降低兒童醫院加護病房非計劃性氣管內管滑脫率

Reducing Unplanned Extubation in Children＇s Hospital Intensive Care Unit

使用呼吸器的病人當發生非計畫性管路滑脫時將導致嚴重的異常事件，因此在兒童醫院的加護病房中發生非計畫性管路滑脫率偏高時，不僅影響病人的生命安全及照護品質，也是值得注意的議題，藉由事件的分析及品質改善，發現造成非計畫性管路滑脫的原因包括:因鎮靜處置認知未落實（25.0%）、缺乏有效的約束（18.7%）、氣管內管照護未依標準流程執行（43.8%）、氣管內管呼吸管路擺放未依標準執行造成（12.4%），造成這些原因主要是因為醫護團隊之間缺乏有效溝通、護理師未依病人身形大小而有不同的約束方式、病人大量口水易滲濕膠布、護理師未能有效地練習更換固定管路宜拉膠布技巧。此次品質改善活動期望能將兒童醫院加護病房非計畫性氣管內管滑脫率由0.18%降至0.14%。改善策略包含:規畫鎮靜劑使用的方式，並配合鎮靜評估表，小於12歲使用RSS，大於12歲則使用RASS進行醫護團隊的溝通、依病人的發展及身形使用不同的約束方式，加強護理師的約束技巧、推廣使用防水宜拉膠及使用低壓抽吸以防止宜拉膠布被滲濕、改變呼吸器管路易垂落的固定方式，及加強約束、管路固定及鎮靜相關教育課程，並依臨床現況修訂氣管內管照護標準，加強查核新進護理師之臨床照護，且列為各單位品管計畫。評值改善策略之成效，非計畫性管路滑脫率由0.18%下降至0.07%，在鎮靜結果方面醫護團隊能達到有效的溝通，進而改善兒童醫院加護病房照護品質。

Unplanned extubation (UE) might potentially lead to serious adverse events in mechanically ventilated patients. As the reported incidence of UE had remained substantial in the patients of the children's hospital intensive care unit, this event might impose high concern for the patient safety of paediatric health care. Because of a higher rate of UE in our children's hospital intensive care unit, we called for analysis and an improvement programme. Methods: By reviewing the UE cases, we found the causes of UE included inadequate sedation (25.0%), ineffective restraint (18.7%), use of incorrect endotracheal tube care standards (43.8%), and incorrect fixing method of ventilator tubing (12.5%). These causes were mainly due to lack of effective communication between staff, the variety of body sizes and restraint methods, copious secretions, and ineffective practice for fixing tape changing. Our programme in a quasi-experimental design included a designing of a protocol of sedative use, the application of Ramsay sedation scale(RSS) for patients younger than 12 years and Richmond agitation sedation scale (RASS) for those older than 12 years, and the implementation of different restraint methods according to the development and body size of children. Additional strategies included the training to enhance the restraining skills of the staff, the application of a water-resistant tape and low-pressure suction to prevent wetting of the fixing tape by secretions, revision of the fixing method of ventilator tube, education programs for better skills in securing the tube as well as restraint and sedation, according to clinic situation to modify endotracheal tube care standards, strengthening the check of the new staffs care situation, and the endotracheal tube care standards as every unit quality control improvement program. We aimed to reduce the UE rate in children's hospital intensive care unit to less than 0.14%, which was the average for peer medical centres in Taiwan. Results: The UE rate was reduced from 0.18% to 0.07% in 2016. Also, we have effective communication of sedative result, reduce conflicts between healthcare workers. Our integrated intervention programme was therefore considered successful in improving the care of intubated patients in the children's hospital intensive care unit.