移行医療の外来診療

Healthcare Transition in Outpatient Clinics

われわれの施設は救命センターを有する地域の基幹病院であるが，近隣の小児医療センターの移転に伴い多くの移行症例が脳神経内科に紹介された。てんかんを有し，発作抑制が困難な症例や医療的ケアを要する重症心身障害児（者）に相当する症例が大半であった。移行にあたっては医療相談室を中心に多職種の連携を行った。移行後は痙攣発作や肺炎などの感染症での救急搬送が多かった。移行教育，人生会議，地域連携が課題であった。

Abstract

Many cases of healthcare transition were referred to the Department of Neurology in our local core hospital with an emergency and critical care center, owing to the relocation of a nearby children's medical center. Most patients presented epilepsy with difficulty in controlling seizures or were children with severe mental and physical disabilities requiring medical care. During the transition, multidisciplinary collaboration centered on the medical consultation office was conducted. After the transition, many patients were transported to emergency rooms for seizures, pneumonia, and other infectious diseases. Education, advanced care planning, and regional collaboration were some of the issues in the process.