某區域醫院利用組合式照護模式降低腦室外引流管感染率之經驗

The Experience of Implementing External Ventricular Drain Bundle Care in a Regional Teaching Hospital

本院2018年裝置腦室外引流管（external ventricular drain, EVD）病人共465人日數，感染個案數4人，感染率8.6‰，較國外文獻感染發生率0.8-2.2‰高。EVD置放過久或管路傷口照護不當，容易導致中樞神經系統感染引發腦膜炎，感染後需使用抗生素治療約需6-10週，除延長住院天數、增加醫療費用，增加病人的痛苦，甚至於影響病人之生命安全，故成立EVD組合式照護小組進行原因分析，擬定相關組合式照護措施以預防感染發生並降低感染率。
EVD bundle care介入措施共有五項：1.手部衛生、2.檢視引流管引流液顏色、3.確認引流管為無菌密閉系統、4.管路照護及皮膚消毒流程、5.每日確認導管留置必要性。透過EVD組合式照護小組運用組合式照護模式，制定腦室外引流管組合式照護工作手冊、EVD bundle Care查檢表及稽核制度等規範。本院建立台灣首創EVD bundle care，自2019年至2022年推行期間，護理人員執行腦室外引流管認知稽核平均正確率從78.3%增加至100%，技術稽核平均正確率從74.3%增加至99.4%，專科護理師執行EVD換藥技術稽核平均正確率從87.5%增加至100%，五大組合式照護遵從率為100%，感染率由介入期前2018年8.6‰降至介入期後2022年0.0‰，經此成效顯示，EVD bundle care的推行，應能有效降低EVD感染率。

The infection rate for external ventricular drains (EVD) at our hospital was 8.6‰in 2018, exceeding the rates reported in the literature and the healthcare- associated infection rate of 1.1‰in 2021, according to Taiwan CDC surveillance data. Prolonged EVD use and improper care can lead to ventriculitis, necessitating an extended antibiotic treatment course of 6–10 weeks, increased hospital stays, higher medical costs, and patient suffering. Consequently, we formed an EVD bundle care team to investigate the causes and implement a bundle care strategy to decrease the EVD infection rate.
By organizing group discussions, establishing a bundle care menu, and implementing checklist and audit systems, the EVD bundle care team introduced bundle care elements, including: 1. Hand hygiene, 2. Observation of the characteristics of EVD fluid, 3. Confirmation of aseptic and closed systems in EVD management, 4. Daily care of EVD, and 5. Daily assessment for the removal of EVD. Following the implementation of EVD bundle care, the average accuracy rate of nurses performing cognitive and technical audits on EVD increased from 78.3% to 100% and from 74.3% to 99.4%, respectively. The average accuracy rate of physician assistants performing technical audits on EVD dressing changes increased from 87.5% to 100%. Compliance with the five bundle care elements reached 100%. The infection rate of EVD declined from 8.6‰in 2018 to 0.0‰in 2022. A trend suggests that EVD bundle care is associated with a low EVD infection rate. Further study is recommended.