降低手術室骨骼銀行保存庫捐贈物之感染率

A Project to Decrease the Infection Rate of Allograft Bones in the Storage of Operating Room Bone Bank

近來移植手術越來越普遍，由於同一個捐贈者的骨骼組織移植到許多受贈者身上，若處理不當，可能導致受贈者受到感染，將影響移植手術病人安全性。因此，本專案將針對手術室骨骼銀行保存庫捐贈物之人員、設備、制度深入探討分析，確認問題以導入解決方案：制定骨骼銀行存取標準作業規範及保存庫管理辦法；開發耐低溫冷凍袋，維持超低溫冰存捐贈物之品質；舉辦相關在職教育及稽核制度執行，增加認知落實執行。其成效：手術室骨骼銀行保存庫捐贈物之感染率由5.8%下降至1.7%，達到專案目的。希望藉由此專案改善，提升骨骼捐贈物保存品質及植入者之安全性，也能提供其他醫療機構，對於骨骼銀行保存庫設立管理作業之參考。

With the recent prevalence of bone grafting, the awareness to the preservation of allograftbone is once again raised. It is a common practice of grafting bones from a single donorto multiple recipients. Inappropriate storage and preparation may result in the infection ofmultiple recipients and compromise patient safety. This project was designed to investigateand analyze potential risk factors, including personnel, equipment, and systemic, relating toallograft bone preservation, identify the issues, and introduce appropriate interventions. Thefollowing interventions were implemented: Standard operating procedure on the bone bankstorage and retrieval, and storage management; developeing LDPE film grade polymer forpacking allograft bones to maintain material quality under very low temperature; and holdingregular in-service educational programs and introducing audit system for the nursing staff.The interventions had effectively achieved the goal of the project by reducing the infectionrate of allograft bone from 5.8% to 1.7%. By introducing this project, we hope to enhance thequality of allograft bone storage and the safety of its recipients, and to provide a referencefor other medical institutes on the establishment of bone bank storage management.