運用品質改善活動提升成人加護病房氣管內管照護安全

Quality Improvement Campaign in Adult Intensive Care Unit to Enhance Endotracheal Tube Care Safety

非計劃性氣管內管滑脫為加護病房常見的管路不良事件，個案醫院運用持續性品 質改善活動期降低成人加護病房非計劃性氣管內管滑脫率及滑脫後重度以上傷害率。 自2009年1月起組成跨部門改善團隊，介入措施包括發展高危險病人篩選表、擬定相關 標準作業流程、加強病人及家屬衛教、加強醫護病間溝通、舉辦氣管內管照護相關教 育訓練等，以提升醫護人員相關照護技能。改善後非計劃性氣管內管滑脫率由0.32%降 至0.063%；滑脫後重度以上傷害率由50%降至0%。提升氣管內管照護安全為國家政策 方向，同時也是醫療院所重要的品質改善活動，在照護過程中，醫護人員應隨時提高 警覺心，才能有效降低管路滑脫及病人自拔機率，未來將持續推動氣管內管照護安全 以提升病人照護品質。

Unplanned extubation (UE) is the most commonly seen incidents in intensive care setting. Theresearch hospital used continuous quality improvement (CQI) campaign with aims to reduced UE rates and its consequences. A multi-discipline team has been organized since january 2009. The interventions would include: screening for high risk UE patients, establishment of standard operation procedure, enhancement of professional skill training, improvement for family education, improvement of communication maong care team emmbers and also between carers and families. The UE rates have reduced from 0.32% to 0.063%; the severe injury rates after UE have drop from 50% to 0%. As a national patient safety goal, improvement of endotracheal tube care ranks as high priority in a hospital’s quality agenda. Healthcare professoinals should take spcial precaution in caring for intubated patients to secure the quality and safety of care.