改善非計劃性氣管內管滑脫率之專案

Reduce the Unplanned Removal Rate of Endotracheal Tubes

莊淑娟(Shu-Chuan Chuage) ； 李愛誠(Ai-Cheng Li) ； 戴佳月(Chia-Yueh Tai) ； 陳亞文(Ya-Wen Chen)

《若瑟醫護雜誌》 7卷1期 (2013/08) Pp. 71-84

摘要

背景與目的：美國醫療機構評鑑聯合會從醫院通報的醫療警訊事件中發現，醫療溝通與團隊合作不良是造成醫療錯誤的重要原因。本院2010年加護病房1-6月非計畫性氣管內管滑脫率為0.69%，高於設定閾值的0.35％及台灣醫療品質指標系列（THIS）0.48％。故本專案目的在改善非計畫性氣管內管滑脫率。方法：藉由現況分析及查閱相關文獻並運用團隊資源管理部分技巧改善。改善方案包括1.製訂氣管內插管管路照護標準及評核表。2.統一教材進行單位內氣管內插管病人照護教育訓練。3.進行加護病房所有團隊成員之團隊資源管理訓練。4.單位導入團隊技巧，如：相互監測、運用提醒及回饋等技巧激勵同仁。5.每日醫療團隊執行briefing，提醒需特別留意之個案，若管路滑脫則進行debriefing，以提升照護品質。6.定期監測及稽核氣管內插管病人照護狀況，並檢討改進。結果：經措施執行後，10-12月進行成效評值，非計畫性氣管內管滑脫發生率由0.69%降至0.34%。結論：本專案證實，經由標準設立、教育宣導，藉由團隊資源管理部分技巧之運用，使同仁凝聚合作共識、事前提醒及事後討論更能促進團隊溝通，進而降低非計畫性氣管內管滑脫率。

關鍵字

非計劃性氣管內管滑脫 ； 加護病房

並列摘要

Background and purpose: From the hospital report published by The Joint Commission on medical errors, it was found that the primary cause of medical errors arises from miscommunication and poor teamwork. In 2010, our hospital’s unplanned extubation rate was 0.69% for the months of January to June, which is higher than the Taiwan medical quality index value (0.48%). The purpose of this project is to improve the unplanned extubation rate. Method: Through analysis of current conditions and referencing related documents and implement a part of skills in team resource management. Methods include 1.Establish a standard procedure for extubation and assessment form. 2.Set uniform training materials to train medical personnel to perform extubation care.3.Perform team resource management training for all team members in the ICU. 4. Introduce team skills, such as: peer monitoring, using notification or feedback and other skills to encourage peers. 5. Daily medical team briefing to emphasize cases which need special care, and debriefing in situations where tubes slip, in order to increase care quality. 6. Periodic monitoring and assessment of care conditions of patients with extubation and make necessary improvements. Results: Post implementation, the results were assessed from October to December and unplanned extubation rate decreased from 0.69% to 0.34%. Conclusion: This project has validated that through establishing standard procedure, applying training, and utilizing a part of team resource management skills, peers were able to establish consensus with briefing and debriefing further encouraging team communication and reducing unplanned extubation rate.

並列關鍵字

unplanned extubation ； intensive care unit