運用跨團隊合作模式降低成人加護病房非計劃性氣管內管滑脫率

Using Team Resource Management to Reduce Unplanned Endotracheal Tube Slippage Rate in Adult Intensive Care Unit

10.6386/CGN.202306_34(2).0006

史意絹(Yi-Chuan Shih)；柯玉真(Yu-Chen Ko)；粘雅淨(Ya-Ching, Nien)；陳雅薰(Ya syun Chen)；莊佩宜(Pei-Yi Chuang)；王美文(Mei-Wen Wang)

加護病房 ； 非計劃性氣管內管滑脫 ； 跨團隊合作模式 ； intensive care unit ； unplanned endotracheal tube slippage ； team resource management

長庚護理

34卷2期（2023 / 06 / 01）

61 - 74

繁體中文;英文

非計劃性氣管內管滑脫為常見之病人安全通報事項，一旦發生將影響病人安全，增加醫療耗費。透過現況分析，確立要因為鎮靜程度評估表（Richmond Agitation-Sedation Scale, RASS）認知不足、無RASS影音輔助教學內容、現行約束工具使用費時且難固定、跨團隊無共同平台討論呼吸訓練及拔管機制及RASS評估後分數沒有相對應的處置等。透過教育訓練、建構自拔高危因子篩選表、RASS評估警示機制、跨團隊介入及約束改良品等對策，使護理人員執行氣管內管照護正確率由68.5上升至96.3、約束技術正確率由68.5上升至96.3及RASS認知正確率由65.9上升至94.1，皆達專案目標。期間也未發生非計劃性氣管內管滑脫情形，顯示本專案措施介入確有其成效，共同維護病人安全，提升照護品質。

Unplanned endotracheal tube slippage is a frequent patient safety concern with significant implications for patient well-being and increased medical costs. A comprehensive analysis of the current situation revealed several fundamental causes, including inadequate awareness of the Richmond Agitation-Sedation Scale (RASS), a lack of multimedia computer-assisted instruction about RASS, inefficient and cumbersome restraint tools, the absence of a common platform for multidisciplinary discussion regarding respiratory training and extubation protocol, and a lack of corresponding management after RASS assessment. To address these critical issues and prevent future incidents, a series of preventive measures were implemented. These measures encompassed staff education and training, the creation of a risk-screening form for self-extubation, the implementation of a RASS warning system, multidisciplinary intervention, and advancements in restraint techniques. As a result of these proactive measures, the accuracy rate of nursing care in endotracheal tube and restraint techniques significantly increased from 68.5% to an impressive 96.3%. Additionally, the validity of RASS recognition rose from 65.9% to 94.1%, effectively reaching the project endpoints. Significantly, during the project period, there were no instances of unplanned endotracheal tube slippage, providing clear evidence of the effectiveness of these interventions. This project was successful and can be applied in clinical practice to uphold patient safety and enhance the overall quality of care.

1. 林佳瑩, C. Y.,施佩華, P.H.,許榕珊, J. S.,陳麗貞, L.C.,謝春蘭, C.L.(2017)。降低氣管內管留置病人疼痛之改善專案。志為護理─慈濟護理雜誌，16(2)，71-81。
   連結：
2. 林麗卿, L. C.,邱艷芬, Y. F.,林碧珠, P. C.(2017)。家屬叮嚀方案對減輕加護病人焦慮和非計劃性拔管之成效。護理雜誌，64(5)，41-49。
   連結：
3. 莊孟蓉, M. J.,曾鳳美, F. M.,李雅芬, Y. F.,洪麗娟, L.C.(2016)。非計劃性氣管內管拔管發生率改善專案。醫務管理期刊，17(2)，115-130。
   連結：
4. 廖曉雯, H. W.,盧美玲, M. H.,廖雪雯, H. W.,邱子易, T. I.(2019)。非計劃性拔除氣管內管之改善專案。領導護理，20(3)，119-132。
   連結：
5. 台灣臨床成效指標(2020)．加護病房非計劃性的氣管內管滑脫事件．取自http://tcpi.jct.org.tw/tcpi/Default.aspx [Taiwan Clinical Performance Indicator (2020). Unplanned extubation in intensive care unit. retrieved from http://tcpi.jct.org.tw/tcpi/Default.aspx]
6. 台灣病人安全資訊網(2018)．台灣病人安全通報系統2018年TPR年報．取自https://ftt.tw/kWmuA [Taiwan Patient Safety Net. (2018). Taiwan patient-safety reporting system annual report 2018. Retrieved from https://ftt.tw/kWmuA.]
7. Ai, Z. P.,Gao, X. L.,Zhao, X. L.(2018).Factors associated with unplanned extubation in the Intensive Care Unit for adult patients: A systematic review and meta-analysis.Intensive and Critical Care Nursing,47,62-68.
8. Cosentino, C.,Fama, M.,Foà, C.,Bromuri, G.,Giannini, S.,Saraceno, M.,Spagnoletta, A.,Tenkue, M.,Trevisi, E.,Sarli, L.(2017).Unplanned extubations in intensive care unit: Evidences for risk factors. A literature review.Acta Bio Medica: Atenei Parmensis,88(Suppl 5),55-65.
9. Crezeé, K. L.,DiGeronimo, R. J.,Rigby, M. J.,Carter, R. C.,Patel, S.(2017).Reducing unplanned extubations in the NICU following implementation of a standardized approach.Respiratory care,62(8),1030-1035.
10. Dunn, A. S.,Reyna, M.,Radbill, B.,Parides, M.,Colgan, C.,Osio, T.,Benson, A.,Brown, N.,Cambe, J.,Zwerling, M.,Egorova, N.,Kaplan, H.(2017).The impact of bedside interdisciplinary rounds on length of stay and complications.Journal of hospital medicine,12(3),137-142.
11. 吳純怡, C. Y.,陳瑞貞, J. C.(2018)。降低加護病房氣管內管自拔發生率。台灣醫學，22(2)，192-198。
12. 財團法人醫院評鑑暨醫療品質策進會(2018)．台灣病人安全資訊網 ．取自https://www.jct.org.tw/mp-1.html [Joint Commission of Taiwan (2018). Taiwan patient safety net. Retrieved from https://www.jct.org.tw/mp-1.html ]
13. 陳楷翔, K. H.,藍文熙, W. H.,常慈, T.,葉育彰, Y. C.,廖文進, W. J.,龔瑞琛, S. S.,黃煜為, Y. W.,鄭高珍, K. C.,陳欽明, C. M.(2016)。台灣成人加護病房病人疼痛、躁動和譫妄診斷指引，第二部份：躁動．台灣疼痛躁動譫妄照護指引。Resuscitation & Intensive Care Med，1，71-81。
14. 衛生福利部(2020)．109-110年度醫院醫療品質及病人安全工作目標 ．取自https://ppt.cc/fPjCZx [Ministry of Health and Welfare. (2020). 109-110 year Taiwan patient safety goals for hospitals. Retrieved from https://ppt.cc/fPjCZx]