Exploring the learning needs of clinicians in Belgium and Sweden regarding prone positioning and skin damage prevention: A qualitative study.

INTRODUCTION: During the coronavirus pandemic (COVID -19), the use of prone positioning in critically ill patients with acute respiratory distress syndrome (ARDS) increased substantially. As a result, clinicians had to (re)learn how to treat the patient in the prone position while preventing adverse events such as pressure ulcers, skin tears and moisture-associated skin damage. AIM: The purpose of the study was to determine participants' learning needs related to patients in the prone position and the prevention of skin damage, such as pressure ulcers, and what they perceived as a positive or negative learning experience. DESIGN: This study used a qualitative methodological framework and employed an exploratory design. PARTICIPANTS: A purposive sample of clinicians (n = 20) with direct or indirect work experience with prone ventilated patients was recruited in Belgium and Sweden. METHODS: Individual semi-structured interviews were conducted in Belgium and Sweden between February and August 2022. Data were analysed thematically using an inductive approach. The COREQ guideline was utilised to comprehensively report on the study. FINDINGS: Two themes were identified: 'Adapting to a crisis' and 'How to learn', with the latter having two subthemes: 'balancing theory and practice' and 'co-creating knowledge'. Unexpected circumstances necessitated a personal adaption, a change in learning methods and a pragmatic adaptation of protocols, equipment and working procedures. Participants recognised a multifaceted educational approach which would contribute to a positive learning experience regarding prone positioning and skin damage prevention. The importance of poising theoretical teaching with practical hands-on training was highlighted with an emphasis on interaction, discussion, and networking between peers. CONCLUSIONS: The study findings highlight learning approaches which may help inform the development of befitting educational resources for clinicians. Prone therapy for ARDS patients is not limited to the pandemic. Therefore, educational efforts should continue to ensure patient safety in this important area.

A New-Onset Facial Lesion in a Hospitalized COVID-19 Patient.

Pressure ulcers form when skin is compressed against a bony prominence, often in the context of prolonged supine or prone-based care. Hospitalized, bedridden patients are at the highest risk of this complication, especially when preventative measures like regular rotational bed treatment are not employed. In this case report, we present a rare case of a COVID-19-related facial pressure ulcer that occurred in the context of regular rotational bed treatment. The lesion was managed by wound care and allowed to heal by secondary intention. Ultimately, we hope that this manuscript will raise awareness for this atypical ulcer location, especially as prone-position treatment approaches take hold.

Clinical and cost effectiveness of a system for turning and positioning intensive care unit patients, when compared to usual care turning and positioning devices, for the prevention of hospital-acquired pressure injuries. A randomised controlled trial.

Pressure injuries affect 13.1% to 45.5% of patients in the intensive care unit and lead to pain and discomfort for patients, burden on healthcare providers, and unnecessary cost to the health system. Turning and positioning systems offer improvements on usual care devices, however the evidence of the effectiveness of such systems is still emerging. We conducted an investigator initiated, prospective, single centre, two group, non-blinded, randomised controlled trial to determine the effectiveness of a system for turning and positioning intensive care unit patients, when compared to usual care turning and positioning devices, for preventing PIs. The trial was prematurely discontinued after enrolment of 78 participants due to COVID-19 pandemic related challenges and lower than expected enrolment rate. The study groups were comparable on baseline characteristics and adherence to the interventions was high. Four participants developed a PI (in the sacral, ischial tuberosity or buttock region), n = 2 each in the intervention and control group. Each participant developed one PI. As the trial is underpowered, these findings do not provide an indication of the clinical effectiveness of the interventions. There was no participant drop-out or withdrawal and there were no adverse events, device deficiencies, or adverse device effects identified or reported. The results of our study (in particular those pertaining to enrolment, intervention adherence and safety) provide considerations for future trials that seek to investigate how to prevent PIs among ICU patients.

Algorithms to prevent pressure injury in COVID-19 patients in prone position / Algoritmos para prevenir lesão por pressão em paciente com COVID-19 em prona / Algoritmos para prevenir la úlcera por presión en pacientes con COVID-19 en prona

Resumo Objetivo Elaborar e validar o conteúdo de dois algoritmos para orientar profissionais da linha de frente na prevenção e no tratamento da lesão por pressão em paciente com COVID-19 em posição prona. Métodos Estudo realizado entre setembro e novembro de 2021. Para a construção dos algoritmos, realizou-se revisão da literatura junto às bases de dados MEDLINE®, SciELO e Lilacs. Foram pesquisados artigos publicados entre 2011 e 2021. A validação dos algoritmos foi feita por 59 profissionais da saúde (enfermeiros, fisioterapeutas e médicos), que trabalhavam na linha de frente da COVID-19, utilizando-se a técnica Delphi. Para a análise de dados, foi adotado o Índice de Validade de Conteúdo e o coeficiente alfa de Cronbach. Resultados No primeiro ciclo de avaliação, os itens dos algoritmos foram considerados pelos juízes como "parcialmente adequados a totalmente adequados", e o Índice de Validade de Conteúdo variou entre 0,87 e 0,92. O coeficiente alfa de Cronbach variou entre 0,95 e 0,96, indicando excelente consistência interna do questionário de avaliação utilizado pelos juízes. Após implementados os ajustes sugeridos pelos juízes, os algoritmos foram reenviados para o segundo ciclo de avaliação, no qual todos os itens foram julgados como "adequado" e "totalmente adequado", resultando em um Índice de Validade do Conteúdo de 1,0. Conclusão Os algoritmos para orientar profissionais da saúde na prevenção e no tratamento da lesão por pressão em pacientes com COVID-19 em posição prona foram avaliados por enfermeiros, fisioterapeutas e médicos que estavam na linha de frente de combate à COVID-19, que chegaram a um consenso quanto ao conteúdo no segundo ciclo de avaliação.

Resumen Objetivo Elaborar y validar el contenido de dos algoritmos para orientar profesionales de la línea de frente sobre la prevención y tratamiento de la úlcera por presión en pacientes con COVID-19 en posición prona. Métodos Estudio realizado entre septiembre y noviembre de 2021. Para la elaboración de los algoritmos, se realizó revisión de la literatura en las bases de datos MEDLINE®, SciELO y Lilacs. Se buscaron artículos publicados entre 2011 y 2021. La validación de los algoritmos fue realizada por 59 profesionales de la salud (enfermeros, fisioterapeutas y médicos), que trabajaban en la línea de frente del COVID-19, utilizando el método Delphi. Para el análisis de datos se adoptó el Índice de Validez de Contenido y el coeficiente alfa de Cronbach. Resultados En el primer ciclo de evaluación, los ítems de los algoritmos fueron considerados por los jueces como "parcialmente adecuados a totalmente adecuados", y el Índice de Validez de Contenido varió entre 0,87 y 0,92. El coeficiente alfa de Cronbach varió entre 0,95 y 0,96, lo que indica una excelente consistencia interna del cuestionario de evaluación utilizado por los jueces. Después de implementar las mejoras sugeridas por los jueces, se reenviaron los algoritmos para el segundo ciclo de evaluación, en el cual todos los ítems fueron calificados como "adecuado" y "totalmente adecuado", con un resultado del Índice de Validez de Contenido de 1,0. Conclusión Los algoritmos para orientar profesionales de la salud sobre la prevención y el tratamiento de la úlcera por presión en pacientes con COVID-19 en posición prona fueron evaluados por enfermeros, fisioterapeutas y médicos que estaban en la línea de frente de combate al COVID-19 y llegaron a un consenso respecto al contenido en el segundo ciclo de evaluación.

Abstract Objective To develop and validate the content of two algorithms to guide frontline professionals in the prevention and treatment of pressure injuries in COVID-19 patients in prone position. Methods Study conducted between September and November 2021. A literature review was performed in MEDLINE®, SciELO and Lilacs databases to build the algorithms. Articles published between 2011 and 2021 were searched. The validation of algorithms was performed by 59 health professionals (nurses, physical therapists and physicians) who worked on the frontline of COVID-19. The Delphi technique was used, and Content Validity Index and Cronbach's alpha coefficient were adopted for data analysis. Results In the first evaluation cycle, the items of algorithms were considered as "partially adequate to totally adequate" by the judges, and the Content Validity Index ranged between 0.87 and 0.92. Cronbach's alpha coefficient ranged between 0.95 and 0.96, indicating excellent internal consistency of the evaluation questionnaire used by the judges. After implementing the adjustments suggested by judges, the algorithms were sent to a second evaluation cycle, in which all items were judged as "adequate" and "totally adequate", resulting in a Content Validity Index of 1.0. Conclusion Algorithms to guide healthcare professionals in the prevention and treatment of pressure injury in COVID-19 patients in prone position were evaluated by nurses, physical therapists and physicians working on the frontline of COVID-19. They achieved consensus on content in the second evaluation cycle.

Pressure injuries in COVID-19 patients: A tertiary center experience.

Pressure ulcers continue to severely impact patient outcomes and increase health care costs. We aimed to examine the incidence and risk factors related to pressure ulcers among COVID-19 patients. A retrospective was conducted between March 2020-April 2021. Baseline differences were examined using chi-square and Fischer's exact test. Logistic regression was employed to examine the association of the collected variables to development of new pressure ulcers. 4608 patients were included, of which eighty-three acquired new pressure ulcers. Risk factors were increased age, peripheral artery disease, abnormal albumin levels, but not prone position.

The risk of pressure ulcers in a proned COVID population.

The utilisation of prone positioning has been vital during the COVID-19 pandemic, however risks the development of anterior pressure ulcers. An observational study was performed to examine the prevalence of pressure ulcers in this population and define risk factors. Eighty-seven patients admitted to critical care were studied. Of 62 patients with >1 day in prone position, 55 (88.7%) developed anterior pressure ulcers, 91% of which were anterior. The most commonly affected site were the oral commisures (34.6%), related to endotracheal tube placement. Prone positioning (p < .001) and the number of days prone (OR 3.11, 95% CI 1.46-6.62, p = 0.003) were a significant risk factors in development of an anterior ulcer. Prone positioning is therefore a significant cause of anterior pressure ulcers in this population.

Abnormal thrombosis and neutrophil activation increase hospital-acquired sacral pressure injuries and morbidity in COVID-19 patients.

Hospitalized patients have an increased risk of developing hospital-acquired sacral pressure injury (HASPI). However, it is unknown whether SARS-CoV-2 infection affects HASPI development. To explore the role of SARS-CoV-2 infection in HASPI development, we conducted a single institution, multi-hospital, retrospective study of all patients hospitalized for ≥5 days from March 1, 2020 to December 31, 2020. Patient demographics, hospitalization information, ulcer characteristics, and 30-day-related morbidity were collected for all patients with HASPIs, and intact skin was collected from HASPI borders in a patient subset. We determined the incidence, disease course, and short-term morbidity of HASPIs in COVID-19(+) patients, and characterized the skin histopathology and tissue gene signatures associated with HASPIs in COVID-19 disease. COVID-19(+) patients had a 63% increased HASPI incidence rate, HASPIs of more severe ulcer stage (OR 2.0, p<0.001), and HASPIs more likely to require debridement (OR 3.1, p=0.04) compared to COVID-19(-) patients. Furthermore, COVID-19(+) patients with HASPIs had 2.2x increased odds of a more severe hospitalization course compared to COVID-19(+) patients without HASPIs. HASPI skin histology from COVID-19(+) patients predominantly showed thrombotic vasculopathy, with the number of thrombosed vessels being significantly greater than HASPIs from COVID-19(-) patients. Transcriptional signatures of a COVID-19(+) sample subset were enriched for innate immune responses, thrombosis, and neutrophil activation genes. Overall, our results suggest that immunologic dysregulation secondary to SARS-CoV-2 infection, including neutrophil dysfunction and abnormal thrombosis, may play a pathogenic role in development of HASPIs in patients with severe COVID-19.

Skin problems among the wheelchair users: a prospective cross-sectional study.

Skin is the largest and the outermost body organ. It is directly affected by the external environment. The biomechanical differences in wheelchair users compared to healthy people make them prone to different risk factors of skin problems. Nevertheless, these patients are under-represented in the dermatologic literature. Objective: The primary objective was to determine the frequency of different skin problems among wheelchair users. The secondary objective is to determine the different precautions they are taking to prevent these problems. Methods: The prospective study followed a cross-sectional design, conducted during the period of the coronavirus disease 2019 curfew between May and June 2020. The survey's link was distributed among adult wheelchair users in Saudi Arabia. The questionnaire was administered using google forms. All statistical analyses were performed using SPSS version 22. Results: The results show that the vast majority of wheelchair users (85%) experienced skin problems. Pressure ulcer (PU) is the most frequently reported skin condition (54%), followed by traumatic wounds, fungal infections, and hand skin dryness and thickening. The commonest preventive measure was using cushions to avoid PUs. Conclusion: Most of wheelchair users reported having a history of skin complaints, of which PU was the most common followed by traumatic wounds and fungal infections. Thus, spreading awareness of the risk factors and preventive methods would help them avoid its development and prevent its negative impact on quality of life. Assessing the different kinds of wheelchairs and cushions to avoid PUs would be an interesting area for future studies.

Decúbito prono en pacientes COVID-19 con síndrome de distrés respiratorio agudo y ventilación mecánica invasiva.

OBJECTIVE: To identify adverse events related to prone positioning in COVID-19 patients with severe disease and acute respiratory distress syndrome, to analyze the risk factors associated with the development of anterior pressure ulcers, to determine whether the recommendation of prone positioning is associated with improved clinical outcomes. METHODS: Retrospective study performed in 63 consecutive patients with COVID-19 pneumonia admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning between March and April 2020. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression. RESULTS: A total of 139 proning cycles were performed. The mean number of cycles were 2 [1-3] and the mean duration per cycle was of 22 hours [15-24]. The prevalence of adverse events this population was 84.9 %, being the physiologic ones (i.e., hypo/hypertension) the most prevalent. 29 out of 63 patients (46%) developed prone-related pressure ulcers. The risk factors for prone-related pressure ulcers were older age, hypertension, levels of pre-albumin <21 mg/dl, the number of proning cycles and severe disease. We observed a significant increase in the PaO2/FiO2 at different time points during the prone positioning, and a significant decrease after it. CONCLUSIONS: There is a high incidence of adverse events due to PD, with the physiological type being the most frequent. The identification of the main risk factors for the development of prone-related pressure ulcers will help to prevent the occurrence of these lesions during the prone positioning. Prone positioning offered an improvement in the oxygenation in these patients.

Characteristics of COVID-19 patients who developed pressure injuries: a scoping review.

OBJECTIVE: To describe the characteristics of patients with COVID-19 who developed pressure injuries (PIs), the characteristics of PIs experienced, and the incidence and prevalence of PIs among the patients with COVID-19. PIs are associated with increased morbidity, mortality and healthcare expense. PIs have been reported among patients who have contracted COVID-19. Understanding the characteristics of COVID-19 patients, and how PIs are prevented and managed, may inform care and optimise the outcomes for COVID-19-positive patients. METHOD: A scoping review was conducted. All study designs, including grey literature, published in the English language from December 2019 to March 2021, reporting on patients with COVID-19 and PIs, were included. RESULTS: In total, 27 publications (n=4820 patients) were included in the review. The reported incidence rate of PIs was 7.3-77.0%. The causative factors noted were: prone positioning (28.5%); medical devices (21.4%); and medical devices used during prone positioning (14.2%). The most common PI sites were the cheeks (18.7%). PIs occurred on average at 14.7 days post-acute care admission. Of the PIs where staging information was specified (67.7%), the most common was Stage 2/II (45.2%). PI risk may intensify on account of the intrinsic mechanism of COVID-19-associated intensive care treatment. CONCLUSION: PI prevention and management should be prioritised for patients with COVID-19, given the reported high prevalence of PIs and exacerbated risk arising from the use of prone position and medical devices. Further research is required to understand the association between COVID-19 and PIs, and to guide effective prevention and treatment approaches.

Incidence of facial pressure injuries in health-care professionals during the COVID-19 pandemic: A systematic review and meta-analysis.

AIM: To evaluate the incidence of facial pressure injuries in health-care professionals during the COVID-19 pandemic in a meta-analysis. METHODS: Related studies were obtained through electronic databases, including PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI) Chinese Scientific Journal (VIP) China Biomedical Literature service systems (CBM) and Wanfang Data (from inception to 27 November 2021). The pooled incidence and the 95% confidence interval of facial pressure injuries were calculated with Review Manager v5.4 software. RESULTS: Overall, 16 studies with 14 430 health-care professionals were included. Pooled results showed that the pooled incidence of facial pressure injury in health-care professionals was 58.8% (95% CI: 49.0%-68.7%; p < 0.01). The results of the subgroup analysis showed that the incidence of facial pressure injury in these staff was high, and predominantly stage I pressure injury, in the following cases: in health-care professionals who wore personal protective equipment for longer than 4 h, in those without any training experience, and on the nose. CONCLUSION: Administrators and researchers should pay attention to preventing facial pressure injury related to the wearing of personal protective equipment (PPE) by ensuring all health-care professionals receive training and by limiting prolonged periods of use.

Prone positioning in COVID-19 patients with acute respiratory distress syndrome and invasive mechanical ventilation.

OBJECTIVE: To identify adverse events related to prone positioning in COVID-19 patients with severe disease and acute respiratory distress syndrome, to analyze the risk factors associated with the development of anterior pressure ulcers, to determine whether the recommendation of prone positioning is associated with improved clinical outcomes. METHODS: Retrospective study performed in 63 consecutive patients with COVID-19 pneumonia admitted to intensive care unit on invasive mechanical ventilation and treated with prone positioning between March and April 2020. Association between prone-related pressure ulcers and selected variables was explored by the means of logistic regression. RESULTS: A total of 139 proning cycles were performed. The mean number of cycles were 2 [1-3] and the mean duration per cycle was of 22h [15-24]. The prevalence of adverse events this population was 84.9 %, being the physiologic ones (i.e., hypo/hypertension) the most prevalent. 29 out of 63 patients (46%) developed prone-related pressure ulcers. The risk factors for prone-related pressure ulcers were older age, hypertension, levels of pre-albumin <21mg/dl, the number of proning cycles and severe disease. We observed a significant increase in the PaO2/FiO2 at different time points during the prone positioning, and a significant decrease after it. CONCLUSIONS: There is a high incidence of adverse events due to PD, with the physiological type being the most frequent. The identification of the main risk factors for the development of prone-related pressure ulcers will help to prevent the occurrence of these lesions during the prone positioning. Prone positioning offered an improvement in the oxygenation in these patients.

Penile pressure ulcers secondary to indwelling catheter and prone positioning for COVID-19 infection.

Prone ventilation is an effective and increasingly utilised tool in the management of Acute Respiratory Distress Syndrome (ARDS), a common sequela of COVID-19 infection. However, its use is associated with a significant risk of pressure ulcers. We report a unique case of prone positioning, catheter-related penile pressure ulcer. Clinical awareness, early recognition and regular repositioning is crucial in the prevention of this complication.

Influencing factors of medical device-related pressure ulcers in medical personnel during the COVID-19 pandemic: A systematic review and meta-analysis.

OBJECTIVE: To determine the influencing factors of medical device related pressure injury (MDRPU) in medical staff by meta-analysis. METHODS: A comprehensive literature search was conducted by PubMed, Embase, Cochrane Library, Web of Science, CNKI, VIP, CBM, and WanFang Data (from inception to July 27, 2022). Two researchers independently performed literature screening, quality evaluation and data extraction, and meta-analysis was conducted with RevMan 5.4 and Stata12.0 software. RESULTS: Total of 11215 medical staff were included in 9 articles. Meta analysis showed that gender, occupation, sweating, wearing time, single working time, department of COVID-19, preventive measures, and level 3 PPE were the risk factors for MDRPU in medical staff (P < 0.05). CONCLUSION: The outbreak of COVID-19 led to the occurrence of MDRPU among medical staff, and the influencing factors should be focused on. The medical administrator can further improve and standardize the preventive measures of MDRPU according to the influencing factors. Medical staff should accurately identify high-risk factors in the clinical work process, implement intervention measures, and reduce the incidence of MDRPU.

Is the Increase in Record of Skin Wounds in Hospitalized Patients in Internal Medicine Units a Side Effect of the COVID-19 Pandemic?

Wound care is an important public health challenge that is present in all areas of the healthcare system, whether in hospitals, long term care institutions or in the community. We aimed to quantify the number of skin wounds reported after and during the COVID-19 pandemic. This descriptive longitudinal retrospective study compared of wound records in patients hospitalized in the internal medicine service during the first year of the COVID-19 pandemic (from 1 March 2020, to 28 February 2021) and previous-year to the outbreak (from 1 January 2019, to 31 December 2019). A sample of 1979 episodes was collected corresponding to 932 inpatients, 434 from the pre-pandemic year and 498 from the first year of COVID-19 pandemic; 147 inpatients were diagnosed with SARS-CoV-2 infection (3.2%). The percentage of wound episodes in the first year of the COVID-19 pandemic was higher than the pre-pandemic year, 17.9% (1092/6090) versus 15% (887/5906), with a significant increase in the months with the highest incidence of COVID cases. This study shows an increase in the burden of wound care during the COVID-19 pandemic, and it could be attributable to the increase in the number of patients hospitalized for SARS-CoV-2 infection in internal medicine units.

Pressure injuries in ventilated COVID-19 patients

Prolonged high-flow nasal oxygenation (HFNO), or non-invasive ventilation (NIV), or endotracheal intubation with prone ventilation in COVID-19 patients may result in pressure sores or ulcers at points on sustained pressure at patient-equipment interphase. Expert nursing care and following the relevant guidelines can prevent the development of such injuries. Copyright © 2022 Faculty of Anaesthesia, Pain and Intensive Care, AFMS. All rights reserved.

The prevention of medical-device related pressure ulcers in a Critical Care Unit

This article explores medical-device related pressure ulcers (MDRPU) in an intensive care unit (ICU) at the Royal United Hospitals Bath NHS Foundation Trust (RUH). The data presented outlines a reduction in PU of 66% over a 6-year period and a reduction in MDRPU of 50% over the same period. MDRPU were particularly challenging to prevent in ICU during the COVID-19 pandemic, where there were additional numbers of patients in the ICU with medical devices in place. Additionally, during the COVID-19 pandemic, an increased number of patients in the ICU were nursed prone (face down), adding additional pressure on the facial structure, a range of measures were put in place to avoid those avoidable MDRPU in the ICU at the RUH. Measures focused on skin checking, offloading and rotation of devices, including endotracheal tubes, non-invasive ventilation, nasogastric (NG) and nasojejunal (NJ) tubes and catheters. A specific comfort and pressure care record was developed for ICU to record the assessments of these at risk areas.

Pressure Injury Link to Entropy of Abdominal Temperature.

This study examined the association between pressure injuries and complexity of abdominal temperature measured in residents of a nursing facility. The temperature served as a proxy measure for skin thermoregulation. Refined multiscale sample entropy and bubble entropy were used to measure the irregularity of the temperature time series measured over two days at 1-min intervals. Robust summary measures were derived for the multiscale entropies and used in predictive models for pressure injuries that were built with adaptive lasso regression and neural networks. Both types of entropies were lower in the group of participants with pressure injuries (n=11) relative to the group of non-injured participants (n=15). This was generally true at the longer temporal scales, with the effect peaking at scale τ=22 min for sample entropy and τ=23 min for bubble entropy. Predictive models for pressure injury on the basis of refined multiscale sample entropy and bubble entropy yielded 96% accuracy, outperforming predictions based on any single measure of entropy. Combining entropy measures with a widely used risk assessment score led to the best prediction accuracy. Complexity of the abdominal temperature series could therefore serve as an indicator of risk of pressure injury.

Development, Implementation, and Evaluation of a Clinical Practice Guideline for Care of Preterm Infants Receiving Non-Invasive Ventilation: A Before and After Study

Background: Nowadays, noninvasive ventilation is the mainstay of the ventilation strategy in the neonatal intensive care units (NICUs) and most of infants, especially preterm infants, having respiratory problems, are provided noninvasive ventilation (NIV) upon their demands. Nevertheless, complication of NIV device-related pressure injury was common, the incidence of nasal injury ranged from 20% to 60%. Limited studies were found evaluating the nursing care of preterm infants receiving NIV. Aims: This study aimed to develop an evidence-based clinical practice guideline for preterm infants receiving NIV, implement the guideline in a NICU of a regional hospital, and evaluate infant outcomes including comfort, incidence of NIV device-related pressure injury. Besides, improvement on nurse's knowledge and practice for caring infants under NIV were assessed. Study Design and Methods: The Iowa Model-Revised was adopted as the theoretical framework to guide the study process. A multidisciplinary workgroup consists of eight stakeholders in NICU was formed for the process and acted as the champions for the new practice. A before and after study design was adopted and included the preimplementation and post-implementation phases. An integrative review was conducted to identify relevant studies from eight electronic databases before the study. All eligible studies were appraised using the Johns Hopkins University's evidence appraisal tool. Neonatal Pain, Agitation and Sedation Scale (N-PASS) for pain assessment and two self-developed NIV care bundle knowledge test and audit tool were used for the study. Results: Due to the COVID-19 pandemic in 2020, the study was extended for a month and ended in January 2021. A total of 74 infants in Pre-implementation phase (before group) and 67 infants in Post-implementation phase (after group) were recruited. Logistic regression model was used to compare the incidence of pressure injury between groups after adjusted for all substantial covariates in the study. Infants in after group had an 84% decreased odds of acquiring pressure injury (adjusted OR=0.149, 95% CI 0.045-0.495, p=0.002). Infant's comfort level whilst receiving NIV was not determined in the study as the after group having a significantly lesser mean time (p<0.001) in calm state but lower N-PASS score. Regarding nurse participants, 71 nurses received the training programme on NIV care bundle, and overall nurses' knowledge level improved immediately (adjusted p<0.001) and at 12 weeks after the programme. Three audits were conducted to evaluate nurses' practice, nurses' compliance rate to the care bundle significantly improved at 12 (p<0.001) and 24 weeks (p<0.001) in comparison with baseline compliance rate in the pre-implementation phase. However, nurses' knowledge retention at 12-week and compliance rate at 24-week after the training programme declined. Conclusion: The evidence-based clinical practice guideline aims to promote comfort and prevent injury in infants receiving NIV, and outcomes of the infants depend on vigilant nursing care and compliance to this clinical practice guideline. Declining of nurse's knowledge level and practice compliance found in the study indicates the needs of continuous education and audit on the practice to sustain the service quality and patient's safety.