26th March 2020 • Emma Cooper
The guidelines put in place by the National Institute for Health and Excellence (NICE) concerning all adults on admission to hospital have been updated after serious concerns were raised about people with learning disabilities, autism, younger people and those with cerebral palsy.
The original guidelines stated that all adults on admission to hospital, irrespective of COVID-19 status, should be assessed for frailty using the Clinical Frailty Scale (CFS) and that comorbidities and underlying health conditions should be considered.
It also said that the 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.
Decisions about admission to critical care should be made on the basis of medical benefit, taking 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.
Concerns for vulnerable people
However, upon publication, there was an outcry from people concerned that applying the score to people with learning disabilities, autism and other stable long-term disabilities, would put them at a disadvantage when decisions were made about admission to critical care in a time of intense pressure.
The NHS Specialist Clinical Frailty Network has since updated their advice on using the CFS, stating 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 new advice also includes a clarification 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.
After listening to the concerns raised, NICE updated the rapid COVID-19 critical care guidelines on 25th March to reflect these clarifications and to emphasise the need to consider additional patient factors when interpreting the CFS score.
It says that clinicians working in critical care should be aware of the limitations of using the CFS tool as the sole assessment of frailty. The CFS should not be used in younger people, people with stable long-term disabilities, learning disabilities, autism or cerebral palsy. An individualised assessment is recommended in all cases where the CFS is not appropriate.
Because these guidelines are being developed quickly to support frontline NHS staff, NICE will be reviewing them each week as new evidence, policy and practice emerges.