老年髋部骨折患者出院准备服务计划专家共识

中国脆性骨折联盟 ,  北京围手术期医学学会老年骨科护理与康复专业委员会 ,  湖南省护理学会骨科专业委员会

骨科临床与研究杂志 ›› 2026, Vol. 11 ›› Issue (5) : 322 -328.

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骨科临床与研究杂志 ›› 2026, Vol. 11 ›› Issue (5) : 322 -328. DOI: 10.19548/j.2096-269x.2026.05.002
指南与共识

老年髋部骨折患者出院准备服务计划专家共识

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Expert consensus on discharge preparation service plan for elderly patients with hip fractures

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摘要

出院准备服务是帮助患者从医院平稳地过渡到家庭或照护机构,保证护理延续性的关键环节。如果出院准备不足,会导致患者身体功能恢复缓慢,容易引起再次骨折甚至死亡等不良结局。通过标准化的出院准备服务计划,能够改善患者相关不良结局。本共识基于临床循证证据,结合骨科护理实践经验,收集相关领域专家意见,聚焦于老年髋部骨折患者的特点和出院准备服务的整个流程,旨在提升老年髋部骨折患者的远期功能恢复水平、降低其再入院率与不良事件风险,改善生活质量,并为临床医务人员提供规范化的实践指导。

Abstract

Discharge preparation services are a crucial link to help patients smoothly transition from hospital to home or care institutions and ensure the continuity of care. Insufficient discharge preparation can lead to slow recovery of patients' physical functions, and may even cause adverse outcomes such as re-fracture or death. Through standardized discharge preparation service plans, the related adverse outcomes of patients can be improved. This consensus is based on clinical evidence-based data, combined with the practical experience of orthopedic nursing, and collects the opinions of experts in related fields. The entire text focuses on the characteristics of elderly patients with hip fractures and the entire process of discharge preparation services. It aims to improve the long-term functional recovery level of elderly patients with hip fractures, reduce their readmission rate and the risk of adverse events, improve their quality of life, and provide standardized practical guidance for clinical medical staff.

关键词

髋部骨折 / 老年人 / 出院准备服务计划 / 专家共识

Key words

Hip fracture / Aged / Discharge preparation service plan / Expert consensus

引用本文

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中国脆性骨折联盟,北京围手术期医学学会老年骨科护理与康复专业委员会,湖南省护理学会骨科专业委员会. 老年髋部骨折患者出院准备服务计划专家共识[J]. 骨科临床与研究杂志, 2026, 11(5): 322-328 DOI:10.19548/j.2096-269x.2026.05.002

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参考文献

[1]

陈旭娟, 朱晓萍, 田梅梅, 等. 老年髋部骨折术后患者肺部感染预测模型的构建及验证[J]. 中华护理杂志, 2021, 56(5): 659-666. DOI: 10.3761/j.issn.0254-1769.2021.05.003.

[2]

Cooper C, Campion G, Melton LJ 3rd. Hip fractures in the elderly: a world-wide projection[J]. Osteoporos Int, 1992, 2(6): 285-289. DOI: 10.1007/BF01623184.

[3]

Zhang Chenghui, Feng Jingnan, Wang Shengfeng, et al. Incidence of and trends in hip fracture among adults in urban China: a nationwide retrospective cohort study[J]. PLoS Med, 2020, 17(8): e1003180. DOI: 10.1371/journal.pmed.1003180.

[4]

Zheng Wei, Cai Qianying, Zhang Changqing, et al. One-year functional outcomes following geriatric hip fracture: a prospective cohort analysis[J]. Orthop Surg, 2025, 17(7): 2130-2140. DOI: 10.1111/os.70081.

[5]

刘刚, 杨明辉, 张京, 等. 《老年髋部骨折诊疗与管理指南(2022年版)》解读[J]. 骨科临床与研究杂志, 2023, 8(2): 73-76. DOI: 10.19548/j.2096-269x.2023.02.002.

[6]

王琳珏, 郭锐. 老年髋部骨折手术治疗的研究进展[J]. 现代诊断与治疗, 2021, 32(9): 1368-1370.

[7]

熊丹莉, 潘路晨, 杨赛, 等. 出院准备计划方案在老年肠造口患者中的应用研究[J]. 护理学杂志, 2023, 38(19): 100-104. DOI: 10.3870/j.issn.1001-4152.2023.19.100.

[8]

Ko Y J, Lee J H, Baek S. Discharge transition experienced by older Korean women after hip fracture surgery: a qualitative study[J]. BMC Nurs, 2021, 20(1): 112. DOI: 10.1186/s12912-021-00637-9.

[9]

Hall K K, Shoemaker-Hunt S, Hoffman L, et al. Making health care safer Ⅲ: a critical analysis of existing and emerging patient safety practices[M]. Rockville (MD): Agency for Healthcare Research and Quality (US), 2020.

[10]

黄淳, 郑西林, 彭伶丽, 等. 老年髋部骨折患者出院准备服务计划的最佳证据总结[J]. 华西医学, 2023, 38(10): 1503-1510. DOI: 10.7507/1002-0179.202308223.

[11]

王婉. 出院准备服务在老年髋部骨折患者术后康复中的应用研究[D]. 内蒙古医科大学, 2020.

[12]

李珊, 李欣潞, 郝德慧, 等. 基于出院需求评估结果制订的护理出院计划对老年髋部骨折术后患者出院准备度、出院指导质量及早期康复效果的影响[J]. 广西医学, 2024, 46(7): 1031-1038. DOI: 10.11675/j.issn.0253-4304.2024.07.14.

[13]

孙超, 奚桓, 李峥, 等. 老年患者出院准备服务专家共识(2019版)[J]. 中华护理杂志, 2020, 55(2): 220-227. DOI: 10.3761/j.issn.0254-1769.2020.02.011.

[14]

王春青, 胡雁. JBI证据预分级及证据推荐级别系统(2014版)[J]. 护士进修杂志, 2015, 30(11): 964-967. DOI: 10.16821/j.cnki.hsjx.2015.11.002.

[15]

徐云明, 吴刚, 刁仁月, 等. 老年脆性髋部骨折患者术后并发症及日常活动能力的危险因素分析及风险预测模型建立[J]. 中国骨伤, 2026, 39(7): 720-730.

[16]

Falaschi P, Marsh D, eds. Orthogeriatrics: the management of older patients with fragility fractures[M]. Cham (CH): Springer, 2021.

[17]

段文静. 老年髋部骨折术后多病共存患者出院准备度现状及影响因素分析[D]. 安徽中医药大学, 2025.

[18]

Dreinhöfer K E, Mitchell P J, Bégué T, et al. A global call to action to improve the care of people with fragility fractures[J]. Injury, 2018, 49(8): 1393-1397. DOI: 10.1016/j.injury.2018.06.032.

[19]

Quality AFHR. Care transitions from hospital to home: IDEAL discharge planning[EB/OL]. (2013-06-15)[2025-10-15]. https://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy4/index.html.

[20]

Fernández-González M, Lozano-Lozano M, Martín-Martín L, et al. Is a telerehabilitation programme for older adults with hip fracture associated with burden of family caregivers who provide support?[J]. Digit Health, 2023, 9: 20552076231213574. DOI: 10.1177/20552076231213574.

[21]

Rocha P, Baixinho C L, Albuquerque C, et al. Nurses' perspective on transitional care for older person with hip fracture: a qualitative study[J]. Int J Orthop Trauma Nurs, 2025, 58: 101214. DOI: 10.1016/j.ijotn.2025.101214.

[22]

Brooks L, Stolee P, Elliott J, et al. Transitional care experiences of patients with hip fracture across different health care settings[J]. Int J Integr Care, 2021, 21(2): 2. DOI: 10.5334/ijic.4720.

[23]

Saletti-Cuesta L, Tutton E, Langstaff D, et al. Understanding informal carers' experiences of caring for older people with a hip fracture: a systematic review of qualitative studies[J]. Disabil Rehabil, 2018, 40(7): 740-750. DOI: 10.1080/09638288.2016.1262467.

[24]

汪晖, 王颖, 刘于, 等. 住院患者出院计划关键任务的证据总结[J]. 中华护理杂志, 2020, 55(9): 1412-1419. DOI: 10.3761/j.issn.0254-1769.2020.09.026.

[25]

Blaylock A, Cason C L. Discharge planning predicting patients' needs[J]. J Gerontol Nurs, 1992, 18(7): 5-10. DOI: 10.3928/0098-9134-19920701-05.

[26]

江雅倩, 汪晖, 刘于, 等. 出院计划综合需求评估量表的编制与信效度检验[J]. 护理实践与研究, 2022, 19(19): 2988-2991. DOI: 10.3969/j.issn.1672-9676.2022.19.

[27]

北京护理学会骨科专业委员会, 中华医学会骨科学分会护理学组, 中华医学会创伤学分会护理学组. 中国老年髋部骨折围手术期护理专家共识(2023)[J]. 中华创伤骨科杂志, 2023, 25(5): 369-379. DOI: 10.3760/cma.j.cn115530-20230104-00004.

[28]

Alper E. Hospital discharge and readmission[EB/OL]. UpToDate, 2025-05-21 [2026-05-07]. https://www.uptodate.com/contents/hospital-discharge-and-readmission

[29]

张咪, 周春兰, 吴艳妮, 等. 老年髋部骨折术后患者家庭康复护理的最佳证据总结[J]. 中华护理杂志, 2022, 57(22): 2777-2783. DOI: 10.3761/j.issn.0254-1769.2022.22.014.

[30]

NICE. Hip fracture: management[EB/OL]. (2023-01-06)[2025-10-13]. https://www.nice.org.uk/guidance/cg124.

[31]

Kane RL. Finding the right level of posthospital care: "We didn't realize there was any other option for him"[J]. JAMA, 2011, 305(3): 284-293. DOI: 10.1001/jama.2010.2015.

[32]

Jones C D, Cumbler E, Honigman B, et al. Hospital to post-acute care facility transfers: identifying targets for information exchange quality improvement[J]. J Am Med Dir Assoc, 2017, 18(1): 70-73. DOI: 10.1016/j.jamda.2016.09.009.

[33]

Adler-Milstein J, Raphael K, O'Malley T A, et al. Information sharing practices between us hospitals and skilled nursing facilities to support care transitions[J]. JAMA Netw Open, 2021, 4(1): e2033980. DOI: 10.1001/jamanetworkopen.2020.33980.

[34]

Health Service Executive. HSE code of practice for integrated discharge planning[R/OL]. (2008-11)[2025-10-15]. https://www.hse.ie/eng/services/publications/hospitals/code-of-practice-for-integrated-discharge-planning.pdf

[35]

Mennuni M, Gulizia M M, Alunni G, et al. ANMCO position paper: hospital discharge planning: recommendations and standards[J]. Eur Heart J Suppl, 2017, 19(Suppl D): D244-D255. DOI: 10.1093/eurheartj/sux011.

[36]

Agency for Healthcare Research and Quality (US). Making healthcare safer IV: a continuous updating of patient safety harms and practices[R]. Rockville (MD): Agency for Healthcare Research and Quality (US), 2023.

[37]

周起, 武文斌. 团体标准T/CAWAORG 004-2023《老年患者出院准备服务指南》解读[J]. 中国老年保健医学, 2024, 22(6): 57-61. DOI: 10.3969/j.issn.1672-2671.2024.06.012.

[38]

Yu S F, Cheng J S, Chen Y C, et al. Adherence to anti-osteoporosis medication associated with lower mortality following hip fracture in older adults: a nationwide propensity score-matched cohort study[J]. BMC Geriatr, 2019, 19(1): 290. DOI: 10.1186/s12877-019-1278-9.

[39]

Fu Ying, Zhu Lijuan, Li Dacheng, et al. Evidence-based intervention on postoperative fear, compliance, and self-efficacy in elderly patients with hip fracture[J]. World J Clin Cases, 2022, 10(10): 3069-3077. DOI: 10.12998/wjcc.v10.i10.3069.

[40]

Malafarina V, Reginster J, Cabrerizo S, et al. Nutritional status and nutritional treatment are related to outcomes and mortality in older adults with hip fracture[J]. Nutrients, 2018, 10(5): 555. DOI: 10.3390/nu10050555.

[41]

张华果, 司文腾, 何宇迪, 等. 老年髋部骨折术后患者跌倒恐惧心理体验的质性研究[J]. 中华护理杂志, 2021, 56(4): 527-533. DOI: 10.3761/j.issn.0254-1769.2021.04.008.

[42]

金秀. 延续性护理方案在老年骨质疏松性髋部骨折术后患者中的应用研究[J]. 当代护士(下旬刊), 2023, 30(2): 88-91. DOI: 10.19793/j.cnki.1006-6411.2023.06.024.

[43]

刘娅, 董桂平, 吴梅, 等. 老年早期糖尿病肾脏病患者出院准备服务的循证证据总结[J]. 中国临床保健杂志, 2025, 28(2): 266-274. DOI: 10.3969/J.issn.1672-6790.2025.02.024.

[44]

Tian Miao, Wang Zhijia, Zhu Yanbin, et al. Incidence, causes, and risk factors of unplanned readmissions in elderly patients undergoing hip fracture surgery: an observational study[J]. Clin Interv Aging, 2023, 18: 317-326. DOI: 10.2147/CIA.S395012.

[45]

蔡迎佳, 徐珍瑾, 唐宏伟, 等. 行为目标达成度理念指导下的随访护理干预对髋部骨折人工关节置换术患者的影响[J]. 护理实践与研究, 2025, 22(5): 760-766. DOI: 10.3969/j.issn.1672-9676.2025.05.020.

[46]

魏贝贝, 王斐, 周丽莉, 等. 老年髋部骨折术后患者随访清单的制订与应用研究[J]. 中华护理教育, 2025, 22(5): 604-610. DOI: 10.3761/j.issn.1672-9234.2025.05.015.

[47]

王礼宁, 李新艳, 朱弈桦, 等. 老年髋部骨折术后二次骨折风险预测模型的构建与验证[J]. 中华骨质疏松和骨矿盐疾病杂志, 2025, 18(1): 49-59. DOI: 10.3969/j.issn.1674-2591.2025.01.006.

基金资助

耶鲁李氏基金会教师资助计划(2024LFG01)

雅礼协会2023中国社区卫生服务计划(2023YC02)

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