運用團隊資源管理改善加護病房呼吸器相關肺炎之專案

Applying Team Resource Management to the Reduction of Ventilator-Associated Pneumonia in the Intensive Care Unit

背景：呼吸器相關肺炎（ventilator-associated pneumonia, VAP）為加護病房常見的醫療照護相關感染之一，本加護單位2011年VAP之平均感染率為千分之1.28，引發專案小組改善動機。經調查確認問題為對VAP照護認知不足、未正確執行拍痰、床頭未抬高30-45度、呼吸器潮濕座加水設備無防水屏障設計、甦醒球及小量噴霧器無定期更換與呼吸治療相關設備易染污或交互感染。目的：VAP感染率由千分之1.28降至千分之1以下。解決方案　運用團隊資源管理概念擬定解決策略，包括舉辦VAP教育、宣導、設計肺部痰液聚集部位備忘錄、標示床頭抬高角度對應高度、使用自動止水潮濕腔、定期更換呼吸治療相關設備與規範呼吸治療相關設備擺放之容器與位置。結果　VAP感染率由千分之1.28下降至千分之0.65。結論　此專案不僅增進團隊能有效合作，更提升重症照護品質。

Background & Problems: Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection in the intensive care unit. The average VAP rate was 1.28 per mille in our unit during 2011. Therefore, we designed a project to identify relevant problems, including: inadequate knowledge about VAP care, incorrect techniques for sputum suction, patient head elevation ＜ 30~45 degrees, ventilator humidifier installed with water equipment designed without water- resistant barriers, failure to change the resuscitator and small-volume nebulizer regularly, and possible cross-contamination between respiratory-care devices. Purpose: We targeted a VAP rate decrease from the current 1.28 per mille to less than 1 per mille. Resolution: The improvement measures implemented included team resource management (TRM) with VAP education, promotion, a written reminder regarding sputum accumulation sites, instruction to elevate the head of patients to an appropriate height, introduction of an auto-stop water adding system, and regular changes of related devices at assigned positions. Results: The VAP rate decreased from 1.28 per mille to 0.65 per mille. Conclusions: The risk identification and associated TRM project improved teamwork and the quality of care in the ICU.