SMART-COP Score for Pneumonia Severity

Why Use

Uses readily available patient information. Can help identify which patients need ICU admission, with 92.3% sensitivity, 62.3% specificity, and an AUC of 0.87, leading to better utilization of resources and treatment initiation. Delayed admission to the ICU is associated with higher 30-day mortality in patients with CAP ( Restrepo 2010 ). Performs comparably well with the 2007 IDSA / ATS guidelines’ minor criteria.

When to Use

Patients with CAP who may require ICU care.

Formula

Pearls / Pitfalls

The SMART-COP Score for Pneumonia Severity was developed to identify patients at increased risk for intensive respiratory or vasopressor support (IRVS). Can help stratify which patients need ICU admission. Does not estimate mortality. Includes age-adjusted cutoffs for respiratory rate and oxygen levels, but otherwise does not explicitly include patient age as a variable, in contrast with PSI or CURB-65 scores. This may preserve the positive predictive value with advancing age. CAP is the single most common cause of sepsis in older patients, but can be difficult to recognize due to blunted fever and tachycardic responses to infection. Consideration of other variables not included in the SMART-COP Score, such as comorbidities, functional status, frailty, and physician gestalt, may still recommend ICU admission.

Critical Actions

For patients with high SMART-COP Scores, consider broadening antibiotic regimen to include MRSA coverage (for ICU admission, necrotizing or cavitary infiltrates, or empyema, previous MRSA infection) and/or to include antipseudomonal coverage (for history of structural lung disease, immunocompromise, or previous Pseudomonas infection). Also, consider if the patient has associated sepsis and treat accordingly.

Advice

Patients who do not meet criteria for ICU admission using the SMART-COP Score should still be evaluated for the need for inpatient admission. They should also receive timely and appropriate empiric antibiotics for CAP, generally a beta-lactam plus a macrolide, or a fluoroquinolone. Goals of care and other variables may recommend against ICU admission even if the SMART-COP Score is high.

More Information

Interpretation: SMART-COP Score Risk Group Risk* 0–2 Low Minimal 3–4 Moderate 1 in 8 5–6 High Consider ICU admission 1 in 3 ≥7 Very high Consider ICU admission 2 in 3 *Of requiring intensive respiratory or vasopressor support (IRVS).