目標體溫管理流程之改善

The Improvement on Target Temperature Management

2015年急救準則中建議心臟停止急救復甦後的昏迷病人應進行目標體溫管理，即低溫治療，目前 文獻建議執行低溫治療的時問應愈快愈好，統計2013年1月至2014年5月接受低溫治療病人到達目標 溫之時問中位數長達431分鐘，超過文獻建議之360分鐘，分析原因包括：對低溫治療認知不足、低溫治療評估無一致判斷標準、急救復甦後未能開立醫囑給予4℃ 生理食鹽水誘導降溫、準備低溫治療用物費 時、調整鎮靜或肌肉鬆弛藥物減少顫科情形無準則致影響降溫。經由急診醫護團隊共同研商改善對策， 包括重新修訂低溫治療流程、設計低溫治療適應症快速評估工具、將給予4℃ 生理食鹽水列為急救醫囑套 餐及常規點班項目、設置用物準備盒與文件盒、擬定藥物調整準則等，並透過在職教育方式加強醫護同仁認知。改善對策實施後，急救復甦後到達目標溫的時問中位數縮短為316分鐘，達到專案設定360分鐘的目標。本專案經過團隊的合作，不僅讓低溫治療流程更順暢，成功縮短到達目標溫時問，醫護人員 對於低溫治療的認知也提升了，期望未來本專案能水平展開至其他加護單位，提升低溫治療的照護品質。

The 2015 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation strongly recommended targeted temperature management (TTM) in comatose patients after cardiac arrest. The current literature suggested that the implementation of TTM should be as soon as possible. After investigation of patients receiving TTM from January 2013 to May 2014, the median time reaching the target temperature was up to 431 minutes, longer than 360 minutes of literature suggested. After analysis, the reasons included cognitive insufficiency in TTM, inconsistent assessment of TTM indication criteria, no 4℃ normal saline medical order for induced cooling after resuscitation, time consuming for TTM preparing, no adjusted reference for sedative or muscle relaxing agents in order to suppress shivering. Through the discussion of emergency team members, improvement strategies included revise TTM process, develop TTM quick assessment tool, set up 4℃ normal saline as after resuscitation regular order and routine check item, set up special box for TTM equipment and document, develop medication adjustment reference, and also enhance staff TTM cognition through in-service education. After implementation of strategies, time to target temperature after resuscitation was shortened to 316 minutes, reaching the goal of 360 minutes. After team member cooperation, the TTM workflow was more smoothly, time interval was shortened to target temperature successfully and the medical staff TTM knowledge increased. This improvement project will be applied to other intensive care unit and enhance TTM care quality in the future.