運用品質改善手法減少早產兒住院低體溫發生率

Quality Improvement Implementation to Reduce Admission Hypothermia in Premature Infants

10.6740/NTUHJN.202007_16(2).0013

劉宜涵(Yi-Han Liu)；張詠婕(Yung-Cheih Chang)；李芷萍(Chih-Ping Lee)；周安國(An-Kuo Chou)

醫療失效模式與效應分析 ； 早產兒 ； 低體溫 ； healthcare failure modes and effects analysis ； preterm infant ； hypothermia

臺大護理雜誌

16卷2期（2020 / 07 / 01）

141 - 155

繁體中文

背景：當新生兒出現低體溫時會有較高的併發症與死亡率，尤其對早產兒及低體重兒影響更甚。本院2016年7月至12月早產兒入院低體溫發生率為57.7%。分析現況發現造成早產兒低體溫之風險最高的原因為：無保暖標準作業流程與稽核制度、產包與包巾無加溫、產房與開刀房房溫為23℃以下、烤燈與保溫設備不足、護理師對早產兒即刻照護標準作業流程執行不完整。目的：運用醫療失效模式與效應分析減少早產兒低體溫發生率。解決方案：增加產房溫度、在肌膚接觸及轉送過程中所有新生兒都額外使用預熱過的厚包巾、調高保溫箱溫度、早產兒出生後立即使用全身包覆的聚乙烯（polyethylene, PE）保暖袋及毛帽，以及提供在職教育增進護理師認知等措施。結果：早產兒低體溫發生率自57.7%降至17.1%。結論：顯示品質改善的施行以及標準化生產過程能夠減少早產兒低體溫發生率。

Hypothermia increases neonatal morbidity and mortality, particularly in preterm infants and infants with low birth weight. This project used quality improvement measures to reduce the incidence of hypothermia in preterm infants. According to statistics, the incidence of hypothermia in preterm infants from July to December, 2016 was 57.7%. According to a hazard analysis, the greatest risk of causing hypothermia in premature infants is due to the lack of standard operating procedures, an auditing system, no heating production package and towel, delivery room temperature ＜ 23°C, insufficient lamps and insulation equipment, and the nursing staff's fully implementation of standard operating procedures for immediate care and care of premature infants. Therefore, in addition to the original regular mode (including regular baby care), several additional measures were enacted, including increasing the temperature of the delivery room and using warm pre-heated towels during skin contact in transferring process. The temperature of the transport incubator increased from 33.5 to 34.5°C. A full-body polyethylene bag and wool cap were used immediately after a birth of premature baby, and in-service education is provided to enhance nurses' knowledge. After implementing this project, the incidence of hypothermia in preterm infants decreased from 57.7% to 17.1%. Quality improvement and standardized delivery processes reduced the incidence of hypothermia in preterm infants.