关键词: 下肢动脉硬化闭塞症；风险分层；闭环管理；延续性护理；戴明环；医院-社区联动

Abstract: Objective: To develop a post-discharge, hospital-community collaborative closed-loop management model for patients with Lower Extremity Arteriosclerosis Obliterans (LEASO) based on multidimensional dynamic risk stratification and evaluate its effects, aiming to optimize postoperative continuity of care strategies. Methods: Using a non-simultaneous pre-post control design, 60 LEASO patients discharged from a tertiary grade A hospital in Nanjing from May to July 2025 were selected as the control group using consecutive sampling. Another 60 LEASO patients discharged from August to October 2025 were selected as the observation group. The control group received routine post-discharge follow-up, while the observation group received targeted closed-loop management based on multi-dimensional risk stratification. The intervention duration is 3 months. The effectiveness outcomes of the two groups were compared. Results: After intervention, the nursing care quality of the observation group was significantly higher than that of the control group (P<0.05). At the 3-month follow-up after discharge, the self-management behaviors of the observation group were significantly better than those of the control group (P<0.05). The unplanned revisit rate of the observation group (4%) was significantly lower than that of the control group (16.67%) (P<0.05). Conclusion: The PDSA-based closed-loop management model integrating multi-dimensional dynamic risk stratification effectively improves out-of-hospital care for ASO patients, as reflected in enhanced self-management behaviors and fewer unplanned revisits. These findings inform chronic disease management across multiple campuses.

Key words: Lower Extremity Arteriosclerosis Obliterans; risk stratification; closed-loop management; continuity of care; Plan-Do-Study-Act; hospital-community linkage