運用組合式照護降低心臟加護病房醫療裝置相關壓傷發生密度

Application of Care Bundles to Reduce Medical-Device-Related Pressure Injury (MDRPI) Incidence in a Coronary Care Unit

背景：壓傷發生會增加醫療成本、延長住院，2015年台灣臨床成效指標（Taiwan clinical performanceindicators, TCPI）心臟內科加護病房（coronary care unit, CCU）壓傷總發生密度0.4%；而本院CCU2016年1~8月壓傷總發生密度1.1%，遠高於TCPI，其中醫療裝置相關壓傷（medical device relatedpressure injury, MDRPI）佔73.1%，發生密度0.8%；導因為預防壓傷設備不完善且敷料不足、未落實執行壓傷預防措施、護理師MDRPI認知不足、預防MDRPI照護之標準化程序未詳盡、MDRPI相關教育學習成效低及未定期稽核壓傷預防措施。目的：降低本心臟內科加護病房MDRPI發生密度至 ≤ 0.4%。解決方案：透過教育、推動種子教師與「耐、壓、用、換、除」組合式照護、改用PE（polyethylene）泡棉約束手套並定期稽核。結果：改善後2016年10月～2017年4月MDRPI發生密度由0.8%降至0.3%，維持期2017年5～7月降為0.1%。結論：顯示專案有效降低MDRPI，建議平行推廣此組合式照護概念，藉此經驗提供臨床照護參考。

Background & Problem: Pressure injuries increase the cost of medical care and prolong hospitalization. The incidence of pressure injury at the target coronary care unit (CCU) from January to August 2016 was 1.1%, which was significantly higher than the 0.4% defined in the 2015 Taiwan Clinical Performance Indicators (TCPI) system. Medical device related pressure injury (MDRPI) accounted for 73.1% of the pressure injuries (incidence: 0.8%). The main causes of the high incidence of MDRPI were: (1) inadequate decompression dressing and restraint equipment, (2) incomplete implementation of prevention interventions in the CCU, (3) inadequate knowledge of MDRPI prevention among nurses, (4) deficient standards for preventing MDRPI, (5) ineffective MDRPI-related education, and (6) insufficient auditing frequencies. Purpose: To reduce the incidence of MDRPI in the target CCU to 0.4% or less. Resolution: Promote a seed-teacher system and a care bundle that “increased skin tolerance, decompression, medical dressing, change, and removal” using education, the adoption of PE-foam binding gloves, and regular audits. Results: The incidence of MDRPI was reduced from 0.8% to 0.3% between October 2016 and April 2017 and further reduced to 0.1% during the maintenance phase between May and July 2017. Conclusions: The results indicate that the improvement program effectively reduced the incidence of MDRPI and thus increased the quality of nursing care. Therefore, the use of a care bundles should be promoted in intensive care units.