Best case/worst case for the trauma ICU: Development and pilot testing of a communication tool for older adults with traumatic injury

Abstract

Background: "Best Case/Worst Case" (BC/WC) is a communication tool to support shared decision making in older adults with surgical illness. We aimed to adapt and test BC/WC for use with critically ill older adult trauma patients.

Methods: We conducted focus groups with 48 trauma clinicians in Wisconsin, Texas, and Oregon. We used qualitative content analysis to characterize feedback and adapted the tool to fit this setting. Using rapid sequence iterative design, we developed an implementation tool kit. We pilot tested this intervention at two trauma centers using a pre-post study design with older trauma patients in the intensive care unit (ICU). Main outcome measures included study feasibility, intervention acceptability, quality of communication, and clinician moral distress.

Results: BC/WC for trauma patients uses a graphic aid to document major events over time, illustrate plausible scenarios, and convey uncertainty. We enrolled 86 of 116 eligible patients and their surrogates (48 pre/38 postintervention). The median patient age was 72 years (51-95 years) and mean Geriatric Trauma Outcome Score was 126.1 (±30.6). We trained 43 trauma attendings and trauma fellows to use the intervention. Ninety-four percent could perform essential tool elements after training. The median end-of-life communication score (scale 0-10) improved from 4.5 to 6.6 (p = 0.006) after intervention as reported by family and from 4.1 to 6.0 (p = 0.03) as reported by nurses. Moral distress did not change. However, there was improvement (less distress) reported by physicians regarding "witnessing providers giving false hope" from 7.34 to 5.03 (p = 0.022). Surgeons reported the tool put multiple clinicians on the same page and was useful for families, but tedious to incorporate into rounds.

Conclusion: BC/WC trauma ICU is acceptable to clinicians and may support improved communication in the ICU. Future efficacy testing is threatened by enrollment challenges for severely injured older adults and their family members.

Level of evidence: Therapeutic, level III.

Trial registration: ClinicalTrials.gov NCT03188055.

Figure 1.. Graphic aid for the Best Case/Worst Case trauma ICU intervention

Patricia Jones is a 73-year-old who presents as a Level I trauma following a fall down a flight of stairs. Injuries notable for bilateral rib fractures, multiple facial fractures and an intracranial bleed. She was intubated in the trauma bay due to poor oxygenation and worsening GCS and admitted to the ICU. Overnight, Patricia’s neurological examination worsens, and a repeat head CT shows significant midline shift. She is taken to the OR with neurosurgery for craniotomy and hematoma evacuation.

Figure 2:. Study CONSORT diagram

*Ineligible due to health status includes participants who did not have decision making capacity, had died or were incapacitated **3 family members completed the After Death Bereaved Family Member Interview instead of the T-QoL survey

Figure 3.

Selected post-training assessment questions as reported by instructors and learners

Figure 4.

Quality of Communication as reported by family members and nurses caring for study patients (higher scores = better communication)