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

Christopher J. Zimmermann, Amy B. Zelenski, Anne Buffington, Nathan D. Baggett, Jennifer L. Tucholka, Holly B. Weis, Nicholas Marka, Thomas Schoultz, Elle Kalbfell, Toby C. Campbell, Vivian Lin, Diane Lape, Karen J. Brasel, Herbert A. Phelan, Margaret L. Schwarze

Research output: Contribution to journalArticlepeer-review

11 Scopus citations

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.

Original languageEnglish (US)
Pages (from-to)542-551
Number of pages10
JournalJournal of Trauma and Acute Care Surgery
Volume91
Issue number3
DOIs
StatePublished - 2021
Externally publishedYes

Bibliographical note

Funding Information:
The authors declare no conflicts of interest. This project was supported by a NIH Exploratory/Developmental Research Grant Award R21AG055876, Schwarze-PI. Christopher Zimmermann is supported by a NIH 2T32HL110853–06 Training Grant.

Publisher Copyright:
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Keywords

  • Communication
  • Older adults
  • Prognosis
  • Oregon
  • Attitude of Health Personnel
  • Intensive Care Units
  • Humans
  • Middle Aged
  • Male
  • Surgeons/education
  • Wounds and Injuries/therapy
  • Clinical Decision-Making
  • Texas
  • Aged, 80 and over
  • Female
  • Aged
  • Evaluation Studies as Topic
  • Wisconsin

PubMed: MeSH publication types

  • Research Support, Non-U.S. Gov't
  • Multicenter Study
  • Journal Article
  • Research Support, N.I.H., Extramural

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