Frail coronavirus patients may be denied critical care under an NHS scale system designed to free up ICU beds.
The controversial ‘Clinical Frailty Scale’ (CFS) ranks patients’ vulnerability from one to nine in order to prioritise those most likely to recover from the killer virus.
Those with a combined score of more than five are said to have uncertainty around the benefits of critical care, according to the system, which has been implemented while NHS hospitals desperately scramble to free up beds and ventilators.
It comes after NHS sources denied that elderly patients would be rejected from critical care using a scoring system – where over-65s with the deadly virus were to be ranked out of 10 based on their age, frailty and underlying conditions.
The most vulnerable coronavirus patients could be denied critical care under a new NHS scoring system designed to free up ICU beds for those most likely to recover. Sources say the draft guidance was scrapped and will not be implemented
Under the guidance, over-65s with the deadly virus would have been ranked out of 10. Pictured: An intubated patient at the South Pest Central Hospital in Budapest, Hungary
More than 5,000 coronavirus patients are being diagnosed at hospitals every day and some intensive care units are already approaching capacity.
NHS doctors and other health professionals were said to have been issued with the scoring system to identify ‘who may not benefit from critical care interventions’, the Financial Times reported.
Patients aged 71 to 75 were said to automatically score four points for their age and an extra three for their frailty.
That would put them at a total of seven points before underlying health conditions are even considered. Dementia, high blood pressure or recent heart and lung disease would also incur more points.
Patients who scored more than eight points were earmarked to be given ‘ward-based care’ and treated with an oxygen mask instead of a ventilator.
Britain is thought to be short of thousands of ventilators, which pump oxygen directly into the lungs of a sedated patient. The machines are the most efficient breathing tools the health service has.
The scoring system was considered in a piece of draft guidance which has now been scrapped, NHS sources say.
Instead, clinicians are being urged to use the ‘Clinical Frailty Scale’ when considering which patients to give critical care.
It does not discriminate against age, but it does weigh up underlying conditions and overall health.
The Clinical Frailty Scale was included in guidelines issued by the NHS regulator, the National Institute for Health and Care Excellence (NICE). It was originally developed at Dalhousie University in Halifax, Canada.
An NHS website outlining how the scoring system works states that it ‘is a reliable predictor of outcomes in the urgent care context’.
‘Like any decision support tool, it is not perfect and should not be used in isolation to direct clinical decision-making,’ it adds.
‘It will sensitise you to the likely outcomes in groups of patients, but clinical decision-making with individual patients should be undertaken through a more holistic assessment, using the principles of shared decision-making.’
NICE recommends clinicians use the Clinical Frailty Scale when considering patients for intensive care
A spokesman for NICE said: ‘In its COVID-19 rapid clinical guideline on critical care for adults, NICE recommends the use of the Clinical Frailty Score in some people in whom it has been validated as part of a holistic assessment – as it was before COVID-19.
‘The guideline makes it clear that it should not be used in isolation to direct clinical decision making and that clinicians should take any decisions about care in conjunction with patients and their carers where possible.
‘The guideline also states that the tool should not be used in certain groups, including those with learning disabilities or with stable long-term disabilities such as cerebral palsy.’
An NHS spokesperson said the health service only followed the clinical frailty scale and would not cherry pick patients who deserve ventilators.
They added: ‘This [the scoring system] is not an NHS approved document, we do not agree with it, and the NHS will not endorse its use in decisions on care.’
It comes little over a week after the British Medical Association released advice on taking older coronavirus patients off ventilators so they can be given to younger and healthier patients.
The BMA guidelines said this will ‘inevitably be indirectly discriminatory against both the elderly and those with long-term health conditions’.
They add it may be necessary to deny some of the most unwell patients potentially life-saving treatment – even if their condition is improving.
The doctors’ union said a simple ‘age cut-off’ policy would be unlawful but ‘relevant factors’ for considering if a patient should get intensive care include their age and underlying health conditions.
‘Some of the most unwell patients may be denied access to treatment such as intensive care or artificial ventilation,’ it says.
‘This will inevitably be indirectly discriminatory against both the elderly and those with long-term health conditions relevant to their ability to benefit quickly, with the latter being denied access to life-saving treatment as a result of their pre-existing health problems.
‘A simple ‘age cut-off’ policy would be unlawful as it would constitute direct age discrimination.
‘A healthy 75-year-old cannot lawfully be denied access to treatment on the basis of age. However, older patients with severe respiratory failure secondary to COVID-19 may have a very high chance of dying despite intensive care, and consequently have a lower priority for admission to intensive care.’
The Alzheimer’s Society said the ‘discriminatory’ system could prevent those with dementia getting treatment even if they could recover from coronavirus.
Are doctors HARMING coronavirus patients by putting them on ventilators too early? Doctors warn the gadgets may be overused and could even damage the lungs of the infected
The nationwide shortage of ventilators and Britain’s rush to build them has been one of the biggest stories of the coronavirus pandemic
But now doctors have warned putting patients on the machines too early could cause more harm than good.
Figures show two-thirds of COVID-19 sufferers who are hooked up to the potentially life-saving machines in the UK do not survive.
Reports in China, Italy and the US have found that less than half of patients who are intubated recover. Experts are unsure why the death rates are so high.
In New York City, at least 80 per cent of coronavirus patients in New York City who have been put on a ventilator have died.
As health officials around the world push to get more ventilators to treat patients, some doctors are moving away from using the breathing machines when they can.
The reason: Some hospitals have reported unusually high death rates for coronavirus patients on ventilators, and some doctors worry that the machines could be harming certain patients.
Mechanical ventilators push oxygen into patients whose lungs are failing. Using the machines involves sedating a patient and sticking a tube into the throat.
Deaths in such sick patients are common, no matter the reason they need the breathing help.
Generally speaking, 40 percent to 50 percent of patients with severe respiratory distress die while on ventilators, experts say.
Ventilators pump oxygen under pressure directly into the lungs via a tube inserted down the throat
Two-thirds of coronavirus patients in the UK who need to be hooked up to a ventilator will die from the illness, official NHS data suggests. Graph also shows the likelihood of critically ill COVID-19 patients surviving based on their age, BMI and whether they have health woes
Higher-than-normal death rates – like those in New York City – also have been reported elsewhere in the US, said Dr Albert Rizzo, the American Lung Association’s chief medical officer.
Similar reports have emerged from China and the United Kingdom.
One UK report put the figure at 66 percent. A very small study in Wuhan, the Chinese city where the disease first emerged, said 86 percent died.
The reason is not clear. It may have to do with what kind of shape the patients were in before they were infected.
Or it could be related to how sick they had become by the time they were put on the machines, some experts said.
But some health professionals have wondered whether ventilators might actually make matters worse in certain patients, perhaps by igniting or worsening a harmful immune system reaction.
That’s speculation. But experts do say ventilators can be damaging to a patient over time, as high-pressure oxygen is forced into the tiny air sacs in a patient’s lungs
Some say it is simply a result of patients being extremely ill when they are put on the machines, which pump oxygen directly into the lungs via a tube down the throat.
But others suggest the ventilators – which can make inflammation in the lungs worse – are being implemented too soon and harming coronavirus patients.
In the most life-threatening cases, COVID-19 can permeate deep into the lungs and cause severe inflammation, making it hard to breathe.
Pumping pressurised oxygen into the lungs can irritate the organs and damage them further.
Dr Paul Marik, chief of pulmonary and critical care medicine at Eastern Virginia Medical School, said this was a ‘vicious cycle’ for coronavirus patients.
Scott Weingart, a critical care physician in New York, told Stat News coronavirus patients get worse ‘as a direct result of intubation’.
He added: ‘High levels of force and oxygen levels, both in quest of restoring oxygen saturation levels to normal, can injure the lungs. I would do everything in my power to avoid intubating patients.’
Dr Paul Marik, chief of pulmonary and critical care medicine at Eastern Virginia Medical School, said putting coronavirus patients on ventilators was a ‘vicious cycle’ because it actually makes them worse
For most people, COVID-19 causes mild or moderate symptoms which clear up in a few weeks.
But roughly 20 per cent, mainly the elderly or those with underlying conditions, fall seriously ill and have trouble breathing.
The killer infection can burrow its way deep into the lungs, causing them to become severely inflamed.
The inflammation causes fluid from nearby blood vessels to leak into the tiny air sacs in the lungs, making breathing harder and cutting the supply of oxygen to the organs.
Intensive care doctors turn to mechanical ventilators as a last resort when patients’ oxygen levels plummet and they can’t be boosted with drugs or non-invasive techniques.
Ventilators pump oxygen under pressure directly into the lungs via a tube inserted down the throat.
Patients are heavily sedated so they can’t fight the sensation of being unable to breathe on their own.
But doctors are panicking and intubating COVID-19 patients sooner because the new virus is causing their blood-oxygen to fall to critically low levels, Stat News reports.
‘Data from China suggested that early intubation would keep 19 patients’ heart, liver, and kidneys from failing due to hypoxia (oxygen deprivation),’ a veteran emergency medicine physician told the website.
‘This has been the whole thing driving decisions about breathing support: Knock them out and put them on a ventilator.’
There are widespread reports that coronavirus sufferers are being ventilated for far longer than other types of patients.
Patients with non-coronavirus related pneumonia are usually intubated for a day or two, compared to coronavirus patients who have can need a ventilator for up to two weeks.
Pushing pressurised oxygen into the organs can cause them to become extremely inflamed and worsen the condition. Very high levels of oxygen can also be harmful.
Dr Paul Marik, chief of pulmonary and critical care medicine at Eastern Virginia Medical School, said this was a ‘vicious cycle’.
It is thought at least 30,000 ventilators will be needed to cope during the peak of the pandemic, as manufacturing companies race to build more (pictured, medical equipment labelled and prepared for use by NHS staff at the ExCeL centre in London)
He told Yahoo News: ‘The ventilator is causing lung injury, which causes them to stay on the ventilator longer, and basically is depleting the supply of ventilators for people who need them. It’s becoming a vicious cycle.’
Dr Eddy Fan, an expert on respiratory treatment at Toronto General Hospital, added: ‘We know that mechanical ventilation is not benign.
‘One of the most important findings in the last few decades is that medical ventilation can worsen lung injury – so we have to be careful how we use it.’
Dr Marik has called on other clinicians to implement a gentler approach than the high-pressure ventilators.
He said anti-inflammatory drugs, as well as breathing masks used in sleep apnoea, should be used for as long as possible before switching to a ventilator.
Not only would it potentially save more lives, he claims, it would also would help relieve a shortage of the machines.
The UK is projected to need 30,000 ventilators at the peak of the outbreak in the next week. It is thought to be thousands short of this number.
It comes after MailOnline revealed two-thirds of coronavirus patients in the UK who need to be hooked up to a ventilator die from the illness.
A report from the Intensive Care National Audit and Research Center (ICNARC) found ventilated patients succumb to the virus 66.3 per cent of the time.
A ventilator is a machine that helps people breathe. It puts oxygen directly into patients’ lungs and removes carbon dioxide from them
That is double the mortality rate of non-virus patients who were put on breathing support between 2017 and 2019, before the outbreak.
The NHS is still 22,000 ventilators short of the estimated 30,000 it will need during the peak of this crisis, which has infected almost 34,000 Britons.
The high death rate has led some doctors to question whether some critically ill COVID-19 patients are being put on ventilation ‘for the sake of it’, when the machine could be spared for a healthy person with a higher chance of survival.
The ICNARC report looked at the first 775 patients who had fallen critically ill with COVID-19 across 285 intensive care units.
Of the 98 patients who needed advanced respiratory support when their lungs started to fail, just 33 patients lived (34 per cent).
Patients in this age range die 73 per cent of the time if they fall seriously ill after contracting the disease.
For critically ill patients aged between 50 and 69, the mortality rate is just over 40 per cent. And a quarter of over-16s succumb to the disease, the figures show.
There are several reasons why older people have trouble fighting off the virus.
The likelihood of having chronic conditions increases markedly as people age, with four out of five over-65s living with at least one underlying health condition.
Elderly people also have weaker immune systems, a natural side-effect of the body ageing. This makes them more vulnerable to serious infections of all types.
The ICNARC report showed obese people are at a heightened risk of dying from coronavirus.
Among patients who needed intensive care after catching the infection, people with a BMI over 30 died 61 per cent of the time.
There was little discrepancy between overweight patients and those with a health body weight.
Those with a BMI under 25 – the ideal range is between 18.5 to 24.9 – the mortality rate was 42.1 per cent. For overweight patients , it was 41.7 per cent.
People with pre-existing health conditions are thought to be at greater risk of developing severe symptoms because of their weakened immune systems.
But the ICNARC report found people with severe underlying health woes were just 10 per cent more likely to die if they fell seriously ill with COVID-19 than otherwise healthy people.
The document also found that most coronavirus patients in intensive care were male, 71 per cent of all cases.
Only 18 patients (9 per cent) had ‘severe co-morbidities’, such as underlying heart conditions or lung disease; while two patients had been pregnant within the last six weeks.
The mortality rate was 58.8 per cent for people with pre-existing conditions and 47.6 per cent for those without.