NHS ‘score’ tool to decide which patients receive critical care

Doctors will use three metrics: age, frailty and underlying conditions write Peter Foster, Bethan Staton and Naomi Rovnick in The FT

Doctors coping with the coming peak of the coronavirus outbreak will have to “score” thousands of patients to decide who is suitable for intensive care treatment using a Covid-19 decision tool developed by the National Health Service.

With about 5,000 coronavirus cases presenting every day and some intensive care wards already approaching capacity, doctors will score patients on three metrics — their age, frailty and underlying conditions — according to a chart circulated to clinicians.

Patients with a combined score of more than eight points across the three categories should probably not be admitted to intensive care, according to the Covid-19 Decision Support Tool, although clinical discretion could override that decision.

The UK is set to exceed 80,000 coronavirus cases on Sunday and 10,000 deaths in hospital with government models showing the peak of the outbreak is now expected to be reached over the next two weeks, leaving the healthcare system facing arguably its toughest challenge since its inception. 

The scale of the pandemic and the speed at which Covid-19 can affect patients, has forced community care workers, GPs and palliative carers to accelerate difficult conversations about death and end-of-life planning among vulnerable groups.

The NHS scoring system reveals that any patient over 70 years old will be a borderline candidate for intensive care treatment, with a patient aged 71-75 automatically scoring four points for their age and a likely three on the “frailty index”, taking their total base score to seven points.

Any additional “comorbidity”, such as dementia, or recent heart or lung disease, or high blood pressure will add one or two points to the score, tipping them into the category suitable for “ward-based care”, rather than intensive care, and a trial of non-invasive ventilation.

Although doctors and care workers stress that no patient is simply a number, the chart nonetheless codifies the process for the life-and-death choices that thousands of NHS doctors will make in the coming weeks.

A frontline NHS consultant triaging Covid-19 patients said the “game-changer” for assessment of patients with coronavirus was that there is no available treatment, meaning doctors can only provide organ support and hope the patient recovers.

“If this was a bacterial pneumonia or a bad asthma attack, then that is treatable and you might send that older patient to intensive care,” the consultant said, adding that decisions on patients were “art not science” and there would be exceptions for patients who were fit enough.

“The scoring system is just a guide; we make the judgment taking into account a lot of information about the current ‘nick’ of the patient — oxygenation, kidney function, heart rate, blood pressure — which all adds into the decision making,” he said.

But it is not just hospital doctors who must make tough decisions. GPs, hospice workers and families with vulnerable members are also involved.

Last week NHS England wrote to all GPs asking them to contact vulnerable patients to ensure that care plans and prescriptions were in place for end of life decisions, leading to many difficult conversations. These have been made harder by the need to conduct them on the phone or via Skype to observe social distancing rules. 

Ruthe Isden, head of health and care at Age UK, the charity, said the need for haste had unsettled many elderly patients, who have felt under pressure to sign “Do Not Resuscitate”, or DNR, forms. 

"Clinicians are trying to do the right thing and these are very important conversations to have, but there’s no justification in doing them in a blanket way,” she said. “It is such a personal conversation and it’s being approached in a very impersonal way.” 

The subject of DNR notices is particularly unsettling for individuals and families who want the best care for their loved ones, but often feel the choices have not been fully explained.

The data clearly show that resuscitation often does not work for elderly patients and can often cause more suffering — including broken ribs and brain damage — while extending life only by a matter of days.

Trumper, Pujara and the art of dominating a spinner

Ian Chappell in Cricinfo

It was a distinct pleasure to watch India bat in the first Test against New Zealand. It was good to see spin bowling played so well.

I especially enjoyed the play of Cheteshwar Pujara. I love the way he quickly gets back to either play a forcing shot through the covers or a pull to the midwicket boundary. Many batsmen limit themselves by "closing off" when they play the pull shot, but Pujara opens up, thrusting his left leg towards the square-leg umpire, and creates a wider arc in which to place the ball. He was well supported by M Vijay, a dangerous opponent because he handles the new ball competently and can extend his innings by playing spin bowling well. This pair and Virat Kohli give India a trifecta of batsmen who can dictate terms to opposition spinners.

As well as watching the Test on television, I was also in the process of reading Gideon Haigh's excellent new book, Stroke of Genius. It's about Victor Trumper's batting artistry captured in one photograph, titled "Jumping Out". In his playing days, Trumper extolled the virtue of footwork with this simple philosophy: "Spoil a bowler's length and you've got him."

This statement accords with the best use of the feet against a top-class legspinner that I've witnessed. Following VVS Laxman's magnificent 2000-01 series against Australia in general and Shane Warne in particular, I asked Warne how he thought he had bowled. "I didn't think I bowled badly," replied Warne. "You didn't," I answered. "When a batsman comes out three metres and drives you wide of mid-on and then when you go higher and shorter to tempt him with the next delivery, he's quickly onto the back foot and pulls through midwicket, that's not bad bowling."
In the words of Trumper, Laxman's nimble footwork, ensured "he'd got him [Warne]." It's this type of decisive footwork that allows a batsman to dictate the bowler's field placings. Both Pujara and Vijay did this exquisitely by employing the late cut and either the square cut or the forcing shot off the back foot. By playing both shots, they forced the fielding captain to place a man behind as well as just in front of point. When a captain has to expend two men patrolling a limited area, it leaves some inviting gaps elsewhere.

Good footwork is not only decisive, it's also physically demanding if you play a long innings. Pujara, like my former team-mate Doug Walters, the best player of offspin bowling I've seen, pushes back with intent. If Mitchell Santner had done something similar instead of just swivelling in the crease, his admirable rearguard action may have continued longer.

Too many batsmen are easily tempted into lazy footwork. They either prop forward one pace or just swivel on the back foot rather than advancing to attack the delivery or quickly retreating to allow more time to place the shot.

Some right-hand batsmen also limit themselves by moving outside off stump to thwart offspinners. This theory is flawed because it's based on survival rather than on developing a method that creates more scoring opportunities as opposed to than fewer.

As well as stifling scoring opportunities, this theory also opens batsmen up to being ambushed by smart bowlers like R Ashwin. He achieved such a dismissal when he cleverly out-thought Ish Sodhi to bowl him behind his pads.

The more proficient a spin bowler, the more attacking a batsman's thought process needs to be. This doesn't mean coming up with ways to belt him to or over the boundary but rather thinking of how to score regularly and frustrate the spinner. This is a demanding process both physically and mentally and isn't achieved by lazy or leaden footwork.

For some time India has been the leading light in producing batsmen who are devoid of gimmicks and rely on tried and tested methods to score at every opportunity. Whatever development methods India are employing for their young batsmen, the rest of the cricket world should start taking notice.