壓瘡是長時間手術之常見合併症，佔所有壓瘡發生率40% 以上，也導致增加感染機率、延長住院天數及增加醫療成本。本院心血管外科手術壓瘡發生率為9%，病人因發生壓瘡導致住院天數倍增，護理時數與醫療成本也相對增加，引發本專案改善動機。分析主因為護理師缺乏壓瘡防護教育訓練、判別壓瘡標準不一、心血管外科手術時間過長、無菌布單過重及不熟悉心血管外科手術流程。故舉辦「壓瘡評估與照護」在職教育、培育護理師判別壓瘡能力、建立雙重核對機制、修改心血管外科皮膚防護操作流程、改變鋪單方式以防水布單取代布中單及以床邊教學模式建立心血管外科流動護理師操作流程。執行改善措施後壓瘡發生率由9% 下降至5%，壓瘡認知得分由71.3% 上升至98.8%，提升心血管外科手術團隊壓瘡預防之共識與手術全期照護品質。

Patients undergoing long operation procedure are at a greater risk of developing a pressure ulcer, accounting for 40% of the total cases. Pressure ulcer can increase the risk of infections, lengthen the length of stay, and increase the duration and costs of nursing care. We collected data on patients who underwent surgery between September and December in 2015 and found that the incidence of pressure ulcers in cerebrovascular surgical patients was 9%. This project was developed to solve the problem of pressure ulcers by setting up standard preventive procedures, creating continuing education courses and bed-side teaching, building the double check review system, and establishing cerebrovascular team resource management. The incidence of pressure ulcer in cerebrovascular surgical patients between June and September in 2016 reduced to 5% and nurses’ understanding of preventive measures increased from 71.3% to 98.8% after the improvement project was carried out. This project improves the awareness of nurses and thus provides a better quality of operative nursing care and also strengthens the cerebrovascular team work.