降低兒科病患靜脈注射後靜脈炎的發生率

Reducing the Incidence of Phlebitis Related to Intravenous Injection in Pediatric Patients

背景：住院兒童經常接受到週邊靜脈導管的治療，用以提供營養與藥物的輸注。經由統計資料顯示，本醫學中心的兒童內科病房，90%以上的住院兒童接受週邊靜脈導管留置。然而，週邊靜脈導管的留置經常伴隨靜脈炎的發生，其發生率在兒童內科病房約為5.07%。評估後發現，靜脈炎的導因可能為：消毒時間不足、注射部位固定方法不合宜、注射處的固定物易鬆脫、重新固定注射部位比率高、與導管移除後傷口照護不佳等。目的：此專案的目的為減少兒童靜脈炎的產生，且發生率能由5.07%降為2.5%。解決方案　2012年4月至7月期間，經文獻查證與為期一週的臨床評估後，初步制定降低靜脈炎發生之策略，並請相關領域之專家（如：感染科醫師、感控師，與專業護理師）針對此策略提出建議。經修正後，解決策略包括：改變消毒溶液為2% chlorhexidine克菌寧消毒、制定靜脈注射固定標準、製作多規格的安全且方便的靜脈注射固定板、擬定靜脈導管移除後傷口照護標準、移除導管預洗澡時使用無菌卡通防水膜。結果　此專案執行三個月後，本單位的兒童靜脈注射靜脈炎發生率已由5.07%下降至2.08%。結論　本專案在推行後，變更消毒溶液以達足夠消毒時間，制定靜脈固定標準與開發新制固定板，以減少重新固定之機會，制訂導管移除後傷口照護標準，進而降低兒童經由靜脈注射後產生靜脈炎的機率，用以提升護理品質及兒童安全。

Background & Problems: Peripheral venous catheter (PVC) is commonly used to provide nutrition and medicine to pediatric inpatients. Phlebitis is a common side effect of PVC insertion. Over 90% of pediatric patients in the paediatric medical ward at the Chang Gung Memorial Hospital (CGMH) receive PVC insertion, with an incident rate of phlebitis of 5.07%. Common cause factors of phlebitis are: insufficient sterilization time, inappropriate methods used to fix the PVC, the use of fixtures that loosen easily, high re-fix rates, and inadequate wound care after catheter removal. Purpose: The purpose of this project was to reduce the incidence rate of PVC-insertion-related phlebitis in children from 5.07% to 2.5%. Resolution: A one-week clinical observation identified the re-inserting / re-fixing of existing PVCs as the principal cause of phlebitis in the CGMH paediatric ward. Therefore, the researchers modified the catheter care bundle based on a review of the literature and the suggestions of clinical pediatric experts. Modifications included applying 2% chlorhexidine to sterilize the insertion site; using a new, non-woven fabric splint to fix the PVC site; providing cartoon- themed waterproof dressings for the first bath after the removal of the PVC; and setting standard operating procedures (SOPs) for PVC insertion and catheter removal. Results: After applying these modifications, the incident rate of phlebitis in children with PVC insertions decreased from 5.07% to 2.08%. Conclusion: The application of 2% chlorhexidine reduces the waiting time for sterilization; the purpose-designed splint strengthens the fixation of the PVC; and the development of the SOPs for PVC insertion and post-removal catheter care reduces the risk of phlebitis. The combination of these strategies effectively reduces the incidence of phlebitis and improves the nursing care quality.