关键词: 多学科合作团队；慢性心力衰竭；延续护理；易损期

Abstract: Objective: To evaluate the effects of continuous nursing model of multi-disciplinary team in the vulnerable period of chronic heart failure. Methods: The study was conducted in a heart failure center of a tertiary hospital in Wuhan and a convenient sampling method was used. A total of 100 patients discharged from June to December 2017 were recruited and assigned to the control group by a convenient sampling method. Another 100 patients discharged from January to June 2018 were assigned to the experimental group. Patients in the control group received the routine continuous nursing and followed up by the heart failure specialized nurses. Patients in the experimental group received the continuous nursing provided by the multidisciplinary team including heart failure specialized physican, heart failure specialized nurse, pharmacist, dietitian, physical therapist, and social worker. The continuous nursing provided by the team included preparation before the discharge, follow up by Wechat and telephone when at home, and referral service when station was stable. Six months later, information of cardiac function, self-care ability, referrals to the community health center, re-hospitalization, and satisfaction between the two groups were compared. Results: Cardiac function and self-careability of patients in the experimental group were significantly higher than those of patients in the control group (P<0.001). The rate of community referrals in the experimental group was 41.0% which was significantly higher than 14.0% in the control group (P<0.05). The satisfaction rate of patients in the experimental group was 94.0% and it was also significantly higher than 83.0% in the control group (P<0.05). Besides, the re-hospitalization rate in the experimental group was 12.0% which was significantly lower than 25.0% in the control group (P<0.05). Conclusion: The continuous nursing provided by the multi-disciplinary team can obviously improve the clinical outcomes and medical experience of patients.

Key words: multidisciplinary; chronic heart failure; continuous nursing; vulnerable period