建構內科病房執行出院計劃之評估工具

Making an Evaluation Tool of Discharge Planning in Medical Ward

近年來老年人口的快速成長，使台灣地區已邁入老人國領域，且隨著壽命的延長使得各種失能問題及慢性病罹患率相對增加，因為此類型疾病需長時間照護，造成病患入院機率增加、住院天數延長，如果病患或照顧者能於出院前即得知正確的醫療資訊和後續的照護計劃安排，則能減少不必要的住院與醫療花費，如此將有助於家庭經濟負擔及降低病患之重複入院率。經實際調查本院內科病房護理人員對於內科住院病患出院計劃執行情形，結果發現內科病房中100%的護理人員均於病患出院前才執行出院計劃，對於出院計劃內容之提供，因無一份實用性之評估工具可供護理人員進行持續性評估，使得臨床護理人員於住院病患出院前才發現病患尚有引流管、傷口照護或抽痰等護理需求，更因聯繫居家照護機構或協尋社會資源提供等服務，造成病患住院天延長。故如能設計一份適合內科病房執行出院計劃之評估工具，將可於病患入院早期即具體評估出病患之需求，並針對其個別性提供適切的出院計劃。本專案係依文獻查證、整合內科病患住院病患屬性及內科病房住院病患照護活動需求後，設立一份符合內科病患需求之「內科病患出院評估」，作為內科病房執行住院病患出院計劃之評估工具。而在專案實施期間，100%護理人員均能於病患入院（或轉入）當班完成內科住院病患之評估，針對其個別性需求擬定出院計劃，並結合本院出院準備服務小組護理師提供病患適切的居家照護資訊與轉介服務。

Over the past few years, the population of the aged has grown rapidly in Taiwan which makes Taiwan become a country of the elderly. Along with the longevity, it brings problems of disability and high rates of chronic disease. Because these problems need long--term care, they usually cause the high hospital admission rate and longer length of stay. If before the discharge, the patient and their family can learn the correct medical information and get appropriate nursing care after discharge, we can reduce unnecessary admission and medical costs. This will also be helpful to lighten their familys' economic burden and to lower the re-admission rate. According to a survey in our hospital, no nurses in medical wards will execute discharging plan until the time of patient discharged. This is because of the lack of a partical evaluation tool, which can offer the nurse's guidelines to evaluate the patients' condition. The lacking also result in the nurses' failure of the nurses to evaluate the patient's need, such as the care of drainage tubes, sputum suction and wound care, etc. Moreover, seeking for a nursing care institution or social service can also prolong the hospitalization. Therefore, an effective evaluation tool is essential for a nurse to execuate discharging probrem on the early days of the patient admission, and to make the most individually suitable discharg planning for each patient. Concerning the conditions and needs of patients in medical wards, this report sets up a list to screen patient. By putting the list into effect, we hope that all nurses can complete evaluating patients on the early days of admission. Making up an individual discharg planning, and together with the discharging service term, we can offer patiene appropriate home care informationand transfer servies.