運用時間管理及品質照護以降低乳癌病人行乳房切除術後之非預期皮膚損傷率

Using Time Management and Quality Improvements to Decrease the Incidence of Unexpected Skin Defects in Post-Mastectomy Breast Cancer Patients

背景：乳癌病人接受乳房全切除手術，由於需移除大範圍的乳房組織，所形成的空腔易累積血水造成血清腫，因此，傷口照護需使用黏性強的宜拉膠布及大量散紗加壓，惟臨床換藥過程中，反覆移除敷料會造成病人非預期皮膚損傷，若病人皮膚缺失且暴露於高風險的醫院環境中，容易增加院內感染及住院天數延長之問題。目的：本專案旨在降低乳癌病人行乳房全切除術後之非預期皮膚損傷率低於15％。解決方案：經參考文獻後藉由本專案乳癌病人（1）增加乳房全切除術後傷口加壓固定標準規範、（2）使用窄版束腹帶取代黏性強的宜拉膠布、（3）利用有彈性材質軟的紗捲代替單包紗布加壓傷口及（4）運用皮膚檢查表來達到持續監測，期望有效減少乳癌病人行乳房全切除術後非預期皮膚損傷率。結果：經介入措施後乳癌病人行乳房全切除術後發生非預期皮膚損傷率由100％減少至13％，及改善護理人員換藥工時由25分鐘至15分鐘。結論：期望藉此專案可以有效提升乳癌病人行乳房全切除術後傷口照護品質、並減少臨床護理人員的換藥工時。 Background & Problems: When patients with breast cancer undergo radical mastectomy, seromas are often caused due to the large area of excised breast tissue and the resulting cavity that fills with blood and water. Therefore, strong adhesive elastic tape and large amounts of gauze are needed to compress the wound. Our clinical experience shows that repeatedly removing dressings during dressing changes significantly increases the risk of unexpected skin defects. However, the increased duration of hospital stays required for these patients with skin defects exposes them to high risk environments, which may result in nosocomial infections and even longer hospitalization durations. Purpose: This project aimed to decrease the incidence of unexpected skin defects in patients after mastectomy to below 15%. Resolution: After a review of the literature, we implemented this project to: (1) build up a standard operating procedure for post-mastectomy wound compression; (2) use narrow girdles instead of strong adhesive elastic tape; (3) use soft elastic bandages to replace the single layer of gauze for wound compression; (4) use a skin examination form as a continuous monitoring tool. We expected that these measurements would effectively decrease the incidence of unexpected skin defects in post-mastectomy patients. Results: After implementing this project, the incidence of unexpected skin defects in post-mastectomy patients decreased from 100% to 13% and the time required by clinical nursing staff to perform wound dressing care decreased from 25 mins to 15 mins per care instance. Conclusions: We hope that this project helps effectively improve postoperative wound care quality in post-mastectomy patients and decreases the time spent by clinical nursing staff on wound dressing care.