團隊資源管理模式降低內科加護病房非計劃性移除氣管內管之成效

Team Resource Management Strategy on Reducing Unplanned Extubation Events of Endotracheal Tube in Medical Intensive Care Unit

李綺婷(Chi-Ting Lee) ； 陳嘉明(Jia-Ming Chen) ； 顏雅卿(Ya-Ching Chen) ； 謝志松(Chih-Sung Hsieh)

《呼吸治療》 12卷1期 (2013/01) Pp. 15-22

https://doi.org/10.6269/JRT.2013.12.1.02

摘要

研依據衛生署與醫策會台灣病人安全通報系統2008年度資料顯示，管路事件為通報中第三高之案件，其中又以氣管內管非計劃性移除比率最高（34.5%），一旦發生非計劃性移除氣管內管可能會造成病人心肺功能喪失，其發生原因分析發現以病人與醫護人員溝通不良之因素最多。依屏東某區域教學醫院內科加護病房有超過60%病患為急性呼吸衰竭需要放置氣管內管並使用呼吸器，其發生非計劃性移除氣管內管之病人，大部分是在約束中自拔，且發現有超過50%自拔管成功率。我們嘗試以團隊資源管理（TRM）模式，藉由提供內科加護病房醫護人員團隊工作技巧訓練，並進行作業流程的檢討與改善，來減少氣管內管非計劃性移除比率，以增進病人安全。研究對象為屏東某區域教學醫院於2010年1月至2011年11月期間所有入住內科加護病房並放置人工氣道（含經口腔插管、經鼻插管）且使用呼吸器的病人。評估應用團隊資源管理的運作模式是否改善氣管內管非計劃性移除的情形。其前置作業由病人安全暨醫療品質單位主導，第一階段準備期間自2010年1月至2010年12月，第二階段課程導入期間自2011年1月至2011年4月，TRM正式運作自2011年5月至2011年11月底止。結果顯示2011年1~11月與去年同期非計劃性移除氣管內管人次分別為8人和14人、即非計劃性移除氣管內管比率為0.30%和0.51%；且於TRM 運作期間（2011年5月至2011年11月底止）與去年同期（2010年5月至2010年11月底止）有顯著差異（8.35±7.90天vs.10.13±8.34天，p=0.039）。使用團隊資源管理模式來加強團隊照護訓練及相互溝通，尤其注重醫護人員與病人及其家屬間之雙向溝通。整個團隊運作從陌生到成熟，可從非計劃性移除氣管內管比率明顯降低，且後半年的呼吸器平均使用天數的減少可看出團隊資源管理模式之成效。

關鍵字

團隊資源管理（Team Resource Management，TRM） ； 非計畫性移除氣管內管（Unplanned Extubation of Endotracheal Tube）

並列摘要

Based on the database of Taiwan patient-safety reporting system, maintained by Taiwan joint commission on hospital accreditation, tube removal incidents took the third place in the ranking events on the year 2008. The most common incident was unplanned extubation of endotracheal tubes (34.5%) that caused by the misunderstanding of patient communication. More than 60% patients in medical intensive care unit of the Pingtung Christian hospital had acute respiratory distress that needed endotracheal intubation and mechanical ventilation. Patients with unplanned extubation may be followed by the consequence of cardiopulmonary dysfunction . Although most of the patients were under the physical restraint, there was still more than 50% self-extubation rate. In this study, we tried to practice the introduction of team resource management (TRM) process on reducing the unplanned extubation and improving patient safety. By means of effective teamwork, we could find out the optimal timing of extubation to make patient feel more comfortable and keep the quality of respiration care. Patients with endotracheal tube connecting to mechanical ventilator in medical intensive care unit were recruited into this study. TRM was proved and directed by patient safety and medical quality committee, the policy was preprocedured for one year and implemented since January, 2011. The trial stage was carried out in the first four months and it was established after May 2011. Results showed the case load of unplanned extubation in 2010 and 2011 (from January to November) were 14 and 8, respectively. The unplanned extubation rate in the same period of 2010 and of 2011 were 0.51% and 0.31% respectively. The average periods of mechanical ventilation from May to November of 2010 and of 2011 were 10.13±8.34 days and 8.35±7.90 days (p=0.039). TRM could enhance a variety of relationships for the health-care team members to improve the communication skills between medical-nursing staffs and patients as well as their families. The effectiveness of TRM reflected upon the significant reductions of the unplanned extubation rates and of the mechanic ventilation periods.

並列關鍵字

Team Resource Management (TRM) ； Unplanned Extubation of Endotracheal Tube