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Clinical update

COVID-19: guidance on when to admit patients to critical care

NICE advises on assessing for frailty and including patients and carers in decision-making


Adults admitted to hospital should be assessed using the Clinical Frailty Scale  Picture: iStock

Essential information

COVID-19, the disease caused by a new coronavirus that emerged in China late last year, is spreading rapidly around the world. The illness, the main symptoms of which are high temperature and/or a new continuous cough, has already caused thousands of deaths. While anyone can become seriously ill with the disease, people with certain health conditions, including lung disease and a compromised immune system, as well as those undergoing some types of cancer treatment, have a higher mortality risk.

What’s new

The National Institute for Health and Care Excellence (NICE) has issued guidance on how to decide whether to admit an adult with COVID-19 to critical care.

This guidance is one of the first of a package of COVID-19 guidelines being developed rapidly to maximise patient safety, make the best use of NHS resources and protect staff from infection. 

It states that, irrespective of COVID-19 status, adults admitted to hospital should be assessed for frailty using the Clinical Frailty Scale (CFS) as part of a holistic assessment.  Clinicans should be aware of the limitations of using the CFS as the sole assessment of frailty, and comorbidities and underlying health conditions should be considered. The CFS should not be used in younger people, people with stable long-term disabilities (for example, cerebral palsy), learning disabilities or autism.

NICE has said however that the tool should not be used in certain groups, including those with learning disabilities or stable long-term disabilities such as cerebral palsy.

The risks, benefits and likely outcomes of treatment should then be discussed with patients, their carers and families using decision support tools (where available) so that they can make informed decisions about treatment.

Decisions about admission to critical care should be made on the basis of medical benefit, the guidance says, taking into account the likelihood that the person will recover to the extent that the outcome will be acceptable to them.

Critical care should be reviewed regularly, and stopped when it is no longer considered able to achieve the desired goals. This decision, and the associated discussion with family and carers and the patient (if possible), should be recorded in the patient’s medical notes.

NICE says the recommendations are based on evidence and expert opinion, and have been verified as extensively as possible. 

Expert comment

Nicki Credland, chair of the British Association of Critical Care Nurses, says:

‘While this document does not deal with specific nursing issues related to critical care nursing and COVID-19, it does give us some further information about admission decisions for critical care, ongoing assessment and treatment planning.

‘Nurses form part of the multidisciplinary team and will be involved in difficult conversations about the COVID-19 surge. This guidance will enable us to support our colleagues in those conversations.

‘We are seeing an escalating number of admissions to intensive care units in relation to COVID-19, particularly in London. This is expected to rise dramatically around the UK and will put huge pressure on all intensive care staff both physically and emotionally. We must ensure that these staff are supported both during the surge and afterwards.’

 

Key points for nurses

  • Support healthcare professionals in areas other than critical care to discuss treatment plans with patients who would not benefit from critical care treatment or who do not wish to be admitted to critical care.
  • Discuss sensitively a do not attempt cardiopulmonary resuscitation decision with patients who have increased frailty (for example a CFS score of 5 or more).
  • The CFS should not be used in younger people, people with stable long-term disabilities, learning disabilities, autism or cerebral palsy. An individualised assessment is recommended in all cases where the CFS is not appropriate.
  • The CFS should not be used in isolation to direct clinical decision-making; clinicians should take any decisions about care in conjunction with patients and their carers where possible.
  • Healthcare professionals should have access to resources to support discussions about treatment plans.
  • Ensure that when treatment outside critical care is the agreed course of action, patients receive optimal care within the ward.

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