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    DECAF Score for Acute Exacerbation of COPD

    Predicts in-hospital mortality in acute COPD exacerbation.
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    INSTRUCTIONS

    Use in patients ≥35 years old, hospitalized with a primary diagnosis of acute exacerbation of COPD. Do not use in patients with comorbidity expected to limit survival <12 months.

    When to Use
    Pearls/Pitfalls
    Why Use

    Patients hospitalized with a primary diagnosis of acute exacerbation of COPD as follows:

    • ≥35 years old.
    • With or without pneumonia.
    • Preadmission evidence of airflow obstruction on spirometry (FEV₁/FVC <0.70).
    • ≥10 pack-year smoking history.

    Do not use if patient has <12 months life expectancy or is on home O₂.

    • The DECAF Score predicts in-hospital mortality in patients admitted to the hospital with acute exacerbation of COPD.
    • Can be used in patients who have evidence of both pneumonia and COPD.
    • Better predictor of in-hospital mortality than CURB-65 in patients who have both pneumonia and an acute exacerbation of COPD.
    • Uses routinely available variables.
    • Variables from initial labs are used to calculate the score.
    • Requires Extended Medical Research Council Dyspnea (eMRCD) score, which may be difficult to obtain in patients with acute encephalopathy, dementia, or those who are intubated.
    • Validated for use at the time of admission in UK hospitals, but not yet validated in US EDs.
    • May assist clinical decision-making in terms of early discharge, escalation of care, or discussion of goals of care:
      • Low risk (score 0-1) patients may be appropriate for early supported discharge.
      • High risk (score 3-6) patients may be appropriate for higher levels of care and/or addressing goals of care.
    • Higher scores may correlate with increased length of stay.
    About the Creator
    Dr. John Steer
    Content Contributors

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    • Increasing DECAF Scores correlate with increased risk for in-hospital mortality.
    • High risk DECAF Scores (3-6) are associated with both high risk of death and short time to death. Consider early escalation and higher level of monitoring versus palliative care for these patients.
    • Low risk DECAF Scores (0-1) are associated with low mortality risk and these patients may be candidates for early discharge.

    Management

    Was not studied to dictate management or treatment options. The score should not replace clinical judgment regarding workup, diagnosis, or treatment.

    Critical Actions

    • Should only be used in admitted patients with a primary diagnosis of an acute COPD exacerbation, not in the outpatient setting or in patients whose COPD is stable.
    • DECAF Scores 5–6 were found to have highest risk of death and shortest time to death, and may warrant early evaluation for escalation of care, higher level of monitoring, or potential palliative care.

    Formula

    Addition of the selected points:

     

    Points

    0

    1

    2

    Extended MRC Dyspnea Scale (eMRCD)

    Not too dyspneic to leave house (eMRCD 1–4)

    Too dyspneic to leave house but independent with washing/dressing (eMRCD 5a)

    Too dyspneic to leave house and wash/dress (eMRCD 5b)

    Eosinopenia (eosinophils <0.05×10⁹/L)

    No

    Yes

    --

    Consolidation on chest x-ray

    No

    Yes

    --

    Acidemia (pH <7.30)

    No

    Yes

    --

    Atrial fibrillation (including history of paroxysmal afib)

    No

    Yes

    --

    Facts & Figures

    Interpretation:

    DECAF Score

    Risk

    Recommendation

    In-hospital mortality*

    0

    Low

    Routine management

    0%

    1

    1.5%

    2

    Intermediate

    Use clinician judgment re: disposition

    5.4%

    3

    High

    Consider escalation of care vs. palliative care

    15.3%

    4

    31%

    5

    40.5%

    6

    50%

    *From Echevarria 2016.

    Evidence Appraisal

    The DECAF Score was derived by Steer et al from evaluating variables associated with in-hospital mortality from a prospective cohort of 920 patients recruited over two years from two institutions in the UK. From this cohort five independent variables with the strongest predictive ability for in-hospital mortality were selected to create the DECAF Score.

    Recruited patients were ≥35 years of age, had ≥10 pack-year smoking history, evidence of preadmission airflow limitation (FEV₁/FVC <0.70) and were hospitalized with a primary diagnosis of acute exacerbation of COPD. Excluded patients were those with a comorbidity expected to limit survival to less than 12 months and those on home oxygen.

    The DECAF Score was internally validated and performed well to predict in-hospital mortality. It was later externally validated in two cohorts of patients. The first cohort consisted of 880 patients from the same hospitals as the original derivation study. The second cohort included 845 patients from 4 different hospitals in the UK.

    In both of these validation cohorts, the DECAF Score performed well to predict in-hospital mortality and again bested other scoring systems including BAP-65, CAPS, APACHE II, and CURB-65.

    Dr. John Steer

    From the Creator

    Why did you develop the DECAF Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

    Exacerbations of COPD (ECOPD) disrupt patients' lives, are a very common reason for hospital admission and have a significant in-hospital mortality rate. Clinicians' estimates of prognosis in patients hospitalized with ECOPD are frequently inaccurate. We developed the DECAF score because a simple, reliable, accurate prediction tool could potentially improve patient care, by identifying patients suitable for hospital discharge or for more intensive therapy / monitoring.

    What pearls, pitfalls and/or tips do you have for users of the DECAF Score? Do you know of cases when it has been applied, interpreted, or used inappropriately?

    DECAF is simple to calculate and apply at the bedside. It requires an assessment of the patient’s usual level of breathlessness and function: the eMRCD score. Errors can be made by misclassification of the eMRCD. eMRCD records an individual's level of breathlessness when they are stable; i.e., "on a good day, during the preceding 3 months."

    In summary, eMRCD 5a is defined by an individual who is "Too breathless to leave their house unassisted but independent in washing and/or dressing"; eMRCD 5b indicates a patient who is "Too breathless to leave the house unassisted and requires help with washing and dressing." Simple walking aids do not constitute assistance but wheelchairs and mobility scooters do.

    How do you use the DECAF Score in your own clinical practice?

    To identify low risk patients (DECAF 0-1) who are suitable for hospital at home or early supported discharge. We have performed an RCT of Hospital at Home versus usual care, with patient selection by DECAF Score. This is awaiting publication.

    Can you give an example of a scenario in which you use it?

    To identify high risk patients that may need dual antibiotics and early input from critical care, with close monitoring.

    What score do you assign to patients who cannot complete the eMRCD (intubated, demented, acute encephalopathy)?

    The eMRCD score refers to the level of activity from the past three months. Therefore, we would assess the eMRCD using information obtained from: recent outpatient clinic records; patient relatives, carers or friends; or the patient's primary care practitioner.

    About the Creator

    John Steer, MBChB, PhD, is a physician in the department of respiratory medicine at North Tyneside General Hospital in North Shields, UK. He is also a member of the Respiratory Medicine Research Group at North Tyneside General Hospital. Dr. Steer's research interests include COPD, ventilation, and quality of life.

    To view Dr. John Steer's publications, visit PubMed

    Content Contributors