Integrating rapid response systems and patient centered goals of care discussions

The conversation regarding allocation of scarce resources has grown into the forefront of hospital systems worldwide, in particular since the start of the COVID-19 pandemic. 1,2 Supply chain disruptions, staffing concerns, and equipment shortages have exposed vulnerabilities within the hospital resource system that have further increased scrutiny of clinician decisions regarding resource allocation. 345 The landscape of delivering patient care in this environment has been wrought with ethical considerations and earnest, widespread efforts geared towards providing transparent, equitable, and efficient health care. 6,7 Additionally, numbers of bedside staff have left the medical field due to the moral injuries developed through the administration and escalation of care deemed futile and inconsistent with the best wishes of their patients. 89101112 Thus, investing the right resources in the right patients is a major healthcare priority.A resurgent expansion in rapid response systems (RRS) across the healthcare field has also occurred since the COVID-19 pandemic. 131415 RRS are safety mechanisms devised of an afferent limb (deterioration monitoring and hospital-specific rapid response criteria) that triggers efferent limb response personnel (typically a critical care registered nurse) capable of providing resources, skills, and potential interventions at the bedside. 161718 The overarching goals of these systems are to intervene prior to a major acute life-threatening deterioration, increase patient safety, and reduce potentially inappropriate or avoidable escalation of resources such as intensive care unit (ICU) bed utilization. 192021 While complexity and variability between RRS themselves, as well as their methods of documentation of outcomes and standardization of alert triggers, have made their impact difficult to study on a larger scale, there is promise in their use as a means of reducing unexpected mortalities. 22 Goals of care (GOC) discussions and palliative care consultations often occur shortly after RRS activation and escalation to the ICU, leading to transition to comfort measures almost immediately upon arrival to the ICU, with those who are escalated to ICU status often demonstrating higher degrees of short-term mortality. 232425 The skill and expertise of more fully developed RRS provider teams enable the utilization of earlier, directed, emergent goals of care discussions to prevent inappropriate escalation of care and allocation of resources towards patients unlikely to derive benefit (e.g., unlikely to survive with acceptable quality of life). 262728 The role of the intensivist practitioner staffing RRS teams in end-of-life discussions outside of the ICU, and preceding escalation, is a growing concept that seeks to intervene earlier in patient care courses to prevent potentially untoward and unjust patient outcomes. 29 These teams are also equipped with the skills and experience to assist primary teams in providing end-of-life care outside of the ICU, including in conjunction with specialized palliative care teams. 30 Intensivists and RRS clinicians are also experienced in leading decision making around patient understanding and goals of care expectations, including desirable, acceptable, and realistic functional status following their clinical course. 31 In addition to the RRS team members' robust experience in caring for the critically ill, the stronger focus and broader involvement of these teams allow for an opportunity to also focus on the development of high-quality communication skills in clinician teams outside of palliative care consultant services. Primary team communication with their patients may be limited by lack of time, structured education, and experience with acutely ill patients at the end of life. 32,33 RRS team members are uniquely granted dedicated, individualized time with these acutely ill patients where they can utilize previous structured experience and may provide a fresh perspective to deteriorating patients and their families beyond what primary team clinicians can provide. These RRS teams also present a prime opportunity for simulated educational interventions aimed at improving, incentivizing, and utilizing high-quality communication skills during end-of-life discussions with patients, their providers, and healthcare proxies. 34 Future Directions As life expectancy in the United States and abroad continues to increase, along with projected increases in potential disability free-living, high-fidelity goals of care discussions led by experienced providers utilizing accurate outcome forecasting become paramount to delivering patient centric care. 353637 Pairing clinician RRS team skillsets with predictive modeling to identify patients with low likelihood of acceptable quality of life survival could further reduce inappropriate allocation of resources and potential futile escalations of care, as well as provide more patient centered and data driven GOC discussions. Two primary factors involved in identifying and predicting patient outcomes following clinical deterioration and subsequent RRS activation are baseline patient disease status (i.e., comorbid disease burden prior to admission) and the severity of the acute illness and deterioration. While studies have characterized patient morbidities (e.g., older age, diagnosis of frailty) potentially benefiting from more robust GOC discussions surrounding and preceding their acute clinical deterioration, there are currently no automated or dynamic tools validated to identify post-deterioration functional outcomes and high short-term mortality rates signaling possible futile care. 38394041 Furthermore, use of the electronic health record (EHR) capabilities continues to expand, with easily available data from the EHR holding valuable potential for providing a vehicle for clinicians to access live patient outcome predictions during important care decision points such as RRT activations. 42 While EHR functionality has been explored extensively in predicting upcoming acute deterioration of patients, less has been done at incorporating this data into active machine learning models to provide primary team, RRS team, or ICU clinicians with data regarding potential mortality immediately following their hospitalization, as well as forecast the post-hospitalization disposition and perseverance of functional status following their potential deterioration. 43,44 Future studies are warranted at incorporating current technological advancements to provide more timely, humane, patient centered, and data driven GOC discussions geared towards providing our patients with end-of-life care in line with their ultimate wishes. While this increase in utilization and integration of predictive machine learning systems into the clinical space holds great promise, it will do little to improve suboptimal communication between provider teams, families, and patients and warrants a multidisciplinary approach with an additional focus on improving communication skills of RRS team members and clinician providers. In addition to a broader approach, these technological integrations, while being data driven, serve as another entry point of provider bias and resource distribution inequities into the clinical space with potential medicolegal ramifications. 45,46 Careful implementation of these systems along with future inquiry regarding the possible impact the inherent bias of these algorithmic forecasting systems has on clinicians is warranted and crucial at maintaining delivery of patient centric humanistic care in these vulnerable patient populations. Overall, the combination of RRS teams with timely EHR based data-driven goals of care conversations has the potential to help guide appropriate resource allocation and utilization to serve both patient and health system needs but requires careful consideration of communication skill development and implications of potential bias before broad implementation.