台灣病人安全通報系統―中心靜脈導管相關事件分析

Analysis on Central Venous Catheter–Related Incidents in the Taiwan Patient-safety Reporting (TPR) System

背景和目的：對於重症病人，中心靜脈導管提供良好的靜脈通路，進行血流動力監測、高濃度營養劑等，更是重要之維生設備。本研究利用台灣病人安全通報系統之中心靜脈導管異常事件分析其影響因子。方法：本研究收集2005-2009 年台灣病人安全通報系統之中心靜脈導管異常事件進行分析，共925件。以卡方檢定比較自拔管路組與意外滑脫組之事件差異；以邏輯斯迴歸分析影響中心靜脈導管異常事件的危險因子。結果：中心靜脈導管異常事件較常發生於年長的男性占62.2%，以內科47.7%為多，地點多發生於加護病房83.1%。51.5%的管路滑脫發生於病人臥床休息時，其中無陪伴者在場為50.4%，病患無約束狀態為51.8%，未使用鎮靜藥物為85.1%，異常事件對病患造成死亡占0.2%，重度傷害為1.4%。發生管路滑脫後，25.9%的病患需重新插管；邏輯迴歸結果顯示就醫科別、事件發生於何項活動及病患意識為影響中心靜脈導管異常事件的重要因素。結論：建立一套中心靜脈導管的臨床治療指引有助於改善其照護安全。

Background and purpose: CVC is important in the critical care for fluid replacement, hemodynamic monitoring, and parenteral nutrition supply. This study reports the central venous catheter-related incidents (CVCRI) from the Taiwan Patient -safety Reporting system (TPR) and investigates its risk factors. Methods: A total of 925 CVCRI(s) reports (2005-2009) from the TPR were retrieved. Incidents characteristics are compared between self-extubation and accidental dislodgement groups using chi-square test. Risk factors are investigated using logistic regression models. Results: CVCRI(s) frequently occurred in elderly male (62.2%), under internal medicine care (47.7%) in intensive care units (83.1%) at night shifts. Around 51.5% of the dislodgements occurred while patients were at rest without accompanied person (50.4%), restrained (51.8%), or sedation (85.1%) and were under clear consciousness level (53.8%). There were 2 (0.2%) deaths and 13 (1.4%) severe injuries. Only 25.9% of CVC dislodgement would need replacement of catheter. Care specialty, time shift, activity type, and consciousness level are important risk factors for CVCRI(s). Conclusions: Establishment of clinical guidelines for patient restraint, sedation, and necessity evaluation for CVC use are critical to improve CVC care safety.