Construction and clinical application of a family-medical staff collaborative integrated care model for improving discharge readiness in neonates with congenital heart disease in PICU
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摘要:
目的 构建家庭-医护协作式一体化照护模式对PICU先心病新生儿出院准备度的医疗干预方案，并研究其临床应用价值。 方法 选取2024年10月—2025年10月首都医科大学附属北京安贞医院收治的120例PICU先心病新生儿作为研究对象，采用随机数字表法分为试验组与对照组，各60例。试验组采取基于家庭-医护协作式一体化照护模式的医疗干预方案，对照组采取常规医疗方案，比较干预前后新生儿出院准备度以及照顾者医疗能力。 结果 干预后试验组患儿照顾者出院准备度总分高于对照组[(183.19±10.73)分vs. (160.55±9.11)分，P < 0.001]，照顾者医疗能力总分高于对照组[(137.86±4.22)分vs. (126.89±4.68)分，P < 0.001]。在控制病情严重程度等混杂因素后，分组仍是出院准备度（B=18.230，95% CI：14.670~21.790，P < 0.001）及照顾者医疗能力（B=10.560，95% CI：8.120~ 13.000，P < 0.001）的独立影响因素。试验组再入院率[6.67%(4/60) vs. 20.00%(12/60)，P=0.032]及并发症总发生率[13.33%(8/60) vs. 31.67%(19/60)，P=0.016]均显著低于对照组。 结论 基于家庭-医护协作式一体化照护模式的医疗干预方案有助于提高PICU先心病新生儿出院准备度，以及照顾者的医疗能力。 Abstract:Objective To construct a family-medical staff collaborative integrated care model for medical intervention of PICU congenital heart disease newborns' discharge readiness, and study its clinical application value. Methods PICU congenital heart disease newborns admitted to Capital Medical University Affiliated Beijing Anzhen Hospital from October 2024 to October 2025 were selected as the research subjects, the experimental group and the control group were 60 cases each. The experimental group adopted a family-medical staff collaborative integrated care model, while the control group adopted a conventional medical plan. The preparation for discharge of newborns and the medical ability of caregivers before and after the intervention were compared. Results After intervention, the total score of discharge readiness in the experimental group was higher than that in the control group [(183.19±10.73) points vs. (160.55±9.11) points, P < 0.001]. The total score of caregivers' medical abilities was higher than that of the control group [(137.86±4.22) points vs. (126.89±4.68) points, P < 0.001]. After controlling for confounding factors such as disease severity, grouping remained an independent influencing factor for discharge readiness (B=18.230, 95% CI: 14.670-21.790, P < 0.001) and caregiver medical ability (B=10.560, 95% CI: 8.120-13.000, P < 0.001). The readmission rate of the experimental group [6.67% (4/60) vs. 20.00% (12/60), P=0.032] and the total incidence of complications [13.33% (8/60) vs. 31.67% (19/60), P=0.016] were significantly lower than those of the control group. Conclusion The family-medical staff collaborative integrated care model effectively enhances discharge readiness in neonates with CHD in the PICU and improves caregiver competency. -
Key words:
- Family-medical staff collaboration /
- Integrated care /
- PICU /
- Congenital heart disease /
- Neonates /
- Discharge readiness
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表 1 家庭-医护协作式一体化照护模式对PICU先心病新生儿出院准备度的医疗干预方案
Table 1. Medical intervention plan for the preparedness of PICU congenital heart disease newborns for discharge based on the family medical care collaborative integrated care model
阶段 主题 具体措施 入院初期 医疗人员培训 每日1 h培训，内容涵盖先心病知识、急救技能、手术要点及用药规范，提升专业能力。 家庭培训 (1)家长参与制定个性化医疗计划。 (2)指导母乳收集与储存，实操考核合格。 (3)模拟演练突发情况(如呼吸困难、发绀)，掌握应急处理。 住院期间 健康教育讲座与评估 (1)每周1次讲座(疾病知识、术后护理、喂养指导、症状监测、心理支持)，线上线下同步。 (2)家属能力评估(知识、操作、心理)，每周1~2次一对一指导，强化技能如用药、急救、喂养。 出院准备 出院前家庭宣教 (1)每周1次家庭医疗指导，包括日常照护、病情观察。 (2)每日20 min技能强化，直至出院。 家庭预出院过渡 (1)全面出院评估。 (2)制定个性化家庭医疗计划。 (3)技能强化培训1 h。 (4)发放宣教手册。 (5)安排定期随访，提供持续支持。 出院后 延续医疗 每月1~2次电话随访，跟踪生长发育，调整医疗计划。 随访 根据病情安排门诊随访，重点关注特殊检查患儿。 
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表 2 对照组实施PICU标准常规医疗模式
Table 2. Control group implements PICU standard conventional medical mode
阶段 主题 具体措施 入院初期 医疗人员 患儿入院后，由责任护士进行常规入院宣教，包括病房环境、作息时间、探视制度等。 住院期间 常规医疗 根据医嘱进行常规治疗和医疗，包括给药、生命体征监测、病情观察等。每周进行一次常规医疗评估，了解患儿的恢复情况和治疗进展。提供常规的出院指导和宣教，安排每周3次的电话交流机会增强家长与医疗团队的沟通，让家长能够直接了解患儿的病情进展，并进行探视。 出院准备 出院前宣教 对即将出院的患儿家属进行宣教，包括出院后的注意事项、随访安排等。 出院后 随访 提供电话随访(每周1~2次)，特别关注那些出院后需要进行特殊检查的PICU新生儿，确保他们得到持续的跟踪与关怀。
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表 3 2组先心病患儿及家庭看护人一般资料比较
Table 3. Comparison of general data between the two groups of children with congenital heart disease and their family caregivers
项目 试验组(n=60) 对照组(n=60) 统计量 P值 胎龄(x±s，周) 37.12±1.95 37.45±1.86 0.949a 0.345 性别(例) 0.134b 0.714 男 33 31 女 27 29 手术时间(x±s，h) 2.81±0.59 2.76±0.65 0.441a 0.660 ASA-PS分级(例) 0.129c 0.897 Ⅱ 2 3 Ⅲ 15 17 Ⅳ 37 31 Ⅴ 6 9 根治手术(例) 0.259b 0.611 是 57 59 否 3 1 急诊手术(例) 0.054b 0.817 是 11 12 否 49 48 术前心律失常(例) 1.081b 0.298 是 3 6 否 57 54 生产方式(例) 0.834b 0.361 顺产 27 32 剖宫产 33 28 家庭看护人(例) 0.583b 0.747 父亲 24 22 母亲 25 29 其他 11 9 户口所在地(例) 0.342b 0.559 农村 18 21 城镇 42 39 住院时间(x±s，d) 10.49±1.21 10.30±1.13 0.889a 0.376 注：a为t值，b为χ2值，c为Z值。
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表 4 2组先心病患儿照顾者新生儿出院准备度量表得分情况比较(x±s，分)
Table 4. Comparison of the scores of the neonatal discharge readiness scale for caregivers of children with congenital heart disease in the two groups (x±s, points)
组别 例数 维度一 t值 P值 维度二 t值 P值 维度三 t值 P值 干预前 干预后 干预前 干预后 干预前 干预后 试验组 60 62.58±5.48 80.96±8.91 18.305 ＜0.001 45.85±4.69 57.76±2.26 17.683 ＜0.001 15.84±2.61 20.20±2.82 8.792 ＜0.001 对照组 60 63.36±6.59 71.78±6.52 9.954 ＜0.001 46.73±4.72 50.21±3.43 4.603 0.001 15.91±2.12 18.13±2.79 4.905 ＜0.001 统计量 0.705a 15.427b 1.024a 32.056b 0.161a 12.103b P值 0.482 ＜0.001 0.308 ＜0.001 0.872 ＜0.001 组别 例数 维度四 t值 P值 总分 t值 P值 干预前 干预后 干预前 干预后 试验组 60 17.78±3.12 24.06±2.02 13.086 ＜0.001 142.26±7.52 183.19±10.73 32.267 ＜0.001 对照组 60 16.83±3.17 20.51±3.11 6.412 ＜0.001 142.70±9.81 160.55±9.11 14.620 ＜0.001 统计量 1.654a 29.874b 0.276a 21.348b P值 0.101 ＜0.001 0.783 ＜0.001 注：a为t值，b为F值。
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表 5 2组先心病患儿照顾者医疗能力比较(x±s，分)
Table 5. Comparison of medical competence of caregivers of congenital heart disease patients in two groups (x±s, points)
组别 例数 知识 t值 P值 技能 t值 P值 态度 t值 P值 问卷总分 t值 P值 干预前 干预后 干预前 干预后 干预前 干预后 干预前 干预后 试验组 60 57.72±4.59 73.38±3.85 28.416 ＜0.001 33.49±3.43 45.39±2.68 28.896 ＜0.001 16.51±1.21 19.18±1.42 11.084 ＜0.001 107.65±5.47 137.86±4.22 45.516 ＜0.001 对照组 60 57.61±4.58 69.01±3.78 19.758 ＜0.001 33.74±3.31 41.05±1.79 18.301 ＜0.001 16.63±1.15 16.87±1.27 1.085 0.282 107.87±4.79 126.89±4.68 24.682 ＜0.001 统计量 0.131a 24.562b 0.406a 37.123b 0.557a 9.385b 0.234a 38.205b P值 0.896 ＜0.001 0.685 ＜0.001 0.579 ＜0.001 0.815 ＜0.001 注：a为t值，b为F值。
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表 6 出院准备度总分及照顾者医疗能力总分的多元线性回归分析
Table 6. Multiple linear regression analysis of total scores of discharge readiness and caregiver medical ability
因变量 自变量 B 95% CI SE β’ t值 P值 出院准备度总分 分组(试验组vs.对照组) 18.230 14.670~21.790 1.792 0.612 10.173 ＜0.001 ASA-PS分级(Ⅳ~Ⅴ vs. Ⅱ~Ⅲ) -3.120 -5.890~-0.350 1.398 -0.142 -2.232 0.027 手术类型(姑息vs.根治) -2.450 -5.120~0.220 1.342 -0.111 -1.826 0.072 住院时间 0.560 0.120~1.000 0.222 0.158 2.523 0.013 照顾着医疗能力 分组(试验组vs.对照组) 10.560 8.120~13.000 1.232 0.502 8.571 ＜0.001 ASA-PS分级(Ⅳ~Ⅴ vs. Ⅱ~Ⅲ) -2.180 -4.030~-0.330 0.936 -0.141 -2.329 0.013 手术类型(姑息vs.根治) -1.670 -3.450~0.110 0.899 -0.108 -1.858 0.066 住院时间 0.320 0.050~0.590 0.136 0.128 2.353 0.020 注：变量赋值如下，对照组=0，试验组=1；ASA-PS分级，Ⅱ~Ⅲ级=0，Ⅳ~Ⅴ级=1；手术类型，根治手术=0，姑息手术=1；住院时间，以实际值赋值。
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表 7 2组先心病患儿出院后30 d临床结局比较[例(%)]
Table 7. Comparison of clinical outcomes between two groups of congenital heart disease patients 30 days after discharge [cases (%)]
组别 例数 再入院 并发症 切口感染 肺炎 喂养困难 心律失常 心力衰竭 总发生 试验组 60 4(6.67) 2(3.33) 2(3.33) 3(5.00) 1(1.67) 0 8(13.33) 对照组 60 12(20.00) 4(6.67) 4(6.67) 6(10.00) 3(5.00) 2(3.33) 19(31.67) χ2值 4.615 5.783 P值 0.032 0.016
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