降低血液透析患者留置雙腔導管感染率之改善方案

Strategies to Reduce Hemodialysis Catheter-Related Infection in Uremic Patients

血液透析雙腔廔管之留置，已成為普遍被接受的暫時性廔管通路方式。本組人員在照護病患過程中，發現留置雙腔廔管之患者常引起廔管插置部位之紅、腫、熱、痛，造成需延長住院天數及增加醫療資源，故引發本專案之動機。於2004年4月1日至8月30日期間，針對透析室及病房護理人員，以實際觀察法進行換藥技術和照護之評核，發現透析護理人員在雙腔廔管換藥技術不確實及病房護理人員廔管照護執行率低，導致感染率高達21%，故本專案目的在於降低透析患者留置雙腔廔管之感染率，經建立評核護理人員雙腔廔管換藥技術及照護顯示，透析護理人員對換藥技術正確率由71.9%提升為93.3%，病房護理人員廔管照護執行率由38%提昇為77%，廔管感染率由21.3%降為6.17%；經以上改善方案，不僅提昇護理人員臨床照護技能，亦降低感染率。

A temporary catheter is usually required for hemodialysis in patients with end-stage renal disease before permanent vascular access is established. A double lumen catheter has been employed as a convenient and easily-placed access for hemodialysis. After the catheter is inserted, it is usually left in for weeks. During this period, dialysis nurses and ward nurses care for the implanted catheter and puncture wound. Nevertheless, catheter-related infection remains an important complication. It causes prolonged hospitalization and incurs more medical costs. It is therefore necessary to identify the factors which precipitate infection and find effective methods of preventing and minimizing this complication. We conducted an interventional study to evaluate the effects of intensive care on catheter-related infections. During the study period from 1 April to 15 August 2004, both ward nurses and hemodialysis nurses were evaluated on their care of femoral double lumen catheters in hemodialysis patients. All nurses were monitored and assessed. The accuracy rate of nursing care and total catheter infection rate were recorded. Then an educational program and a scoring system were initiated. Afterward, the nursing care was reevaluated and compared with previous results before implementing the interventional program. Through this multi-factorial approach, we found that the accuracy rate increased from 71.9% to 93.3% in hemodialysis nursing care; and from 38% to 77% in ward nursing care. Overall, the infection rate was reduced from 21.3% to 6.17%. We conclude that the hemodialysis catheter-related infection rate was high but could be reduced significantly with appropriate nursing care.