Highlight
The Best Case/Worst Case-ICU (BC/WC-ICU) communication tool enables structured and consistent prognostic discussions between trauma ICU clinicians and families.
Implementation across eight high-volume US trauma centers shows feasibility with high clinician adherence and effective family reach.
Barriers such as competing clinical demands, communication discomfort, and doubts about innovation impact long-term maintenance.
Effective use of BC/WC-ICU reduces moral distress among clinicians and supports improved aligned decision-making by families.
Study Background and Disease Burden
Trauma intensive care units (ICUs) face complex communication challenges, especially when caring for seriously injured older adults who experience rapid and significant changes in their health trajectory and functional status. Optimal decision-making in this context requires clear understanding of prognosis to align care goals between clinicians, patients, and families. However, clinicians often struggle with prognostic uncertainty and communication barriers, which can contribute to inconsistent messaging, family distress, and moral distress among providers.
Advanced communication tools tailored to critical care settings are essential to support clinicians in these discussions. The Best Case/Worst Case (BC/WC) framework, originally developed for surgical decision-making, has been adapted for use in ICUs (BC/WC-ICU) to facilitate daily, structured prognostic conversations using graphic aids that illustrate a spectrum of possible outcomes, enhancing clarity and empathy in discussions. To date, evidence on its implementation in trauma ICUs remains limited.
Study Design
This quality improvement study took place within a multicenter randomized clinical trial framework at eight high-volume trauma centers across the United States. The study period spanned October 2023 to January 2025. Institutional sites participated in sequential waves of implementation; each site underwent a 3-month intensive implementation training phase aimed at educating trauma team members—including attendings, fellows, residents, advanced practice providers, and bedside nurses—on the BC/WC-ICU tool.
The intervention consisted of using the BC/WC-ICU tool daily during clinical rounds. This involved a team discussion of major events occurring in the past 24 hours and formulation of best- and worst-case scenarios for the patient’s recovery, which were then annotated on a standardized graphic aid. Clinicians subsequently used the graphic aid to communicate with patients’ families about prognosis, fostering shared understanding and decision-making.
Implementation outcomes were assessed through the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate penetration, utility, adherence, fidelity, and sustainability.
Key Findings
In total, 208 trauma surgeons, intensivists, and fellows completed individualized one-on-one BC/WC-ICU training sessions. The tool was utilized across an estimated 1300 patient-family encounters during the study period, indicating broad reach.
Clinicians reported that BC/WC-ICU effectively supported families by providing consistent prognostic messaging, which facilitated improved downstream decision-making and alleviated moral distress experienced by the care team. The fidelity of graphic aid use was high; site mean scores ranged from 6.22 to 7.12 out of 8 on a standardized rubric, demonstrating accurate and consistent use of the tool.
Adherence to the BC/WC-ICU intervention varied by site, with mean adherence rates ranging from 45% (SD 30.4) to 100% (SD 0). Factors impeding full implementation included competing clinical task demands, clinician fear or discomfort in discussing prognosis, misunderstandings about how to employ the tool, and perceptions that BC/WC-ICU lacked novelty or incremental utility, leading to skepticism about its adoption.
Regarding sustainability, long-term maintenance at 12 months post-training was limited in most centers, with only one trauma center demonstrating sustained integration into daily practice, suggesting challenges in embedding the tool into routine workflows.
Expert Commentary
The study highlights the feasibility and benefits of structured communication strategies such as BC/WC-ICU in the high-acuity, fast-paced trauma ICU environment where prognostic uncertainty and rapid clinical changes are common.
By explicitly framing discussions around best and worst recovery scenarios, the tool improves transparency and patient/family engagement, which are pivotal for ethically aligned care. The graphic aid further serves as a tangible communication aid enhancing comprehension and memory.
However, this intervention’s success depends critically on institutional culture, clinician attitudes, and operational integration. Barriers such as workload pressures and reluctance to prognosticate underscore the need for ongoing support, training reinforcement, and leadership endorsement.
It is crucial to address misconceptions around the tool and clearly communicate its evidence-based benefits to overcome hesitancies. Future studies might explore augmenting BC/WC-ICU with digital aids or integrating it into electronic health records to streamline use.
Limitations include variability in site adherence and the lack of patient/family outcomes beyond decision-making quality, which are important for evaluating holistic impact.
Conclusion
The BC/WC-ICU communication tool represents a promising advance for trauma ICU teams to engage patients and families in meaningful prognostic conversations that support decision-making and reduce clinician moral distress.
Successful implementation requires comprehensive training, addressing systemic barriers such as competing demands, and fostering a culture valuing communication as integral to quality critical care. Sustained use may benefit from targeted efforts to embed the tool within clinical workflows and continuous quality improvement cycles.
Future research should explore strategies to enhance adoption, investigate impacts on patient-centered outcomes, and adapt the tool to diverse care settings to maximize its clinical utility.
References
Fritz ML, Hernandez AH, Zelenski AB, Nitkowski J, Sobol C, Kwekkeboom K, Bradley T, Tsang J, Bushaw K, Dudek A, Stalter L, Schwarze ML. Best Case/Worst Case Communication Tool for Trauma Intensive Care Units. JAMA Surg. 2025 Sep 24:e253782. doi: 10.1001/jamasurg.2025.3782. Epub ahead of print. PMID: 40991261; PMCID: PMC12461598.
