Background Many nurses, particularly those working in intensive care units, experience anxiety and burnout as a result of caring for patients with complex conditions and high mortality rates. This situation often leads to employee dissatisfaction and high turnover. Local Problem The purpose of this project was to reduce anxiety related to patient death among nurses in a 17-bed medical intensive care unit through the implementation of a previously developed evidence-based postdeath reflection activity called “The Pause.” Methods Unit leaders received training in the Pause. Staff nurses anonymously and voluntarily completed preintervention and postintervention surveys collecting self-reported demographic data and scores on the revised Collett-Lester Fear of Death Scale, which measures fear and anxiety about death. The intervention was performed by a trained staff member when a patient died. Quantitative data were evaluated using descriptive statistics and measures of effect size. Results A total of 38 nurses (54% of nursing staff members) completed the preintervention survey, and 22 nurses (31% of nursing staff members) completed the postintervention survey. The mean total score on the revised Collett-Lester Fear of Death Scale decreased by 15% (Cohen d = 0.53) from before to after the intervention, indicating reduced overall anxiety related to patient death among participating nurses. Conclusion Implementation of the Pause was associated with a decrease in anxiety among bedside nurses. Given the minimal cost and workload for staff members, along with the positive outcome, continuation of this intervention is recommended.
Background Chest radiography confirms initial nasogastric tube placement but is impractical for repeated verification during feeding and medication administration. Local Problem Nasogastric tube placement verification practices on the neuroscience unit delayed feedings and medication administration due to radiograph interpretation and physician order wait times. The aim of this quality improvement project was to assess feasibility, usability, and adoption of gastric aspirate pH testing and tube length measurement for ongoing nasogastric tube placement verification after initial chest radiography confirmation. Methods The Stevens Star Model of Knowledge Transformation guided this project and involved assessing relevance and feasibility of the practice change, developing an action plan, implementing the intervention, and evaluating the results. The quality improvement intervention was to use gastric aspirate pH testing along with distal tube length measurement at the nostril exit site, rather than gastric auscultation, for ongoing nasogastric tube placement verification. Results With 100% staff compliance with workflow and process measures, the project was feasible and usable. A total of 141 gastric aspirate samples were tested over 6 months. Gastric placement was confirmed (pH ≤5.5) in 131 samples. Ten of the 141 samples had a pH of greater than 5.5, indicating placement not confirmed. Postimplementation surveys indicated that staff nurses accepted the practice change. Conclusion Gastric aspirate pH testing along with tube length measurement is feasible and effective for ongoing nasogastric tube placement verification in patients with stroke and other neurological conditions. The next step is to incorporate suggested process improvements into the next practice change cycle.
Background Decreasing unplanned extubation rates in critically ill patients is an important element of care in the intensive care unit. However, most available literature on unplanned extubation addresses its prevalence, risk factors, and patient outcomes; few articles offer specific, reproducible interventions for preventing unplanned extubation. Local Problem In the adult medical intensive care unit of a large academic tertiary care hospital, the unplanned extubation rate in the last quarter of 2018 was 2.0 per 100 ventilator days, higher than the internal benchmark of 1.06 per 100 ventilator days. Methods A quality improvement project was initiated to identify patients’ risk for unplanned extubation and implement interventions according to risk level. The risk categories and associated bundled nursing interventions were created by an expert work group using available literature and data collected on the unit. The effectiveness of the interventions was tested by continually monitoring unplanned extubation rates. Results After the project’s initiation in 2019, the rate of unplanned extubations in the intensive care unit decreased from 1.307 per 100 ventilator days in 2018 to 0.344 in 2023. A 2-proportion z test revealed a significant difference in unplanned extubation rates between 2018 and 2023 (P < .001), indicating that the project implemented in 2019 effectively reduced unplanned extubation events over time. Conclusion By integrating evidence-based interventions, fostering a culture of safety, and emphasizing proper patient assessment and communication, substantial progress was made in decreasing unplanned extubation rates.
Part 1 of this series, “Selecting Interventions,” explored how to choose interventions for evidence-based practice implementation that fit the patient population, practice setting, and clinician workforce. Part 1 also introduced the Consolidated Framework for Implementation Research as a roadmap. Using Critical Care Nurse publication exemplars on hospital-acquired pressure injury prevention, part 1 illustrated how innovations can be single, bundled, or blended. Part 2 of the series shifts the focus from what to implement to how to make it stick. This article unpacks 9 elements of the implementation process domain of the Consolidated Framework for Implementation Research: teaming, assessing the context, assessing needs of innovation recipients and deliverers, planning, tailoring strategies, engaging, doing, reflecting and evaluating, and adapting. These elements provide practical, evidence-informed guidance for teams ready to not only embed innovations but sustain them in everyday practice.
Background Extracorporeal membrane oxygenation, although lifesaving, is invasive. Complications affecting all body systems mandate reevaluation of goals of care. When extracorporeal membrane oxygenation is nonbeneficial, planning for de-escalation/decannulation to allow natural death must occur. Local Problem In a tertiary care facility with 64 beds using extracorporeal membrane oxygenation, practices varied regarding extracorporeal membrane oxygenation initiation, patient/family communication, futility determination, and symptom management during de-escalation. Symptom management during transition to comfort-directed care was suboptimal, increasing patient, family, and team discomfort. The goals of this quality improvement project were to mitigate practice variability and improve patient experience and communication, allowing for comfortable, natural death. Methods Palliative care integration, literature review of best practices, and creation of an interprofessional task force were process improvements during extracorporeal membrane oxygenation de-escalation. New clinical guidelines provided structure, consistency, and evidence-based care processes mitigating practice variability during de-escalation/decannulation. Results Successful guideline implementation decreased practice variability, lessening patient/family stress and discomfort. After implementation, team member self-reports of secondary trauma and moral distress symptoms during extracorporeal membrane oxygenation de-escalation/decannulation decreased. Team members reported improved end-of-life care delivery with family education and support, patient advocacy, and symptom management. Family members appreciated attention to the patient’s and their own well-being during end-of-life care. Structured debriefings helped staff members process feelings toward end-of-life care and identified opportunities for improvement. Conclusion Guideline application decreased practice variability in extracorporeal membrane oxygenation de-escalation/decannulation, incorporating patient and family preferences. Death became more comfortable and dignified. Decreased practice variability and proactive symptom management improved patient/family experience.
Background Although nurses’ attitudes toward teamwork and work-related well-being have been explored, evidence is limited on the impact of a team-based method to manage interpersonal conflicts among nursing staff members. Local Problem Nursing leaders on a 20-bed critical care service unit at a large teaching hospital in the southwestern United States received increasing reports of interpersonal conflicts between direct care staff members. They chose to address this problem by acknowledging the incivility and implementing improvement initiatives. Methods This project, which followed a plan-do-study-act cycle, compared perceptions of interpersonal communication and workplace engagement initiatives before and after implementation of the Triple D Method: Discuss, Decide, Deliver and compared the presence of self-care behaviors before and after the promotion of well-being practices. Data were collected through voluntary and anonymous questionnaires. Responses were assessed 1 month before and 6 months after implementation of the interventions. Interventions Each month, nurses and nursing assistants met with the unit’s nurse leaders to discuss teamwork barriers, decide on strategies to limit these barriers, and implement the chosen solutions. Well-being practices were promoted. Results Staff perceptions of interpersonal conflict management and engagement initiatives improved after implementation of the Triple D Method. The promotion of well-being practices was effective in increasing reported self-care behaviors. Conclusion The results demonstrated that the Triple D Method was useful in supporting interpersonal conflict management. The promotion of well-being practices was effective in increasing reported well-being behaviors and fostering a healthy work environment. These strategies should be replicated in direct care settings with larger sample sizes.
BACKGROUND:In this evidence-based practice project, point-of-care ultrasonography by advanced practice providers was implemented in a central Florida intensive care unit. The project was guided by the following question: Does implementation of point-of-care ultrasonography by critical care advanced practice providers over 3 months decrease time to intravenous fluid, vasopressor, or inotrope administration or modify the treatment plan for patients with undifferentiated shock, as compared with current practice without point-of-care ultrasonography? REVIEW OF EVIDENCE:A strong body of evidence supports using advanced practice provider-performed point-of-care ultrasonography to enhance care for critically ill patients. IMPLEMENTATION:Baseline data on treatment of patients with undifferentiated shock, including intravenous fluid volume and time to intervention, were collected over 60 days. Advanced practice providers then completed in-person point-of-care ultrasonography training focused on clinical application and integration into decision-making. A second 60-day data collection period tracked evaluation and treatment by advanced practice providers. EVALUATION:Time to intervention did not significantly differ between preintervention and postintervention groups. However, point-of-care ultrasonography findings consistently changed or refined patient care. SUSTAINABILITY:The project site will continue advanced practice provider-led point-of-care ultrasonography across all intensive care units. CONCLUSIONS:Implementation of point-of-care ultrasonography by critical care advanced practice providers does not delay intervention, helps confirm clinical diagnoses, and refines treatment delivery for patients with undifferentiated shock. Point-of-care ultrasonography provides a structured approach to assessment and management and should continue to be used in intensive care units.
BACKGROUND:The United States declared endemic measles eliminated in 2000. However, outbreaks continued, with resurgences in 2019 and 2025. In 2025, more than 2200 cases across 48 outbreaks, the most since 1992, were reported. In the first half of 2026, 2073 cases were reported. Declining measles, mumps, and rubella vaccination rates have increased susceptibility among children. Acute and critical care nurses are central to early recognition and management of measles for optimal outcomes. OBJECTIVE:To summarize current evidence on measles epidemiology, pathophysiology, clinical presentation, complications, treatment strategies, and acute and critical care nursing implications, emphasizing preparedness amid rising case numbers. METHODS:A literature review was conducted using PubMed and CINAHL databases and websites of Centers for Disease Control and Prevention, World Health Organization, professional organizations, and pediatric hospitals. English-language sources published from 2015 to August 2025 were prioritized; relevant earlier studies were included. Reference lists were searched for additional articles. DATA SYNTHESIS:Measles is among the most contagious human diseases. Typical features include fever, cough, coryza, conjunctivitis, and morbilliform rash. Severe respiratory and neurological complications may require critical care hospitalization. Complications like encephalitis may present weeks to years after acute infection. Management remains supportive, with vitamin A supplementation recommended. Acute and critical care nursing priorities include early recognition, isolation precautions, specimen collection, respiratory and hemodynamic support, neurological monitoring, serial assessments, hydration, nutrition, and caregiver education. CONCLUSION:Measles is resurging in the United States despite being vaccine preventable. Nurse preparedness, including knowledge of clinical features, complications, and infection control, is essential to mitigate morbidity and mortality and to support outbreak prevention. (Critical Care Nurse. Published online ahead of print July 17, 2026).
