運用品管圈手法提升腦中風病人鼻胃管移

Improving the Nasogastric Tube Removal Rate in Stroke Patients Using a Quality Control Circle Method

背景：腦中風後吞嚥障礙發生率約40%至70%，常導致吸入性肺炎與生活品質下降。本單位雖初次吞嚥篩檢率達98.8%，然腦中風病人鼻胃管移除率僅52.7%，低於國內標竿值57.4%。經品管圈真因分析確立五大問題：缺乏常規在職教育、跨領域團隊協作認知不足、篩檢表版本不一致、缺乏多職類衛教工具，以及病人轉換單位時篩檢時機不明確且再次執行吞嚥篩檢率僅60.3%。
目的：提升腦中風病人鼻胃管移除率，根據現況值52.7%，將目標值設定為67.8%。
解決方案運用品管圈手法實施改善措施：（1）舉辦跨領域協作與篩檢在職課程，並明確定義各職類的介入時機與定位；（2）整合「三階段吞嚥篩檢表」，加入口腔清潔前置步驟與臨床決策指引；（3）建立護理、中醫、語言治療之多職類衛教單張；（4）修訂作業指導書，明確規範「單位轉換時」需再次執行篩檢。
結果：專案介入後，腦中風病人鼻胃管移除率由52.7%提升至69.9%，達成預期目標，且自出院日起後續追蹤六個月內無重新置管案例。再次執行吞嚥篩檢率由60.3%大幅提升至97.4%。附加效益方面，移除管路節省之技術時數轉化為高價值個別化照護（每日約15分鐘），並預估為每個家庭每年節省24，708元之醫療成本。
結論：本專案透過流程標準化與強化跨領域團隊合作，有效消弭照護空窗期，實質提升病人安全與照護品質。

Background & Problems: Post-stroke dysphagia, which affects 40% to 70% of stroke survivors, frequently leads to aspiration pneumonia and diminished quality of life. Despite achieving a 98.8% initial swallowing screening rate, the nasogastric tube removal rate in our unit of 52.7% was below the national benchmark of 57.4%. A quality control circle root cause analysis was conducted, with five critical issues identified. These included a lack of routine in-service education, insufficient interdisciplinary collaboration, inconsistent screening tool versions being used, a deficit in integrated educational resources, and ambiguous re-screening protocols during patient transfers that resulted in a low re-screening rate (60.3%).
Purpose: This project was implemented to increase the nasogastric tube removal rate in stroke patients from the baseline of 52.7% to a minimum target of 67.8%.
Resolution: Four key interventions were implemented using quality control circle methodologies. These included: (1) Organizing interdisciplinary workshops to clarify intervention timing and professional roles across disciplines; (2) Integrating a“Three-Stage Swallowing Screening Tool”incorporating pre-procedural oral hygiene protocols and clinical decision-making algorithms; (3) Developing interdisciplinary patient education materials encompassing nursing, traditional Chinese medicine, and speech-language pathology; and (4) Revising standard operating procedures to mandate re-screening during all inter-unit transfers.
Result: Post-intervention, the nasogastric tube removal rate increased from 52.7% to 69.9%, which exceeded the targeted goal. Notably, no re-intubations occurred within the six-month post-discharge follow-up period. In addition, the re-screening rate during inter-unit transfers improved markedly from 60.3% to 97.4%. Ancillary benefits included redirecting approximately 15 minutes of tube maintenance time per nurse daily into high-value individualized patient care, and an estimated savings in annual healthcare costs of NT$24,708 per family.
Conclusion: The process standardization and enhanced interdisciplinary synergy achieved under this project effectively eliminated gaps in care, resulting in substantially improved patient safety and care quality.