預防手術部位感染之多模式策略

Implementation of Multimodal Strategies to Prevent Surgical Site Infections

手術部位感染是一種嚴重且通常可預防的併發症，會增加病人的罹病率、死亡率，並造成醫療保險系統巨大的財政負擔。手術部位感染的原因和預防方法是複雜的並涉及許多因素，預防手術部位感染的策略包括：領導者須提供足夠資源（特別是人力資源）、組織多學科團隊、親自參與和支持減少手術部位感染的策略，以及樹立安全文化；術後監測手術部位感染，並進行發生手術部位感染的根本原因分析，以確定問題的領域和改進機會；實施基於實證的策略（包括風險評估、血糖控制、腸道準備、皮膚準備、抗藥菌的去移生、預防性抗生素、維持正常體溫、手術之無菌技術、術後傷口照護等），以取得更好的成效；並確保改進的策略是可持續的，以提升醫療品質與保障病人安全。論質計酬的鼓勵措施可有效地促使醫院實施預防感染的策略和增進遵從性，以減少手術部位感染。建議學習美國預防手術部位感染的策略，由健保署與疾病管制署，投入資金與人力，規劃執行國家級預防手術部位感染的長期計畫，由醫療保險單位、醫療政策單位、與全國醫院一起合作改善手術照護品質、降低手術部位感染、提升病人安全、與減少醫療支出。

Surgical site infection (SSI) is a serious and often preventable complication that increases patient morbidity and mortality rates, and confers a significant fiscal burden to the healthcare insurance system. The causation and prevention of SSI are complex and multifactorial. The issues of prevention of SSI include the role of leadership in providing resources, organizing a multidisciplinary team, involving and supporting the strategy to reduce SSI, and setting a culture of safety; performing postoperative surveillance for SSI and a root-cause analysis to identify problem areas and opportunities for improvement; implementing evidence-based strategies (including risk assessment, glycemic control, mechanic bowel preparation, skin preparation, decolonization of multidrug resistant microorganism, prophylactic antibiotic, maintaining intraoperative normothermia, aseptic surgical technique, and wound care) to achieve a better outcome; and finally, ensuring that improvement changes can be sustained. Pay-for-performance incentives may provide a more effective method for implementing strategies and motivating compliance to reduce surgical site infections. Learning from the strategies implemented in the United States to prevent surgical site infections, we suggest that the National Health Insurance Administration and Taiwan Centers for Disease Control provide financial support and human resources to initiate a long-term national surgical infection prevention project. Together with health-care providers, they can collaborate on the project to reduce surgical site infections, improve patient safety, and reduce healthcare cost.