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 in-service 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.