Quality statement 1: Mortality risk assessment in primary care using CRB65 score

Quality statement

Adults have a mortality risk assessment using the CRB65 score when they are diagnosed with community‑acquired pneumonia in primary care.

Rationale

Assessing mortality risk using the CRB65 score in primary care informs clinical judgement and supports decision‑making about whether care can be managed in the community or if hospital assessment is needed. This ensures that treatment is based on the severity of the infection and will improve treatment outcomes.

Quality measures

Structure

Evidence of local arrangements to ensure that adults have a mortality risk assessment using the CRB65 score when they are diagnosed with community‑acquired pneumonia in primary care.

Data source: Local data collection.

Process

Proportion of community‑acquired pneumonia diagnoses of adults in primary care at which the adult has a mortality risk assessment using the CRB65 score.

Numerator – the number in the denominator at which the adult has a mortality risk assessment using the CRB65 score.

Denominator – the number of diagnoses of community‑acquired pneumonia in adults in primary care.

Data source: Local data collection.

Outcome

Mortality.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care services) ensure that adults have a mortality risk assessment using the CRB65 score when they are diagnosed with community‑acquired pneumonia in primary care.

Healthcare professionals (such as GPs and nurse practitioners) carry out a mortality risk assessment using the CRB65 score when an adult is diagnosed with community‑acquired pneumonia in primary care. Details of the risk assessment should be shared if the adult is referred to hospital or outpatient care.

Commissioners (NHS England area teams and clinical commissioning groups) commission services in which adults have a mortality risk assessment using the CRB65 score when they are diagnosed with community‑acquired pneumonia in primary care.

What the quality statement means for patients, service users and carers

Adults diagnosed with community‑acquired pneumonia by their GP have a first assessment to find out how serious the pneumonia is. This includes a 'CRB65 score', which uses the person's age, symptoms and blood pressure to help decide the how serious the risks are for that person and whether they need to go to hospital.

Source guidance

Pneumonia in adults: diagnosis and management (2014) NICE guideline CG191, recommendations 1.2.1 and 1.2.2

Definitions of terms used in this quality statement

Community‑acquired pneumonia

Pneumonia that is acquired outside hospital. Pneumonia that develops in a person living in a nursing or residential home is included in this definition. Pneumonia that develops in people who are immunocompromised, and terminal pneumonia associated with another disease are not included.

[Pneumonia in adults (2014) NICE guideline CG191 and expert opinion]

Mortality risk assessment in primary care

When a clinical diagnosis of community‑acquired pneumonia is made in primary care, the healthcare professional should assess whether the person is at low, intermediate or high risk of death by calculating the CRB65 score at the initial assessment (box 1).

Box 1 CRB65 score for mortality risk assessment in primary care 1

CRB65 score is calculated by giving 1 point for each of the following prognostic features:

  • confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time)2

  • raised respiratory rate (30 breaths per minute or more)

  • low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)

  • age 65 years or more.

Patients are stratified for risk of death as follows:

  • 0: low risk (less than 1% mortality risk)

  • 1 or 2: intermediate risk (1–10% mortality risk)

  • 3 or 4: high risk (more than 10% mortality risk).

1 Lim WS, van der Eerden MM, Laing R et al. (2003) Defining community‑acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 58: 377–82.

2 For guidance on delirium, see the NICE guideline on delirium.

[Pneumonia in adults (2014) NICE guideline CG191, recommendation 1.2.1]

Equality and diversity considerations

It is important to be aware of dementia when assessing confusion, and to adapt the assessment approach to meet individual needs.

Healthcare professionals should be aware of the needs of adults at the end of life and agree the approach for managing pneumonia in the context of the person's overall care plan.