66 Instrumental Improvement in ECMO Care % % % 14.2% % % 23.1% 94.4% 4.4% 4.4%

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1 65 兒科加護病房病人放置葉克膜護理流程完整性之改善方案吳金玲 1* 林怡秀 1 黃小萍 2 徐玲蕙 3 徐旭香 4 1 高雄長庚紀念醫院兒科加護病房副護理長 3 高雄長庚紀念醫院護理部副督導 2 高雄長庚紀念醫院兒科加護病房護理長 4 高雄長庚紀念醫院護理部督導由於醫療科技的進步, 體外維生系統 (extracorporeal membrane oxygenation, ECMO), 亦稱葉克膜, 現今在加護病房應用日益頻繁統計本院 2009 年使用葉克膜救治個案共有 26 人, 其中 18 歲以下個案共 4 例 (15.4%), 由於個案數不多, 致單位護理人員照護時壓力大經驗及熟練度不足, 因而成立專案小組探討葉克膜照護之相關問題 ⑴ 提昇葉克膜放置前用物準備醫囑開立完整性達 98% ⑵ 減少用物準備耗時少於 60 分鐘 ⑶ 提昇護理人員對葉克膜照護認知準確性達 99% 實施的介入措施有 : 規劃葉克膜專用工作車以提升臨床工作便利性及安全性 ; 制訂葉克膜導路放置準備檢視表以提高管路放置完整性減少耗時 ; 舉辦葉克膜照護在職教育以提升護理人員葉克膜照護認知及技能 ; 訂定葉克膜見習制度以增加護理人員葉克膜照護經驗, 減少不熟練所致之疏失本專案實施後, 葉克膜放置前用物準備醫囑開立完整性由 25% 增加到 100%; 葉克膜放置前用物準備時間由 90 分鐘縮短到 40 分鐘, 護理人員對於葉克膜照護完整性由 51.2% 提昇到 99.2%, 均達專案目標顯示專案實施後能有效的減少葉克膜放置準備時間及作業流程之完整性, 提昇護理人員對於葉克膜照護知能之準確性, 完善單位中葉克膜照護品質關鍵詞 : 葉克膜檢視表見習制度兒科加護病房 (extracorporeal membrane oxygenation, ECMO) % * bean570@adm.cgmh.org.tw doi: /jn

2 66 Instrumental Improvement in ECMO Care % % % 14.2% % % 23.1% 94.4% 4.4% 4.4% ㈠㈡ 59.5% 59.5% 59.5% nursing of extra-corporeal membrane oxygenation, ECMON13001 ㈢ 2008N3 100% % % 17.1% 34.3% % 51.2% ㈠ 25% 25% ㈡㈢ 51.1% 99% % 100%

3 67 ㈠ 98%㈡ 60 ㈢ 99% % extracorporeal membrane oxygenation, ECMO 2006Wu, Wu, Chen, Sun, & Li, %Kolla Kolla et al.,

4 68 Instrumental Improvement in ECMO Care 2 48 ㈠㈡㈢㈣㈤

5 ㈠ OO ㈡㈢㈣㈤ 40.5% ㈠㈡㈢㈣㈠㈡㈢ 35 ㈣ 98.6%

6 70 Instrumental Improvement in ECMO Care N = 35 % % activated clotting time, ACT % % % 100% Combes et al., [Wu, C. J., & Wang, C. J. (2007). A project of central venous catheter nursing quality anomaly. The Kaohsiung Journal of Nursing, 24(1), 1223.] [Wu, S. C. (2008). A study of educa-

7 71 tion and training in organization. Quality Magazine, 44(5), 5253.] [Lin, W. C. (2010). Teaching strategies. In P. F. Lin (Ed.), Teaching principle: The application in nursing practice (2nd ed., pp ). Taipei City, Taiwan, ROC: Farseeing.] ECMO[Ko, W. J., & Tsai, P. J. (2006). ECMO manual (1st ed.). Taipei City, Taiwan, ROC: Kingdom.] [Chen, Y. S. (2007). Standardization. Quality Magazine, 43(10), 1923.] [Hsu, Y. C., Lin, Y. W., & Chang, C. Y. (2010). Caring for a patient with ECMO: A case report. The Kaohsiung Journal of Nursing, 27(1), 8495.] [Huang, L. H. (2003). Transition from student nurse to staff nurse. The Journal of Nursing, 51(4), 3336.] 2002ECMO ECMO [Yeh, 6367[Yeh, 6367[Yeh, H. T., & Wu, S. J. (2002). Nursing care of extracoporeal membrane oxygenation. The Journal of Nursing, 49(3), 6367.] [Cheng, Y. F., Hung, C. W., Chen, Y. C., & Huang, S. (2005). A project of improving unplanned re-catheterization intravenous in pediatric ward. Chang Gung Nursing, 16(1), 8493.] [Liou, [Liou, [Liou, H. L. (2007). Nursing care of patients with extracorporeal membrane oxygenation. VGH Nursing, 24(2), ] [Bien, 4152[Bien, 4152[Bien, M. Y., Jung, F., Lin, Y. S., & Yang, S. S. (2010). Clinical application of extracorporeal membrane oxygenation. Journal of Respiratory Therapy, 9(1), 4152.] Combes, A., Leprince, P., Luyt, C. E., Bonnet, N., Trouillet, J. L., Leger, P.,... Chastre, J. (2008). Outcomes and longterm quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock. Critical Care Medicine, 36(5), doi: / CCM.0b013e31816f7cf7 Kolla, S., Awad, S. S., Rich, P. B., Schreiner, R. J., Hirschl, R. B., & Bartlett, R. H. (1997). Extracoporeal life support for 100 adult patients with severe respiratory failure. Annals of Surgery, 226(4), doi: / Wu, S. J., Chen, M. R., Sun, S., & Li, J. Y. (2007). Extra-corporeal membrane oxygenation for acute respiratory distress syndrome: A single center experience. Acta Cardiologica Sinica, 23(2),

8 72 Instrumental Improvement in ECMO Care Nursing Approaches to Improve Extracorporeal Membrane Oxygenation (ECMO) Care in a Pediatric Intensive Care Unit Chin-Ling Wu 1 * I-hsiu Lin 1 Hsiao-Ping Huang 2 Ling-Hui Shu 3 Hsu-Hsian Shu 4 1 BSN, RN, Assistant Head Nurse, Pediatric Intensive Care Unit, Chang Gung Memorial Hospital, Kaohsiung; 2 BSN, RN, Head Nurse, Pediatric Intensive Care Unit, Chang Gung Memorial Hospital, Kaohsiung; 3 BSN, RN, Assistant Supervisor, Department of Nursing, Chang Gung Memorial Hospital, Kaohsiung; 4 BSN, RN, Supervisor, Department of Nursing, Chang Gung Memorial Hospital, Kaohsiung. Abstract Background: Medical technology advances have led to the increasingly frequent use of extracorporeal membrane oxygenation (ECMO) in intensive care unit applications. Four of the 26 patients treated using ECMO in 2009 at our hospital were under 18 years of age. Limited nurse experience with ECMO and resultant nursing staff nervousness / pressure when using this technique encouraged us to establish an ad hoc group to explore ECMO care and related issues. Purpose: Improvement measures were implemented to (1) raise the pre- ECMO placement integrity of order sheets to 98%; (2) reduce materials preparation time to below 60 minutes; and (3) enhance nursing care ECMO cognitive accuracy to 99%. Resolution: We implemented the following intervention measures: (1) A dedicated ECMO vehicle was deployed to enhance clinical work convenience and safety; (2) a ECMO technique preparation checklist was developed to improve tubing placement and reduce preparation time; (3) an ECMO care in-service education program was developed to enhance nurses ECMO care awareness and skills; (4) an ECMO trainee system was established to increase nurses ECMO care experience and reduce negligence-related errors. Results: Project results included: material preparation order sheet accuracy rose from 25% to 100%; average materials preparation time fell from 90 to 40 minutes, and nursing staff ECMO cognitive accuracy increased from 51.2% to 99.2%. The program achieved all stated objectives. Conclusions: This program enhanced the quality of ECMO care for pediatric patients, reduced materials preparation times, and improved the nursing approach to ECMO care.. Key Words: extracorporeal membrane oxygenation (ECMO), checklist, trainee system, pediatric intensive care unit. Accepted for publication: June 28, 2012 *Address correspondence to: Chin-Ling Wu, No. 123, Dapi Rd., Niaosung District, Kaohsiung City 83301, Taiwan, ROC. Tel: +886 (7) ext. 8601; bean570@adm.cgmh.org.tw

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