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Who to escalate during a pandemic? A retrospective observational study about decision-making during the COVID-19 pandemic in the UK
  1. Stephanie Beresford1,
  2. Aditi Tandon1,2,
  3. Sofia Farina1,
  4. Brian Johnston1,3,
  5. Maryam Crews1,
  6. Ingeborg Dorothea Welters1,3
  1. 1 Department of Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
  2. 2 Department of Anaesthesia, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
  3. 3 Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Faculty of Health and Life Sciences, Liverpool, UK
  1. Correspondence to Prof. Dr. med. Ingeborg Dorothea Welters, Liverpool University Hospitals NHS Foundation Trust, Liverpool L7 8XP, UK; I.Welters{at}


Background Optimal decision-making regarding who to admit to critical care in pandemic situations remains unclear. We compared age, Clinical Frailty Score (CFS), 4C Mortality Score and hospital mortality in two separate COVID-19 surges based on the escalation decision made by the treating physician.

Methods A retrospective analysis of all referrals to critical care during the first COVID-19 surge (cohort 1, March/April 2020) and a late surge (cohort 2, October/November 2021) was undertaken. Patients with confirmed or high clinical suspicion of COVID-19 infection were included. A senior critical care physician assessed all patients regarding their suitability for potential intensive care unit admission. Demographics, CFS, 4C Mortality Score and hospital mortality were compared depending on the escalation decision made by the attending physician.

Results 203 patients were included in the study, 139 in cohort 1 and 64 in cohort 2. There were no significant differences in age, CFS and 4C scores between the two cohorts. Patients deemed suitable for escalation by clinicians were significantly younger with significantly lower CFS and 4C scores compared with patients who were not deemed to benefit from escalation. This pattern was observed in both cohorts. Mortality in patients not deemed suitable for escalation was 61.8% in cohort 1 and 47.4% in cohort 2 (p<0.001).

Conclusions Decisions who to escalate to critical care in settings with limited resources pose moral distress on clinicians. 4C score, age and CFS did not change significantly between the two surges but differed significantly between patients deemed suitable for escalation and those deemed unsuitable by clinicians. Risk prediction tools may be useful in a pandemic to supplement clinical decision-making, even though escalation thresholds require adjustments to reflect changes in risk profile and outcomes between different pandemic surges.

  • COVID-19
  • critical care
  • frailty
  • clinical management

Data availability statement

Data are available upon reasonable request. Data are available on request.

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Data availability statement

Data are available upon reasonable request. Data are available on request.

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  • Handling editor Mary Dawood

  • SB and AT contributed equally.

  • Contributors SB, AT, SF and BJ collected the data. All authors contributed to writing and revising the manuscript. The study was designed by MC and IW. All authors have approved the final manuscript. IW accepts full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.