Intended for healthcare professionals

Rapid response to:


Prognostic assessment will be important in flu pandemic

BMJ 2006; 332 doi: (Published 23 February 2006) Cite this as: BMJ 2006;332:490

Rapid Response:

Physiological-social scoring in pandemic flu

While we agree with Bonten and Prins1 that anticipatory planning is
required with respect to antibiotic usage in a potential influenza
pandemic, there are several issues raised by Dr Barlow’s response2.

Although CURB-65 and CRB-65 have been validated in terms of 30-day
mortality3, their limitations with respect to prediction of mortality have
recently been highlighted. Their value as a track and triage tool has not
been established. This is of prime important as the numbers of
presentations expected during a flu pandemic require that an instrument be
developed which recognises the physiological derangement and social and
comorbid factors which normally influence hospital admission criteria.
Ideally this tool would be applicable across the health economy and
amenable to use in primary and secondary care by medical, nursing and
allied health professionals. Given the magnitude of a pandemic (we
calculate that attendances at our emergency department may be in excess of
600% of normal4), it is imperative that any clinical guidance recognises
that degradation with scale will occur as the pandemic progresses. We
therefore suggest that any triage tool should be scalable in terms of
admission threshold.

Using the principle that physiological parameters deteriorate for
several hours to days before catastrophic decompensation, we suggest that
a modification of the previously published medical early warning score5
will provide a useful triage tool to identify those in need of admission
and reassure those fit to self-care at home. The modification addresses
comorbid and social factors. We refer readers to our recent
correspondence in the European Respiratory Journal for further details of
the validation of our tool6.

Kirsty Challen

John Bright

Andrew Bentley

Darren Walter

1. Bonten MJ, Prins JM. Antibiotics in pandemic flu. BMJ 2006;332:248

2. Barlow GD. Prognostic assessment will be important in flu pandemic. BMJ

3. Lim W, van der Eerden M, Laing R, Boersma W, Karalus N, Town G, et al.
Defining community acquired pneumonia severity on presentation to
hospital: an international derivation and validation study. Thorax

4. UK Health Departments. UK Influenza Pandemic Contingency Plan. London:
Department of Health, 2005.

5. Subbe C, Kruger M, Rutherford P, Gemmell L. Validation of a modified
early warning score in medical admissions. Quarterly Journal of Medicine

6. Challen K, Bright J, Bentley A, Walter D. A physiological-social score
for triaging of pandemic influenza patients. European Respiratory Journal
2006;27:in press.

Competing interests:
None declared

Competing interests: No competing interests

03 March 2006
Kirsty Challen
Research Fellow in Emergency Medicine
John Bright, Andrew Bentley, and Darren Walter
South Manchester University Hospitals Trust