坂井 志麻

AIM: The aim of this study is to analyse the risk factors for unplanned readmissions within 1 month after hospital discharge to develop a seamless support system from discharge to home care. BACKGROUND: With shorter hospital stay lengths, understanding the characteristics of patients with multiple risk factors is important to prevent rehospitalization. DESIGN: This is a single-centre retrospective descriptive study. METHODS: Logistic regression and decision tree analyses were performed using eight items from the records of 3117 patients discharged from a university hospital between April-September 2017 as risk factors. RESULTS: Unplanned readmission risk was significantly associated with emergency hospitalization (odds ratio [OR]: 3.12, 95% confidence interval [CI]: 2.04-4.77), malignancy (OR: 2.16, 95% CI: 1.44-3.24), non-surgical admission (OR: 1.76, 95% CI: 1.07-2.88), hospital stay of ≥ 15 days (OR: 1.66, 95% CI: 1.14-2.43) and decline in activities of daily living owing to hospitalization (OR: 1.68, 95% CI: 1.06-2.64). The highest risk combinations for rehospitalization were as follows: emergency hospitalization and malignancy; emergency admission, non-malignancy and a hospital stay of ≥15 days; and scheduled hospitalization, no surgery and a hospital stay of ≥15 days. CONCLUSIONS: Patients with multiple risks for unplanned readmission should be accurately screened and provided with optimal home care.

本実践報告の目的は,継続看護マネジメントを基盤に開発した多職種連携教育プログラムの実施とその評価をし,プログラム改善の示唆を得ることである.プログラム参加者はA病院と関連施設に所属する多職種チーム(7チーム:43人)であった.評価方法はプログラム終了後に自記式質問紙調査を実施した.調査協力者は31人(回収率:72.1%),看護師26人,社会福祉士・栄養士・理学療法士等の専門職種が5人であった.自己評価得点は研究協力者全体で「学びを他の参加者と共有することができた」が最も高かった.参加者の学びは,看護師は【多職種の視点で協働するチームの力を認識する】,他職種は【多職種の強みの発揮と連携の大切さを学ぶ】,さらに【対象・家族の目標を中心に考える視点の必要性を学ぶ】等,チームが共通の目標に向かう基盤づくりになった.多職種参加を促すため,CNMの理解を深めプログラムの時間配分の検討が課題である.(著者抄録)

目的:認知症・認知機能低下を伴う入院高齢者への多職種連携による退院支援が,在院日数短縮,QOL向上に有効か,システマティックレビューとメタアナリシスにより評価する.方法:PRISMAの手法を用いてシステマティックレビューとメタアナリシスを行った.適格基準は(1)認知機能障害のある平均年齢65歳以上の入院高齢者,(2)多職種による退院支援,(3)対照は通常ケア(対照群),(4)ランダム化比較試験とした.メタアナリシスはRev Man 5.4.1を用いて変量効果モデルによる分析,異質性はI2で評価した.結果:採択6文献のメタアナリシスより,介入群と対照群の在院日数,QOLのアウトカムに有意差は認めなかった.結論:認知症高齢者の在院日数短縮,QOLの向上に対し,退院支援の有効性は示されなかった.今後,多職種退院支援に関する研究を積み重ねる必要性が示唆された.(著者抄録)

【目的】本研究は継続看護マネジメント(以下、CNMと略す)教育プログラム(基礎編)の研修に参加した看護職の学びの特徴を明らかにし、教育プログラムの意義と今後の活用への示唆を得ることである。【方法】CNM研修受講者252人に自記式質問紙調査を行った。対象は有効回答188人(74.6%)であった。調査はCNM研修を評価する19項目と「新しい学び」と「実践での活用」の自由記述で構成した。【結果】所属は、病棟、退院支援、外来、訪問看護、教育等であった。評価得点19項目のうち5項目で、訪問看護が病棟より有意に高く、学びの特徴として病棟看護師はCNMを新たな実践概念として学び、訪問看護師は自らの実践を振り返りCNMと実践を結びつけていた。【考察】CNM研修は多様な場で働く看護職が患者を時間軸で捉えることで、生活者としての理解や目標志向を学ぶ機会となる。また、自らの活動の場の特徴や役割を意識化し、看護職間の相互理解を促進する可能性が示唆された。(著者抄録)

CONTEXT: In recent times, advance care planning for patients' end-of-life care preferences has attracted much attention worldwide. OBJECTIVES: To develop the Readiness for Advance Care Planning (RACP) Scale. METHODS: Participants included 624 Japanese citizens who were registered with a web-based survey company as of February 2019. Items regarding the process of advance care planning (ACP) were developed based on a literature review and expert panel discussions. The expert panel included nine experts and practitioners in the field of end-of-life care. Construct validity, concurrent validity, internal consistency, and test-retest reliability were evaluated. RESULTS: Initially, 37 items were collected. Examination of the floor effect, item-total, good-poor analysis, and exploratory factor analysis yielded a five-factor model with 28 items. The goodness of fit of the model was GFI = 0.80, CFI = 0.91, and RMSEA = 0.08. The concurrent validity was statistically significant (rs = 0.26-0.45, ps < 0.001). Cronbach's alpha for the overall scale was 0.95. The corresponding values for the subscales ranged from 0.90 to 0.97. The intraclass correlation coefficients indicating test-retest reliability was 0.66 (P < 0.001) for the total scale and ranged from 0.52-0.65 for the five subscales. CONCLUSIONS: The validity and reliability of the scale were generally acceptable. The RACP is an appropriate instrument to evaluate the level of readiness for ACP behaviors among people of various generations at every health stage. More studies are needed to examine the clinical utility of the RACP, both nationally and internationally.

目的:外来看護師の在宅療養移行支援実践評価尺度を開発し,その妥当性と信頼性を検討する.方法:文献検討とインタビューより抽出したデータを基に,外来看護師の在宅療養移行支援実践評価尺度原案を作成した.全国805施設の外来看護師を対象に質問紙調査を行い,妥当性・信頼性の検証を行った.結果:分析対象は360名で(有効回答率22.3%),探索的因子分析の結果,25項目4下位尺度を作成した.モデルの適合度は,GFI=.845,AGFI=.812,CFI=.904,RMSEA=.073であった.収束的妥当性はr=.741(p<.001)で,弁別的妥当性はr=-.471(p<.001)であった.尺度全体のクロンバックαが.945で,下位尺度は.771〜.915であった.結論:本尺度の妥当性,信頼性は,統計量的に許容範囲であることが確認された.地域包括ケアシステムにおいて,外来看護師が実践する在宅療養移行支援の標準的指標となり,教育研修の効果測定に活用できる.(著者抄録)

【目的】認知症および認知機能低下を有する入院・入所高齢者への身体拘束減少に有効な介入プログラムについてシステマティックレビューとメタアナリシスにより評価する。【方法】The Cochrane Handbookの手法により、系統的レビューを行った。文献の適格基準は、(1)入院・入所中の65歳以上の認知症等高齢者を対象、(2)身体拘束をアウトカム指標に含む、(3)ランダム化比較試験とした。メタアナリシスには、Review Manager 5を用い、変量効果モデルによるリスク比(RR)を算出し、異質性はI2統計量により評価した。【結果】14文献が選定され、そのうちスタッフ教育による身体拘束の減少を報告した文献が4件あった。スタッフ教育の内容は、ケアの理念、せん妄予防、拘束帯使用の意思決定、拘束代替案、認知症ケアや入所者との相互作用の強化であり、時間数は30分〜16時間と幅があった。メタアナリシスでは6文献、1,355人分を統合したが、身体拘束の実施者数に差は認められず(RR=0.88;95%Confidence Interval=0.72-1.08;I2=70%)、盲検化、および症例減少バイアスを認めた。【結論】高齢者ケア施設に勤務するスタッフへの教育は、入院・入所高齢者の身体拘束の減少に定性的評価では有効である可能性が示唆されたが、メタアナリシスでは統計学的有意差がみられず、エビデンスは限定的である。(著者抄録)

AIM: End-of-life care for people with dementia is becoming increasingly important as the global population ages. However, there is no agreed definition of a good death for people with dementia. The current review examined previous literature to establish the current state of knowledge on this issue. METHODS: We conducted a scoping review using a standard methodological framework. Relevant studies were identified from four databases. Studies were included if they were in English, discussed palliative or end-of-life care for dementia, and defined or explained a good death. The definitions or explanations of a good death were categorized into subthemes, and grouped into broader themes. RESULTS: We identified 11 articles discussing or explaining a good death in dementia, which were published between 2009 and 2017. Most of these studies drew on the views of healthcare professionals and/or family members of people with dementia, and only one considered the views of people with dementia themselves. Ten themes were identified, including pain-free status, peaceful/comfort, dignity, family presence, surrounded by familiar things and people, person-centered communication, spirituality, life completion, treatment preferences, and other. CONCLUSIONS: The characteristics of a good death in dementia showed similarities with those identified more generally. However, there were some themes that were specific to end-of-life care in dementia, notably "surrounded by familiar things and people" and "person-centered communication". To obtain a fuller picture of the nature of a good death in dementia, researchers need to examine the views of people living with dementia.

AIMS: To develop the Discharge Planning of Ward Nurses (DPWN), a Japanese self-evaluation instrument for ward nurses' discharge planning practices. DESIGN: Cross-sectional survey. METHODS: Participants were 624 ward nurses from six hospitals in Japan with a discharge planning department. Items about discharge planning practices were collected from literature and interviews with nurses and researchers. Construct validity, concurrent validity, internal consistency and test-retest reliability were tested. RESULTS: Initially, 55 items were collected. Examination of the floor effect, item-total, good-poor analyses and exploratory factor analysis yielded a four-factor model with 24 items ('teaching home-care skills with community/hospital professionals,' 'identifying clients' potential needs early in the discharge process,' 'introducing social resources' and 'identifying client/family wishes and building consensus for discharge'). The four-factor structure was supported by confirmatory factor analysis. The DPWN correlated with scales ascertaining similar concepts, supporting concurrent validity. Internal consistency and test-retest reliability were generally satisfactory.

The purpose of this study was to investigate the effect of a discharge planning educational program on multidisciplinary team staff in a community. We provided training to nurses of a university hospital. The training covered an introduction to discharge planning, decision-making support, home care medicine and home nursing care, the medical social welfare system, and case review meetings. It was conducted every year from September through February between 2012 and 2015. Before and after the training, the awareness of nurses was evaluated by using self-administered questionnaires and the Discharge Planning scale for Ward Nurses(DPWN), and discharge planning satisfaction was measured using a visual analogue scale (VAS). The study process was reviewed and approved by the Ethics Committee of Tokyo Women's Medical University. The questionnaires were distributed to 96 nurses; of these, responses of 72 nurses(pre- and post-training)were analyzed(response rate: 75.0%). The average number of years of nursing experience was 8.5± 7.7. The total score of the DPWN and its subscales, as well as the VAS, with regard to satisfaction level significantly increased after the training(p<0.01), indicating that training improved nurses' awareness of discharge planning practices.

Since 2006, the department of home nursing care at Tokyo Women's Medical University Hospital has held a half year long 6-courses home medical care workshop for our hospital nurses by inviting local medical and welfare specialists as their lecturers. The objective of the workshop was to gain a wider range of knowledge and understanding of hospital discharge support system and home medical care services. In order to evaluate the level of understanding and achievement obtained from the workshop, a questionnaire survey was conducted in 2010 asking the participants to fill out a self evaluation form before and after the course. In addition to that, a class evaluation form was handed out after each class to evaluate a level of understanding of each lecture. The result showed that all aspect of the evaluation levels went up(p<0. 05). Some of the free comments were summarized in the followings: 1 ) Positive results were obtained by working together, and we learned how to coordinate with the regional medical specialists through specific case studies. 2 ) It was a good opportunity for the nurses to receive a direct advice from facilitators(visiting nurses)on cases at hand. 3 ) The lectures' talks based on their experiences brought us a feeling of closeness in the regional home medical care. After the course was concluded, the following issues were raised by hospital ward nurses in the area of difficulties at the time of patient's discharge from the hospital: 1 ) The coordination between doctors and other medical specialists, 2 ) Handling of different requirements among the different family members, 3 ) Timing of patient discharge planning, and 4 ) Lack of knowledge in social resources and medical health insurance system. Hence, we would like to incorporate these survey findings.

A survey was conducted to 75 unit-nurses to verify the change in nurses' knowledge and practice before or after the intervention by using a discharge support planning tool at highly advanced medical center. The discharge support planning tool was made from four sheets: Screening Sheet I - an identification sheet for patient who needs a discharge plan at an early stage, Screening Sheet II - an activity evaluation sheet to check the patient's daily activities, Screening Sheet III - a direction confirmation sheet for the family and medical practitioners, and Screening Sheet IV - a discharge flow chart to show overall discharge arrangements. In the survey results, the unit nurses' knowledge and practice was significantly increased after the use of the discharge support planning tool(p<0.05)in the following areas: (1) collection of information regarding the economic situation and social environment, (2) preparedness of medical services, and (3) a team work between nurses and dieticians for discharge support planning. A satisfaction to the discharge support planning tool was also increased(p<0.01). Utilizing the discharge planning tool is a useful manual to determine the contents of the discharge planning. It also gives an idea for inexperienced nurses what the discharge planning tool is all about.

癌患者の終末期ケアについての研究は多いが、高齢者の特性を踏まえた終末期ケアについては明らかにされていない。多くの高齢者は病院で最期を迎えている現状から、質の高い高齢者医療施設において、終末期における高齢者の状態、特に苦痛について実態を把握することを目的として調査を行った。その結果から医療施設における高齢者の特性を踏まえた終末期ケアの課題を見出す。2003年10月から4ヵ月間に、高齢者高度医療専門病院の呼吸器、循環器および脳神経病棟において死亡し、入院1週間以上の75歳以上の高齢者について、看護師より情報を収集した。得られたデータは35例であり、平均年齢は81.5歳、男性19名(54.2%)、平均在院日数は23.1日で、うち癌患者は14名(40.0%)であった。身体的苦痛は便秘(71.4%)、浮腫(66.6%)、呼吸困難と疲労感・倦怠感(45.7%)、疼痛(34.3%)の順に多かった。入院時に混乱ありが16名(45.7%)、興奮あり9名(25.7%)であった。癌疾患を有する患者と有しない患者を比較した結果、癌患者の苦痛が強いという結果は示さなかった。呼吸困難についても2群で同様の傾向を示しており、呼吸困難ありは全体で45.7%であった。酸素療法を実施していたのは82.9%であり、呼吸困難の訴えは酸素療法実施者の割合に比べ少なかった。入院時に認知障害ありが82.8%、意識障害ありは71.4%であり、認知に障害のあった人が多いことが呼吸困難の訴えを少なく捉えていたのではないかと考えられた。高齢者は認知機能が低下してからの入院であったことから、入院早期の興奮や混乱への対応が重要である。さらに意識レベルが早期から低下することへの対応や、認知の障害のある高齢者の苦痛を把握する方法の開発が必要であることが示唆された。(著者抄録)