進住本院小兒、新生兒加護中心，需插放氣管內管治療的病人高達50-60%，兒科醫 師們鑑於經鼻氣管插管優點多，已不再經口插管。但醫護人員同時反應拔管後約有半數以上 病人產生鼻壓瘡現象，經由意外事件品管小組整理分析後，發現主要是由不當的鼻氣管插管 固定方法所造成。因此，本專案的目的在於改善鼻氣管插管固定方法與建立其標準護理技術， 以避免鼻壓瘡產生，及制定氣管插管護理標準，發展其結果品質監測指標，作為護理人員執 行護理活動之準則和確保氣管插管之護理品質。改善後半年(84年1-6月)，平均經弄插管天數 8.9天，較改善前半年(83年6-11月)的5.1天多了3.8天，但插管滑脫次數僅3次，滑脫率為 0.38%，改善前有17次，滑脫率為2.63%;鼻壓瘡4件，發生率為0.5%，改善前則多於55件，發 生率大於8.5%，於是制定了「氣管插管護理標準」和發展結果品質監測指標，可連續客觀地 監測插管護理品質，於85年1月開始監測，發現插管滑脫率從85年的0.89%降至86年1-6月的 0.55%，鼻壓瘡發生率在85年1月-86年6月間為0%，顯示此方法的安全性和可行性。

　　　　　Up to 50-60 % of patients admitted to our PICU and NICU needed endotracheal tube intubation. Since nasal endotracheal tubes have many advantages, pediatrics do not perform oral endotracheal intubation any more. However, after the removal of nasal endotracheal tubes, nursing staffs found that about 50 % of patients have nasal pressure sores The Incidental Event Quality Control Group] found that this complication was caused by improper fixation of the nasal endotracheal tube. To avoid nasal pressure sores, we improved the fixation method of nasal endotracheal tubes and standarized the nursing technique. We also developed quality control monitoring to ensure nursing quality of endotracheal tubes. After half a year (Jan. June, 1995) , the average days of nasal endotracheal intubation was 8.9 days, which was 3.8 days more than before (5. 1 days, June Nov. ,1994) . Disconnection happened 3 times (0.38%) , as compared with before ( 17 times, 2.63%) . There were 4 cases of nasal pressure sore (0.5%) , as compared with before (55 cases, > 8.5%) . We can objectively monitor nursing quality of endotracheal tubes after the establishment of nursing standardization and development of quality control monitoring. Since January, 1996, (from 1996 to Jan June, 1997) the disconnection rate decreased from 0.89% to 0.55 % . While the incidence of nasal pressure sore was 0 %. It indicated the safety and practicabity of this fixation method of endotracheal tubes.