SMART-COP Score for Pneumonia Severity

Identifies patients with CAP at risk of ICU admission, intensive respiratory or vasopressor support (IRVS).

Refer to the text below the score for more information on the model, its benefits, limitations and how it compares to other tools.


SMART-COP score can accurately identify patients with community acquired pneumonia who will require intensive respiratory or vasopressor support (IRVS). It can help with clinician therapeutic management, allocation of resources and better patient outcomes, especially as late admission to the ICU has been associated with increased mortality in CAP.


SMART-COP scores range between 0 and 11, where the higher the score, the greater the likelihood for the CAP patient to require ICU admission.

SMART-COP Score Risk group Risk of requiring intensive respiratory or vasopressor support (IRVS)
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

1Age
2Multi-lobar involvement on chest x-ray
3Albumin <3.5 g/dL (35 g/L)
4Respiratory rate ≥25
5Tachycardia ≥125
6Confusion (new onset)
7PaO2 <70 mmHg, SaO2 ≤93%, or PaO2/FiO2 <333
8pH <7.35
9sBP <90 mmHg
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SMART-COP Score Explained

This is a nine item risk stratification tool to be used in adult patients, with clinical and radiographic findings consistent with community acquired pneumonia (CAP), to identify those at risk for intensive respiratory or vasopressor support (IRVS).

SMART-COP 0 points 1 point 2 points
Multilobar CXR involvement No Yes -
Albumin <3.5 g/dL No Yes -
Respiratory rate <25, if age ≤50

<30, if age >50
≥25, if age ≤50

≥30, if age >50
-
Tachycardia ≥125 No Yes -
Confusion (new onset) No Yes -
Oxygen parameters PaO2 ≥60 (or SaO2 >90% or P/F ratio ≥250), if age >50

PaO2 ≥70 (or SaO2 >93% or P/F ratio ≥333), if age ≤50
- PaO2 <60 (or SaO2 ≤90% or P/F ratio <250), if age >50

PaO2 <70 (or SaO2 ≤93% or P/F ratio <333), if age ≤50
Arterial pH <7.35 No - Yes
sBP <90 mmHg No - Yes

The respiratory and the oxygen items include two age-adjusted cut-offs set for 50 years old.

 

Result Interpretation

SMART-COP scores range between 0 and 11, where the higher the score, the greater the likelihood for the CAP patient to require ICU admission.

SMART-COP Score Risk group Risk of requiring intensive respiratory or vasopressor support (IRVS)
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

For patients with SMART-COP scores of 5 or more, clinicians should consider broadening antibiotic regimen to include MRSA and/or antipseudomonal coverage.

A SMART-COP score of <3 points better identified the majority of patients who received IRVS than did PSI classes IV and V and CURB-65 group 3.

 

About the Original Study

The original 2008 study by Charles et al. included patients (with a mean age of 65.1 years) diagnosed with community acquired pneumonia (882 CAP episodes) at six Australian hospitals over a 28 month period.

Multivariate logistic regression was performed to identify features at initial assessment that were associated with receipt of IRVS

The study cohort had a 13.4% ICU admission rate, a 10.3% IRVS rate, and a 5.7% 30-day mortality rate. In the derivation cohort, the score demonstrated 92.3% sensitivity and 62.3% specificity (AUC 0.87) for accurately predicting need for IRVS.

A SMART-COP score of 3 or more points correctly identified 92% of patients who received IRVS, including 84% of patients who did not need immediate admission to the intensive care unit.

It was also validated during the original study on 7,464 patients from 5 existing databases (including PORT), resulting an AUC range of 0.72 – 0.87.

 

Benefits and Limitations

The SMART-COP accurately identifies those patients with CAP at risk of needing ICU admission (92.3% sensitivity, 62.3% specificity and AUC of 0.87), with intensive respiratory and/or vasopressor support (IRVS). It uses readily available patient information and is quick to calculate.

The model was found to perform comparably well with the 2007 IDSA/ATS guidelines’ minor criteria.

However, the score does not apply to patients with significant immunosuppression and does not estimate mortality.

Clinicians should further consider other patient individual variables such as other comorbidities, functional status, frailty which may recommend inpatient admission stay regardless of the SMART-COP score.

Similarly, goals of care and other patient variables may recommend against hospital admission even if the SMART-COP score is high.

 

Other Similar Scores

The Pneumonia Severity Index (PSI) and the CURB-65 are two other pneumonia severity assessment tools that predict likely 30-day mortality. The results from these scores are heavily dependent on patient age and comorbidities.

A comparison of PSI with CURB-65, another pulmonary stratification tool, indicated that the former shows less specificity (52.2% compared to 74.6%) in terms of risk prediction, although both scores carry a similar sensitivity, and more so, in ICU, the PSI fares slightly better.

 

References

Original reference

Charles PG, Wolfe R, Whitby M, Fine MJ, Fuller AJ, Stirling R, Wright AA, Ramirez JA, Christiansen KJ, Waterer GW, Pierce RJ, Armstrong JG, Korman TM, Holmes P, Obrosky DS, Peyrani P, Johnson B, Hooy M; Australian Community-Acquired Pneumonia Study Collaboration; Grayson ML. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis. 2008; 47(3):375-84.

Validation

Marti C, Garin N, Grosgurin O, Poncet A, Combescure C, Carballo S, Perrier A. Prediction of severe community-acquired pneumonia: a systematic review and meta-analysis. Crit Care. 2012; 16(4):R141.


Specialty: Pulmonology

System: Respiratory

Objective: Risk prediction

Type: Score

No. Of Items: 9

Year Of Study: 2008

Abbreviation: SMART-COP

Article By: Denise Nedea

Published On: May 14, 2024

Last Checked: May 14, 2024

Next Review: May 14, 2029