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.
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).
- 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)
|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)
|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|
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.
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.