降低急診護理人員血液培養採檢污染率

Reducing Blood Culture Contamination Rates in the Emergency Department

背景：不適當血液培養採檢技術，除影響醫護團隊臨床判斷與後續處置外，有危害病人癒後之疑慮。2015年1月1日至2015年12月31日南部某區域教學醫院急診室血液培養污染率為5.63%，遠超過美國微生物學會及本院檢驗科訂定標準3%。目的：藉由專案手法釐清現場問題，並依據所確立問題擬定改善措施，期望藉由本次專案及改善措施將血液培養污染率降至3%以下。解決方案：依現況分析歸納問題有，（一）護理人員：採檢物品擺放於床面上、教育訓練不足、未依標準作業規範執行；（二）制度：標準技術規範不一致、消毒液更改及未訂定戴手套。（三）病人：於採集第一套血液為發生血液培養污染之高危險群、病人屬高齡以及長照機構住民居多。經增設床旁工作檯、Slogan標語與抽血流程海報、製作標準技術影片、在職教育，並採一對一模具教學及每月污染回饋數值予人員之改善策略。結果：於評值期2016年10月1日至12月31日間，有效將血液培養污染率由5.63%降至1.51%。結論增加硬體設備、多元教學方式與定期回饋，不僅顯著改善血液培養污染率，亦提升護理人員對於血液培養採檢標準技術之知識與技能，希冀可供同儕參考。 Background & Problems: Rate of contamination is a well-known indicator of quality of care in the emergency department. Blood-culture results may affect clinical decision making. From January 1, 2015 to December 31, 2015, the contamination rate of blood culture in our emergency department was 5.63%, which exceeded the maximum of 3% suggested by the American Society for Microbiology and the clinical laboratory at our hospital. Purpose: Using a quality improvement strategy, this project aimed to (1) identify potential factors contributing to the high blood culture contamination rate and (2) achieve a blood culture contamination rate below 3%. Resolution: The factors that were identified as potentially contributing to the high blood culture contamination rate were: (a) Nursing staff: lack of related education and training and ignorance of related clinical guidelines; (b) The system: inconsistent and non-evidence-based clinical guidelines (e.g., no requirement to use sterile gloves when obtaining blood cultures and changing disinfectants); (c) The patient: older patients, residents of long-term care facility, and patients whose blood culture were in the first set were associated with higher blood culture contamination rates. Our quality improvement strategy included: design a new bedside working plate, develop slogans and posters illustrating the proper blood-drawing procedure, make a video introducing current standard technology, provide continuing education, monitor contamination rates, and provide individual feedback and retraining for those with higher contamination rates. Result: The strategy was implemented from October 1, 2016 to December 31, 2016, during which period the blood culture contamination rate reduced from 5.63% to 1.51%. Conclusion: Improving equipment, using multiple teaching methods, and providing regular feedback not only significantly reduced the blood culture contamination rate but also enhanced the knowledge and skills of nursing staff in terms of blood culture sampling. We hope that our results are referenced by other nursing departments and used to improve the blood culture contamination rates in other clinical settings.