運用跨團隊合作提升加護病房病人呼吸器脫離率

Interdisciplinary Cooperation Increased the Mechanical Ventilation Weaning Rate in Intensive Care Unit Patients

呼吸器能降低病人呼吸肌肉作功，並維持足夠的氣體交換，但長期使用將導致橫膈肌萎縮與呼吸肌力下降，並對呼吸器產生依賴。本加護病房病人14天呼吸器脫離率僅38.5％，故成立改善專案。分析呼吸器脫離率低的原因有：（1）病人面：呼吸肌力不足、譫妄及疼痛不適；（2）醫療人員面：假日未交班而延遲拔管、拔管時機過早導致重插管、呼吸器照護及脫離流程認知不足；（3）政策面：缺乏呼吸器照護及脫離流程相關在職教育。運用跨團隊合作方式，以ABCDEF bundle為架構，執行包括：（1）肺部復健運動訓練計畫、（2）睡眠促進計畫、（3）非藥物輔助疼痛控制措施、（4）訂定假日拔管作業標準程序、（5）舉辦呼吸器個案討論會及（6）在職教育訓練。專案實施後，病人14天呼吸器脫離率達77.8％，而延遲拔管率由13.6％降至0％、重插管率由8.5％降至0％。運用跨團隊合作能有效提升病人呼吸器脫離率，改善醫療照護品質。

Mechanical ventilation (MV) is designed to support work of breathing and maintain adequate gas exchange. However, long-term use of MV leads to diaphragm atrophy, overall weakening of respiratory muscles and hence ventilator dependence. The 14-day weaning rate was only 38.5% in our intensive care unit. A specific project was set up aiming at raising the MV weaning rates. The potential causes of low weaning rates were assessed and categorized as follows: (1) patient factor: weakness of respiratory muscles, delirium, pain and discomfort; (2) medical staff factor: task missing during work shift on holidays, premature extubation demanding quick reintubation, and inadequate familiarity with related care and weaning protocol; (3) policy factor: lack of relevant education. To solve the above problems, ABCDEF bundle was adopted as the framework with interdisciplinary cooperation, including: (1) lung rehabilitation exercises, (2) sleep promotion programs, (3) alternative pain management, (4) standard operating procedures for work shift on holidays concerning extubation, (5) case conferences on patients with ventilators, and (6) educational programs for medical staffs. After implementing the strategy, the 14-day weaning rates raised 77.8%, while the delayed extubation rate was reduced from 13.6% to 0%, and the reintubation rate was reduced from 8.5% to 0%. This strategy with interdisciplinary collaboration effectively increased the weaning rate of MV and improved the quality of medical care.