CURB-65

What?

A 72-year-old male presented to the Emergency Department (ED) in the morning having woken with shortness of breath and a slight change to the colour of his sputum. His temperature had been recorded as 38.1C by the ambulance crew who brought him to hospital.

He had a long history of chronic pulmonary obstructive disease (COPD) and had been admitted to the ED 12 times in the past year. Good home support was provided by community matrons and he was keen to go home rather than be admitted.

The clinical examination findings are shown in the clinical summary and the patient was diagnosed with an exacerbation of COPD, which may have been infective in origin i.e. a Community Acquired Pneumonia (CAP).

For this case the CURB-65 score was utilised to determine whether the patient could go home, or would benefit from an in-patient admission.

So what?

In the assessment and management of CAP, assessment of disease severity is essential to guide therapeutic options such as need for hospital or ICU admission, potential for discharge to own home and the extent of investigation (Lim et al 2003).

The CURB-65 and CRB-65 (for initial triage without bloods) scoring tool was developed by the Lim et al (2003) for the British Thoracic Society to aid decision-making. Their derivation study found a number of elements which if present demonstrated an effect on mortality for this patient group (Lim et al 2003).

CURB-65 elements:

  • Confusion (new disorientation to person, place or time)
  • Urea >7 mmol/l (blood)
  • Respiratory rate ≥30/min
  • Blood pressure <90mmHg Systolic
  • Age ≥65 years

In this case the patient had a CURB-65 score of 1 based on age >65 years. This meant he had a low risk of death and that home treatment is appropriate (Wyatt et al 2012). A summary of the recommendations based upon the score is shown in table 1 and 2.

Table 1 – Treatment based on CURB-65 scoring (Lim et al 2003)

CURB-65 Score Deaths Recommendation
0 0.6% Low risk; consider home treatment
1 2.7% Low risk; consider home treatment
2 6.8% Short in-patient stay or closely supervised home treatment
3 14% Severe pneumonia; admit +/- ITU
4 or 5 27.8% Severe pneumonia; admit +/- ITU

Table 2 – Treatment based on CRB-65 scoring (where blood results are not immediately available)

CRB-65 Score Deaths Recommendation
0 0.9% Very low risk of death; home treatment
1 5.2% Slightly increased risk of death; consider admission
2 12% Increased risk of death; consider admission
3 or 4 31% High risk of death; urgent admission

Now what?

The research conducted by Lim et al (2003) gives a quantitative reference relating to the risk of mortality associated with CAP. After discussion around the risks and in conjunction with patient request to go home it was appropriately decided that the patient could be discharged. Given his extensive history, support from community matron’s meant that his condition could be closely monitored over the next few days and any deterioration could be quickly acted upon.

After reviewing the evidence base for the CURB-65 score, it is appropriate to apply it to patients presenting with CAP in the ED and it provides an appropriate and high quality evidence base.

 

Rob Fenwick

 

 

References

Driscoll, J. (2007) Practicing clinical supervision: a reflective approach for healthcare professionals (2nd edition). Elsevier. Edinburgh.

Lim, W. S., van der Eerden, M. M., Laing, R., Boersma W. G., Karalus, N., Town, G. I., Lewis, S. A & Macfarlane, J. T. (2003) Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. Volume 58, pp377-382.

Wyatt, J., Illingworth, R., Graham, C & Hogg, K. (2012) Oxford handbook of emergency medicine (4th edition). Oxford University press. Oxford.

8 thoughts on “CURB-65

  1. Kirsty Challen says:

    This has been subject to some discussion………
    CURB-65 was developed as a mortality predictor. Thus it can’t always be extrapolated to use as a site of care tool. See background:

    http://thorax.bmj.com/content/66/4/351.1.full.html
    http://thorax.bmj.com/content/66/12/1092.3.full.html

  2. rob fenwick says:

    Thanks for your comment. Agree that the tool is not there to completely support an admit or discharge decision, however when discussing cases that are on the borderline of admit/discharge on the risk/benefit profile I think CURB-65 is one of the sources of information & context that can be helpful with the paucity of further evidence base.

  3. Anonymous says:

    Ah yes, the subtle difference between guidance & protocol & the frustration when the receiving doc fails to get that & responds “but their CURB-65 is 1, they should go home”……….

  4. Kirsty Challen says:

    Ah yes, the subtle difference between guidance & protocol & the frustration when the receiving doc fails to get that & responds “but their CURB-65 is 1, they should go home”……….

  5. When I was in the NHS in 2006 I discharged a patient at 3 hours and 50 odd minutes with a CURB65 score of 0.

    Needless to say gut instinct was under-developed but still said he looked average and was tachycardic, febrile etc. Came back got intubated the next day. Have heard lots of similar stories.

    “SMARTCOP” score predicts a percentage need for mechanical ventilation so would be my current preference along with the guideline for NSW. I find this percentage useful to discuss with the team and patient.

    Ref
    http://lifeinthefastlane.com/wp-content/uploads/2010/07/etg-smartcop.pdf

    Is there current NICE or other guidance on what to use in the UK?

  6. rob fenwick says:

    Thanks Andrew,

    Interesting link and a paper I need to have a look at. I certainly haven’t seen the “SMART-COP” score in widespread use in our region. There is a useful NICE Clinical Knowledge Summary (CKS) on CAP (see link below), advocating the use of CURB-65 but with the caveat that this decision tool should be used in conjunction with clinical judgement and available social support (which seems like a sensible approach)

    http://cks.nice.org.uk/chest-infections-adult#!scenario:1

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