Obstacle Factors | Countermeasure groups | Games |
No capacity management working mechanism | Countermeasure 1: Establish CHF whole capacity management mechanism | 1) MDT 2) working mode of whole-process capacity management 3) Formulation of clinical pathway 4) training and assessment |
There is a lack of quantifiable tools for measuring body mass and water and salt, and the relevant indicators are not monitored | Countermeasure 2: Using quantifiable tools for indicator monitoring | 1) Body mass monitoring 2) inlet and outlet monitoring 3) sodium salt guidance |
Lack of specific drug guidance for CHF patients | Countermeasure 3: Standardize the monitoring item index and frequency in the use of special drugs | 1) Drug monitoring platform 2) Drug guidance 3) Timed medicine box |
No individualized health education program | Countermeasure 4: Multi-approach individualized health education program | 1) Self-management manual 2) Lecture on capacity management 3) Self-care ability improvement guidance 4) Guidance on relieving thirst symptoms |
There is a lack of supervision system for patients to return to their families after discharge | Countermeasure five: Carry out volume management follow-up | 1) Establish electronic archives 2) Develop follow-up procedures 3) Extended care outside the hospital |