雙腔靜脈導管感染不僅影響醫療照護品質，甚至威脅病患生命安全。據感控發現2010年1月至3月雙腔靜脈導管感染率驟增，其中1人因感染敗血症死亡，故成立專案小組。本小組以「導管護理技術標準」、「導管照護查檢表」，查核護理人員及主要照顧者導管照護情形，發現透析導管感染要因有：護理人員及主要照顧者導管照護知識不足、照護導管時洗手步驟不正確、導管護理技術不正確及稽核制度不明確。經推動修訂「導管護理技術標準」、制定「導管傷口評估表」、進行護理人員及主要照顧者的教育訓練、實施稽核制度、增加洗手設備等措施，有效降低靜脈導管感染率由10.8‰降至6.1‰，進步率43.5％。成效顯著，不僅提升護理人員專業能力，更有效降低雙腔靜脈導管感染率。

Infection of double-lumen venous catheter not only affects quality of medical care but also threatens the patient’s life and safety. According to the analysis report from our infection control center, the infection rate of double-lumen venous catheter increased significantly from January to March in 2010, with one patient dying of sepsis. A task force was therefore set up for infection control. Our team checked catheter care conditions from nurses and primary caregivers. Using the “Technical Nursing Standards for Catheter Care” and “Catheter Care Checklist,” we found that the major causes of dialysis catheterinfection included: Insufficient knowledge on catheter care in nurses and primary caregivers, inadequate method of hand washing during catheter care, incorrect technique in catheter nursing care and inaccurate checking technique. After revising the “Technical Nursing Standards for Catheter Care”, define the “Evaluation of catheter wound”, we also promoted promote educational training of nurses and primary caregivers. Checklists were implemented and hand-washing equipment setup. After these measures were implemented, the infection rate of venous catheter was effectively reduced from 10.8‰ to 6.1‰, an improvement 43.5%. We concluded that our intervention was successful in improving the professional ability of nurses and effective in decreasing the infection rate of double-lumen venous catheter.