人工血管照護指引的建立與成效評值

Establishing Guidelines for Nursing Care of Port-A and Evaluating Their Effectiveness

目的：本院人工血管感染密度自2013年度為0.320‰，至2014年8月上升至0.890‰。有鑑於臨床實務的需求，故成立人工血管照護指引發展團隊，以建置人工血管照護指引，期望藉此提升人工血管照護品質，以降低患者人工血管血流感染密度。方法：本實證運用方案分三階段，第一階段依據實證整合步驟，建置人工血管的組合式照護。第二階段遵循計劃-測試-研究-執行循環，擬訂患者人工血管照護標準步驟，工作人員執行策略，與機構管理策略，最後階段以八項指標評值人工血管照護指引推行成效。結果：2014年10月1日至2014年12月31日監測護理人員人工血管組合式照護措施遵從率由75.0％上升到100.0％、手部衛生遵從率由90.0％上升到96.0％、手部衛生執行正確率由90.3％上升到97.0％、人工血管照護查檢表完成率100.0％、人工血管每日照護評估表完成率100.0％、裝備可近性以設置專用推車放置相關物料方便人員取用；另外消毒過程不正確之執行消毒範圍為大於人工敷料範圍缺失率5.28％降至0.00％，未等待消毒液自然乾燥缺失率自5.83％降至0.00％。再者，人工血管相關血流感染密度自0.890‰降至0.084‰，明顯提升照護品質。結論：人工血管感染會引發病人罹病率、死亡率、醫療花費的增加。推行人工血管組合式照護能有效降低感染率，由執行此實證運用方案，建議人工血管的照護，應強調護理人員教育訓練及加強醫護溝通，以改變醫療照護方式。

Purposes: The incidence of prosthetic Port-A infections in our hospital increased from 0.320‰ in 2013 to 0.890‰ in 2014. To address the needs in clinical practice, a team was established to develop guidelines for the nursing care of Port-A for improving the nursing quality to lower the infection rate. Methods: This evidence utilization do project was divided into three phases. The first phase established care bundles for Port-A based on an analysis of evidence-based practices. The second phase followed a plan-do-study-act cycle to devise a standard nursing procedure for patients with Port-A and let the staff implement and the institution manage the strategies. The last phase evaluated the effectiveness of the nursing guidelines with eight indicators. Results: From October 1 to December 31, 2014, the nursing staff’s compliance with the Port-A care bundles increased from 75.0% to 100.0% and their compliance with hand hygiene practices increased from 90.0% to 96.0%. The accuracy in performing hand hygiene practices increased from 90.3% to 97.0%. There was a 100.0% completion rate of the Port-A cannulation checklist and the daily evaluation form of Port-A care. The accessibility of equipment was improved by placing special trolleys with relevant materials for the staff to use. As for improper disinfection, the failure rate of disinfecting an area larger than the coverage of wound dressings decreased from 5.28% to 0.00%; the rate of failing to wait for the disinfectant to air-dry declined from 5.83% to 0.00%. Analysis showed that the rate of Port-A related infections decreased from 0.089‰ to 0.084‰. The nursing quality improved evidently. Conclusions: Port-A related infections can lead to an increase in the morbidity and mortality of patients and in medical expenses. Implementing Port-A care bundles can effectively lower the infection rate. This evidence utilization project suggests that nursing care of Port-A should focus on educating and training the nursing staff while reinforcing nurse-physician communication, in order to bring a change to the healthcare approaches.