Ib qho tseem ceeb ntawm Kev Pov Hwm Zoo Thiab Kev Txhim Kho Kev Ua Haujlwm Rau Kev Kho Mob Raum Mob Raum: Ib Txoj Kev Rau Kev Sib Koom Tes Daim Ntawv Pov Thawj
Mar 17, 2022
Hu rau: Audrey Hu Whatsapp / hp: 0086 13880143964 Email:audrey.hu@wecistanche.com
Abstract
Interprofessional kev saib xyuas rau cov kab mob hauv lub raum ntev ua kom yooj yim rau kev xa khoom zoo, kev saib xyuas dav dav rau cov neeg ua haujlwm nyuaj, muaj kev pheej hmoo. Interprofessional kev saib xyuas yog cov peev txheej-intensive thiab yuav tsum tau muaj txiaj ntsig zoo. Kev sib koom ua ke daim ntawv pov thawj yog ib qho kev yeem ua haujlwm uas txhim kho cov txiaj ntsig ntawm tus neeg mob, muab kev siv tau sab nraud rau kev tswj hwm hauv tsev kho mob, thiab txhim kho kev pom rau cov neeg mob thiab cov neeg muab kev xa mus. Qhov no yog ib lub hauv paus, kev tshawb fawb rov qab piav qhia txog kev lees paub zoo thiab kev txhim kho kev ua haujlwm ntawm cov kab mob raum ntev, kev sib koom ua ke daim ntawv pov thawj, thiab cov txiaj ntsig zoo. Tag nrho ntawm 440 tus neeg mob tau suav nrog hauv kev tshuaj xyuas, kaum peb qhov ntsuas tau zoo uas suav nrog kev soj ntsuam thiab cov txheej txheem ntawm kev saib xyuas tau tsim thiab ntsuas rau lub sijhawm ob xyoos txij li 2009- mus rau 2017. Kev txhim kho tseem ceeb lossis tsawg kawg ua haujlwm siab tsis tu ncua yog sau tseg rau cov cim qhia tau zoo xws li kev tswj ntshav siab (85 feem pua), kev kwv yees ntawm kev pheej hmoo plawv (100 feem pua), ntsuas hemoglobin Alc (98 feem pua), tshuaj tiv thaiv (93 feem pua), kev xa mus rau vascular nkag thiab hloov pauv (100 feem pua), Kev tso chaw ntawm kev nkag mus rau kev lim ntshav mus tas li (61 feem pua), kev sib tham ntawm cov lus qhia qib siab (94 feem pua), kev kawm online tus neeg mob (71 feem pua) thiab ua tiav cov ntaub ntawv mus ntsib chaw ua haujlwm (100 feem pua). Cov qhab nia siab ntawm tus neeg mob siab (94-96 feem pua) yog ua raws li kev saib xyuas zoo.
Ntsiab lus: mob raum mob; interprofessional kev saib xyuas; kev ruaj ntseg zoo
Cistanche kho mob raum mob tau zoo
1 Kev Taw Qhia
Interprofessional (P) kev saib xyuas rau cov kab mob hauv lub raum ntev ua kom yooj yim rau kev xa cov kev saib xyuas rau ib qho nyuaj, cov neeg muaj kev pheej hmoo. Cov tswv yim pov thawj-raws li kev ua kom qeeb ntawm cov kab mob raum ntev tau piav qhia zoo tab sis tsis tas li siv rau tus neeg mob. Cov pab pawg sib tham tau tsom mus rau kev siv cov pov thawj-raws li kev saib xyuas kom ua rau qeeb zuj zus ntawm cov kab mob hauv lub raum, qhia cov neeg mob txog lawv cov kab mob, thiab ua kom muaj kev hloov pauv mus rau theem kawg ntawm lub raum kab mob (ESRD). Qhov kev saib xyuas dav dav no tau pom tias yuav txo tau mus pw hauv tsev kho mob [1-6] txo qis kev tuag [13A.7-9] qeeb kev loj hlob ntawm cov kab mob raum tsis zoo [1-3,10,1l] thiab npaj cov neeg mob rau kev hloov pauv hauv kev saib xyuas [4.7 8]. Txawm hais tias cov txiaj ntsig zoo li no, cov kev pab cuam rau mob raum mob raum tsis yooj yim rau kev siv vim muaj peev txheej. Cov neeg tawm tswv yim ntawm kev saib xyuas IP yuav tsum muab pov thawj ntawm tus nqi los ua pov thawj tus nqi ntxiv txij li cov kab mob hauv lub raum siv tsis sib xws ntawm cov nyiaj pab kho mob thoob ntiaj teb[12,13]. Daim Ntawv Pov Thawj Ua Haujlwm Sib Koom (TJC) yog cov txheej txheem kev yeem ua haujlwm uas txhim kho cov txiaj ntsig ntawm tus neeg mob, muab kev siv tau sab nraud rau kev tswj hwm hauv tsev kho mob, thiab txhim kho kev pom rau cov neeg mob thiab xa mus rau cov kws kho mob. Nyob rau hauv daim ntawv no, peb piav qhia txog kev txhim kho IP Cov kab mob raum ntev thiab txoj hauv kev rau TJC cov kab mob tshwj xeeb hauv kev saib xyuas mob raum.
Cistanche txhim kho lub raum ua haujlwm
2 Cov ntaub ntawv thiab cov txheej txheem
Nov yog ib qho kev tshawb nrhiav rov qab, ib lub chaw kawm ntawm txhua tus neeg laus uas tau txais kev saib xyuas hauv IP Chronic raum Program Program txij Lub Xya Hli 2011- txog 2016. Peb suav tag nrho cov neeg laus uas muaj kab mob raum ntev tau txais kev saib xyuas IP. Cov neeg mob uas muaj tsawg dua 3 lub hlis ntawm kev soj ntsuam hauv qhov kev zov me nyuam raug tshem tawm los ntawm kev soj ntsuam, cov ntaub ntawv kho mob suav nrog cov neeg mob pej xeem, kev tsis sib haum xeeb, kev kuaj pom, cov cim tseem ceeb ntsuas thaum mus ntsib kws kho mob, tshuaj, txheej txheem kev saib xyuas nrog rau cov txiaj ntsig ntawm kev pib lim ntshav. , kev hloov pauv lossis kev tuag raug muab rho tawm los ntawm cov ntaub ntawv kho mob hauv hluav taws xob (EHR) txhawm rau txheeb xyuas cov neeg mob pej xeem thiab kev ntsuas kev ua tau zoo rau txhua lub voj voog rov qab, peb siv cov ntaub ntawv piav qhia suav nrog tus lej thiab tus qauv sib txawv (SD) lossis qhov nruab nrab thiab ntau yam rau cov ntaub ntawv txuas ntxiv thaum tsim nyog, zaus suav, thiab feem pua ntawm cov ntaub ntawv categorical. Cov txheeb cais piav qhia tau suav nrog R version (3.4.2). Lub koom haum saib xyuas lub koom haum (IRB) rau tib neeg cov kev kawm tau pom zoo txoj kev tshawb no nrog kev zam ntawm kev tso cai.
2.1. Kev piav qhia
Tus kws muag tshuaj tau sau daim ntawv thov rau IP Chronic raum Kab Mob Program thiab tau txais nyiaj txiag los ntawm kev noj qab haus huv. Qhov kev pab cuam no tau tsim los ua nws tus nqi chaw thiab cov kws muag tshuaj nyiaj tau txais kev txhawb nqa los ntawm cov kab ke kev noj qab haus huv rau kev saib xyuas cov neeg mob ncaj qha thiab kev tswj hwm ntawm Chronic raum kab mob program. Tus kws kho mob nephrologist thiab kws muag tshuaj tau tsim cov txheej txheem rau qhov kev zov me nyuam nrog rau daim ntawv tshaj tawm txoj haujlwm, lub sijhawm kho mob, cov lus piav qhia txoj haujlwm, cov ntawv sau ua qauv, thiab cov qauv xaj. Peb lub koom haum IP Chronic raum Kev Pabcuam tau qhib rau xyoo 2007 thiab muab kev saib xyuas zoo rau cov neeg mob raum mob rau theem 2 txog 5. Cov neeg mob raug xa mus rau kev saib xyuas IP los ntawm nephrologist lossis los ntawm kev xa ncaj qha los ntawm lwm yam kev qhuab qhia. Qhov kev zov me nyuam tsis muaj cov qauv xa mus tshwj xeeb; es txhua tus neeg mob uas tus kws kho mob xa mus xav tias yuav tau txais txiaj ntsig los ntawm IP Kev Kho Mob raum Kab Mob yog tsim nyog. Qhov kev zov me nyuam muaj ob lub tsev kho mob ib nrab hnub, uas ua haujlwm nyob rau hauv tib lub cev qhov chaw raws li lwm lub tsev kho mob nephrology. Cov neeg mob tau pom txhua 1 txog 6 lub hlis nyob ntawm qhov mob hnyav. Kev mus ntsib yog kwv yees li 90 thiab 45 feeb rau cov neeg mob tshiab thiab rov qab los, feem. Pab pawg IP tseem ceeb muaj xws li nephrologist / kws kho mob tus thawj coj, kws muag tshuaj / tus thawj tswj hwm, tus nais maum, kws noj zaub mov, tus neeg ua haujlwm sib raug zoo, thiab tus neeg saib xyuas kev kawm. Interprofessional kev saib xyuas yog muab los ntawm lub koom haum Chronic raum cov lus qhia thiab sau tseg hauv EHR. Cov lus qhia txog kab mob raum ntev tau tsim los siv rau Kev Kho Mob Raum Txhim Kho Ntiaj Teb Cov Txheej Txheem (KDIGO) cov lus qhia, Cov Kab Mob Raum Ua Tau Zoo Tshaj Lij (KDOQI), Cov Txheej Txheem Koom Tes Hauv Lub Tebchaws Kev Kub Siab, American Diabetes Association Cov Lus Qhia Txog Kev Kho Mob Ntshav Qab Zib, American Heart Association cov lus qhia nrog rau cov ntaub ntawv tseem ceeb thiab qib siab [ 14-69]. Cov no tau pom zoo los ntawm peb lub koom haum Pharmacy thiab Therapeutics Committee thiab hloov kho txhua xyoo.
Cov neeg mob tau txais ntau yam kev pabcuam ntxiv rau cov kev kho mob nephrology ib txwm muaj xws li kev ntsuas kev pheej hmoo ntawm lub plawv, kev noj zaub mov noj rau cov kab mob raum tsis zoo, kev poob phaus, txhaj tshuaj tiv thaiv, kev haus luam yeeb, kev kho tshuaj kho mob thiab kev tswj hwm, kev teem sijhawm tshuaj kho tus kheej, kev pab cuam nrog kev pov hwm thiab kev thauj mus los. raws li kev pab cuam nrog kev hloov pauv kev saib xyuas mus rau kev hloov pauv, lim ntshav lossis tsev kho mob (Tshooj Ntxiv A). Kev kawm rau tus neeg mob yog muab thaum txhua qhov kev mus ntsib ntawm tus kheej, los ntawm cov yeeb yaj kiab kev kawm online thiab hauv chav kawm. Cov ntsiab lus kev kawm muaj xws li kev qhia txog kab mob raum, tshuaj noj, thiab mob raum mob, kev noj haus, kev sib koom tes hauv zej zog, kev hloov lub raum, thiab kev hloov pauv.
Txhua tus neeg hauv pab pawg tau txhais lub luag haujlwm thiab lub luag haujlwm los txhim kho kev saib xyuas neeg mob kom zoo. Txhua tus tswv cuab ntawm pab pawg IP tau txais kev taw qhia rau qhov kev zov me nyuam thiab lub koom haum cov txheej txheem kab mob raum. Cov tswvcuab hauv pab pawg tau raug tshuaj xyuas rau qhov kev ua tau zoo ua ntej thiab yuav tsum ua kom pom qhov muaj peev xwm txuas ntxiv thiab kev kawm txhua xyoo. Kev muaj peev xwm raug ntsuas los ntawm kev hais lus thiab los ntawm kev ua yeeb yam ntawm kev txawj yog qhov tsim nyog. Cov neeg koom nrog teb cov lus nug txog cov xwm txheej me me los sim lawv txoj kev paub txog kab mob raum mob ntev, tag nrho cov hom phiaj ntawm kev saib xyuas raws li theem kab mob raum, kev kuaj ntsuas, thiab cov khoom noj muaj phosphorus thiab potassium. Cov txuj ci xws li kev ntsuas ntshav siab lossis kev tswj hwm cov tshuaj raug ntsuas los ntawm kev ua qauv qhia. Cov ntsiab lus niaj hnub hauv kev kho mob raum mob tau raug tshuaj xyuas thaum lub sijhawm yuav tsum tau sau ntawv txhua hli dub. Tus Thawj Saib Xyuas Kev Kho Mob thiab Tus Thawj Saib Xyuas Kev Pabcuam ua haujlwm tshuaj xyuas txhua xyoo rau txhua tus tswvcuab hauv pab pawg uas suav nrog 360-degree tawm tswv yim los ntawm pab pawg.
2.2. Tsim Kev Ntsuas Kev Ntsuas Zoo thiab Kev Txhim Kho Kev Ua Haujlwm (QAPI) thiab Kev Sau Npe Kab Mob raum
Pab neeg IP tau txiav txim siab qhov ntsuas qhov tsim nyog uas suav nrog kev kho mob, txheej txheem, thiab kev ntsuas nyiaj txiag xws li kev tswj ntshav siab (BP), qhov tshwm sim ntawm cov hlab ntsha mus tas li thaum pib lim ntshav, tus nqi txhaj tshuaj, kev kawm ntawm cov neeg mob ntawm lwm tus (Table 1). Cov kev ntsuas no tau raug xaiv los ntawm lawv qhov tseem ceeb rau kev ncua kev mob raum mob ntev, txhim kho kev hloov pauv hauv kev saib xyuas, txhim kho cov neeg mob kev paub dhau los, thiab siv tau rau feem coob ntawm cov pej xeem. Txhua qhov ntsuas tau zoo tau raug txiav txim siab, lub hauv paus thiab cov hom phiaj tau tsim thiab cov tswv yim tau tsim los ua kom tiav cov hom phiaj Piv txwv li, peb tau txhais BP tswj raws li feem pua ntawm cov neeg mob ua tiav lub hom phiaj BP raws li Pawg Neeg Saib Xyuas Kev Sib Koom Tes. Peb tau tsim peb lub hauv paus tus nqi tswj thiab teem lub hom phiaj rau kev txhim kho. Cov tswv yim kom ua tiav lub hom phiaj suav nrog kev pab kho mob kev kawm txog kev ntsuas BP, muab kev saib xyuas BP hauv tsev thiab cov ntawv teev cia rau cov neeg mob rau kev saib xyuas hauv tsev, kev kawm rau tus neeg mob, thiab kev saib xyuas hauv xov tooj rau cov neeg mob ntshav siab.
Peb tau tsim ib daim ntawv teev npe mob raum mob rau EHRenabling qhov kev qhia paub txog cov kab mob raum tsis zoo. Cov ntaub ntawv raug rho tawm hauv hluav taws xob thiab nthuav tawm hauv QAPI dashboard, uas tau tshuaj xyuas txhua hli los ntawm pab pawg IP thiab xa mus rau TJC. Tag nrho cov ntawv tshaj tawm raug tshuaj xyuas kom meej thaum lub rooj sib tham pab pawg txhua hli thiab cov tswv yim tshiab kom ua tiav cov hom phiaj yog tsim los ntawm qhov xav tau.
Cistanche kho mob raum
3. Cov txiaj ntsig
Tag nrho ntawm 440 tus neeg mob tam sim no tau txais kev saib xyuas hauv IP Chronic raum kab mob program. Cov pej xeem tau sau tseg hauv Table 2.
Qhov nruab nrab hnub nyoog ntawm cov pej xeem yog 64.2 ± 14.5 xyoo, 55 feem pua yog txiv neej thiab feem ntau yog Dawb nrog 24 feem pua ntawm cov neeg mob Hispanic uas yog haiv neeg thib ob. Feem ntau ntawm cov neeg mob yog nyob rau hauv mob raum mob theem 3 (51 feem pua) ua raws li theem 4 (24 feem pua) thiab theem 5 (17 feem pua). Kwv yees li ib nrab ntawm cov neeg mob muaj ntshav qab zib thiab 92 feem pua ntawm cov ntshav siab.
Ua ntej thawj daim ntawv pov thawj xyoo 2010, peb xaiv cov kev ntsuas zoo hauv qab no: (1) kev tswj ntshav siab (qhov nruab nrab systolic thiab diastolic ntshav siab, feem pua ntawm cov neeg mob SBP Tsawg dua lossis sib npaug li 130 mmHg, feem pua ntawm cov neeg mob SBP Tsawg dua lossis sib npaug li 140 mmHg), (2) nruab nrab hemoglobin, (3) kev tshuaj ntsuam xyuas rau cov neeg mob uas tsim nyog xa mus rau kev phais vascular thiab kev hloov pauv thiab (4) feem pua ntawm cov neeg mob uas muaj kev kawm txog kab mob raum tsis pub dhau 3 lub hlis ntawm chaw kho mob (Table 3).
Peb tau sau 6 lub hlis ntawm cov ntaub ntawv ntawm cov kev ntsuas no rau kev lees paub thawj zaug. Qhov nruab nrab systolic ntshav siab yog 127-137 mmHg, 36-44 feem pua ntawm cov neeg mob muaj SBP Tsawg dua lossis sib npaug li 130 mmHg, thiab 56-76 feem pua ntawm cov neeg mob muaj SBP tsawg dua lossis sib npaug li 140 mmHg. Yim caum yim mus rau 100 feem pua ntawm cov neeg mob tau txais kev xa mus rau vascular phais lossis hloov pauv. Cov feem pua ntawm cov neeg mob uas tau txais hauv chav kawm Kev kawm mob raum mob raum hauv thawj 3 lub hlis ntawm kev koom nrog hauv tsev kho mob tau nce los ntawm 33 feem pua rau 50 feem pua. Peb tau txais Daim Ntawv Pov Thawj Kab Mob Tshwj Xeeb rau cov kab mob raum ntev uas tsis muaj kev tshawb pom los txhim kho thiab tau raug suav tias yog thawj qhov kev pabcuam hauv Tebchaws Meskas nrog rau qhov kev xaiv no. Tom qab tau txais peb daim ntawv pov thawj, peb tus neeg soj ntsuam tau caw peb los nthuav qhia peb cov txiaj ntsig ntawm qhov kev pab cuam rau Lub Rooj Sib Tham Zoo Net rau Lub Chaw rau Medicare thiab Medicaid.
Hauv thawj lub voj voog rov ua dua tshiab 2011-2013, peb xaiv cov ntsuas hauv qab no: (1) SBP Tsawg dua lossis sib npaug ntawm 130 mmHg (2) kev txhaj tshuaj tiv thaiv kab mob pneumococcal (3) kev sib tham txog cov lus qhia qib siab (4) kev mus ntsib chaw ua haujlwm tshem tawm tus nqi (Table 4).
Kev tswj nruj ntawm SBP Tsawg dua lossis sib npaug ntawm 130 mmHg tau ua tiav hauv 47-58 feem pua ntawm cov neeg mob thiab SBP Tsawg dua lossis sib npaug li 140 mmHg tau txais hauv 74-85 feem pua ntawm cov neeg mob. Kev txhaj tshuaj tiv thaiv kab mob pneumococcal suav nrog Prevnar 13 thiab Pneumovax 23 thiab tus nqi tau nce sai los ntawm 49 feem pua hauv thawj peb lub hlis twg mus rau 93 feem pua ntawm lub quarter kawg ntawm lub voj voog, ib yam li cov feem pua ntawm cov neeg mob uas tau tham txog cov lus qhia siab heev nrog peb cov neeg ua haujlwm hauv zej zog, los ntawm 29 feem pua 94 feem pua ntawm ob lub xyoos. Peb tsis tuaj yeem txhawb nqa qhov txo qis ntawm qhov kev tshem tawm ntawm kev mus ntsib tom chaw ua haujlwm tom qab thawj zaug poob ntawm 28 feem pua rau 19 feem pua.
Nyob rau hauv lub thib ob recertification voj voog 2013-2015, peb xaiv cov nram qab no zoo ntsuas: (1) SBP Tsawg dua los yog sib npaug rau 130 thiab 140 mmHg (2) feem pua ntawm cov neeg mob pib hemodialysis (HD) nrog AVF los yog arteriovenous graft (AVG) , (3) hnub nruab nrab ntawm kev xa mus rau thawj lub sijhawm teem rau hauv chaw kho mob raum mob thiab (4) feem pua ntawm cov ntawv kaw hauv EHR hauv 48 teev (Table 5).
Thaum Lub Kaum Ob Hlis 2013, Lub Koom Haum Koom Tes Hauv Tebchaws tau tshaj tawm cov lus qhia tshiab qhia txog lub hom phiaj ntshav siab ntawm s140mmHg thiab peb tau txiav txim siab kom tsis txhob taug qab SBP lub hom phiaj ntawm s130 mmHg. Peb ua tiav SBP tswj kom tsawg dua lossis sib npaug li 140 mmHg hauv 79-85 feem pua ntawm cov neeg mob. Qhov feem pua ntawm cov neeg mob pib lim ntshav nrog AVF lossis AVG txawv ntawm 25 txog 100 feem pua hauv ntau lub hlis twg nrog qhov nruab nrab tag nrho ntawm 77 feem pua. Lub sijhawm tos nruab nrab ntawm kev xa mus rau thawj qhov chaw kho mob raum mob raum tau teem sijhawm txawv ntawm 7 mus rau 37 hnub. Qhov feem pua ntawm cov ntawv kaw hauv 48 teev tau txhim kho los ntawm 45 feem pua rau 100 feem pua
Hauv lub voj voog thib peb rov ua dua tshiab 2015-2017, cov kev ntsuas zoo hauv qab no tau raug xaiv: (1) tus neeg mob saib cov yeeb yaj kiab kev kawm online, (2) txuas ntxiv ntawm qhov ntsuas ntsuas mus tas li, (3) kev txiav txim ntawm hemoglobin Alcevery 6 hli rau cov neeg mob ntshav qab zib. , thiab (4) kev kwv yees thiab cov ntaub ntawv ntawm atherosclerotic cardiovascular kab mob (ASCVD) kev pheej hmoo (Table 6).
Kaum tsib cov yeeb yaj kiab qhia txog tus neeg mob tau tsim los txhim kho kev kho mob, kev saib xyuas tus kheej, thiab cov txiaj ntsig kev kho mob rau cov neeg mob raum mob. Pab neeg mob raum mob ntev, suav nrog tus kws kho mob nephrologist, kws muag tshuaj, kws kho mob noj zaub mov, thiab tus neeg ua haujlwm sib raug zoo, txhua tus tsim ob peb 5-15 cov yeeb yaj kiab min ntawm cov ncauj lus tshwj xeeb ntsig txog mob raum mob rau tus neeg mob uas tau txheeb xyuas los ntawm txhua tus neeg hauv pab pawg. Cov yeeb yaj kiab tau raug ua yeeb yaj kiab ua lus Askiv ntawm lub chaw tsim khoom uas nyob hauv lub tsev kawm ntawv loj. Tag nrho cov txheej txheem ntawm kev npaj thiab ua yeeb yaj kiab tau siv peb lub hlis. Tom qab tsim cov yeeb yaj kiab tiav. Ib qhov txuas mus rau cov yeeb yaj kiab tau muab faib los ntawm e-mail, EHR tus neeg mob xa xov thiab muab tso rau hauv lub vev xaib mob raum kab mob. Ib daim ntawv tshaj tawm cov yeeb yaj kiab tau tsim thiab muab faib rau cov neeg mob hauv tsev kho mob thiab hauv kev xa ntawv. Rau cov neeg mob uas tsis muaj khoos phis tawj, kev siv internet, lossis xov tooj ntawm tes, DVD tau muab faib rau hauv tsev kho mob lossis cov yeeb yaj kiab tau muab tso rau tus neeg mob hauv tsev kho mob computer. Txhua tus neeg mob raug nug txog kev saib yeeb yaj kiab thaum mus ntsib chaw ua haujlwm thiab qhov no tau sau tseg hauv EHR siv cov chaw ntse rau kev rho tawm cov ntaub ntawv hluav taws xob. Muaj qhov nce siab thiab sib npaug ntawm feem pua ntawm cov neeg mob saib peb cov yeeb yaj kiab kev kawm online los ntawm 0 mus rau 71 feem pua, 15 cov yeeb yaj kiab tau txais tag nrho ntawm 284.808 views thiab tag nrho cov naj npawb ntawm cov neeg saib ib qho yeeb yaj kiab nyob ntawm 276 txog 132,710 nyob deb tshaj peb cov neeg mob. Cov yeeb yaj kiab uas muaj kev pom siab tshaj plaws suav nrog cov ntsiab lus ntawm; (1) cov tsos mob ntawm lub raum (132710 views), (2) theem ntawm cov kab mob raum (91,265 views), thiab (3) kuaj qhov tseem ceeb ntawm cov kab mob raum (18,615 views).
Rau lwm qhov kev ntsuas zoo, qhov feem pua ntawm kev lim ntshav mus tas li ntawm kev lim ntshav pib yog 0-100 feem pua (nruab nrab 61 feem pua), thiab, tus naj npawb ntawm cov neeg mob pib lim ntshav qis qis txij li 0-3 ib hlis. Kev kuaj hemoglobin Alc tau siab ntawm qhov pib ntawm 90 feem pua thiab tseem nyob twj ywm siab nrog ntau yam ntawm 89-98 feem pua .ASCVD qhov kev pheej hmoo tsis yog ib txwm tau sau tseg hauv chaw ua haujlwm mus ntsib cov ntawv hauv paus. Tom qab kev siv lub tshuab xam zauv ASCVD automated nyob rau hauv EHR, peb tau ua kom pom cov ntaub ntawv nce tam sim ntawd mus rau 82 feem pua hauv thawj peb lub hlis twg ntawm kev siv thiab nce ntxiv mus rau 100 feem pua cov ntaub ntawv. Peb tau txais daim ntawv pov thawj rov qab uas tsis muaj kev tshawb pom rau kev txhim kho thiab cov lus pom zoo ntawm kev txhim kho kev kawm hauv online rau cov neeg mob uas mob raum.
Kev txaus siab ntawm tus neeg mob tau ntsuas los ntawm Kev Ntsuas Cov Neeg Siv Khoom ntawm Cov Chaw Kho Mob thiab Kev Tshawb Fawb Kev Tshawb Fawb uas tswj hwm los ntawm Press Ganey thiab sau rau txhua daim ntawv pov thawj thiab rov ua dua tshiab. Txij xyoo 2012 txog rau tam sim no, feem pua ntawm cov kev tshawb fawb uas cov neeg mob tau tshaj tawm "yog, tiag tiag" ntawm 3- taw tes ntsuas rau lawv qhov yuav pom zoo rau qhov kev pab cuam thiab tus kws kho mob sib txuas lus yog kwv yees li 94 feem pua thiab 96 feem pua , feem.
Cistanche kho mob raum
4. Kev sib tham
Hauv txoj kev tshawb no, peb tau pom tias kev saib xyuas IP rau cov kab mob raum tsis zoo tuaj yeem siv tau thiab txhawb nqa lub sijhawm ntev ntawm lub tsev kawm ntawv Cov txheej txheem tau txais TJC ntawv pov thawj yog kev kawm thiab muaj txiaj ntsig. Nws muab lub sijhawm los tshuaj xyuas cov haujlwm ua haujlwm thiab txheeb xyuas qhov tsis sib xws hauv kev saib xyuas. TJC daim ntawv pov thawj ua kom muaj cov txheej txheem tsis tu ncua ntawm kev txhim kho kev ntsuas zoo, kev siv cov kev cuam tshuam kom ua tiav cov hom phiaj kev pab cuam, thiab ntsuas cov txiaj ntsig. Hauv kev sib piv rau lwm lub koom haum tswj hwm, TJC ntawv pov thawj muab kev yooj yim rau cov kev pab cuam los txiav txim siab lawv tus kheej cov ntsiab lus ntawm kev ua haujlwm. Hauv yim xyoo dhau los, peb tau txhais thiab ntsuas 13 qhov ntsuas tau zoo rau kev saib xyuas kab mob raum. Zuag qhia tag nrho, peb tuaj yeem txhim kho kev ua tau zoo ntawm feem ntau ntawm cov ntsuas kev ua tau zoo lossis tsawg kawg tuav cov kev ua haujlwm siab. Feem ntau cov ntsuas tau so haujlwm thaum kawg ntawm lub voj voog recertification. Qee qhov tau suav tias yog qhov tseem ceeb rau kev kho mob raum mob thiab tau txuas ntxiv mus ntxiv.
4.1.Kev tswj ntshav siab
Kev tswj ntshav siab tseem yog ib qho kev ntsuas kev ua tau zoo rau 3 lub voj voog ntawm kev rov ua dua vim tias nws yog qhov tseem ceeb los tiv thaiv kev mob raum tsis zoo thiab peb pom muaj lub sijhawm rau kev txhim kho kev ua haujlwm. Qhov nruab nrab, kev tswj ntshav siab tau ua tiav hauv 81 feem pua ntawm cov neeg mob, Thaum peb tsom mus rau lub hom phiaj nruj dua (<130 0="" mmhg),="" between="" 53-67%="" of="" our="" patients="" were="" able="" to="" achieve="" that="" target="" despite="" a="" drop="" in="" control="" with="" the="" implementation="" of="" more="" stringent="" targets,="" we="" still="" achieved="" higher="" rates="" of="" control="" compared="" to="" the="" literature.="" thanamayooran="" and="" colleagues="" demonstrated="" that="" 40%="" of="" patients="" achieved="" a="" target="" blood="" pressure="" of=""><130 0="" mmhg="" when="" receiving="" ip="" chronic="" kidney="" disease="" care[75].="" surveys="" of="" the="" general="" population="" have="" demonstrated="" that="" 13.2-37%="" of="" patients="" with="" chronic="" kidney="" disease="" achieve="" a="" target="" blood="" pressure="">
Kev ua tiav lub hom phiaj hauv tsev kho mob ntshav siab tau ua pov thawj tias nyuaj. Txhawm rau txhim kho kev tswj ntshav siab, tag nrho pab pawg IP tau koom nrog ntau yam. Peb cov kws pab kho mob muaj kev ntsuam xyuas kev ua tau zoo txhua xyoo ntawm kev ntsuas ntshav siab kom raug thiab xyuas kom cov kev ntsuas ntshav siab tau rov ua dua thiab sau tseg. Cov kws noj zaub mov qhia txog kev txwv kev noj zaub mov sodium thiab qhia cov neeg mob txog kev nyeem cov ntawv qhia zaub mov. Tus kws muag tshuaj ntsuam xyuas cov tshuaj ua raws li kev noj haus, qhov tsis zoo ntawm cov tshuaj antihypertensives thiab optimizes kev kho mob. Cov kws saib xyuas mob ua haujlwm niaj hnub soj ntsuam kev ntsuas ntshav hauv tsev rau cov neeg mob uas nws qhov chaw kuaj mob ntsuas tsis yog lub hom phiaj. Tus kws saib xyuas kev noj qab haus huv soj ntsuam cov peev txheej nyiaj txiag thiab hais txog kev cuam tshuam rau kev nkag mus rau cov tshuaj thiab muab cov ntshav ntsuas ntshav dawb rau cov neeg mob xav tau. Tus kws kho mob tshuaj xyuas pab pawg cov lus pom zoo, sau cov phiaj xwm ua kom zoo rau cov tshuaj tiv thaiv kab mob ntshav qab zib thiab suav nrog cov hauv paus ntsiab lus ntawm kev noj qab haus huv (kev tawm dag zog tsis tu ncua, noj zaub mov tsawg, txwv tsis pub haus cawv, thiab lwm yam). Ntau tshaj 90 feem pua ntawm peb cov neeg mob saib xyuas thiab nkag mus hauv tsev ntshav siab. , uas ua kom yooj yim kho cov tshuaj raws li kev nyeem hauv tsev. Ib tug tseem ceeb ntawm cov neeg mob muaj lub tsho dawb kub siab, yog li kev siv cov ntaub ntawv hauv tsev kho mob underestimates tseeb ntshav siab tswj [28,70]. Nrog rau kev siv thiab nce kev koom tes ntawm tus neeg mob hauv EHR, nws tuaj yeem ua tau los qhia txog kev ua tau zoo raws li kev nyeem hauv tsev. Cov phiaj xwm yav tom ntej rau kev tswj ntshav siab suav nrog kom cov neeg mob nkag mus rau hauv lawv lub tsev nyeem ntawv rau hauv MvChart portal ntawm EPIC EHR siv lawv lub xov tooj ntawm tes lossis laptop kom muaj nuj nqis raug kaw thiab ua tau. Peb tseem tsis tau ua raws li qhov pib ntshav siab vim qhov tsis muaj cov ntaub ntawv qhia kev kawm thiab cov peev txheej los qhia cov neeg mob txog kev tshaj tawm hluav taws xob no.
4.2.Kev kawm
Kev kawm txog kab mob raum ntev yog qhov tseem ceeb hauv kev txhawb nqa cov neeg mob kom muaj kev koom tes hauv lawv txoj kev saib xyuas thiab tau cuam tshuam nrog kev txo qis hauv tsev kho mob thiab kev tuag [1,3-5,7,8,11]. Nyob rau hauv qhov kev cia siab, randomized, tswj kev sim ntawm IP Cov kab mob raum mob rau kev kawm txog kev cuam tshuam, pab pawg neeg saib xyuas IP tau pom tias muaj kev ncua tseem ceeb hauv kev pib kho ntshav qab zib piv rau pawg saib xyuas ib txwm muaj (p<0.0001)[78]. pre-dialysis="" education="" is="" important="" in="" assuring="" a="" smooth="" transition="" to="" dialysis="" including="" placement="" of="" permanent="" access="" and/or="" transition="" to="" transplantation="" |79].="" peritoneal="" dialysis(pd)and="" home="" hemodialysis="" (hd)="" are="" underutilized="" in="" the="" united="" states="" with~90%="" of="" patients="" receiving="" in-center="" hd="" [80].="" we="" believe="" that="" extensive="" education="" provided="" to="" our="" patients="" was="" the="" reason="" for="" a="" relatively="" high="" percentage="" of="" our="" patients="" starting="" renal="" replacement="" therapy="" with="" pd="" (30%)="" compared="" to="" in-center="" hd="" (70%).="" this="" is="" consistent="" with="" other="" studies="" that="" showed="" that="" chronic="" kidney="" disease="" education="" is="" associated="" with="" an="" increased="" selection="" of="" home="" hd="" and="" pd="" modalities="" as="" opposed="" to="" in-center="" hd="" [81].in="" a="" survey="" of="" practicing="" nephrologists,="" over90%="" of="" the="" nephrologists="" would="" choose="" home="" dialysis="" for="" themselves,="" yet="" few="" chronic="" kidney="" disease="" patients="" are="" on="" home="" dialysis="" therapy="" [82].="" clinicians="" should="" apply="" the="" same="" standards="" for="" taking="" care="" of="" patients="" that="" they="" would="" desire="" for="" themselves="" or="" family="" members,="" should="" they="" develop="" esrd.="" various="" medical="" programs="" are="" increasingly="" adopting="" technology="" solutions="" to="" support="" self-management="" practices="" [83,84].="" we="" were="" able="" to="" educate="" many="" more="" patients="" with="" online="" videos="" than="" group="" classes="" (70%="" vs.="" 33%="" respectively).="" online="" education="" provides="" the="" solution="" to="" several="" barriers="" faced="" with="" in-person="" education="" including="" transportation="" to="" the="" facility,="" scheduling,="" leaming="" pace(i.e.,="" patients="" can="" watch="" videos="" at="" their="" convenience="" and="" pace),="" and="" frequent="" physician="" visits="" or="" hospitalization.="" one="" major="" limitation="" is="" the="" production="" of="" videos="" in="" different="" languages.="" due="" to="" limited="" resources,="" we="" did="" not="" translate="" the="" education="" videos="" into="" spanish;="" consequently,="" not="" every="" patient="" benefited="" from="" the="">
4.3. Vascular Access
Kev nkag mus mus tas li tsim nyog rau kev lim ntshav ntev ntev yog qhov nyuaj los ntawm ntau qhov chaw kho mob thiab kev puas siab puas ntsws ua rau qhov no yog qhov tseem ceeb tab sis nyuaj metric. Kev siv AVF rau HD yog txuam nrog kev txhim kho kev tuag thiab kev mob nkeeg thiab tus nqi qis dua piv rau kev siv lub hauv paus venous catheter [10,72,85]. Tshaj li kaum xyoo dhau los, tus nqi ntawm AVF siv nyob rau hauv cov neeg mob dialysis ntau tau zoo tuaj ntawm kwv yees li 35 feem pua rau 65 feem pua I80]. Txawm li cas los xij, ntawm kev pib lim ntshav.AVF siv txuas ntxiv qis heev nrog ntau dua 80 feem pua ntawm cov neeg mob pib lim ntshav siv lub tunneled catheter [80. Qhov pib tshwm sim ntawm kev lim ntshav tseem muaj ntau dhau thiab yuav ua rau muaj kev tuag ntau thiab mob ntshav qab zib hauv thawj 6 lub hlis ntawm kev pib lim ntshav, tshwj xeeb tshaj yog rau cov neeg mob hnub nyoog 65 xyoo [80].
Earle hauv peb txoj kev txhim kho, peb tau ntsib kev qeeb qeeb los ntawm tus neeg mob xa mus rau kev phais vascular mus rau qhov tseeb thiab / lossis qhov chaw nkag mus rau vascular mus tas li. Txhawm rau daws qhov teeb meem no, peb tau tsim ib lub tsev kho mob raum mob raum-vascular phais, teem sijhawm ib hlis ib zaug, qhov twg cov neeg mob uas mob raum mob siab tuaj yeem pom tus kws kho mob nephrologist thiab kws phais mob thaum tib lub sijhawm mus ntsib. Qhov kev sib koom tes ntawm kev saib xyuas no ua rau muaj kev ntsuam xyuas vascular nkag mus rau lub sijhawm thiab kev phais. Qhov nruab nrab, 77 feem pua ntawm cov neeg mob pib HD nrog kev ua haujlwm AVF hauv thawj 2- xyoo voj voog thiab 61 feem pua ntawm lub voj voog thib ob. Ib qho kev sib tw uas peb tau ntsib nrog qhov ntsuas tau zoo no yog cov neeg mob tsawg uas hloov pauv ntawm cov kab mob raum mob raum theem 5 mus rau HD ua rau nws nyuaj rau kev sib piv thiab cov ntaub ntawv sib piv ib hlis ib hlis lossis ua kom pom kev txhim kho tseem ceeb. Peb cov txiaj ntsig zoo ib yam li lwm cov kev tshawb fawb pom tias muaj AVF ntau dua ntawm 45.2-68.4 feem pua ntawm cov neeg mob tau txais IP Cov kab mob raum mob raum kev kho mob piv rau 4.8-58.8 feem pua hauv cov pab pawg saib xyuas ib txwm muaj [1, A4,{15}},87]. Txawm hais tias tau txais kev kawm tiav thiab kev saib xyuas IP, muaj cov neeg mob uas yuav pib HD nrog lub tunneled catheter rau ntau qhov laj thawj suav nrog (1) kev xa mus lig rau cov neeg mob uas muaj kab mob raum siab thiab kev noj qab haus huv tsis zoo, (2) kev lim ntshav sai rau mob raum raug mob hauv Cov neeg mob uas yav tas los muaj mob nruab nrab (tsis yog qib siab) Cov kab mob raum tsis zoo ntawm lub hauv paus thiab (3) cov neeg mob uas pib xaiv cov tshuaj peritoneal dialysis, tseem pib nrog HD vim qhov tsis pom kev tsis zoo hauv kev noj qab haus huv Peb tab tom tsim thiab siv cov txheej txheem rau kev pib ceev PD (hauv { {20}} h tom qab tso PD catheter) los daws qhov teeb meem tom kawg.
Cistanche
4.4. Kev hloov pauv
Cov ciaj sia taus rau cov neeg mob nrog ESRD yog qhov zoo dua rau cov uas tau hloov lub raum piv rau cov neeg tau txais kev lim ntshav ntev [80]. Peb qhov kev zov me nyuam ua kom muaj kev xa mus raws sij hawm ntawm cov neeg sib tw tsim nyog rau qhov kev hloov pauv ib zaug GFR mus txog 20 mLmiry1.73 m2. Peb qhov kev paub dhau los yog tias cov neeg mob los ntawm peb qhov kev pab cuam raum mob raum IP tau txais txiaj ntsig zoo txog kev noj qab haus huv (i, e, kev saib xyuas kev noj qab haus huv, kev saib xyuas tus kheej ntawm cov txiaj ntsig kev noj qab haus huv, thiab kev ua raws li kev noj tshuaj) thiab muaj kev pheej hmoo siab dua ntawm kev tso npe rau hauv cov npe tos ( tsis qhia). Txawm li cas los xij, peb tsis tau ntsuas thiab muab piv rau peb qhov kev xa mus rau cov npe piv rau qhov kev saib xyuas nephrology li ib txwm. Qee cov neeg mob tau txais preemptive raum hloov pauv thaum lwm tus pib nce lub sijhawm tos ua ntej pib lim ntshav (Le, ib zaug GFRis qis dua 20 mL / min / 1.73 m²). qhov pom tseeb thiab pom ntawm cov npe hloov pauv hauv txhua tus neeg mob EHR.
4.5. Kev txhaj tshuaj
Kev txhaj tshuaj tiv thaiv yog ib lub tswv yim tiv thaiv kev noj qab haus huv uas muaj txiaj ntsig zoo tshaj plaws los txo cov neeg mob thiab kev tuag cuam tshuam nrog kev sib kis. Cov neeg mob uas mob raum mob yuav tsum tau txhaj tshuaj tiv thaiv kab mob npaws txhua xyoo, tshuaj tiv thaiv kab mob pneumococcal, thiab kab mob siab B [71]. Peb tsom mus rau kab mob pneumococcal es tsis yog txhaj tshuaj tiv thaiv kab mob siab B vim tias peb lub hauv paus tus nqi rau kev txhaj tshuaj tiv thaiv kab mob siab B yog qhov siab thaum muaj lub sijhawm los txhim kho cov tshuaj tiv thaiv kab mob pneumococcal. Txhawm rau txhim kho qhov kev ntsuas no, peb tau lees paub cov ntaub ntawv tseeb ntawm keeb kwm txhaj tshuaj tiv thaiv los ntawm tus kws muag tshuaj rau txhua tus neeg mob thiab peb tau kho cov txheej txheem txhaj tshuaj tiv thaiv. Peb tau ntsib kev nce ntxiv hauv cov tshuaj tiv thaiv kab mob pneumococcal los ntawm lub hauv paus ntawm tsawg dua 50 feem pua mus rau ntau dua 90 feem pua ntawm cov neeg mob thaum kawg ntawm lub voj voog qhia.
4.6.Cov lus qhia Advanced
Thaum lub sijhawm rov ua ntawv pov thawj, muaj lub sijhawm los tham txog cov nyiaj laus ntawm kev ntsuas thiab kev siv cov kev ntsuas tshiab. OurJoint Commission tus kws tshawb fawb tau xav tias cov neeg muab kev pabcuam hauv lub tsev kho mob raum mob raum IP nyob rau hauv txoj haujlwm tshwj xeeb los tham txog kev hloov pauv hauv kev saib xyuas thiab cov neeg mob nyiam thiab tau hais tias peb pib taug qab kev sib tham txog cov lus qhia siab heev nrog peb cov neeg mob. Kev sib tham txog cov lus qhia siab heev tuaj yeem tsis xis nyob tshwj xeeb tshaj yog nyob rau hauv qhov chaw kho mob thiab nrog cov neeg mob hluas. Peb tus kws saib xyuas kev noj qab haus huv tau npaj tau zoo tshaj plaws thiab ua haujlwm los coj kev sib tham nrog cov neeg mob. Txawm hais tias peb pom muaj kev txhawj xeeb txog qhov kev ntsuas no, peb muaj peev xwm pib sib tham txog cov lus qhia siab heev hauv 90 feem pua ntawm cov neeg mob, uas yog ib qho kev txhim kho tseem ceeb los ntawm tus nqi qis dua 30 feem pua. Hauv xyoo 2015, Medicare siv nyiaj ntau tshaj S64 billion rau cov neeg tau txais txiaj ntsig nrog mob raum mob thiab S34 billion rau ESRD cov nqi tag nrho ntau dua $ 98 billion [80]. Tus nqi yog qhov tsis txaus ntseeg siab rau cov neeg mob lim ntshav hauv xyoo kawg ntawm lawv lub neej. Kev sib tham txog cov lus qhia siab heev nrog cov neeg mob ntshav qab zib thiab lim ntshav yog qhov tseem ceeb los xaiv cov kev kho mob uas ua raws li cov neeg mob nyiam thaum txo cov nqi tsis tsim nyog rau zej zog.
4.7. Kev pheej hmoo mob plawv
Kab mob plawv (CVD) tseem yog qhov ua rau tuag hauv Tebchaws Meskas thiab feem ntau lwm lub tebchaws tsim [88]. Ntawm cov neeg mob uas muaj kab mob raum ntev, kev tuag los ntawm CVD yog ntau dua li kev nce mus rau ESRD. Cov kab mob raum ntev tau raug txheeb xyuas tias yog ib qho kev pheej hmoo ntawm kev ywj pheej rau CVD, txawm tias tom qab hloov kho rau cov xwm txheej ib txwm muaj [74]. Qhov kev pheej hmoo rau CVD nce raws li GFR poob [80,89]. Kev ntsuam xyuas qhov kev pheej hmoo yog qhov tseem ceeb vim tias qhov kev pheej hmoo loj heev thiab qhov tsis zoo tshwm sim tom qab CVevent hauv cov neeg mob uas mob raum mob raum piv rau cov pej xeem (piv txwv li, hloov kho ob xyoos ntawm cov neeg mob uas mob myocardial infarction yog 81 feem pua ntawm cov pej xeem, piv rau 56. Qhov feem pua ntawm cov kab mob raum ntev4-5[80]. Kev kwv yees kev pheej hmoo rau CVD hauv cov neeg mob uas muaj kab mob raum tsis zoo vim muaj cov kab mob plawv thiab cov kab mob uas tsis yog ib txwm muaj, Online thiab smartphone kev pheej hmoo lub laij lej tau tsim los ntawm American College ntawm Cardiology, muaj: http://tools.ac.org/ASCVD-Risk-Estimator-Plus/!/calculate/estimate (Last Accessed: 625/18). hauv EHR, ua rau muaj kev nce nrawm thiab nrawm hauv cov ntaub ntawv ntawm qhov kev pheej hmoo tseem ceeb no los ntawm xoom mus rau 100 feem pua ntawm qhov kawg ntawm lub voj voog qhia. Cov neeg mob uas muaj kev pheej hmoo siab ASCVD tau txais kev saib xyuas ntxiv n hais txog kev kawm txog qhov tseem ceeb ntawm kev hloov pauv txoj kev ua neej, kev tswj xyuas kev kho mob tsim nyog, thiab kev xa mus rau cardiology.
4.8. Lwm qhov ntsuas
Rau lwm qhov ntsuas, peb tau ua tiav kev txhim kho tus nqi ntawm kev ua tiav ntawm cov ntaub ntawv mus ntsib chaw ua haujlwm hauv EHR hauv 48 teev ntawm kev mus ntsib hauv chaw ua haujlwm los ntawm qis dua 50 feem pua mus rau kwv yees li 100 feem pua. hli. Peb tsis tau txhim kho ntau yam hauv qee cov txheej txheem ntsuas xws li kev tshem tawm hauv tsev kho mob lossis kev nkag mus rau kev saib xyuas vim muaj ntau yam sab nraud ntawm peb txoj kev tswj hwm.
4.9.Kev sib tw
Tus nqi them ua ntej ntawm pab pawg IP yog qhov kev sib tw loj tshaj plaws rau kev siv thiab tswj xyuas tus kab mob raum mob raum IP. Tus qauv nqi-rau-kev pabcuam hauv Tebchaws Meskas tsis them rov qab ntau tus neeg koom tes uas tsis yog cov kws kho mob lossis cov kws tshaj lij kev xyaum ua haujlwm (tus kws kho mob txuas ntxiv). Dieticians raug them rov qab los ntawm Medicare rau kev ntsuam xyuas cov neeg mob mob raum mob raum theem 4, txawm hais tias peb ntsib teeb meem logistical nrog teem sijhawm cov neeg mob rau ob qhov kev mus ntsib (nrog rau tus kws kho mob thiab kws kho mob) thaum tib lub raum kab mob mus ntsib, tau txais kev pov hwm kev tso cai rau txhua qhov kev mus ntsib nrog rau noj zaub mov, thiab muab tus kws kho mob xa mus rau tus kws noj zaub mov rau txhua qhov kev mus ntsib tom ntej. Medicare muab cov nyiaj them rov qab rau 6 qhov kev kawm ntawm kev lim ntshav, tab sis cov kev sib tham no yuav tsum muaj tsawg kawg yog 30 feeb ntev thiab muab los ntawm tus kws kho mob lossis tus kws kho mob txuas ntxiv. Kev tswj xyuas cov tshuaj kho mob muab los ntawm tus kws muag tshuaj tsis tuaj yeem them rov qab raws li Medicare qauv tam sim no txij li kev mus ntsib tus kab mob raum tau ua tiav nrog tus kws kho mob. Cov kev pabcuam social worker tsis tuaj yeem them rov qab tshwj tsis yog muaj kev sab laj rau kev mob hlwb. Txawm li cas los xij, IP Cov Kev Pabcuam raum mob raum muaj peev xwm tsim tau cov nyiaj tau los qis lossis tsis ncaj los ntawm kev nce cov neeg mob sab nraud 'kev pib lim ntshav, ntau cov neeg mob pib lim ntshav nrog kev nkag mus tas li, siv PD ntau dua, txhim kho kev xa mus rau kev hloov pauv hauv lub raum pub dawb, thiab dhau los ua tus nqi siab dua. hloov pauv. Tag nrho cov no pab txhawb tus nqi ntawm kev saib xyuas IP lossis txawm tias ua rau IP Cov kab mob raum mob raum tau txais txiaj ntsig zoo.
Xyoo 2015, Medicare ESRDExpenditure/neeg/xyoo yog S88750 rau tus neeg mob HD, 575,140 rau tus neeg mob PD thiab $34,084 rau tus neeg mob hloov pauv [80]. Cov neeg mob uas tau txais kev lim ntshav nrog AVF muaj tus nqi qis dua / cov tswv cuab / xyoo piv rau cov neeg uas muaj HD catheters [80]. Tsis ntev los no, Lin thiab cov npoj yaig tau soj ntsuam tus nqi-zoo ntawm qhov theoretical IP Cov kab mob raum mob raum piv rau kev saib xyuas kab mob raum niaj hnub hauv U, S Medicare cov neeg tau txais txiaj ntsig nrog theem 3 thiab 4 Cov kab mob raum ntev ntawm hnub nyoog 45 thiab 84 xyoo, Cov qauv kev tshwm sim tau pom tias Medicare-nyiaj pab cuam IP Cov kab mob raum ntev tuaj yeem ua rau tus nqi zoo los ntawm kev txo qis qhov xav tau rau RRT thiab ua kom lub neej ntev [13].
Qhov chaw kuj tseem yuav ua rau muaj kev sib tw thaum tsim ib txoj haujlwm tshiab. Peb pib qhov chaw ruaj ntseg los ntawm kev sib koom tib qhov chaw kho mob thiab kev faib sijhawm raws li cov chaw kho mob nephrology, Qhov no tsis yog qhov nyuaj piv rau kev ruaj ntseg qhov chaw tshiab uas yog ib feem ntawm peb lub hom phiaj los nthuav cov kev pab cuam. Peb tawm tsam nrog qhov tau txais qhov chaw tshiab los ntxiv cov chaw kho mob ntxiv hauv lwm thaj chaw kom zoo dua rau peb cov neeg mob sib txawv.
4.10.Kev txwv ntawm Peb Txoj Kev Kawm
Muaj ob peb yam kev txwv rau peb txoj kev kawm. Qhov no yog ib qho kev soj ntsuam, piav qhia kev tshawb fawb soj ntsuam qhov cuam tshuam ntawm Kev Sib Koom Tes Kev Pom Zoo thiab Kev Tshawb Fawb Txog Kev Kho Mob thiab cov txheej txheem ntawm kev saib xyuas cov txiaj ntsig rau cov neeg mob mob raum mob. Txij li tsis muaj pawg tswj hwm hauv qhov kev tshawb fawb no, nws muaj peev xwm ua tiav cov txiaj ntsig kev kho mob hauv qhov kev pab cuam no tuaj yeem ua tiav hauv tsev kho mob raws li kws kho mob. Txawm li cas los xij, ntau tus neeg koom tes tau coj ntau txoj haujlwm txhim kho kom zoo (piv txwv li, kev txhaj tshuaj tiv thaiv los ntawm tus kws muag tshuaj, cov lus qhia siab heev los ntawm cov neeg ua haujlwm hauv zej zog, kev siv tshuaj ntxuav tes mus tas li los ntawm tus kws kho mob nephrologist) thiab nws tsis zoo li tias ib pab neeg ib leeg tuaj yeem ua txhua yam ntawm nws. Qhov kev sib koom ua ke no yog qhov tseem ceeb rau peb txoj kev vam meej thiab qhov kev txhim kho kom zoo no yuav tsis zoo li yuav muaj nyob rau lub sijhawm ntev hauv tsev kho mob raws li kws kho mob. Thib ob, qee tus neeg mob xa mus rau peb qhov kev pabcuam tau txais kev saib xyuas hauv lub tsev kho mob nephrology ua ntej xa mus thiab nws muaj peev xwm ua tau qhov kev saib xyuas yav dhau los tau cuam tshuam rau lawv cov txiaj ntsig, tab sis qhov kev tsis ncaj ncees no yuav muaj nyob rau hauv ob qho tib si cov lus qhia rau cov txiaj ntsig ntawm kev txaus siab, Qhov kawg, Cov txiaj ntsig yuav tsis tuaj yeem nthuav dav rau cov kev kawm uas tsis yog kev kawm muab qhov sib txawv ntawm cov ntaub ntawv xov xwm, cov neeg mob, thiab cov tswv cuab hauv pab pawg IP. Kev tshawb fawb ntxiv yog xav tau los sib piv cov txiaj ntsig thiab qhov txiaj ntsig ntawm kev saib xyuas IP rau kev saib xyuas kab mob raum li niaj zaus thiab ntsuas qhov ua tau ntawm kev nthuav tawm cov qauv kev saib xyuas no rau lwm lub tsev.
Cistanche extract
5. Cov lus xaus
Kev sib koom ua ke daim ntawv pov thawj xav tau kev txhim kho thiab kev siv cov kev ruaj ntseg zoo thiab cov phiaj xwm txhim kho kev ua haujlwm. Kev kho mob raum mob raum muaj cov txheej txheem nyuaj thiab kev txhim kho hauv cov txiaj ntsig kev ntsuas tau ua tiav zoo tshaj plaws los ntawm kev siv pab pawg raws li qhov kev saib xyuas zoo yog qhov tseem ceeb rau txhua tus neeg hauv pab pawg IP. Kev ua tiav daim ntawv pov thawj tsis yog ib txoj haujlwm yooj yim, nws yuav tsum muaj kev coj noj coj ua, kev mob siab rau, kev cog lus rau lub sijhawm, thiab kev txhawb nqa hauv lub koom haum nrog cov nqi zog ntawm kev lees paub hauv tebchaws, kev lees paub sab nraud ntawm kev saib xyuas zoo rau cov neeg mob peb ua haujlwm.
Cov ntaub ntawv
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