加護病房病人接受約束處置護理及非計畫性氣管內管滑脫之狀況

Physical Restraints and Unplanned Endotracheal Extubation Among Patients in Intensive Care Units

唐秀燕(Hsiu-Yen Tang)

指導教授 ： 黃惠滿

長榮大學/健康科學學院/護理學系(所)/碩士(2016年)

摘要

背景:加護病房氣管內管留置病人經常接受約束處置護理來預防氣管內管滑脫，但仍
發生非計畫性氣管內管滑脫事件，有探討之必要。
目的:探討內外科加護病房氣管內管留置病人接受約束處置護理及非計畫性氣管內管
滑脫之狀況。
方法:採病歷回溯分析，收集南部某區域教學醫院六個加護病房，2014年1月1日至6
月30日共381位氣管內管留置病人，自擬「加護病房病人基本屬性及病房特性
問卷」、「加護病房病人接受約束處置護理紀錄表」、「加護病房病人發生非
計畫性氣管內管滑脫事件紀錄表」三份問卷收集資料。
結果:加護病房氣管內管留置病人:(1)有接受約束處置護理比率為76.7%且以男性
多於女性，診斷有呼吸系統及無神經系統疾病者多於無呼吸系統及有神經系統
疾病者；無呼吸系統疾病診斷、有癌症疾病診斷者其約束總時數顯著少於有呼
吸系統疾病診斷、無癌症疾病診斷者。(2)有接受約束處置護理者以有使用鎮
靜劑者為最多，且以使用Benzodiazepines之種類為主。(3)疾病嚴重程度
愈高者愈不可能接受約束處置護理，且疾病嚴重程度愈輕者其接受約束處置護
理之總時數愈長。(4)意識狀況愈清醒者愈有可能接受約束處置護理，且其接
受約束處置護理的總時數愈長。(5)病房的護病比愈高，病人接受約束處置護
理的護理品質愈完整。(6)每1,000人日數之非計畫性氣管內管滑脫率為0.9‰
(五位)，五位病人以年齡大於65歲居多，疾病嚴重程度屬中度以上，且以預防
非計畫性拔管而接受約束處置護理者為主，其中三位病人氣管內管滑脫後不需
再重新置入，四位病人發生氣管內管滑脫時護理人員未在病人單位。(7)診斷
有呼吸系統疾病者(OR=2.456，p<.05)、APACHEⅡ(OR=.937，p<.01)、
昏迷指數(OR=1.237，p<.001)、管路數量(OR=1.273，p<.05)四個變項
為加護病房氣管內管留置病人接受約病束處置護理之預測因子。
結論/實務應用:加護病房病人診斷為呼吸系統疾病、APACHE Ⅱ低、昏迷指數高、
管路數量愈多者為加護病房約束處置護理高危險群，應密切觀察並擬定照護計
畫，即早給予替代性約束措施，並討論盡早移除氣管內管的可行性，以降低病
人接受非必要性約束處置護理及發生非計畫性氣管內管滑脫事件之比率。

關鍵字

非計畫性氣管內管滑脫 ； 約束處置護理 ； 加護病房

並列摘要

Background: Patients with indwelling endotracheal tubes in intensive care units (ICU) often require physical restraints to prevent unplanned extubation. However, unplanned extubating incidents are still found and thus require further investigation.
Purpose: To investigate physical restraints and unplanned endotracheal extubation for patients with indwelling endotracheal tubes in medical and surgical ICUs.
Methods: This is a retrospective medical record review study. From January 1st and June 30th, 2014, 381 patients with indwelling endotracheal tubes at six ICUs in one southern regional teaching hospital were eligible for this study. Three self-designed questionnaires, including “Demographic Data of the Patients and Characteristic of the ICU”, “Nursing Logs for Patients With Physical Restraint in the ICU” and “Accident Reports of Patients With Unplanned Extubation in the ICU”, were applied for data collection.
Results: For patients with indwelling endotracheal tubes in the ICU: (1) 76.7% of these patients received physical restraint. In this group, male patients were greater in number than female patients. Patients who were diagnosed with respiratory disorders and patients without neurological diseases were greater in number than those who were diagnosed with neurological diseases and patients without respiratory disorders. Moreover, total restraint time for patients with cancer, were diagnosed without respiratory disorders was significantly shorter than those who without cancer, had respiratory disorders. (2) Patients who received physical restraint most likely received sedative treatment, especially Benzodiazepines-based sedatives. (3) Patients who had more severe diseases were less likely to require physical restraint. Patients who had milder diseases required longer physical restraint. (4) Patients with higher GCS scores were more likely to require longer physical restraint. (5) In the ICU ward, the higher the nurse-patient ratio, the better the quality of physical restraint. (6) The unplanned extubation rate per 1,000 patient-days was 0.9‰(five patients).Among the five patients, all of them were more than 65 years old and had moderate or more severe diseases. The primary reason for requiring physical restraint was to prevent unplanned extubation. Three of these patients did not require re-intubation after unplanned extubation and four patients had extubating incidents while the nursing staffs were away from the patient beds. (7) Four predictors for patients with indwelling endotracheal tubes in the ICU who required physical restraint: respiratory disorders (OR=2.456, p<.05), APACHE Ⅱ (OR=.937, p<.01), GCS score (OR=1.237, p<.001) and number of tubes/catheters (OR=1.273，p<.05).
Conclusions/Clinical Application: ICU patients, especially those diagnosed with respiratory disorders, or those with either lower APACHE II scores, higher GCS scores or multiple tubes/catheters, are high-risk populations for physical restraint. For reducing unnecessary restraint procedures and the incident of unplanned extubation, close monitoring and alternative restraint proceduresl must be provided as early as possible. Also, the health professionals should discuss the feasibility of early removal of endotracheal tubes.

並列關鍵字

unplanned extubation ； physical restraints ； intensive care unit

參考文獻

財團法人醫院評鑑暨醫療品質策進會(2013年1月1日)•台灣臨床成效指標執行手冊

財團法人醫院評鑑暨醫療品質策進會(2014年4月30日)•加護病房身體約束事件•取

財團法人醫院評鑑暨醫療品質策進會(2015年11月26日)•加護病房非計畫性氣管內

財團法人醫院評鑑暨醫療品質策進會(2014年5月23日)•醫院評鑑基準及評量項目

財團法人醫院評鑑暨醫療品質策進會(2014年11月12日)•台灣臨床成效指標通報系