Authors

1Juan José Zamora Sánchez, 2Rosa Martínez Luque, 3Nuria Puig Girbau, 3Magda Lladó Blanch, 4Francisco Quilez Castillo

Position

¹Enfermero. Hospitalización a domicilio. Hospital Germans Trias i Pujol. ²Enfermera hospitalaria de enlace, Hospital Germans Trias i Pujol. ³Enfermera. Centro de Atención Primaria Llefia, Badalona.⁴Enfermero adjunto del proceso de Hospitalización. Hospital Germans Trias i Pujol.

Contact address

Avda. Comunitat Europea 10, 3º-2º Derecha. 08917 Badalona (Barcelona).

Contact email: jzamora34094@coib.net

Abstract

PREALT is a continuity of care programme aimed at ensuring continuity of care between Hospital Care and Primary Care that has been operating at the Hospital Germans Trias i Pujol since 2006. The Home Hospitalisation Unit (HHU) constitutes one of the main provider units of patients to the programme.
Objectives: to analyse the main clinical characteristics of patients referred to the PREALT programme from the HHU and the nursing problems that exist at discharge and to assess the adequacy of the programme and to detect the opportunity for improvement.
Methodology: descriptive study based on the applications for inclusion into the programme during 2007 referred by the HHU. Variables analysed included: activity, age, gender, pathology upon admission, medical past history, Charlson, Barthel, assessment of basic needs and nursing problems at discharge.
Results: during 2007 a total of 121 applications for admission into the PREALT programmed were referred by the HHU, 56,2% men and 43,8% women, mean age 70 years (SD 14,31).
The main admission criteria of assessed patients are: postoperative period (23,1%), exacerbation of COPD (19%), other respiratory processes (15,7%), neoplasias or examinations (9,9%), postoperative period following knee arthroplasty (8,3%), diabetic foot or skin lesions (8,2%) and others (15,8%). Patients present a moderate to high morbidity rate and a mild to moderate dependence profile to undertake activities of daily life (ADL). The most important nursing problem at discharge is the deficit in self-care, which exists in more than half of the cases. Other prevalent problems were the ineffective management of symptoms, risk of ineffective management of the therapeutic regimen, deterioration of skin integrity, which occurs in nearly 50% of cases; and the risk of fall and pain, present in over one third of patients.
Conclusions: the results on activity obtained allow us to confirm that the continuity of care programme is of great utility for patients admitted to the HHU who need continuity of care. In analysing the data, the following opportunities for improvement are identified: the inclusion of carers in the care plans, suggesting that the burden on the carer and the quality of life perceived by the patient be assessed as well as to carry out a systematic assessment of the risks which would allow, among other things, to assess the risk of malnourishment of the patients and the risk of psychological morbidity of the carer.

Keywords:

domiciliary hospitalisation; assessment of needs; Nursing diagnosis; patient dischargecontinuity of patient care

Versión en Español

Título:

Programa de continuidad de cuidados al alta en una unidad de hospitalización a domicilio