Abstract
IMPORTANCE: 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). OBJECTIVE: To evaluate implementation of the Best Case/Worst Case-ICU (BC/WC-ICU) communication tool. DESIGN, SETTING, AND PARTICIPANTS: 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. INTERVENTION: 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. MAIN OUTCOMES AND MEASURES: Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM implementation outcomes) of the intervention. RESULTS: 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. CONCLUSIONS AND RELEVANCE: 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.