Pulmonology
DECAF Score
Mortality risk in COPD exacerbation.
Education and reference only. Not a substitute for clinical judgement, local policy or product labelling. Always verify before clinical use. Values are calculated in your browser and never stored.
Background
The DECAF score predicts in-hospital mortality in patients admitted with an acute exacerbation of COPD, using five variables available on admission. The acronym stands for Dyspnoea (graded by the extended MRC dyspnoea score), Eosinopenia, Consolidation on chest X-ray, Acidaemia (arterial pH below 7.30) and atrial Fibrillation. Dyspnoea contributes up to 2 points and the remaining variables 1 point each, giving a maximum of 6. It uses simple clinical, radiological and laboratory data routinely obtained on admission.
Interpreting the result
A score of 0 to 1 indicates low mortality risk, where many patients may be suitable for early or supported discharge pathways. A score of 2 represents intermediate risk warranting inpatient care and review. A score of 3 or more indicates high mortality risk, prompting close monitoring, early senior input and consideration of escalation or, where appropriate, advance care planning. The score helps stratify exacerbations objectively rather than relying on impression alone.
Worked example
A patient admitted with a COPD exacerbation is too breathless to leave the house and dependent for washing and dressing (eMRCD 5b, 2 points), has consolidation on the chest X-ray (1 point) and atrial fibrillation (1 point), with a pH above 7.30 and a normal eosinophil count. The total is 4, placing them in the high-risk group, which should prompt close monitoring and senior review.
Pearls / pitfalls
- Eosinopenia means a low eosinophil count on admission and is a marker of acute stress — do not confuse the criterion with the eosinophilic phenotype used to guide some therapies.
- The dyspnoea component uses the patient's stable-state (baseline) functional status, not their breathlessness during the acute illness.
- A high score flags mortality risk and should prompt senior review and, where relevant, advance care planning — it does not by itself dictate the ceiling of care.
- The score informs but does not replace clinical judgement and assessment of comorbidities and trajectory.
Evidence & validation
Derived and validated by Steer and colleagues in 2012, the DECAF score showed good discrimination for in-hospital mortality in COPD exacerbations and has since been externally validated. It is used to support risk stratification and disposition decisions in acute COPD care.
Frequently asked questions
What does a high DECAF score mean?
A score of 3 or more indicates a high risk of in-hospital mortality from the COPD exacerbation. It should prompt close monitoring, early senior input and consideration of escalation or advance care planning.
What is the eosinopenia criterion?
It refers to a low eosinophil count on admission, which acts as a marker of acute physiological stress. It is distinct from the eosinophilic phenotype assessed in stable COPD, which is used for different purposes.
Which dyspnoea grade does DECAF use?
It uses the extended MRC dyspnoea score reflecting the patient's usual, stable-state function. Grades 5a and 5b (too breathless to leave the house, with 5b also dependent for washing or dressing) contribute the dyspnoea points.
Can a low DECAF score support early discharge?
A low score (0–1) identifies patients at low mortality risk who may be suitable for supported or early discharge pathways, where appropriate. The decision must still account for the full clinical picture and social circumstances.
References
- Steer J, Gibson J, Bourke SC. The DECAF Score: predicting hospital mortality in exacerbations of chronic obstructive pulmonary disease. Thorax. 2012;67(11):970–976.
- NICE NG115: Chronic obstructive pulmonary disease in over 16s: diagnosis and management. 2018.
About the creator
Steer J et al.
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