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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Every hour of delayed accumulated by the Intensive Medicine Service &#40;IMS&#41; increases the patient&#8217;s IMS-related and in-hospital mortality rates by 1&#46;5&#37; and 1&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> To anticipate the detection and management of patients with significant clinical worsening&#44; rapid response systems &#40;RRS&#41; have been developed in association with IMS&#46; Although quality healthcare is at the center of the entire healthcare system&#44; the Spanish Society of Intensive&#44; Critical and Coronary Unit Medical Care &#40;SEMICYUC&#41; has not published any quality indicators associated with the activity of quality healthcare<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> that is monitored by keeping count of activations&#44; cardiac arrests&#44; and occasionally&#44; by estimating its repercussion in deaths and hospital admissions&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The goal of this scientific letter is&#8212;based on a registry of the activity developed by our RRS&#8212;to analyze the prognostic dimension of several definitions of delayed alert &#40;DA&#41; for IMS admission and justify its estimation as a quality indicator to identify situations with room for improvement and deviation from the routine clinical practice&#46; Our RRS is part of a tertiary level hospital with 2 different headquarters with 800 beds combined &#40;35 of the IMS&#41;&#44; 41 500 annual hospital admissions &#40;2000 in IMS&#41; and 200 000 hospital stays&#46; It was first implemented back in 2012 in all hospital areas &#40;except for IMS&#44; pediatrics&#44; and surgical rooms&#41;&#46; The RRS is activated after clinical assessment by the nursing staff and&#44; also&#44; after registering into electronic health records values outside the range of vital statistics with a superimposed message of risk situation flashing on the screen&#46; This is suggestive of call to the treating physician to activate the intensivist&#44; when appropriate&#46; If the former cannot be found or in cases of suspected great severity&#44; the nursing staff should call the intensivist&#46; All the physical examinations performed at the intensive care unit are prospectively registered into a database including demographic variables&#44; pluripathology &#40;hypertension stage &#8805; 2&#44; diabetes&#44; chronic lung disease&#44; kidney&#44; liver or heart failure&#44; neoplasm&#44; and tracheostomy carrier&#41;&#44; alert criterion &#40;cardiocirculatory&#44; respiratory&#44; neurological&#44; airway&#44; warning due to cardiac arrest&#44; subjective feeling of severity of the nurse or treating physician&#41;&#44; warning service&#44; working schedule&#44; and score obtained from the patients&#8217; risk scale&#46; If the patient is hospitalized&#44; the stay&#44; the IMS-related mortality rate&#44; and the 24-hour APACHE score<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> are duly noted if they develop multi-organ failure &#40;MOF&#41; and if it is a DA&#46; A total of 3 periods based on the evolution of our RRS were selected for analytical purposes&#58; during the first period &#40;P1&#41;&#44; between January and June 2013&#44; the Goldhill<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> risk assessment tool &#40;EPAR&#41; with data from 1 of the 2 headquarters &#40;280 beds&#44; 17 of the IMS&#41; was used&#59; both the second period &#40;P2&#41;&#44; between March and November 2014&#44; and the third period &#40;P3&#41;&#44; between May and June 2018&#44; included both headquarters and the VIEWs scale&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In P3 the emergency alerts were included&#46; MOF was defined as damage to two or more organs with high scores &#62; 2 in the SOFA<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> scale&#46; DA in P1 was defined as EPAR<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> &#62; 3 or &#8805; 2 in the assessment of systolic arterial pressure or pulse oximetry at some point of the 3 working schedules prior to IMS admission&#46; In P2 and P3 the DA was defined with VIEWs<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> scores &#62; 7 in some of the 3 working schedules prior to IMS admission&#44; and also if they had been referred from the ER or had stayed there for over 5&#8239;hours&#46; DAs were compared with the rest using Fisher&#8217;s exact test&#44; the chi-square test&#44; Mann-Whitney <span class="elsevierStyleItalic">U</span> test&#44; and the odds ratio &#40;OR&#41; with <span class="elsevierStyleItalic">P</span> values &#60; &#46;05&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A total of 244 alerts were reported in P1&#44; 544 in P2&#44; and 343 in P3&#46; The day&#8217;s average number of DAs was 0&#46;81&#44; 1&#46;87&#44; and 2&#46;85&#44; respectively&#44; in each period&#46; Also&#44; the percentage of DAs was 13&#46;52&#37;&#44; 6&#46;3&#37;&#44; and 6&#46;9&#37;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the differences of patients with DA at admission and the rest&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The OR of deceased patients with DA in P1 was 2&#46;39 &#40;95&#37;CI&#44; 0&#46;62-6&#46;98&#41;&#44; 4&#46;14 in P2 &#40;95&#37;CI&#44; 1&#46;84-9&#46;31&#41;&#44; and 4&#46;25 &#40;1&#46;37-13&#46;2&#41; in P3&#46; On the other hand&#44; the OR for developing MOF in P1 was 6&#46;86 &#40;95&#37;CI&#44; 2&#46;39-19&#46;71&#41; and 6&#46;14 &#40;95&#37;CI&#44; 2&#46;5-15&#46;08&#41; in P3&#46; In conclusion&#44; DAs multiply the chances of dying and developing MOF&#46; Assessing this percentage facilitates the comparison between periods and hospitals and monitors the quality of the afferent arm &#40;detection&#41; of RRS&#46; Establishing indicator standards is complex because the medical literature on this regard is scarce&#59; however&#44; with the existing literature&#44; with the trajectory of implementation of the actual protocols&#44; and with our own protocols the percentage should be &#60; 20&#37;&#46; This means that 80&#37; of the alerts that go off should not come with a delay&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">None reported&#46;</p></span></span>"
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P1 &#40;N&#8239;&#61;&#8239;80&#41;</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P2 &#40;N&#8239;&#61;&#8239;266&#41;</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P3 &#40;N&#8239;&#61;&#8239;247&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">33 DA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">47 No DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">34 DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">232 No DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">24 DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">223 No DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age md &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">75 &#40;65-80&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72 &#40;58-76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">67 &#40;58&#46;5-78&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72 &#40;69-79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">70&#46;5 &#40;64&#46;5-76&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">68 &#40;52-77&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#37; Pluripath&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">66&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">59&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;51&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">55&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">50&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;58&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">58&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">52&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&#37; Sepsis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">66&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60; &#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60; &#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">9&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60; &#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#37; M&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;38&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">64&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">79&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#37; MOF&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60; &#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">----&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">----&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">----&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&#37; Dead patients&nbsp;\t\t\t\t\t\t\n
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Scientific Letter
Delayed alert to rapid response systems: proposal of a new quality indicator
Alerta tardía a los sistemas de respuesta rápida: propuesta de un nuevo indicador de calidad
S. Castaño Ávila
Corresponding author
, F. Fonseca San Miguel, J.A. Urturi Matos, M. Iturbe Rementería, C. Pérez Lejonagoitia, S. Iribarren Diarasarri
Servicio de Medicina Intensiva, Hospital Universitario Araba, Vitoria-Gasteiz, País Vasco, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Every hour of delayed accumulated by the Intensive Medicine Service &#40;IMS&#41; increases the patient&#8217;s IMS-related and in-hospital mortality rates by 1&#46;5&#37; and 1&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> To anticipate the detection and management of patients with significant clinical worsening&#44; rapid response systems &#40;RRS&#41; have been developed in association with IMS&#46; Although quality healthcare is at the center of the entire healthcare system&#44; the Spanish Society of Intensive&#44; Critical and Coronary Unit Medical Care &#40;SEMICYUC&#41; has not published any quality indicators associated with the activity of quality healthcare<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> that is monitored by keeping count of activations&#44; cardiac arrests&#44; and occasionally&#44; by estimating its repercussion in deaths and hospital admissions&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The goal of this scientific letter is&#8212;based on a registry of the activity developed by our RRS&#8212;to analyze the prognostic dimension of several definitions of delayed alert &#40;DA&#41; for IMS admission and justify its estimation as a quality indicator to identify situations with room for improvement and deviation from the routine clinical practice&#46; Our RRS is part of a tertiary level hospital with 2 different headquarters with 800 beds combined &#40;35 of the IMS&#41;&#44; 41 500 annual hospital admissions &#40;2000 in IMS&#41; and 200 000 hospital stays&#46; It was first implemented back in 2012 in all hospital areas &#40;except for IMS&#44; pediatrics&#44; and surgical rooms&#41;&#46; The RRS is activated after clinical assessment by the nursing staff and&#44; also&#44; after registering into electronic health records values outside the range of vital statistics with a superimposed message of risk situation flashing on the screen&#46; This is suggestive of call to the treating physician to activate the intensivist&#44; when appropriate&#46; If the former cannot be found or in cases of suspected great severity&#44; the nursing staff should call the intensivist&#46; All the physical examinations performed at the intensive care unit are prospectively registered into a database including demographic variables&#44; pluripathology &#40;hypertension stage &#8805; 2&#44; diabetes&#44; chronic lung disease&#44; kidney&#44; liver or heart failure&#44; neoplasm&#44; and tracheostomy carrier&#41;&#44; alert criterion &#40;cardiocirculatory&#44; respiratory&#44; neurological&#44; airway&#44; warning due to cardiac arrest&#44; subjective feeling of severity of the nurse or treating physician&#41;&#44; warning service&#44; working schedule&#44; and score obtained from the patients&#8217; risk scale&#46; If the patient is hospitalized&#44; the stay&#44; the IMS-related mortality rate&#44; and the 24-hour APACHE score<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> are duly noted if they develop multi-organ failure &#40;MOF&#41; and if it is a DA&#46; A total of 3 periods based on the evolution of our RRS were selected for analytical purposes&#58; during the first period &#40;P1&#41;&#44; between January and June 2013&#44; the Goldhill<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> risk assessment tool &#40;EPAR&#41; with data from 1 of the 2 headquarters &#40;280 beds&#44; 17 of the IMS&#41; was used&#59; both the second period &#40;P2&#41;&#44; between March and November 2014&#44; and the third period &#40;P3&#41;&#44; between May and June 2018&#44; included both headquarters and the VIEWs scale&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In P3 the emergency alerts were included&#46; MOF was defined as damage to two or more organs with high scores &#62; 2 in the SOFA<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> scale&#46; DA in P1 was defined as EPAR<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> &#62; 3 or &#8805; 2 in the assessment of systolic arterial pressure or pulse oximetry at some point of the 3 working schedules prior to IMS admission&#46; In P2 and P3 the DA was defined with VIEWs<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> scores &#62; 7 in some of the 3 working schedules prior to IMS admission&#44; and also if they had been referred from the ER or had stayed there for over 5&#8239;hours&#46; DAs were compared with the rest using Fisher&#8217;s exact test&#44; the chi-square test&#44; Mann-Whitney <span class="elsevierStyleItalic">U</span> test&#44; and the odds ratio &#40;OR&#41; with <span class="elsevierStyleItalic">P</span> values &#60; &#46;05&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A total of 244 alerts were reported in P1&#44; 544 in P2&#44; and 343 in P3&#46; The day&#8217;s average number of DAs was 0&#46;81&#44; 1&#46;87&#44; and 2&#46;85&#44; respectively&#44; in each period&#46; Also&#44; the percentage of DAs was 13&#46;52&#37;&#44; 6&#46;3&#37;&#44; and 6&#46;9&#37;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the differences of patients with DA at admission and the rest&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The OR of deceased patients with DA in P1 was 2&#46;39 &#40;95&#37;CI&#44; 0&#46;62-6&#46;98&#41;&#44; 4&#46;14 in P2 &#40;95&#37;CI&#44; 1&#46;84-9&#46;31&#41;&#44; and 4&#46;25 &#40;1&#46;37-13&#46;2&#41; in P3&#46; On the other hand&#44; the OR for developing MOF in P1 was 6&#46;86 &#40;95&#37;CI&#44; 2&#46;39-19&#46;71&#41; and 6&#46;14 &#40;95&#37;CI&#44; 2&#46;5-15&#46;08&#41; in P3&#46; In conclusion&#44; DAs multiply the chances of dying and developing MOF&#46; Assessing this percentage facilitates the comparison between periods and hospitals and monitors the quality of the afferent arm &#40;detection&#41; of RRS&#46; Establishing indicator standards is complex because the medical literature on this regard is scarce&#59; however&#44; with the existing literature&#44; with the trajectory of implementation of the actual protocols&#44; and with our own protocols the percentage should be &#60; 20&#37;&#46; This means that 80&#37; of the alerts that go off should not come with a delay&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">None reported&#46;</p></span></span>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">P1&#44; first period&#59; P2&#44; second period&#59; P3&#44; third period&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">DA&#44; delayed alert&#59; p&#44; significance level&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#37;&#44; percentage&#59; APACHE&#58; Acute Physiology and Chronic Health Evaluation II&#59;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> CA&#44; cardiac arrest&#59; IQR&#44; interquartile range&#59; M&#44; males&#59; Md&#44; median&#59; MOF&#44; multi organ failure&#59; pluripath&#44; pluripathological patients&#59; score&#44; risk score&#46;</p>"
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P1 &#40;N&#8239;&#61;&#8239;80&#41;</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P2 &#40;N&#8239;&#61;&#8239;266&#41;</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P3 &#40;N&#8239;&#61;&#8239;247&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">33 DA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">47 No DA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">34 DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">232 No DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">24 DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">223 No DA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Age md &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">75 &#40;65-80&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">72 &#40;58-76&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">67 &#40;58&#46;5-78&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;53&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">70&#46;5 &#40;64&#46;5-76&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">68 &#40;52-77&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&#37; Pluripath&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;51&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">55&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#37; Sepsis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60; &#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60; &#46;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">44&#46;7&nbsp;\t\t\t\t\t\t\n
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ISSN: 21735727
Original language: English
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