Abstract: 【Objective】 To evaluate the efficiency and feasibility of standardized management mode of discharged high risk neonates from NICU of primary hospital. 【Methods】 The following-up center for discharged NICU high-risk neonates was to establish and the follow-up processes and intervention model were also set up. High-risk neonates born from Jan. 2007 to Jan. 2009 were followed up with periodic evaluation, advice and guidance, and the implementation of early intervention. 【Results】 About 2 505 of high-risk neonates were recruited into this standardized management mode. The filing number and the rate of follow-up at 6month, one year and two years after this mode performed were significantly higher than that of two years before this mode performed(P<0.001). About 253 neonates with mental and motor developmental abnormalities were performed early hospital combined family intervention. Compared with control group, there was no significant difference between intellectual and motor developmental index at 2 yeas of age. 【Conclusion】 Setting up network of supervision to high-risk neonates, unified management and multi-course cooperation combined with family based intervention are efficiency and feasibility modes for primary hospital.

Key words: primary hospital, high risk infants, system management, developmental

摘要： 【目的】 探讨基层妇幼保健院NICU出院高危儿规范管理的模式,评估其可行性及有效性。 【方法】 建立NICU出院高危儿随访中心,设置随访流程及干预模式,对2　505例建档高危儿随访、定期评价、咨询及指导,实施早期干预。 【结果】 2 505例高危儿规范管理后2年与2年前的建档数、第一次随访以及建档后半年、1年、2年随访率均有明显提高(P<0.001)。253名智力和运动发育偏差、发育异常的婴儿进行了医院和家庭相结合的方式干预,干预组和对照组儿童2岁时的智力发育指数和运动发育指数均无显著差异(P>0.05)。 【结论】 建立高危儿监测网,统一管理,多学科合作并配合家庭式的干预模式,对改善高危儿生存质量是可行、有效的管理模式。

关键词: 基层医院, 高危儿, 系统管理, 发育障碍