運用多元化策略降低外科高齡病人譫妄發生率

Using Multiple Strategies to Reduce the Incidence of Delirium in Older Adult Patients Receiving Surgery

背景：外科高齡病人常因環境、手術與麻醉、疼痛及管路留置因素造成急性譫妄，出現譫妄時容易發生病人安全事件，統計某醫學中心外科病房≥65歲病人譫妄發生率為12.3％，因譫妄因素而自拔管路發生率占該病房通報台灣病人安全通報系統之「管路事件」的84.2％、跌倒發生率占「跌倒事件」的33.3％，嚴重影響病人安全及增加醫療支出。目的：降低外科高齡病人譫妄發生率由12.3％至6.6％。解決方案：舉辦譫妄照護教育訓練，提升醫療團隊預防譫妄處置及照護執行率；制定外科譫妄高危險因子評估表，以早期篩選高危險病人；導入RADAR（recognizing acute delirium as part of your routine）譫妄辨識方法，快速辨識病人認知改變；建立外科高齡病人譫妄預防及治療照護作業，提升照護品質；購置床上運動器材增加病人活動力；建立外科高齡病人譫妄專屬病室，提供優質譫妄照護服務。結果：外科高齡病人譫妄發生率降低至6.5％、醫師預防譫妄處置執行率提升至98％、護理師預防譫妄照護執行率提升至100％。結論：本專案改善後成效良好，平行展開其他外科系病房，建立外科高齡病人譫妄專屬病室為外科病房之首創，能將其概念納入未來病房規劃之參考，提升醫療照顧品質。

Background & Problems: Older adult patients receiving surgery experience a relatively high rate of developing acute delirium due to factors related to the environment, surgery and anesthesia, pain, and indwelling line, which puts these patients at higher risk of patient safety incidents. The incidence of delirium among older patients receiving surgery in our ward was 12.3%. Moreover, in our ward, delirium-attributed self-extraction accounted for 84.2% of the “tubing events” reported via the Taiwan Patient-safety Reporting System and delirium-attributed falls accounted for 33.3% of the “fall events”. Thus, delirium in this patient population had a serious effect on patient safety and increased medical expenses. Purpose: Reduce the incidence of delirium in older adult patients receiving surgery from 12.3% to 6.6%. Methods: Strategies used included providing delirium care education and training to improve the delivery of delirium preventive treatments and the care implementation rate by care teams; formulating a surgical delirium high-risk factor assessment scale for the early screening of high-risk patients; adopting the “RADAR” delirium identification method for the rapid identification of cognition changes; establishing delirium prevention and treatment care guidelines for quality-of-care improvement; introducing bedside exercise equipment to increase patient mobility; and designating a dedicated delirium ward for these patients to provide high-quality delirium care services. Results: The incidence rate of delirium in older adult patients receiving surgery was reduced to 6.5%. In addition, the implementation rate of delirium prevention treatment was increased to 98% in physicians and 100% in nurses. Conclusions: This project resulted in significantly improved outcomes and was expanded to the other surgical wards. The innovative concept of incorporating a designated delirium ward for older patients receiving surgery into other wards may be referenced in future ward planning and strategies for improving the quality of medical care.