Guidelines Are Not Enough: The Added Impact of a Multidisciplinary Intervention on Palliative Care Delivery for Critically Ill Trauma Patients

Introduction: The benefit of palliative care (PC) for critically ill patients is well established. In 2017, the American College of Surgeons TQIP published best-practice guidelines for delivering PC to trauma patients. Prior work suggests that without a dedicated implementation strategy, guidelines alone are insufficient to change clinician behavior. Two years after guideline publication, our Level I trauma center implemented a multidisciplinary PC intervention that included a decision-support tool, provider trainings, and new workflows based on the TQIP guidelines. We assessed changes in PC use and clinical outcomes after each intervention.

Methods: A retrospective cohort study of adult trauma patients admitted to the ICU for ≥72 hours at a single academic Level I trauma center from 10/2015 to 8/2021 was conducted. Three cohorts were identified: Cohort 1 “Pre-Guideline”; Cohort 2 “TQIP Guideline Only”; Cohort 3 “Guidelines + Intervention”. Data collected included demographics, injury characteristics, PC use and clinical outcomes. We compared PC use and outcomes across the 3 cohorts.

Results: A total of 667 patients were analyzed. There were no significant differences in age, sex, insurance status, injury mechanism and severity, or in-hospital mortality across the 3 cohorts. After each intervention, there was earlier and increased number of PC consultations, more PC consults before death, increased PC consultation before tracheostomy and fewer ventilator days.

Conclusion: Multidisciplinary clinical intervention was more effective than guidelines alone in improving delivery of palliative care to critically ill trauma patients. Development of a dedicated implementation guide for TQIP-PC guidelines may improve scalability and delivery of PC in all trauma centers.