降低非計劃性氣管內管拔除率之改善專案

A Project to Reduce Unplanned Endotracheal Extubation

本專案旨在降低內科加護單位氣管內管拔除率，本單位於2014年1-4月非計劃性氣管內管平均拔除率0.358%，高於本單位閾值0.192%，病人氣管內管管路安全照護發出警訊，引發作此專案之動機。分析原因為止痛劑使用標準執行未落實、溝通輔具不足、氣囊管路固定不正確、傳統型口咬器不適用、約束技術不正確。於2014年5月至2015年2月進行改善專案，落實疼痛評估與處置、製作溝通圖卡、訂立高危險咬管病人照顧標準查核表、推行改良型口咬器、定期考核約束技術正確性。經專案實施後非計劃性氣管內管拔除率降至0%，達成專案目標，有效維護病人氣管內管管路安全，藉此專案成效供臨床照護之參考。

Our average rate of unplanned endotracheal extubation from January to April in 2014 was 0.358%, which had exceeded the threshold of 0.192%. The project was created in response to the compromised safety of intubated patient. According to the analysis, the possible factors for high rate of unplanned endotracheal extubation were as followed : analgesics standards were not implemented, insufficient communication tools for patients and medical personnels, incorrect endotracheal tube fixation, traditional bite block inapplicable, and inappropriate physical restraint. The project, lasted from May, 2014 to Feburary, 2015, implemented pain evaluation and treatment, communication cards, check list and care plans for high risk patients, improved bite blocks, and regular physical restraint evaluation. The implementation of the project had successfully attained its intended goal by reducing the unplanned endotracheal extubation rate to 0% and secured the safety of intubated patients. We would like to share our successful experience of patient safety management as a reference for clinical care.