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