運用預防手術部位感染組合式照護降低冠狀動脈繞道手術術後感染

Implementing the Care Bundle: Effectiveness of Reducing Surgical Site Infection in Coronary Artery Bypass Surgery

外科手術部位感染 （surgical site infections, SSI） 為第四常見醫學中心醫療照 護相關感染 （healthcare associated infections, HAIs） 部位，病人若發生手術部位 感染，除了增加醫療費用，住院天數延長外，甚至會影響到病人生命安全，本院 2015 年 1 月至 2016 年 8 月共有 113 人次進行冠狀動脈繞道手術，有 5 位病人 發生手術後傷口感染情況，感染率 4.42% （5/113），相較於同期同儕醫學中心感 染率 1.53% 偏高，故於 2016 年 09 月至 2017 年 12 月推動冠狀動脈繞道手術， 手術部位感染組合式照護措施 （surgical site infection care bundle, SSI bundle） 計畫。 計畫內容指引參考美國疾病管制中心 （centers for disease control and prevention, CDC） 1999 年及世界衛生組織 （world health organization, WHO） 2016 年所公佈的降低 SSI 建議措施，檢視本院目前執行現況，擬訂改變措施 有：一、病人術前沐浴落實提醒病人並呈現於護理交班單且主動提供含 2% chlorhexidine gluconate （CHG） 抗菌劑，二、使用拋棄式刀頭之電動除毛機進行 皮膚除毛，三、增加使用計時器等待皮膚消毒劑自然乾燥，四、術後 2 天血糖監 測對象改為全部手術病人皆監測且控制 ≤ 180 mg/dL，五、手術後傷口換藥時間 統一改為術後第二天。 執行期間共有 93 人次進行冠狀動脈繞道手術，其中有 2 位病人於術後發生 手術後傷口感染，感染率由之前 4.42% 下降至 2.15% （p < 0.001），結論本研究 使用手術部位感染組合式照護措施並加上嚴格術前和術後的血糖控制，推行經驗 表示是能有效降低 SSI 的發生。（感控雜誌 2020:30:215-227）

Surgical site infection (SSI) is the fourth most common healthcare-associated infection (HAI) in medical centers. It increases the medical cost, prolongs the hospital stay and affects the patients' safety. From January 2015 to August 2016, 113 patients underwent coronary bypass surgery in our hospital and 5 of them had postoperative SSIs. The infection rate was 4.42% (5/113), which was higher than the infection rate of 1.53% in the Taiwan Medical Center in the same period. Therefore, from September 2016 to December 2017, the SSI care bundle (SSI Bundle) program for coronary bypass surgery was promoted. The program guidelines were based on the recommendations of the US Centers for Disease Control (CDC) 1999 and the World Health Organization (WHO) 2016. Examining the current situation of our hospital and the differences between the CDC and WHO recommendations, the following procedures were changed: (1) actively providing a 2% chlorhexidine gluconate (CHG) antibacterial agent for the patient to bathe before the operation and presenting it on the care shift list, (2) using a disposable or electric razor for hair removal, (3) using a timer in the operation room to make sure the disinfectant has dried before starting the surgery, (4) monitoring blood glucose for all patients within 2 days after surgery, and (5) wound dressing done on the second day after surgery. During the implementation of the program, a total of 93 patients underwent coronary bypass surgery. Two of the patients had SSIs after surgery, and the infection rate decreased from 4.42% to 2.15% (p < 0.001). In conclusion, this study uses SSI care bundle measures combined with strict preoperative and postoperative blood sugar control. The implementation experience shows that it can effectively reduce the occurrence of SSI.