A Channel 12 news story suggesting that changes to patient classification is behind the rising number of severely ill COVID-19 patients has triggered heated debate and deepened public mistrust in Israel.
Prof. Idit Matot of Tel Aviv Sourasky Medical Center (Ichilov Hospital) argues that the changes, which are based on a World Health Organization document, are responsible for the recent rise in the number of coronavirus patients reported to be in severe condition. Many of those patients would previously have been considered only moderately ill.
Haaretz has examined the issue to provide a deeper understanding of the data and its affect on evaluating the status of the pandemic in Israel.
Have changes been made to patient definitions?
Health Ministry guidelines have not changed. WHO guidelines were updated in May, and in fact they narrow the definition of severely ill patients.
What brought this topic to the headlines was a request to the Health Ministry to properly set criteria for defining the patient conditions. Currently they are not uniform; each hospital or physician does as they see fit, according to various clinical considerations.
What is the significance of the number of severely ill patients for the infection index?
The number of severely ill patients and the number of those breathing with the aid of ventilators is one of the central factors of the coronavirus infection index.
Whether justified or not, this figure is a focal point in managing the pandemic in Israel and other countries and in making decisions on shutting schools, businesses and the like in order to “flatten the curve” – that is, to prevent a steep rise in the number of severely ill patients that would burden the health system to the point of breakdown. Since it takes time for an infected person to become severely ill, the number of severely ill patients reflects a cycle of illness that began two to three weeks beforehand.
What characterizes those severely ill with COVID-19?
One of the noted clinical characteristics of the illness in comparison to other respiratory illnesses is that the deterioration to serious breathing problems is very swift. The knowledge thus far accumulated by Israel and elsewhere, is that some patients experience a serious worsening in their condition within 10 days to two weeks, sometimes even as quickly as within a day or less.
Under these circumstances the spreading lung infection leads to serious collapse of the breathing apparatus and in effect leads to lung collapse, and later to further organ failure, blood infection and damage to blood vessels and the heart.
How do doctors determine when someone is severely ill or at other stages of the illness?
It’s important to have set criteria for determining the condition of coronavirus patients both in order to provide proper, timely treatment and for the purpose of reaching decisions about clinical trials. The definitions may vary depending on information and clinical experience. In principle, those who set the criteria and direct the medical teams are the health authorities of each country.
The Health Ministry is the authority that sets these definitions in Israel. Most of these definitions are either dictated by or partially based on clinical instructions issued by the World Health Organization or other health organizations. But in effect Israeli hospitals each operate under different sets of instructions.
How does the WHO set criteria?
The organization’s definitions have changed a number of times in the course of the pandemic, alongside the additional knowledge gained about the illness and its treatment. On May 27 the organization issued its detailed “Clinical management of Covid-19 – interim guidance” document. These instructions are based on discussions and consultations in international forums and medical and scientific reviews, expert panels on infectious respirator disease, experts on hematological infection and others.
Has Israel fully adopted the WHO guidelines?
The answer to that is, not exactly. The symptoms and clinical findings are the same but how they categorize patient’s condition is different. For example, the WHO has four definitions of medical conditions pertaining to coronavirus: “mild,” “moderate,” “severe” and “critical.”In Israel there are only three categories: “mild” “moderate” and “severe.”
How does the WHO define a “severely ill” patient?
The WHO’s definition of “severe” overlaps Israel’s “moderate” category and includes coronavirus patients with lung disease who have one of the following symptoms: A breathing rate of more than 30 breaths per minute, severe respiratory distress and oxygen saturation level lower than 90 percent.
What is Israel’s definition of severely ill?
A severely ill patient with coronavirus in Israel overlaps the critical category of the WHO. It’s a patient with respiratory failure and/or hematological infection.
What changes have occurred in the WHO’s definitions?
In clinical instructions issued by the WHO, an oxygen saturation level that is below 93 percent was regarded as severe in March, whereas in May it was set as 90 percent or below. That is, the current criteria actually narrow the definition of severely ill patients. Since May, the definition has remained the same.
What is different about Israel’s definitions?
Generally in Israel there is a lack of uniformity in diverse areas in regards to the coronavirus, from treatment to clinical guidelines. During the crisis, hospitals adopted various treatment protocols and medical definitions. The definitions of patient conditions appear in Health Ministry documents in various contexts, but the issue has not been assimilated and supervised by the Ministry.
Strangely, Israeli Health Ministry documents have put the oxygen saturation floor at 90 percent since March, for determining severe cases, before the last WHO update. In other words this change of definition didn’t happen just recently, but it is possible that more hospitals are now implementing that definition.
What does all this mean in regard to the treatment of coronavirus patients in Israel?
In principle, this may have been meaningful had all the hospitals had standard, set criteria. But in effect, with or without the WHO, that is not the case. Physicians interviewed by Haaretz said that defining the condition of a patient is influenced by many parameters and is determined in the end on the basis of a doctor’s assessment.
“There is no standard, what you judge by in the field is how the patient looks. Nobody even knows the line about the 90 percent oxygen saturation level,” a senior physician at a hospital in central Israel says. A senior doctor at another hospital says that only recently have they adopted the WHO criteria and therefore the situation is different from one medical facility to another. In the United States, it often differs according to the physician.
How do doctors actually determine a patient’s condition?
Assessing a patient’s condition is based on clinical indexes but doctors also consider many other factors such as background illnesses, respiratory ailments, surgery, a general impression of the person’s health situation. It also depends on the doctor’s professional experience.
Does sticking by the updated oxygen saturation level change the picture regarding severely ill coronavirus patients in Israel?
The Channel 12 report said that the updated measure was responsible for the rise in numbers of severe cases, referencing claims by physicians at Ichilov and Sheba hospitals. Prof. Matot was quoted to say that 40 percent of the patients reported as severe were not regarded as such by the previous criteria. It said that of the 16 severe patients at Sheba, 10 were included only due to the change in criteria.
Other hospitals have not claimed any change in numbers due to a change in one definition or another. Does this mean they are not actually severely ill patients and that the figures are inflated? The answer in the end is a medical one: The changes that were made in WHO criteria were already being used by Israel since March. The question with respect to the “real” conditions of these patients is a clinical one. The WHO found it necessary to include them in the severe category on the basis of tests, examinations and the opinions at its disposal.
By the same token you may rightfully ask why some of those in moderate condition weren’t described as severe earlier. Prof. Galia Rahav, director of the infectious disease department at Sheba, recently wrote a letter to the Health Ministry asking it to standardize the situation and have Israeli hospitals match their criteria. “Definition of a patient has become a complete mess. Everyone describes the severity of the illness differently.”
If indeed the situation is standardized in accordance with WHO criteria then would Israel see more severely ill cases?
It depends on what criteria will be adopted by the ministry and how different they are from those currently available in each hospital, but the gap is unlikely to be large. The ministry says the issue of the changes in criteria by which to determine the conditions of coronavirus patients is now being reviewed by the epidemiological team and it will soon submit recommendations.
In a response, a source in the Health Ministry said, that every so often, the criteria used by various organizations are published. The epidemiological team is discussing these criteria and will submit its recommendations to the medical division and distribute it as instructions or a guide sheet. There is no set rule for now.
Original: Ido Efrati – HAARETZ