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Covid-19: doctors are given new guidelines on when to admit patients to critical care

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1189 (Published 24 March 2020) Cite this as: BMJ 2020;368:m1189

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  1. Gareth Iacobucci
  1. The BMJ

Decisions about whether to admit patients with covid-19 to critical care should consider the medical benefit including the patient’s likelihood of recovery, the National Institute for Health and Care Excellence (NICE) has recommended.

The advice is among a raft of recommendations included in three new rapid guidelines from NICE advising doctors on caring for people with suspected or confirmed covid-19.

The guidelines, published on 21 March, cover critical care, delivery of systemic anticancer treatments, and dialysis service delivery. They are the swiftest NICE has ever published and were produced in collaboration with NHS England and NHS Improvement with support from specialist societies and royal colleges.

The guideline on critical care1 says that “irrespective of covid-19 status” all patients on admission to hospital should continue to be assessed for frailty.

For patients with confirmed covid-19, the guideline says the decision to admit a patient to critical care should be based on “taking into account the likelihood that a person will recover from their critical care admission to an outcome that is acceptable to them.”

The advice comes amid growing fears that escalating pressure on the UK’s limited intensive bed capacity could lead to a similar situation to that faced by doctors in Italy, who have been forced to choose which patients to allocate to beds to.

Last week, before the guidance was published, the health select committee chair Jeremy Hunt had pressed NHS England’s medical director Stephen Powis on what doctors should do if they were forced to make “impossible decisions” about who to allocate intensive care beds.2 Powis said the NHS was boosting capacity “to ensure that we do everything that we possibly can not to get into that circumstance.” But he added, “Of course, nothing is certain in medicine and doctors have to make difficult decisions, and if that becomes the case, we will support them.”

Alison Pittard, dean of the Faculty of Intensive Care Medicine, said that while intensive care doctors are used to taking difficult decisions on when to admit patients, the guidance was welcome as it would empower doctors from other specialties to have conversations with patients at an earlier stage about risks, benefits, and possible outcomes of different treatment options.

She said, “There is no doubt we are under immense pressure. This guidance is not necessarily changing the decision on whether to admit, but it is changing where the decision occurs. It will free up critical care doctors to treat those who are already critically ill which is welcome.”

NICE’s new rapid guideline on treating patients with cancer3 advises taking into account the level of immunosuppression associated with treatments and cancer types, capacity and resource matters, and “balancing the risk of cancer not being treated optimally with the risk of the patient being immunosuppressed and becoming seriously ill from covid-19.”

Suggested alterations to cancer treatment include switching intravenous treatments to subcutaneous or oral alternatives if beneficial, shorter treatment regimens, decreasing the frequency of immunotherapy regimens, longer breaks between treatment, and deferrals of treatments that prevent long term complications such as bone disease.

There could also be home delivery of oral drugs and provision of repeat prescriptions of oral drugs or other at home treatments without patients needing to attend hospital, it added.

Patients under kidney dialysis who are suspected of having covid-19 should be assessed to see if their treatment should be delayed until their test results are known, the third rapid guideline4 says. NICE also recommends checking whether current outpatient transport providers are prepared to provide services to patients with confirmed covid-19 and, if not, whether alternatives are available.

Further updated guidelines are expected in the coming weeks on symptom management, patients receiving radiotherapy, and patients with rheumatoid arthritis.

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