降低血液透析動靜脈瘻管阻塞率之改善專案

A Project to Reduce the Occlusion Rate in Hemodialysis Arteriovenous Access

背景：瘻管阻塞易導致單位值班護理人員，需加班及花時間連絡處理血管問題。病人也需忍受侵入性治療及手術的痛，導致病人透析焦慮感加深，嚴重影響透析品質。目的：本專案旨在降低血液透析病人動靜脈瘻管阻塞率，改善目標為人工、自體動靜脈瘻管每月阻塞率分別由18.6%降至15%以下、5.2%降至2.6%。解決方案　本專案自2012年9月起至2013年7月止，透過專案成員的病歷回溯、文獻查證、會議討論及文件整理，歸納合併四項動靜脈瘻管阻塞率主因，分別為：（一）透析時低血壓、（二）瘻管重複穿刺、（三）血流異常，和（四）水分控制不佳。解決方案為：增修表單工具、調整照護流程及擬定在職教育。結果　人工動靜脈瘻管阻塞率由改善前18.6%降至7.4%，自體動靜脈瘻管阻塞率由改善前5.2%降為0.9%。結論　以精簡方式，如製作預防低血壓、大圖示衛教單張、設計止血帶量尺、透析瘻管簡易輪序穿刺表、水份控制小卡與提醒血流異常者提早返診，使人工與自體動靜脈瘻管統計數據皆低於目標值，希冀可供其他透析院所參考。

Background & Problems: Vascular occlusions in patients frequently necessitate that duty nurses work overtime to manage related vascular problems. For patients, vascular occlusions require invasive treatments that are painful, take time to heal, and increase anxiety. Furthermore, vascular occlusions seriously influence the effectiveness of hemodialysis. Purpose: This project worked to reduce the rates of occlusion from 18.6% to ＜ 15% for hemodialysis arteriovenous grafts (AVGs) and from 5.2% to ＜ 2.6% for arteriovenous fistulas (AVFs). Method: This project was conducted between September 1st, 2012 and July 31th, 2013. Our approach used a retrospective study, literature review, meeting discussions, and data compilation. The four main problems identified as associated with occlusion were: (1) low blood pressure during hemodialysis; (2) successive fistula puncture sites were located too close to one another; (3) abnormal blood flow; and (4) poor moisture control. Our solutions included: 1) adjusting and creating forms; 2) adjusting related nursing procedures; and 3) organizing a related lecture for our department. Result: The occlusion rates of AVG and AVF decreased from 18.6% to 7.4% and 5.2% to 0.9%, respectively. Conclusion: We significantly reduced AVG and AVF occlusion rates by using simple methods such as using a tourniquet ruler, designing big-print, illustrated patient instruction sheets on preventing low blood pressure, creating a simplified fistula puncture site series chart, creating a moisture control card, and scheduling follow-up visits for patients with abnormal blood flow at the OPD. This project provides a reference for other hemodialysis departments.