目的 构建基于社区的COPD家庭—社区—医院优化管理路径,为COPD患者的慢性病管理提供依据。 方法以PDCA循环为理论框架,编制COPD家庭—社区—医院优化管理路径专家咨询问卷,选取天津市临床诊疗、临床护理、社区护理、护理管理、护理教育领域的15名专家进行2轮问卷函询,结合专家意见及指标界值筛选法完成优化路径的最终构建。结果函询专家的权威系数为0.90,2轮函询的积极系数分别为93.75%、100%。最终确定的COPD家庭—社区—医院优化管理路径,包括评估、计划、实施、评价、变异、反馈6项一级指标,21项二级指标。一级、二级指标协调系数分别为0.16、0.14,条目重要性评分均>3.5分,变异系数为0.053~0.137。结论构建的COPD家庭—社区—医院优化管理路径,具有较好的科学性、可靠性。

Objective A community-based management pathway of "family-community-hospital" was constructed to provide theoretical basis for chronic disease management of COPD. Methods By using "Plan-Do-Check-Act" as the theoretical framework we designed"family-community-hospital" pathway for COPD. Fifteen experts in the field of clinical diagnosis and treatment,clinical nursing,community nursing,nursing management and nursing education in Tianjin were selected and two rounds of questionnaire consultations were conducted. The final pathway was completed by combining expert opinions and the index threshold screening method. Results The authority coefficient of experts was 0.90. The response rates of two rounds consultation were respectively 93.75% and 100%. The optimal management pathway of COPD in family-community-hospital was consisted of 6 first-level indicators and 21 second-level indicators. The first-level indicators included assessment,plan,action,evaluation,variation and feedback. The coordination coefficients were respectively 0.16 and 0.14. The score of the importance was up 3.5 points.The coefficient of variation was among 0.053 and 0.137. Conclusion The optimal management pathway of COPD with"family-community-hospital" has been proved to be scientific.