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博碩士論文 etd-0416116-140905 詳細資訊
Title page for etd-0416116-140905
論文名稱
Title
以「醫療失效模式與效應分析」於加護病房中心導管組合式感染控制流程之改善
Applying Healthcare Failure Mode and Effects Analysis in the Improvement of Central Venous Catheter Bundle Care
系所名稱
Department
畢業學年期
Year, semester
語文別
Language
學位類別
Degree
頁數
Number of pages
102
研究生
Author
指導教授
Advisor
召集委員
Convenor
口試委員
Advisory Committee
口試日期
Date of Exam
2016-05-03
繳交日期
Date of Submission
2016-05-16
關鍵字
Keywords
病人安全、血流感染、組合式照護、醫療失效模式與效應分析、加護病房
Patient Safety, Blood Infection, Bundle Care, Failure Mode & Effect Analysis in Healthcare, Intensive Care Uunit
統計
Statistics
本論文已被瀏覽 5769 次,被下載 30
The thesis/dissertation has been browsed 5769 times, has been downloaded 30 times.
中文摘要
目的:
中心導管的放置是加護病房病人常見的醫療處置, 2014 年因應美國疾病管制局(Centers for Disease Control and Prevention, CDC)提倡Bundle Care 「零感染」計畫,以期能降低感染率,增加病人安全。期望藉由CDC 管路照護標竿學習,建立符合醫院臨床需求之Bundle Care 流程來改善中心導管相關血流感染率,落實CLABSI「零感染」目標。
方法:
研究小組運用醫療失效模式與效應分析(Healthcare Failure Mode and Effects Analysis, HFMEA)工具介入,研究南區某加護病房醫護人員,執行中心導管組合式照護流程之風險因素,以期降中心導管低血流感染率。
結果:
自2014 年3 月1 日至2015 年3 月31 日,經HFMEA 分析後,提出36 項建議改善措施,再針對組合式中心導管流程完整性與相關血流感染率增加的原因,依照可行性、重要性、迫切性及效益性進行決策矩陣分析,篩選出7 項措施進行改善:一、供用物可近性:創新「CVC」包。二、洗手標語:設計專屬CVC 公仔、動態式提示洗手娃娃機。三、提供最大無菌覆蓋面:由頭至腳230*200 公分。四、訂2% CHG 使用規範。五、訂中心導管置入流程及照護查檢表。六、設置導管品管監測看板。七、規劃並舉辦醫療人員bundle care 概念、2%CHG 使用、中心導管置入及照護教育訓練。經研究介入後,中心導管組合照護流程正確率47.5%上升至5.42%,醫師執行正確率由53.3%上升至93.3%,護理人員執行正確率43.7%上升至91.2%,平均相關血流感染率由研究前4.91‰降至1.07‰,本研究追蹤其改善成效,在中心導管放置的天數與中心導管血流感染發生率進行改善前後t 檢定,中心導管放置的天數p=0.033;中心導管血流感染發生率p=0.029,皆達統計上顯著差異。
結論:
藉由護理、醫療、感管、供應室等跨領域團隊合作共同努力之下,制訂照護流程標準化,透過教育訓練、制定查核表、創新「CVC」包、醫護共同評估導管等方式,利用正向回饋機制,即時公佈感染率,亦大大提升單位士氣,且在改善過程中不需額外增加成本,成功創造一個優質重症照護品質的經驗。
Abstract
Objective:
The placement of a central venous catheter, also known as a central line, is a
common medical procedure that often takes place in the intensive care unit (ICU). In 2014 the Centre for Disease Control and Prevention (CDC) proposed the concept of bundle care intervention in hopes to decrease chances of infection and improve patient safety. We hope to use the guidelines set by the CDC as a benchmark for establishing an effective bundle care procedure that can be used in hospitals to decrease risk of central line associated bloodstream infection, and eventually implement the ultimate goal of “zero infection”.
Method:
The Healthcare Failure Mode and Effects Analysis (HFMEA) tool was used to evaluate risks that may occur during the care process of central line placement in the South ICU and to decrease risk of central line-associated bloodstream infection.
Result:
Between March 1, 2014 to March 31, 2015, a total of 36 measures of improvement were proposed after using HFMEA analyzation. Because of increased infection rates and lack of completion in bundle care procedure, these 36 measures were then narrowed down according to feasibility, importance, urgency, and benefits. In the end, a final of seven areas of improvement were selected to carry out: 1) Availability and accessibility of materials: innovate new CVC bundles. 2) Hand rinsing signs: design special CVC dolls and dynamic hand washing reminders. 3) Provide maximum sterile protection: 230x200 cm² from head to toe. 4) Develop a 2% CHG usage guideline. 5) Set a checklist for
central line placement procedure and care. 6) Set up a bulletin board for monitoring central line quality care. 7) Plan, train, and educate concepts of bundle care, usage of 2% and central line placement and care for all medical staff. After the intervention of this study, percentage of correctness in the performance of central line bundle procedure and care increased from 47.5% to 85.42%. Specifically, percentage of procedure correctness performed by doctors increased from 53.3% to 93.3%, and percentage of procedure correctness performed by nursing staff increased from 43.7% to 91.2%. Overall, related infection caused by central line had also decreased from 4.91‰ before this study to 1.07‰. The research used t-test to evaluate the intervention on days central
catheter placement (p=0.033) and catheter-Associated bloodstream infection rate
(p=0.034). These results had statistical significance.
Conclusion:
After a vast amount of hard work and interdisciplinary cooperation from the nursing staff, medical staff, infection and supply department, a standardised procedure of care was finally set and carried out. Through educational training, setting guidelines and a checklist, innovation of a new CVC bundle, collaborative assessment of central line from medical staff, and immediate reports of infection rates, a form of positive reinforcement had succeeded in increasing the department’s morale. In addition, no extra cost was needed to make any of these improvements. All in all, this new and innovative experience was a success in creating a higher quality of care for patients.
目次 Table of Contents
目錄
第一章 緒論.. 1
第一節 研究背景與研究動機 1
第二節 研究目的. 2
第二章 文獻探討 3
第一節病人安全 3
第二節 中心導管血流感染 6
第三節 中心導管組合式感控措施 8
第四節 醫療失效模式與效應分析 12
第三章 研究方法 19
第一節 研究設計與架構 19
第二節 中心導管組合式血流感染資料分析 21
第三節 運用HFMEA於個案研究步驟 22
第四章 研究結果 27
第一節 中心導管組合式照護流程 28
第二節 HFMEA於中心導管組合式照護流程 33
第三節 降低中心導管血流感染對策 62
第四節 結果 77
第五章 討論與建議 84
第一節 研究討論 84
第二節 研究限制 86
第三節 研究建議 86
參考文獻 87
一 中文文獻 87
二 英文文獻 88

圖次
圖 2-1 失效模式決策樹分析 18
圖3-1研究架構 20
圖3-2 HFMEA模式執行步驟 23
圖4-1中心導管組合式照護流程圖主要流程圖 32
圖4-2 次要流程 40
圖4-3 CVC包 67
圖4-4 創意CVC包 67
圖4-5 CVC專車 68
圖4-6 安心架 68
圖4-7 洗手標誌比賽 69
圖4-8 洗手標籤及搖頭公仔 69
圖4-9 最大無菌面 70
圖4-10 符合曝露部位10*10CM 70
圖4-11 執行醫師穿戴無菌衣 71
圖4-12 黏貼方式 71
圖4-13 制定黏貼方式 72
圖4-14 監測數據波型 72
圖4-15 CVC公仔放置天數提示卡 73
圖4-16 置入流程查核表 73
圖4-17 品質監測看板 74
圖4-18 教育訓練公告 74
圖4-19 教育訓練 75
圖4-20 教育訓練 75
圖4-21 教育訓練 76
圖4-22 CLABSI海報 76
圖4-23 CVC使用率 82
圖4-24 中心導管置放天數 82
圖4-25 平均血流感染率 83
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