Quality statement 1: Mortality risk assessment
Quality statement
Adults diagnosed with community-acquired pneumonia have a mortality risk assessment using CRB65 in primary care or CURB65 in hospital. [2016, updated 2025]
Rationale
The CRB65 scoring system in primary care and CURB65 scoring system in hospital can be used to stratify adults with community-acquired pneumonia for risk of death within 30 days. Using clinical judgement together with mortality risk assessment supports stratification of disease severity and informs decisions about place of care.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Process
a) Proportion of adults diagnosed with community-acquired pneumonia in primary care who had a mortality risk assessment using CRB65.
Numerator – the number in the denominator who had a mortality risk assessment using CRB65.
Denominator – the number of adults diagnosed with community-acquired pneumonia in primary care.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from electronic medical records.
b) Proportion of adults diagnosed with community-acquired pneumonia in hospital who had a mortality risk assessment using CURB65.
Numerator – the number in the denominator who had a mortality risk assessment using CURB65.
Denominator – the number of adults diagnosed with community-acquired pneumonia in hospital.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
What the quality statement means for different audiences
Service providers (primary and secondary care services) ensure that adults have a mortality risk assessment when they are diagnosed with community-acquired pneumonia.
Healthcare professionals (such as doctors, nurses and paramedics who are working in primary care) carry out a mortality risk assessment when an adult is diagnosed with community-acquired pneumonia. In primary care, the person should be seen for a face-to-face appointment if pneumonia is suspected.
Commissioners ensure that they commission services in which adults have a mortality risk assessment when they are diagnosed with community-acquired pneumonia.
Adults diagnosed with community-acquired pneumonia have an assessment to find out how serious the pneumonia might be and where they should receive treatment, for example at home or in hospital.
Source guidance
Pneumonia: diagnosis and management. NICE guideline NG250 (2025), recommendations 1.2.1 and 1.2.7
Definitions of terms used in this quality statement
Pneumonia
Pneumonia is an infection of the lung tissue in which the air sacs in the lungs become filled with microorganisms, fluid, and inflammatory cells, affecting the function of the lungs. It is diagnosed clinically based on symptoms such as focal chest signs, increased respiratory rate, low oxygen saturations, illness severity and other features. In secondary care, diagnosis is usually confirmed by chest X‑ray. [Adapted from NICE's clinical knowledge summary on chest infections in adults and expert opinion]
Community-acquired pneumonia
Pneumonia that is acquired outside hospital, or within 48 hours of admission. Pneumonia that develops in a nursing home resident is included in this definition. When managed in hospital the diagnosis is usually confirmed by chest X‑ray. [NICE's guideline on pneumonia, terms used in this guideline]
Mortality risk assessment
When a clinical diagnosis of community-acquired pneumonia is made, the healthcare professional should assess whether the person is at low, intermediate or high risk of death. In primary care, this is done by calculating the CRB65 score at the initial assessment (box 1). In secondary care, this is done by calculating the CURB65 score (box 2).
CRB65 score is calculated by giving 1 point for each of the following prognostic features:
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confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time); for guidance on delirium, see NICE's guideline on delirium
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raised respiratory rate (30 breaths per minute or more)
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low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
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age 65 years or more.
Adults are stratified for risk of death (within 30 days) as follows:
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0: low risk (less than 1% mortality risk)
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1 or 2: intermediate risk (1 to 10% mortality risk)
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3 or 4: high risk (more than 10% mortality risk).
CURB65 score is calculated by giving 1 point for each of the following prognostic features:
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confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time); for guidance on delirium, see NICE's guideline on delirium
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raised blood urea nitrogen (over 7 mmol per litre)
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raised respiratory rate (30 breaths per minute or more)
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low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
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age 65 years or more.
Adults are stratified for risk of death as follows:
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0 or 1: low risk (less than 3% mortality risk)
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2: intermediate risk (3 to 15% mortality risk)
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3 to 5: high risk (more than 15% mortality risk).
[NICE's guideline on pneumonia, recommendations 1.2.1 and 1.2.7]
Equality and diversity considerations
It is important for healthcare professionals to be aware and mindful of any learning disabilities and mental health conditions, including dementia, when assessing confusion. They may need to adapt the assessment approach to meet individual needs. This may include obtaining information from people who know the person well, for example their carer, to inform the assessment.
Some people with a learning disability can present with physical differences affecting respiratory rate and blood pressure. Healthcare professionals should be mindful of this and, where possible, assess for changes against baseline observations. They should also monitor the subtle signs of deterioration with support from family and carers, where possible.
Any language barriers should be considered when assessing confusion. Involving an interpreter can assist with this and it is also helpful to obtain information from people who know the person well.
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. They should take into account any advance care plan or treatment escalation plan.