鼻導管持續正壓呼吸器（Nasal Prong Continuous Positive Airway Pressure, NCPAP）已被廣泛運用在治療高危險性新生兒呼吸窘迫症候群，固定方式為決定能否成功渡過呼吸窘迫之重要因素。本單位之高危險性新生兒多需使用NCPAP，但常見管路滑脫導致呼吸暫停及心搏過緩合併低血氧情形或需重固定而造成工作上的負荷。經現況分析發現：NCPAP護理技術標準書內容未描寫管路固定細節，固定方式不一致、同仁未接受安撫技巧相關之在職教育且執行率低及NCPAP固定帽彈性疲乏，導致NCPAP管路滑脫率高達131% 。改善目標為降低NCPAP管路滑脫率至65.5%，藉著修訂NCPAP護理技術標準書並宣導、實施安撫技巧在職教育及查核、製作新式固定帽三項解決辦法後，滑脫率降至28%；而NCPAP平均使用天數由10天下降為5天為本專案最佳之附加效益。

Nasal continuous positive airway pressure (NCPAP) has been used extensively in the treatment of infants with respiratory distress syndrome (RDS). The way to fasten the device determinates the success to go through RDS. In our unit, most of the infants need to use NCPAP, but pipeline slippage occurs frequently which causes apnea bradycardia and cynosis. Besides, resetting the device will increase the work load. The current analysis: NCPAP nursing standard does not describe in detail the way to fix pipeline. With no consistent instruction on how to fix pipeline, no comfort skill on job training among colleagues and NCPAP cap fatigue, all these led to a high NCPAP pipeline slippage rate of 131%. The following 3 methods decreased slippage rate to 28% and reduced the average number of days of NCPAP usage to 5 days, firstly, modifying the NCPAP nursing standard books, secondly, carrying out comfort skill on-job-training, and thirdly, making new device to fix pipeline. These are the best benefits of this project.