跨團隊合作提升心臟科術後直送加護病房病人轉運安全

Team resource management improves safety of transfer of post-surgical critical patients to intensive care unit

術後直送加護病房病人轉運安全是重要的。本單位心臟科術後直送加護病房轉運 安全完整率僅86.4%，轉運過程管路滑脫率2.1%。原因為缺乏跨單位病人轉運流程、無 特定Team Leader、無轉運查核工具、無在職教育及新進人員訓練等。經新增跨團隊轉 運安全作業規範、設立轉運Team Leader、張貼跨團隊病人轉運安全流程圖及LOAD轉 運人員位置圖、創新病人轉運安全標語及管路滑脫有感標示、新增跨團隊病人轉運安 全查核表、錄製跨團隊病人轉運安全影片及持續品質審查後，術後直送加護病房轉運 安全完整率達100%，轉運過程管路滑脫率降為0%，故跨團隊合作確可提升術後直送加 護病房轉送安全，未來可供類似單位參考。

Safety in transferring post-operative critical patients to intensive care unit is very important. Before the establishment of team resources management (TRM) protocol, our unit, Cardiovascular unit, hit only 86.4% in completion of safe transfer. Of those not completed were dislodgement of lines 2.1%, lack of multidisciplinary standardized protocol, no specific team leader, lack of a proper evaluation tool in transfer and no advanced training of the staff. After establishment of TRM protocol, assignment of a team leader, posting TRM algorithm and chart suggesting proper positions for staffs during transfer, innovative slogans and stickers, evaluation forms in patient transfer, making videos showing how TRM in transferring patient to ICU and persistent quality control, we had reached 100% in safe transfer. There was no dislodgement of lines during transfer after executing TRM protocol. We concluded that TRM does promote safety in transferring post-surgical critical patients to ICU.