北部某醫學中心外科加護病房呼吸器相關肺炎組合式照護推動經驗

Use of VAP Bundle to Prevent Ventilator-Associated Pneumonia in a Medical Center Surgical Intensive Care Unit

呼吸器相關肺炎（Ventilator associated pneumonia, VAP）是可以預防的，在加護病房，呼吸器相關肺炎是造成病人死亡的主要原因。本研究自2011年3月至2012年12月，於外科加護病房，運用查檢表七個項目：呼吸器使用適應症評估；每日鎮靜劑暫停、使用消化性潰瘍預防用藥、每四小時口腔護理、翻身／平躺前抽吸口腔分泌物、維持床頭抬高30～45度及氣管內管氣囊壓力，推動呼吸器相關肺炎組合式照護，查檢表執行遵從率由剛開始50%上升至74%，外部稽核遵從率由79%提升到93%。研究期間，內部稽核查檢表遵從率在2012年7、8月間曾下滑至50%以下，經由教育訓練及定期將外部稽核資料回饋臨床單位可以促使照護團隊提高遵從率。此外藉由改善連接呼吸器端管路長度及床頭抬高30～45度之刻度區間用紅色粗膠帶標識，也有助於床頭抬高的遵從率維持在95%以上。執行22個月，呼吸器相關肺炎感染由5.1‰降低至2.8‰（P=0.01），呼吸器相關肺炎感染個案數明顯減少50%。推行經驗顯示運用呼吸器組合式照護可以有效降低呼吸器相關肺炎。

Although preventable, ventilator-associated pneumonia (VAP) is a main cause of death due to nosocomial infections in the intensive care unit (ICU). This study was conducted in the surgical ICU of a medical center in Taipei, Taiwan, from March 2011 to December 2012. A multidisciplinary ventilator bundle team was established during the study period. The bundle checklist included daily “sedation vacation” and assessment of readiness to extubate, peptic ulcer prophylaxis, oral hygiene care every 4 h, suction of oral secretions before changing position, as well as maintaining a 30-45˚ head elevation and endotracheal tube cuff pressure. The results showed a daily goal checklist implementation rate increase from 50% to 74%. The ventilator bundle compliance rate, assessed by external audit, increased from 79% to 93%. During the study period, the checklist execution rate declined to <50% between July and August 2012, although education, training, and regular feedback from external auditing units can encourage the clinical care team to improve implementation rates. Checklist implementation rate had declined to <50%between July and August 2012. Nevertheless, staff education and regular feedback from external audit data can improve implementation rates. In addition, longer respiratory tubing and thick red tape marks improved the compliance rate of maintaining a head-up position to 95%. Twenty-two months after implementation, VAP incidence decreased from 5.1 to 2.8 per 1,000 ventilator days (P = 0.01). Our results show that implementation of ventilator bundles can reduce VAP incidence.