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.

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Britain and Covid-19

by Giffenman

This is an unusual time for the whole world as it deals with the Corona pandemic. In my opinion when the crisis ends our world will be an entirely different place from what it was in early 2020. Every one’s consciousness would have been affected by coping with the disease and I hope it will result in a different and more egalitarian politics.

The Corona pandemic has laid bare the unpreparedness of the UK government to the crisis. Its much touted public health system, the NHS, has been found short of equipment, manpower and ideas to cope with the disease. The NHS had warned the government in 2016 about its inability to cope in the case of such a breakout but the report was suppressed. This is not surprising since governments since the 1980s have been privatising the NHS by stealth.

Boris Johnson, the British Prime Minister, did not want the UK to respond like China, Korea or Germany did to Covid-19. He wanted to use Darwinian principles of ‘survival of the fittest’ and get Britons to develop herd immunity. It could be that he was aware that the NHS was in no position to cope with the pandemic and did not want the facts exposed. His ultimate ignominy was that he was afflicted by Corona and has spent the last few nights in a NHS hospital.

The biggest surprise in this period has been the behaviour of the chancellor Rishi Sunak. He has, in the past few days, made unlimited funds available for the nation to cope with the health and economic impact of the pandemic. This is in sharp contrast to the austerity agenda in vogue since 2010. Sunak’s popularity has shot up among the public and he is being touted as a replacement for the currently invalid Prime Minister.

Even more surprising is the behaviour of the czars of the independent Bank of England (BOE). In synchronised operations with Rishi Sunak they slashed interest rates to 0.1% and agreed to borrow large amounts to kick-start the economy. Then a couple of days ago, they even abandoned their orthodox ideology on borrowings via gilts and decided to create money out of thin air to help the government deal with the crisis. The BOE even surprised itself when it stopped commercial banks from paying dividends to their shareholders.

If the financial and economic arm of the government is taking such unorthodox and knee-jerk measures in a concerted manner one does not need much imagination to imagine what might be their prognoses for the UK economy in the immediate future.

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Information can make you sick

Trader turned neuroscientist John Coates in The FT on why economic crises are also medical ones.

As coronavirus infection rates peak in many countries, the markets rally. There is a nagging worry that a second wave of infections might occur once lockdowns are lifted or summer passes. But for anyone immersed in the financial markets there should be a further concern. Volatility created by the pandemic could itself cause a second wave of health problems. Volatility can make you sick, just as a virus can. 

To get an inkling of what this other second wave might look like, it helps to recall what happened after the credit crisis. That event was both a financial and medical disaster. Various epidemiological studies suggest it may be responsible for 260,000 cancer deaths in OECD countries; a 17.8 per cent increase in the Greek mortality rate between 2010-16; and a spike in cardiovascular disease in London for the years 2008-09, with an additional 2,000 deaths due to heart attacks. The current economic crisis may be far worse than 2008-09, so the medical fallout could be as well. 

Why do financial and medical crises go hand in hand? Many of the above studies focused on unemployment and reduced access to healthcare as causes of the adverse health outcomes. But research my colleagues and I have conducted on trading floors for the past 12 years suggest to me that uncertainty itself, regardless of outcome, can have independent and profound effects on physiology and health. 

Our studies were designed initially to test a hunch I had while running a trading desk for Deutsche Bank, that the rollercoaster of physical sensations a person experiences while immersed in the markets alters their risk-taking. After retraining in neuroscience and physiology at Cambridge University, I set up shop on various hedge fund and asset manager trading floors, along with colleagues, mostly medical researchers. Using wearable tech and sampling biochemistry, we tracked the traders’ cardiovascular, endocrine and immune systems.

My goal was to demonstrate how these physiological changes altered trader performance. Increasingly, though, I came to see that a trading floor provides an elegant model for studying occupational health. 

One remarkable thing we found was that traders’ bodies calibrated sensitively to market volatility. For humans, apparently, information is physical. You do not process information dispassionately, as a computer does; rather your brain quietly figures out what movement might ensue from the information, and prepares your body, altering heart rate, adrenaline levels, immune activation and so on. 

Your brain did not evolve to support Platonic thought; it evolved to process movement. Our larger brain controls a more sophisticated set of muscles, giving us an ability to learn new movements unmatched by any other animal — or robot — on the planet. If you want to understand yourself, fellow humans, even the markets, put movement at the very core of what we are. 

Essential to our exquisite motor control is an equally advanced system of fuel injection, one that has been misleadingly termed “the stress response”. Stress connotes something nasty but the stress response is nothing more sinister than a metabolic preparation for movement. Cortisol, the main stress molecule, inhibits bodily systems not needed during movement, such as digestion and reproduction, and marshals glucose and free fatty acids as fuel for our cells. 

The stress response evolved to be short lived, acutely activated for only a few hours or days. Yet during a crisis such as the current one, you can activate the stress response for weeks and months at a time. Then an acute stress response morphs into a chronic one. Your digestive system is inhibited so you become susceptible to gastrointestinal disorders; blood pressure increases so you are prone to hypertension; fatty acids and glucose circulate in your blood but are not used, because you are stuck at home, so your risks increase for cardiovascular disease. Finally, by inhibiting parts of the immune system, stress impairs your ability to recover from diseases such as cancer, and Covid-19. 

So why the connection with uncertainty? The stress response is largely predictive rather than reactive. Just as we try to predict the future location of a tennis ball, so too we predict our metabolic needs. When we encounter situations of novelty and uncertainty, we do not know what to expect, so we marshal a preparatory stress response. The stress response is comparable to revving your engine at a yellow light. Situations of novelty can be described, following Claude Shannon, inventor of information theory, as “information rich”. Conveniently, informational load in the financial markets can be measured by the level of volatility: the more Shannon information flowing into the markets, the higher the volatility. 

In two of our studies we found that traders’ cortisol levels did in fact track bond volatility almost tick for tick. It did not even matter if the traders were making or losing money; just put a human in the presence of information and their metabolism calibrates to it. Take a moment to contemplate that curious result — there are molecules in your blood that track the amount of information you process. 

Today, with historically elevated volatility, there is a good chance cortisol levels are trending higher. Immune systems could also be affected. When your body is attacked by a pathogen, your immune system coordinates a suite of changes known as “sickness behaviour”. You develop a fever, lose your appetite and withdraw socially. You also experience increased risk aversion. 

Central to the immune response is inflammation, the process of eliminating pathogens and initiating tissue repair. However, inflammation can also occur in stressful situations, because cytokines, the molecules triggering inflammation, assist in the recruitment of metabolic reserves. If inflammation becomes systemic and chronic, it contributes to a wide range of health problems. We found that interleukin-1-beta, the first responder of inflammation, tracked volatility as closely as cortisol. 

Recently we have focused on the cardiovascular system. Working with a large and sophisticated fund manager, we have used cutting-edge wearable tech that permits portfolio managers to track their cardiovascular data, physical activity and sleep. The cardiovascular system similarly tracks volatility and risk appetite.

In short, here we may have a mechanism connecting financial and health crises. On the one hand, fluctuating levels of stress and inflammation affect risk-taking. In a lab-based study, we found that chronically elevated cortisol caused a large decrease in risk appetite. Shifting risk presents tricky problems for risk management — and for central banks. Physiology-induced risk aversion can feed a bear market, morphing it into a crash so dangerous that the state has to step in with asset purchases. On the other hand, chronically elevated stress and inflammation are known to contribute to a wide range of health problems. 

We are not accustomed to combining financial and medical data in this way. But corporate and state health programs should start. 

The markets today are living through a period of volatility the likes of which I have never encountered. March was, to put it mildly, information rich. As a result, there is now the very real possibility of a second wave of disease. Viruses can make you sick, but so too can information.