提升加護病房醫護人員執行中心導管組合式介入措施之完整率

Increasing the Completion Rate of Central Vascular Catheter Bundle Care in an Intensive Care Unit

推動中心導管組合式介入措施，能有效降低中心導管相關血流感染。本單位2009年導管相關血流感染密度為3.3，隔年2月導入組合式介入措施，但至4月仍高至3.7，故引發專案動機。經現況分析發現：（一）執行技術前未確實洗手；（二）插管前皮膚清潔不完整；（三）消毒方式不正確；（四）插管時未舖無菌大洞巾；（五）未每日進行導管護理評估，及評估移除時機。為提升執行完整率，擬定改善對策包括：（一）落實查核洗手時機；（二）製作宣導海報、提醒標語及教學光碟；（三）舉辦在職教育；（四）插管用物置放標準化；（五）擬定導管護理評估及移除時機之策略；（六）建立組合式介入措施稽核機制；（七）修訂「中心導管插入及護理程序重點查檢表」；（八）回饋稽核結果。成效為插管程序完整率由47％提升至97％，導管護理程序完整率由42.4％提升至95.8％，2011年1至3月感染密度下降至0，並持續維持至7月，達「零」感染目標，提供安全的醫療環境。

According to the literature, the promotion of central vascular catheter (CVC) bundle care can effectively reduce central catheter-related blood stream infections. In 2009, density of infection for catheter-related bloodstream infections at our intensive care unit (ICU) was 3.3%. CVC bundle care was introduced at our ICU in February 2010, during which the density of infection was 3.7%; the density of infection remained high two months later. To investigate, a multifactorial analysis was conducted, which revealed that certain conditions disrupted the effectiveness of CVC bundle care, such as hand washing, cleaning and disinfecting the skin, the laying size of sterile towels, using incorrect disinfection techniques, and the daily assessment of the removal of the line. To enhance the implementation of the completion rate, we proposed several improvement measures, including providing on-the-job training, distributing informative, posters, health educational leafl ets, and training CDs, and conducting performance audits. Consequently, the completion rate of CVCinsertion improved from 47% to 97%, and the rate of comprehensive nursing care increased from 42.4% to 95.8%, resulting in an excellent density of infection of 0% from January to July of 2011. Therefore, the implementation of our suggestions resulted in a safe medical environment.