Authors

Alba Fernández Pita1, Teresa de la Huerga Fernández-Bofill2, Sofía Pascual Sánchez2, Carolina Tessainer Cabellos-Nocq1

Position

1Especialista en Enfermería Familiar y Comunitaria. Centro de Salud Lavapiés. Dirección Asistencial Noroeste. Gerencia de Atención Primaria de Madrid2Especialista en Enfermería Familiar y Comunitaria. Centro de Salud Valdezarza Sur. Dirección Asistencial Noroeste. Gerencia de Atención Primaria de Madrid

Contact address

Alba Fernández Pita. Pº de la Esperanza, 41-1º A. 28005 Madrid.

Contact email: alba.fpita@gmail.com

Abstract

Objective: to learn about the number of patients at risk who received early nursing care (between 24 and 72 hours) in Primary Care after their hospital discharge, as well as the type of care.
Method: a transversal descriptive study in two health centres from the North-West Healthcare Management (Primary Care Management in Madrid), including those >18-year-old patients discharged from the Hospital Universitario Fundación Jiménez Díaz during November, 2014, and using documentary sources (PC-Madrid and hospital discharge reports). The variables for the study were: age and gender of the patient, Nursing Discharge Report; high-risk patient; communication with the liaison nurse, and action by the Primary Care Nurse.
Results: out of those 493 patients that were discharged from hospital, 33.3% met some of the requirements to be considered high-risk patients. Sixty four per cent (64%) of high-risk patients received a Nursing Discharge Report. The liaison nurse contacted the Primary Care referral nurse of the patient in 5.5% of cases. From these high-risk patients, 63.4% met the criterion for Inefficient Management of Own Health. From the patients who met the characteristics to be included in the high-risk group, 41.4% did not receive nursing care within 72 hours after their hospital discharge; from the remaining 58.6% who received nursing care, 81.3% asked for a visit on-demand with the nurse in their health centre.
Conclusions: a high percentage of patients were left without early Nursing Care after hospital discharge; therefore, continuity of care is a weakness within the activities by the Primary Care Nurse. The new strategies for addressing chronicity (liaison nurse, proactive telephone follow-up, computer tools, etc.) will enable an improvement in the quality of care and ensure patient safety.

Keywords:

Case Management; continuity of care; Health Primary Care; family and community nursing; liaison nurse; hospital discharge; research; transversal descriptive study

Versión en Español

Título:

¿Cuántos pacientes reciben una atención enfermera temprana tras su alta hospitalaria?