降低加護病房非計劃性氣管內管拔管之改善專案

The reduction of Unplanned Endotracheal Extubation in an Intensive Care Unit

管路異常事件之非計劃性氣管內管拔管現象一直是醫療照護上的重要課題,若 不幸發生易造成病人二度傷害,最嚴重甚至死亡。統計本單位 2016 年 1 月至 8 月非 計劃性氣管內管拔管率為 0.69% 高於前一年度,經現況分析後確立問題為:(1) 未 正確執行約束,及 (2) 未設有鎮靜或止痛處理流程,(3) 對鎮靜或止痛藥使用方式及 注意事項不清楚。經專案小組擬定解決方案包括:修訂鎮靜疼痛評估表單、制定鎮 靜止痛藥物用法及注意事項、修訂約束標準流程、規劃在職教育等措施。專案實施 後,非計劃性氣管內管拔管率降至 0.28%。經本專案的成果顯示,藉由持續性的教 育訓練、標準化設立、提升團隊共識及照護技能,進而降低非計劃性氣管內管拔管 率,達到提升病人安全與提高照護品質的目的。

 

Unplanned endotracheal extubation causes discomfort to patients and can result in death. From January to August 2016, 0.69% of endotracheal extuba- tions rate in the case unit were unplanned, which was higher than the figure for the previous year. Current problems are (1) inappropriate restraints, (2) lack of protocols for sedatives or analgesics and (3) a lack of knowledge with regard to sedatives or analgesics.

This project proposes a revised a pain assessment form to establish criteria for the use of sedative analgesics, a list of precautions when using sedative analge-sics as a revision to the standard procedure for physical restraint and a schedule for in-service education.

After this project, the rate for unplanned endotracheal extubation decreased from 0.69% to 0.28%. The results show that continuous education and training, standardization, team consensus and increased care skills reduce the number of unplanned endotracheal extubations and increases patient safety and care quality.