Zusammenfassung

OBJECTIVES: To evaluate the efficacy of nursing care and monitoring of patients over 65 in primary care, to reduce the rate of readmission and to extend time till readmission. DESIGN: Non-randomised clinical trial with control. SETTING: Base Area 8, Madrid, Spain. Primary and specialist care. PARTICIPANTS: Patients over 65 admitted from home with the pathologies under study. There were 97 patients in the study, 49 in the intervention group and 48 in the control group. INTERVENTIONS: In the intervention group, link nursing conducted visits every 48 hours and provided health education to carer and patient. Patients in the control group received conventional care. Patients in both groups were contacted by phone by primary care nurses 2, 6, 12, and 24 weeks after their hospital discharge. MEASUREMENTS: Readmission for the same reason was recorded. As a secondary variable, time till readmission was recorded. RESULTS: Patients in the control group were admitted more often than those in the experimental group (OR, 3.3; 95% CI, 1.13-9.52; adjusted for the admission diagnosis). The result was consistent, on conducting an analysis of the time elapsed before readmission (HR, 2.29; 95% CI, 1.03-5.10; adjusted in the same way). CONCLUSIONS: A planned intervention into discharges with full, individual evaluation reduces readmissions and increases the time till readmission in patients over 65.