UK COVID-19 Daily: NICE Issues Critical Care Guidelines 

Tim Locke

March 21, 2020

Editor's note, 30th March 2020: NICE has updated the rapid critical care guideline to give more clarity over use of CFS scores. This article may not reflect the latest COVID-19 information. Find the latest news, expert opinion, and guidance in Medscape UK's COVID-19 Resource Centre

Medscape UK has been sifting through today’s coronavirus news to bring you what we think you need to know about.

NICE Rapid COVID-19 Guidelines

The National Institute for Health and Care Excellence (NICE) has published its first three rapid COVID-19 guidelines.

They cover hard choices around a patient's chances of recovery in critical care, cancer patients, and dialysis.

Critical Care NICE guideline [NG159]

All patients admitted to hospital should be assessed for frailty irrespective of COVID-19 status.

Risks and benefits and likely outcomes should be discussed with patients, carers or advocates and families using decision support tools (where available) so that they can make informed decisions about their treatment wherever possible.

For patients with confirmed COVID-19, decisions about critical care admission should be made on the basis of medical benefit and should take into account the likelihood that the person will recover to an outcome that is acceptable to them and within a period of time consistent with the diagnosis.

Systemic Cancer Treatments NICE guideline [NG161]

Where decisions need to be made about prioritising patients for treatment, these need to take into account the level of immunosuppression associated with individual treatments and cancer types, and any other patient-specific risk factors. They should also balance the risk from cancer not being treated optimally versus the risk of becoming seriously ill if they contract COVID-19 because of immunosuppression.

Where changes need to be made to usual care because of system pressures, consideration should be given to delivering treatment in different and less immunosuppressive regimens, different locations, or via another route of administration.

Dialysis NICE guideline [NG160]

Patients with suspected COVID-19 should be assessed to see whether dialysis could be delayed until their COVID-19 status is known. 

NICE also recommends that outpatient transport services should get patients to their dialysis as scheduled to avoid their condition deteriorating.

It should also be ensured that appropriate transport services are available by finding out what current transport providers are prepared to provide, and whether there are alternative providers if the current providers will not transport patients infected with COVID-19.

Daily Press Conference

Today's figures showed a total of 233 patients in the UK who tested positive for coronavirus have died.

Medical questions at today's Downing Street daily press conference were taken by Stephen Powis, national medical director at NHS England and professor of renal medicine at University College London.

He was asked if doctors were already having to take life and death decisions over rationing critical care: "Doctors and other clinicians are very used to having discussions with patients and relatives about treatment choices. And frankly, our aim is to make sure that we're in a position that those discussions are, as they have always been."

That can only happen, he said, if everyone followed social distancing and isolation guidance.

"Yes, we are working night and day to increase capacity, but an increase in capacity and the reducing demand that will come from everybody paying attention, young and old, to the guidance that's been given, will give us the best possible chance that doctors and clinicians can have those discussions in the way they've always had them."

He was also asked about critical care nurse Dawn Bilbrough's video which went viral, showing how upset she was after a long shift to find that shop shelves were empty due to panic buying.

"Frankly, we should all be ashamed that has to happen. It's inacceptable," Prof Powis said.

https://twitter.com/BBCBreakfast/status/1240890320008642562

 

Tough Decisions

Debate had already begun about what happens when there are more COVID-19 patients than ventilators to support them.

Rahuldeb Sarkar, a respiratory medicine and critical care consultant in Kent told Reuters decision-making was being reviewed, including ventilator rationing.

"It will be tough, and that’s why it’s important that you know, that two or more consultants will make the decisions."

He continued that in normal times a patient on a ventilator  “would be given some more days to see which way it goes," but said if the worst predictions about the spread of the virus proved correct, he suspected "it will happen quicker than before".

NHS Deal With Private Hospitals

The NHS has done a cost-price deal with private hospitals to boost capacity.

NHS England said the deal provides:

  • 20,000 fully qualified staff 

  • 8000 hospital beds across England

  • Nearly 1200 more ventilators

Chief Executive of the Independent Healthcare Providers Network, David Hare, said in a statement: "Independent hospitals are boosting emergency capacity to put at the disposal of the NHS over these coming weeks. We have worked hand-in-hand with the NHS for decades and will do whatever it takes to support the NHS in responding to this pandemic.

"This significant additional capacity across the country will be a major boost to the NHS’s efforts to treat those patients that need hospital care over the coming period and the independent sector stands ready to maintain that support for as long as needed."

Editor's note, 21st March 2020: This article was updated to include the latest statistics.

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