关键词: 社区卫生服务中心；延续性照护；脑卒中；护理；调查研究

Abstract: Objective: To investigate current status of transitional care for stroke patients among 76 community hospitals in Shanghai, and to provide reference for improving transitional care service. Methods: Totally 76 community hospitals in 14 municipal districts of Shanghai were recruited and the directors of nursing departments were investigated the current status, contents and development factors and inhibitors of transional care for stroke patients in their hospitals. Results: Among 76 community hospitals, 9 hospitals did not carry out transitional care for stroke patients. Among the 67 hospitals with transitional care, only 9 (13.4%) community hospitals indicated that transitional care for stroke patients was well developed with 40 (59.7%) not well developed and 18 (26.9%) poor. Most of the transitional care projects for stroke patients in community hospitals were incomplete. "Blood pressure control instruction", "blood glucose control instruction" and "smoking cessation guidance" were better than other aspects, while "rehabilitation psychological nursing (depression and anxiety)", "health education on risk factors of stroke" and "observation of stroke condition" were poor. Conclusion: At present, transitional care service for stroke patients has been implemented in most community hospitals, but there are some deficiencies in service content, form and management. Community hospitals should further improve the single chronic disease nursing projects, strengthen management, form a standardized nursing quality system and improve the nursing service capacity of primary hospitals under the favorable conditions of regional linkage "hospital-community"and sinking of high-quality resources.

Key words: community hospital; transional care; stroke; nurse; investigation