Best Case/Worst Case Communication Tool for Trauma Intensive Care Units

Advanced communication techniques can support seriously injured older adults facing a significant change in health trajectory or functional status. Optimal use of these techniques requires effective implementation among trauma team members in intensive care units (ICUs).

To evaluate implementation of the Best Case/Worst Case-ICU (BC/WC-ICU) communication tool.

This quality improvement study involved implementing the BC/WC-ICU in the context of a randomized clinical trial. Each site received 3 months of implementation training during 1 of 4 sequential waves from October 2023 to September 2024; ongoing implementation was evaluated until January 2025. Participants included such trauma team members as attendings, fellows, residents, advanced practice providers, and bedside nurses at 8 high-volume trauma centers across the United States.

BC/WC-ICU is a communication tool used daily on rounds that includes team discussion of major 24-hour events and of the best- and worst-case scenarios for recovery, which are annotated on a graphic aid. Clinicians use the graphic aid to discuss prognosis with patients and families.

Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM implementation outcomes) of the intervention.

Two hundred eight trauma surgeons, intensivists, and fellows completed 1-on-1 training, and the intervention reached an estimated 1300 patient families. Clinicians reported the intervention effectively supported families through consistent messaging about prognosis that improved downstream decision-making and reduced moral distress. Mean (SD) site adherence ranged from 45% (30.4) to 100% (0), and graphic aid fidelity was high, with sites scoring a mean (SD) 6.22 (2.02) to 7.12 (1.39) on an 8-point rubric. Implementation was hindered by competing clinical tasks, fear of communicating prognosis, misunderstanding the tool, and a belief that BC/WC-ICU was not innovative, which generated hesitance about the intervention's utility. Long-term use of the intervention lagged at 12 months with the exception of 1 trauma center.

This study found that implementation of BC/WC-ICU in trauma ICUs is feasible, supports prognostic communication, and can improve the clinician-family relationship. Future efforts to advance clinician-patient communication will need to consider identified barriers, including the rapid pace and high acuity of critical care and disincentives to prioritize communication.