An Audit Assessing Compliance With CURB-65 (Confusion, Urea, Respiratory Rate, Blood Pressure, and Age ≥65 Years) Documentation in Adult Patients Admitted With Community-Acquired Pneumonia at a Tertiary Institution in Trinidad and Tobago

Introduction Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality worldwide. Early severity assessment is essential in guiding decisions regarding hospital admission, level of care, and antimicrobial management. The CURB-65 (Confusion, Urea, Respiratory Rate, Blood Pressure, and Age ≥65 Years) score is a validated clinical prediction tool recommended by the National Institute for Health and Care Excellence (NICE) NG250 guidelines for assessing mortality risk in adult CAP patients. Despite its clinical relevance, documentation and utilisation of the CURB-65 score are often inconsistent in busy healthcare settings. This audit aimed to assess CURB-65 documentation in adult patients admitted with CAP at the Sangre Grande Hospital Campus (SGHC), Trinidad and Tobago, and the effectiveness of targeted educational interventions in improving adherence. Methodology A retrospective and prospective clinical audit was conducted in the Internal Medicine Department at SGHC. Adult patients aged ≥18 years admitted with CAP between March and May 2025 were included in the retrospective phase, while patients admitted between February and April 2026 formed the prospective post-intervention phase. Data were collected from paper and electronic medical records. Variables assessed included demographic characteristics, CURB-65 documentation, and score accuracy. The intervention included a CME sensitisation session on CURB-65 and NICE NG250 guidelines, followed by monthly reminders circulated through the departmental WhatsApp communication platform. Data were analysed using Microsoft Excel and SPSS 23. Chi-square testing was used to compare documentation rates pre- and post-intervention. Results In the retrospective phase, 67 patient records were analysed. CURB-65 documentation was identified in only 10.3% (n = 7) of cases, although all documented scores were calculated correctly. Following the intervention, 76 patient records were analysed during the prospective phase. CURB-65 documentation increased significantly to 43.4% (n = 33), with 90.9% (n = 30) of documented scores calculated correctly. Statistical analysis showed a significant improvement in documentation compliance after the intervention (p < 0.001). The majority of patients in both phases had CURB-65 scores of 0 or 1, suggesting that a substantial proportion may have been suitable for outpatient management depending on clinical judgement and comorbidities. Discussion This audit demonstrated poor baseline compliance with CURB-65 documentation at SGHC, consistent with findings from studies conducted in Oman, China, and Ireland. Education through CME sessions and regular reminders significantly improved compliance rates. The findings reinforce the importance of ongoing clinical education and guideline sensitisation in improving adherence to evidence-based practice. Despite the improvement, documentation rates remained below the NICE-recommended standard of 100%, indicating the need for further quality improvement measures, including electronic decision-support tools and institutional clinical pathways. Conclusion CURB-65 documentation for CAP patients at SGHC was initially suboptimal but improved significantly following targeted educational interventions and sensitisation. However, future interventions such as CURB-65 posters, incorporating the score into initial clerking documents and the Health Information System should be implemented as part of a formal improvement project.