Application effect of nurse-dominated transition care model in the transition from hospital to home care for COPD patients at the county level
护士主导的过渡期护理模式在县域内慢阻肺患者从医院到家庭衔接中的应用效果

摘要

目的 分析在县域内慢阻肺患者从医院到家庭衔接过程中采取护士主导的过渡期护理模式的实际效果；方法 选取2025年1月至6月本院收治的120例慢性阻塞性肺疾病（COPD）急性加重期出院患者，以随机数字表法分组，各60例。对照组实施常规出院护理，观察组实施护士主导的过渡期护理模式，比较两组预后情况、治疗依从性等指标；结果 观察组患者在出院后30d、90d内急性加重再入院率及90d内急诊就诊次数均低于对照组（P<0.05）。干预后30d及3个月后观察组的治疗依从性评分更高、生活质量得分更低、自我管理能力得分更高、护理服务满意度评分更高（P<0.05）；结论 在县域内慢阻肺患者从医院到家庭衔接护理中引入护士主导的过渡期护理模式，能够改善预后情况，提升患者治疗依从性、生活质量、自我管理能力及护理满意度，应用价值良好。

Abstract

Objective To analyze the practical efficacy of a nurse-dominated transition care model during the transition from hospital to home care for chronic obstructive pulmonary disease patients at the county level.
Methods A total of 120 discharged patients with acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) admitted to our hospital from January to June 2025 were selected and randomly divided into two groups of 60 each. The control group received conventional discharge care, while the observation group received the nurse-dominated transition care model. Outcomes such as prognosis and treatment adherence were compared between the two groups.
Results The observation group exhibited lower rates of readmission due to acute exacerbation within 30 days and 90 days post-discharge, as well as fewer emergency visits within 90 days compared to the control group (P<0.05). After 30 days and 3 months of intervention, the observation group demonstrated higher treatment adherence scores, lower quality of life scores, higher self-management ability scores, and greater satisfaction with nursing services (P<0.05).
Conclusion   The implementation of a nurse-dominated transition care model in the transition from hospital to home care for COPD patients at the county level improves prognosis, enhances treatment adherence, quality of life, self-management ability, and nursing satisfaction, demonstrating significant clinical value.