【媒库文选】护士的使命:让老年病患回家受助

02-13 14:10   参考消息网  

Nurses with a mission:

Send older ER patients home with help

护士的使命:让老年病患回家受助

Carla Johnson 卡拉·约翰逊

hen 86-year-old Carol Wittwer took a taxi to the emergency room, she expected to be admitted to the hospital. She didn't anticipate being asked if she cooks for herself. If she has friends in her high-rise. Or if she could spell lunch backward.

"H-C-N-U-L," she said, ruling out a type of confusion called delirium for the geriatrics-trained nurse of Northwestern Memorial Hospital's emergency department.

Wittwer's care is part of a new approach to older patients as U.S. emergency rooms adapt to serve the complex needs of a graying population. That means asking more questions, asking them earlier and, when possible, avoiding a hospital stay for many older patients.

The surprising truth? Hospitals can make older patients sicker. Infections, incontinence and weakening muscles from bed rest can cascade into delirium, frailty and death. More than 30 percent of older adults go home from a hospital stay with a minor or major health problem they picked up at the hospital.

But for an ER doctor, sending an elderly patient home sometimes feels risky.

"The doctors are not comfortable sending you home unless you're safe," said Northwestern Medicine's Dwayne Dobschuetz, "It's easier to admit older patients than to send them home."

Emergency rooms have been called the hospital's front door, so that's where reformers are starting.

"The emergency department is not designed with older adults in mind," said Dr. Scott Dresden, who heads the Geriatric Emergency Department Innovations program at Northwestern. "You've got really thin stretchers. You've got patients in the hallway. There's mechanical noise all around."

Early research at Northwestern and other hospitals shows care from geriatrics-trained nurses in the ER can reduce the chances of a hospital stay after a patient's emergency visit and for a month afterward.

About 100 hospitals in the United States have opened geriatric emergency departments or trained ER teams in geriatrics care. These teams can arrange home services such as light housekeeping or a break for a caregiver.

This kind of emergency medicine is only about a decade old. An influential 2007 article described the emergency department of the future, designed to prevent confusion and falls in the elderly and to increase their comfort.

It would have windows and skylights instead of windowless spaces with glaring bulbs. Pressure-reducing mattresses instead of thin ones. Soundproofing.

Above all, it would hire nurses trained to untangle the complex complaints of aging, slowing down the frenetic pace of the ER enough to fully evaluate each patient. Physical therapists and pharmacists would be ready to help out.

Now, the ideas are catching fire. Northwestern's geriatrics ER has soundproofed rooms with comfortable beds and windows. Hospitals in New York, New Jersey, Pennsylvania, North Carolina, Wisconsin, Illinois and Georgia formed a collaborative to share ideas.

The latest nudge is an accreditation program, launched this year.

"We want to have at least 50 certified hospitals by the end of 2018," said Dr. Kevin Biese of University of North Carolina at Chapel Hill School of Medicine, who leads the accreditation push for the American College of Emergency Physicians.

Wittwer might have been admitted to the hospital before the GEDI program. Instead, the team set her up with home visits from a nurse and a physical therapist.

"They were great," Wittwer said of the nurses a few days later from her high-rise apartment. "It looks like an army of people are going to be coming over here today. I'll be OK."

当86岁的卡罗尔·威特沃乘坐出租车来到急诊室的时候,她以为要被收治入院;不料被问了几个问题:她是否自己做饭;在她所住的高层楼房里有没有朋友;或者她能不能倒着拼写“午餐”(英文为LUNCH)这个词。

她回答“H-C-N-U-L”。对于西北纪念医院急诊科一名接受过老年病学培训的护士来说,这个回答排除了神志不清的可能。

威特沃受到的护理从一个侧面反映了应对老年患者的新方法,其背景是美国的急诊室为了服务于老龄化人群的复杂需求而求变。它意味着要多提问,早提问,尽可能避免让许多老年患者住院。

惊讶吧?住院有可能让老年病人的病情加重。感染、尿失禁以及卧床休息导致的肌肉衰弱可能会发展为神志不清、身体虚弱甚至死亡。超过30%的老年人出院回家时伴有在医院患上的或轻或重的健康问题。

但是对于急诊室医生来说,打发老年病人回家有时让人感觉有风险。

西北医院的德韦恩·多布许茨说:“若非万无一失,医生是不放心让你回家的。收治老年病患入院要比打发他们回家更容易。”

急诊室一直被称为医院的大门,所以这里是改革入手的地方。

西北大学老年急诊科创新项目负责人斯科特·德雷斯登博士说:“急诊科的设计并没有考虑到老年人。担架非常单薄,走廊里有病人,周围到处是机械噪音。”

西北大学医学院以及其他医院所做的早期研究表明,病患如果在急诊室得到接受过老年病学培训的护士照料,其在急诊后以及急诊一个月后入院治疗的几率就能下降。

美国约有100家医院开设了老年急诊科或培训了老年病护理急诊队伍。这些团队可安排家政服务,如做做简单的家务或让护工休息一下。

这种急救医学问世才10年。2007年的一篇重要文章描述了未来的急诊科,其设计宗旨是防止老年人糊涂和跌倒、提高他们的舒适度。

未来急诊科室将设窗户和天窗,而不是无窗的房间和刺眼的灯泡,配备减压床垫而不是薄床垫,还隔音。

最重要的是,它将招募接受过培训的护士来理清老年人复杂的病情,放慢急诊室风风火火的步伐,从而可以充分评估每个患者。理疗师和药剂师将时刻待命。

现在,这些想法正大行其道。西北大学医学院老年病急诊室设有隔音的房间、舒适的床铺和窗户。纽约州、新泽西州、宾夕法尼亚州、北卡罗来纳州、威斯康星州、伊利诺伊州和佐治亚州的医院形成协作分享观念。

最新举动是今年推出资质鉴定计划。

北卡罗来纳大学教堂山医学院的凯文·比泽博士说:“我们希望到2018年底至少有50家认证医院。”他主管美国急救医师学院的资质鉴定工作。

如果是在老年急诊科创新项目问世以前,威特沃可能就要被收治入院了。相反,这个团队为她安排了一名护士和一名理疗师上门家访。

几天后,威特沃在她位于高楼层的寓所里提到这些护士说:“他们很棒。好像今天会有一大群人来我家。我会很好的。”(涂颀译自美联社2月2日电)