 phone calls. There were 636 co-ordinations. The most common nursing diagnosis made was physical mobility disorder (61% of patients). Conclusions. A mechanism was created to improve continuity from hospital discharge to contact with the PC team. The link nurse coordinates and manages patients before they are handed over to PC
Subject(s)
Aged , Middle Aged , Humans , Continuity of Patient Care , Nursing , Nurse's Role , Program EvaluationABSTRACT
OBJECTIVE: To evaluate the link nurse programme after 2 years of operation. DESIGN: Descriptive study. SETTING: Primary vare in the towns of Sant Boi de Llobregat and Sant Vicenç dels Horts (Barcelona) and the County Hospital of Sant Boi, Spain. PATIENTS: Patients discharged from the hospital (October 2000-October 2002) and who needed ongoing care in the primary care centre or at home. INTERVENTIONS: Joint visits of the link nurse and the hospital unit's supervisor to work out the care plan before discharge. The PC team was informed of the transfer of the patient and his/her care plan. Subsequent home visits were by the link nurse, the primary care team or both together. RESULTS: 854 patients (57.6% women) were studied. Women's mean age was 69.82 (SD, 4.7) and men's was 61.7 (SD, 9.6) (P<.0001). The link nurse made 2241 hospital visits, 81 home visits, and 434 phone calls. There were 636 co-ordinations. The most common nursing diagnosis made was physical mobility disorder (61% of patients). CONCLUSIONS: A mechanism was created to improve continuity from hospital discharge to contact with the PC team. The link nurse coordinates and manages patients before they are handed over to PC.
