骨科病房啟動了績效改善 (PI) 委員會，因為過去兩個月內，與導尿管相關的尿路感染 (CAUTI) 發生率激增了 40%。病歷稽核顯示，術後導尿管平均留置長達五天，且尿袋經常被發現平放在病患的大腿上。委員會中的註冊護理師應提議哪些系統性策略以降低 CAUTI 發生率？（多選題）
The orthopedic unit initiates a Performance Improvement (PI) committee because the rate of Catheter-Associated Urinary Tract Infections (CAUTI) has surged by 40% over the last two months. Chart audits reveal urinary catheters are left in place for an average of five postoperative days, and collection bags are frequently found resting on the patients' thighs. Which systemic strategies should the RN on the committee propose to reduce the CAUTI rate? (Select all that apply.)
- AImplement a nursing-driven protocol allowing RNs to discontinue urinary catheters without a fresh physician order when clinical criteria are met.✓ 正解實施由護理人員主導之常規，允許護理師在符合臨床標準時，無需醫師新開立之醫囑即可拔除導尿管。
- BIssue an official written warning to the night shift staff primarily responsible for emptying the collection bags.對主要負責排空尿袋之夜班人員發出正式書面警告。
- CRequire daily nursing assessment and documentation specifically justifying the ongoing need for an indwelling catheter.✓ 正解要求護理人員每日評估並記錄持續留置導尿管之必要性。
- DMandate that collection bags be hung securely on the side rails of the bed to ensure they remain off the floor.強制規定將尿袋牢固懸掛於床欄上，以確保其不接觸地面。
- EInitiate mandatory in-service training on strict aseptic insertion and maintaining the bag below the level of the bladder.✓ 正解實施強制性在職訓練，強調嚴格無菌插入技術及保持尿袋低於膀胱水平。
本題探討品質改善計畫（Quality Improvement）以及預防 CAUTI 的臨床指引（CDC 標準群集照護）。CAUTI 預防的核心在於「盡早移除」及「維持封閉引流系統且低於膀胱」。提議制定「護理驅動常規（Nursing-driven protocol）」能授權護理師一旦評估病患不需要尿管時，即可不經由醫師開單直接依臨床標準移除，這能大幅縮短留置天數（選項A正確）。強制要求每日重新評估並記錄留置尿管的「必要性」（如尿滯留、重症監測），能避免醫師或護士忘記拔除（選項C正確）。強化無菌技術且確保留置袋「始終低於膀胱」是防堵逆流的關鍵（選項E正確）。選項B錯誤，現代品質改善依循「不責難（Just Culture）」文化，發出書面警告屬於懲罰性措施，不能解決系統面的知識與流程漏洞。選項D為危險的臨床錯誤，尿袋絕對不可掛在可移動的床欄（Side rails）上（若拉起床欄尿袋會被抬高導致逆流），而應固定在不可移動的床架（Bed frame）上。
This item addresses quality improvement (QI) and the clinical guidelines for preventing CAUTI (the CDC bundle for catheter care). The core of CAUTI prevention is 'early removal' and 'maintaining a closed drainage system below the level of the bladder.' Proposing a nursing-driven protocol empowers nurses to remove urinary catheters according to clinical criteria once they are no longer needed, without requiring a new physician order, which substantially decreases catheter dwell time (option A is correct). Requiring a daily nursing assessment with documentation specifically justifying the ongoing need for the catheter helps prevent physicians or nurses from forgetting to remove it (option C is correct). Reinforcing aseptic insertion technique and ensuring the bag is 'always below the level of the bladder' is key to preventing reflux (option E is correct). Option B is incorrect: modern quality improvement follows a 'just culture' that is non-punitive, and issuing written warnings is a punitive measure that does not address systemic knowledge or process gaps. Option D is a dangerous clinical error: collection bags must never be hung on movable side rails (raising the rails would elevate the bag and cause reflux); they should be secured to the immovable bed frame instead.
推行 Nursing-driven protocol 在美國極為普遍，讓美國護理師能自主拔除無適應症的尿管。在台灣的醫事環境中，拔除各類導管通常仍需要具體醫師在 HIS 系統開立 DC (Discontinue) 醫囑，不過台灣的感控護理師 (ICN) 同樣大力推廣盡早移除與「懸掛於床架下方」的知識。