本專案旨在提升加護病房護理人員對「食道球放置流程」照護完整性。現況發現「食道球放 置流程」照護完整性僅38.3%。確立原因：認知正確率52.1%、備物易遺漏、管路操作及流程照 護不熟悉、用物放置分散、缺乏在職教育、衛材變更未舉辦教育訓練、標準作業規範未修訂、新 進人員輔導手冊無專科評核。改善方案：(1) 製作指引手冊，(2) 製作食道球專用盒，(3) 制定流程 照護檢視表，(4) 制定新進人員專科評核，(5) 舉辦在職教育，(6) 舉辦食道球技術指導。專案改善 後，護理人員對「食道球放置流程」照護完整性由38.3% 提升至91%、認知正確率由52.1% 提升 至91%，有效提升「食道球放置流程」照護完整性及放置時效，完善專業照護品質。

The purposes of the project were to improve the integrity of Sengstaken-Blakemore tube (S-B tube) placement process and care for nurses in intensive care units. Before the improvement program, the rate of integrity of nursing care for S-B tube placement process was 38.3%. The causes were: insufficient knowledge about S-B tube placement process (only 52.1% correctness), incompleteness of material preparation, unfamiliarity with the S-B tube placement, dispersion of the appliance, lack of inservice education and training, lack of revision of standard operating practices, lack of evaluation for coaching new staff. We implemented the following interventions, including developing a guidelines manual, providing a complete S-B package, designing a checklist for S-B tube placement, developing an evaluation form for training new nurses; and developing an in-service education and training program. After the improvement program, the completion rate increased from 38.3% to 91%, the accuracy rate of nurses’ knowledge increased from 52.1% to 91%. The program has improved the integrity and timeliness of S-B tube placement and enhanced the quality of care.