中國醫藥大學 附設醫院 以醫療 品 管路 質觀點談 留置之照護 麻醉部 部主任 吳世銓 副教授 2009.04 1 1

品 質 斤斤計較 衡量的指標 眾人之口 2 2

產品品質 服務品質 滿足對產品或服務的期待 期待 3 3

生 命 變化 Dynamic Unpredictable Non-linear 不可預期 4 4

病患安全 5 5

通報、RCA分析、檢討、改善、再檢討改善 能力及绩效的表现 卓 越 辨識改善防範與監控 通報、RCA分析、檢討、改善、再檢討改善 處置與記錄 事前 避免 事中 事後 多元、持續 6

管路的種類 1.氣管內管及氣切導管(tracheostomy tube) 2.末梢靜脈(peripheral IV line) 3.動脈導管(A-line) 4.中央靜脈導管(CVP line) 5.鼻胃管(NG tube) 6.導尿管(俗稱Foley cath.) 7.胸管(chest tube)

管路的種類 8. 腦室引流管 9. 各種造廔術專用導管(胃,腸,腎) 10. 其他各種患部引流管 11. 洗腎用留置導管 8. 腦室引流管 9. 各種造廔術專用導管(胃,腸,腎) 10. 其他各種患部引流管 11. 洗腎用留置導管 12. 止痛用的硬膜外導管(epidural cath.) 13. 救命用的 IABP、ECMO 14. 緊急調整心律(cardiac pacing)的 wire

管路的意外事件 大量出血 空氣栓塞 腦部缺氧 敗血症 給藥錯誤 非計劃性手術 緊急照X光 死亡 賠償

The drive to survive Unplanned extubation in the ICU Krinsley JS, Barone JE Chest 2005;128:560-566 Outcomes after 100 UE

Patient-initiated device removal in ICUs: A national prevalence study Lorraine CM et al. Critical Care Medicine 2007;35:2714-2720 Consequences of patient-initiated device removal

Airway accidents in intubated ICU patients: An epidemiological study Kapadia FN et al. Critical Care Medicine 2000;28:659-664. 5,046 MV for 9,289 days in 4 yrs. Preventability ETT Group Tracheotomy Group Total Fully preventable 6 5 11 Partly preventable 13 4 17 Unpreventable 7 1 8 26 10 36 Most are preventable

檢討原因 放置時沒放對位置 自拔或意外滑脫 意外折到(kinking)或阻塞 導管被挾斷 不明原因斷裂 Overused, underused, misused

Root Cause Analysis 根本原因分析

結構 執行 結果

医疗质量小组 病人安全小组

現有 該有

該做 表現

六縱六橫 議題 能力 安全 適時 效應 效率 平等 病人中心 該懂的 該講的 該幫的 該做的 該教的 該改的

管路照護品質之重點工作 降低管路留置期間之感染率 氣管內管自拔及滑脫率之改善 管路照護之異常改善 管路錯接之預防

Unplanned extubation in orally intubated medical patients in the ICU: A prospective cohort study Bouza C. et al. Heart and Lung 2007;36:270-276. Intentional n=24 Accidental n=10 P value Ventilatory support <0.003 Full MV 2 (8%) 6 (60%) Weaning Trial 22 (92%) 4 (40%) Sedation <0.001 Nonsedated 21 (87.5%) 3 (30%) Sedated 3 (12.5%) 7 (70%) Time of day 0.002 Morning shift 5 (21%) 8 (80%) Evening shift 4 (17%) 1 (10%) Night Shift 15 (62%) Caregivers at bedside 7 (29%) 0.03 Not at bedside 17 (71%) UE increased the need for MV and ICU care. There was a moderate to high potentially modifiable risk factors for UE, suggesting unsatisfactory ICU practice. More in intentional, intentional less serious condition; more when nurse is away;

Unplanned extubation in orally intubated medical patients in the ICU: A prospective cohort study Bouza C. et al. Heart and Lung 2007;36:270-276. Reintubation n=14 Non-reintubation n=20 P value Ventilatory support Full MV 7 (87.5%) 1 (12.5%) 0.004 Sedated 9 (90%) 1 (10%) 0.003 Time of day 0.002 Morning shift 8 (61.5%) 5 (38.5%) Evening shift 1 (17%) 5 (83%) Night Shift 5 (33%) 10 (67%) Length of stay (d) 24 (13-67) 8 (2-25) 0.001 Total days on MV 22 (11-65) 7 (1-23) UE increased the need for MV and ICU care. There was a moderate to high potentially modifiable risk factors for UE, suggesting unsatisfactory ICU practice. And accidental sicker, most MV and sedation and morning shiftwith UE need reintubation; reintubation LOS TDMV are longer.

Retrospective; All UE were self extubations; 15 reintubation Retrospective; All UE were self extubations; 15 reintubation. Most with low levels of sedation in the hour preceding the extubation (mean Ramsay 2.42). Pt needing reintubation had higher Ramsay 2.85 than did not 2.0. Ramsay score correlated with the need for reintubation (r=0.423; p=.03. Of the 31 pts 27 were restrained at the time of extubations p<0. 001. Nurses32.3% had less than 5 years’ experiencein nursing and 51.6% had less than 5 years’ experience in ICU care; 89% of extubation occurred when the nurse was away from the bedside. Sedative and analgesic dose in the 24 h before extubation did not differ significantly from those in the 2 h before extubation 15/31

Influence of physical restraint on unplanned extubation of adult intensive care patients: A case-control study Chang LY et al. American Journal of Critical Care 2008;17:408-416 Impaired level of consciousness on admission to the ICU and the presence of nosocomial infection intensify the risk for unplanned extubation, even when physical restraints are used.

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Reporting unplanned extubation Birkett KM et al Reporting unplanned extubation Birkett KM et al. Intensive and Critical Care Nursing 2005;21:65-75 4.9% Quality of care Establish/revise ETT fixation protocols Sedation Appropriate use of restraints Clinical pathways Early and nurse led weaning Nurse led extubation A system of anonymous reporting to more freely reflect incidence. 3.2%

Measurable outcomes of quality improvement in the Trauma ICU: The impact of a daily quality rounding checklist DuBose JJ, Inaba K et al. J Trauma 2008;64:22-29 Daily QRC facilitated improved compliance rate for placement

Measurable outcomes of quality improvement in the Trauma ICU: The impact of a daily quality rounding checklist DuBose JJ, Inaba K et al. J Trauma 2008;64:22-29 Daily QRC facilitated improved compliance rate for placement

Unexplanned extubation in a pediatric ICU: impact of a quality improvement programme da Silva PSL et al. Anaesthesia 2008;63:1209-1216 Implementation of a continuous quality improvement programme is effective in reducing the overall incidence of UE

提升管路安全留置品質 增修照護標準作業流程 教育訓練與評值 建立品管監測機制 研發病人及主要照護者指導工具與策略 針對警訊事件及通報案例進行醫療團隊的溝通及檢討改善

遵循標準化的步驟及checklists 使用 fail-safe 或有警報器的醫材 制定固定方法 貫徹無菌觀念 有多條管路時，清楚標記以預防打結或混亂 (spaghetti syndrome)

插 CVP 時用超音波定位 影像確認管路位置的正確性 新手使用Sim Lab假人練好工夫(插胸管或打CVP) 0.9%

管路留置品質管理的成效 醫護人員 行政管理 教 學 臨 床 病 人 研 究 醫療品質及安全照護 注重護理品質，保障病人權利 增加人員正確處置的認知及流程順暢度，讓能正確提報數據及在工作上增加信心，作業易被肯定，提昇個人醫療品質及工作滿意度 管路留置品質管理的成效 醫護人員 建立病人管路事件危險及評估工具 建立管路照護表 護理人員自學手冊 提高執行力及增加利潤 減少病人管路事件的次數，減少失敗成本及醫療糾紛，並縮短平均住院日數 行政管理 教 學 提昇了護理人員對管路照顧及異常事件上的認識 醫療品質及安全照護 注重護理品質，保障病人權利 臨 床 病 人 研究確實回報的成效，提昇相關人員對研究方法的認知、增加本院的研究成果 。 研 究

積極的品質管理獲得 ? 提升病人滿意度，創造品牌形象 能給病人及醫院提供明確科部優異數據證明 提升醫院競爭優勢 創造出病患、醫護人員及醫院的三贏局面 35 35

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