***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Abstract Objectives : To determine whether earlier clinical intervention by a medical emergency team prompted by clinical instability in a patient could reduce the incidence of and mortality from unexpected cardiac arrest in hospital . Design : A non-r and omised , population based study before ( 1996 ) and after ( 1999 ) introduction of the medical emergency team . Setting : 300 bed tertiary referral teaching hospital . Participants : All patients admitted to the hospital in 1996 ( n=19 317 ) and 1999 ( n=22 847 ) . Interventions : Medical emergency team ( two doctors and one senior intensive care nurse ) attended clinical ly unstable patients immediately with resuscitation drugs , fluid , and equipment . Response activated by the bedside nurse or doctor according to predefined criteria . Main outcome measures : Incidence and outcome of unexpected cardiac arrest . Results : The incidence of unexpected cardiac arrest was 3.77 per 1000 hospital admissions ( 73 cases ) in 1996 ( before intervention ) and 2.05 per 1000 admissions ( 47 cases ) in 1999 ( after intervention ) , with mortality being 77 % ( 56 patients ) and 55 % ( 26 patients ) , respectively . After adjustment for case mix the intervention was associated with a 50 % reduction in the incidence of unexpected cardiac arrest ( odds ratio 0.50 , 95 % confidence interval 0.35 to 0.73 ) . Conclusions : In clinical ly unstable in patients early intervention by a medical emergency team significantly reduces the incidence of and mortality from unexpected cardiac arrest in hospital . What is already known on this topic In most studies mortality from unexpected cardiac arrest in hospital exceeds 50 % Such events are usually preceded by signs of clinical deterioration in the hours before cardiac arrest What this paper adds Early intervention by a medical emergency team significantly reduced the incidence of and mortality from unexpected cardiac arrest in BACKGROUND Patients with cardiac arrests or who die in general wards have often received delayed or inadequate care . We investigated whether the medical emergency team ( MET ) system could reduce the incidence of cardiac arrests , unplanned admissions to intensive care units ( ICU ) , and deaths . METHODS We r and omised 23 hospitals in Australia to continue functioning as usual ( n=11 ) or to introduce a MET system ( n=12 ) . The primary outcome was the composite of cardiac arrest , unexpected death , or unplanned ICU admission during the 6-month study period after MET activation . Analysis was by intention to treat . FINDINGS Introduction of the MET increased the overall calling incidence for an emergency team ( 3.1 vs 8.7 per 1000 admissions , p=0.0001 ) . The MET was called to 30 % of patients who fulfilled the calling criteria and who were subsequently admitted to the ICU . During the study , we recorded similar incidence of the composite primary outcome in the control and MET hospitals ( 5.86 vs 5.31 per 1000 admissions , p=0.640 ) , as well as of the individual secondary outcomes ( cardiac arrests , 1.64 vs 1.31 , p=0.736 ; unplanned ICU admissions , 4.68 vs 4.19 , p=0.599 ; and unexpected deaths , 1.18 vs 1.06 , p=0.752 ) . A reduction in the rate of cardiac arrests ( p=0.003 ) and unexpected deaths ( p=0.01 ) was seen from baseline to the study period for both groups combined . INTERPRETATION The MET system greatly increases emergency team calling , but does not substantially affect the incidence of cardiac arrest , unplanned ICU admissions , or unexpected death Objective To determine whether the introduction of an intensive care unit-based medical emergency team , responding to hospital-wide preset criteria of physiologic instability , would decrease the rate of predefined adverse outcomes in patients having major surgery . Design Prospect i ve , controlled before- and -after trial . Setting University-affiliated hospital . Patients Consecutive patients admitted to hospital for major surgery during a 4-month control phase and during a 4-month intervention phase . Interventions Introduction of a hospital-wide intensive care unit-based medical emergency team to evaluate and treat in- patients deemed at risk of developing an adverse outcome by nursing , paramedical , and /or medical staff . Measurements and Main Results We measured incidence of serious adverse events , mortality after major surgery , and mean duration of hospital stay . There were 1,369 operations in 1,116 patients during the control period and 1,313 in 1,067 patients during the medical emergency team intervention period . In the control period , there were 336 adverse outcomes in 190 patients ( 301 outcomes /1,000 surgical admissions ) , which decreased to 136 in 105 patients ( 127 outcomes /1,000 surgical admissions ) during the intervention period ( relative risk reduction , 57.8 % ; p < .0001 ) . These changes were due to significant decreases in the number of cases of respiratory failure ( relative risk reduction , 79.1 % ; p < .0001 ) , stroke ( relative risk reduction , 78.2 % ; p = .0026 ) , severe sepsis ( relative risk reduction , 74.3 % ; p = .0044 ) , and acute renal failure requiring renal replacement therapy ( relative risk reduction , 88.5 % ; p < .0001 ) . Emergency intensive care unit admissions were also reduced ( relative risk reduction , 44.4 % ; p = .001 ) . The introduction of the medical emergency team was also associated with a significant decrease in the number of postoperative deaths ( relative risk reduction , 36.6 % ; p = .0178 ) . Duration of hospital stay after major surgery decreased from a mean of 23.8 days to 19.8 days ( p = .0092 ) . Conclusions The introduction of an intensive care unit-based medical emergency team in a teaching hospital was associated with a reduced incidence of postoperative adverse outcomes , postoperative mortality rate , and mean duration of hospital stay Reports of cluster r and omised trials require additional information to allow readers to interpret them accurately The effective reporting of r and omised controlled trials has received useful attention in recent years . Many journals now require that reports conform to the guidelines in the Consoli date d St and ards of Reporting Trials ( CONSORT ) statement , first published in 1996 and revised in 2001 . The statement includes a checklist of items that should be included in the trial report . These items are evidence based whenever possible and are regularly review ed . The statement also recommends including a flow diagram to show the flow of participants from group assignment through to the final analysis . The CONSORT statement focused on reporting parallel group r and omised trials in which individual participants are r and omly assigned to study groups . However , in some situations it is preferable to r and omly assign groups of individuals ( such as families or medical practice s ) rather than individuals . Reasons include the threat of contamination of some interventions ( such as dietary interventions ) if individual r and omisation is used . 5 Also , in certain setting s r and omisation by group may be the only feasible method of conducting a trial . Trials with this design are variously known as field trials , community based trials , place based trials , or ( as in this paper ) cluster r and omised trials . In an earlier discussion paper we considered the implication s of the CONSORT statement for the reporting of cluster r and omised trials . Here we present up date d guidance , based on the 2001 revision of the CONSORT statement A ‘ patient‐at‐risk team ’ , established to allow the early identification of seriously ill patients on hospital wards , made 69 assessment s on 63 patients over 6 months . Predefined physiological criteria were not able to reliably predict which patients would be admitted to the intensive care unit . The incidence of cardiopulmonary resuscitation before intensive care admission was 3.6 % for patients seen by the team and 30.4 % for those not seen ( p < 0.005 ) . Of admissions seen by the team , 25 % died on the intensive care unit compared with 45 % of those not seen ( not significant , p = 0.07 ) . Among those not seen by the team , mortality was 40 % for those who did not require resuscitation and 57 % for those who did ( not significant ) . Many critically ill ward patients had abnormal physiological values before intensive care unit admission . Identification of critically ill patients on the ward and early advice and active management are likely to prevent the need for cardiopulmonary resuscitation and to improve outcome OBJECTIVE To determine the effect of a community hospital-wide program enabling nurses and prehospital personnel to mobilize institutional re sources for the treatment of patients with nontraumatic shock . DESIGN Historically controlled single-center study . SETTING A 180-bed community hospital . PATIENTS Patients in shock who were c and i date s for aggressive therapy . INTERVENTIONS From January 1998 to May 31 , 2000 , patients in shock received st and ard therapy ( control group ) . During the month of June 2000 , intensive education of all health-care providers ( ie , prehospital personnel , nurses , and physicians ) took place . From July 1 , 2000 , through June 30 , 2001 , patients in shock ( protocol group ) were managed with a hospital-wide shock program . The program included early recognition of shock and the initiation of therapy by nonphysicians . Frontline personnel mobilized a shock team , which used goal -directed resuscitation protocol s , early intensivist involvement , and rapid transfer to the ICU where protocol s specific to shock etiology were implemented . MEASUREMENTS AND MAIN RESULTS Eighty-six and 103 patients , respectively , were enrolled in the control and protocol groups . Baseline characteristics were similar . The protocol group had significant reductions in the median times to interventions , as follows : intensivist arrival , 2:00 h to 50 min ( p < 0.002 ) ; ICU/operating room admission , 2 h 47 min to 1 h 30 min ( p < 0.002 ) ; 2 L fluid infused , 3 h 52 min to 1 h 45 min ( p < 0.0001 ) ; and pulmonary artery catheter placement , 3 h 50 min to 2 h 10 min ( p 0.02 ) . Good outcomes ( ie , discharged to home or to a rehabilitation center ) were more likely in the protocol group than in the control group ( p = 0.02 ) . The hospital mortality rate was 40.7 % in the control group and 28.2 % in the protocol group ( p = 0.035 ) . CONCLUSION Similar to current practice in patients who have experienced trauma or cardiac arrest , the empowerment of nonphysician providers to mobilize hospital re sources for the care of patients with shock is effective . A community hospital program incorporating the education of providers , the activation of a coordinated team response , and early goal -directed therapy expedited appropriate treatment and was temporally associated with improved outcomes . R and omized multicenter trials are needed to further assess the impact of the shock program on outcomes AIM ( 1 ) To identify risk factors for in-hospital cardiac arrest ; ( 2 ) to formulate activation criteria to alert a clinical response culminating in attendance by a Medical Emergency Team ( MET ) ; ( 3 ) to evaluate the sensitivity and specificity of the scoring system . METHODS Quasi-experimental design to determine prevalence of risk factors for cardiac arrest in the hospitalised population . Weighting of risk factors and formulation of activation criteria to alert a grade d clinical response . ROC analysis of weighted cumulative scores to determine their sensitivity and specificity . SETTING An acute 700 bed district general hospital with 32,348 adult admissions in 1999 and a catchment population of around 365,000 . SUBJECTS 118 consecutive adult patients suffering primary cardiac arrest in-hospital and 132 non-arrest patients , r and omly selected according to stratified r and omisation by gender and age . RESULTS Risk factors for cardiac arrest include : abnormal respiratory rate ( P = 0.013 ) , abnormal breathing indicator ( abnormal rate or documented shortness of breath ) ( P < 0.001 ) , abnormal pulse ( P < 0.001 ) , reduced systolic blood pressure ( P < 0.001 ) , abnormal temperature ( P < 0.001 ) , reduced pulse oximetry ( P < 0.001 ) , chest pain ( P < 0.001 ) and nurse or doctor concern ( P < 0.001 ) . Multivariate analysis of cardiac arrest cases identified three positive associations for cardiac arrest : abnormal breathing indicator ( OR 3.49 ; 95 % CI : 1.69 - 7.21 ) , abnormal pulse ( OR 4.07 ; 95 % CI : 2.0 - 8.31 ) and abnormal systolic blood pressure ( OR 19.92 ; 95 % CI : 9.48 - 41.84 ) . Risk factors were weighted and tabulated . The aggregate score determines the grade of clinical response . ROC analysis determined that a score of 4 has 89 % sensitivity and 77 % specificity for cardiac arrest ; a score of 8 has 52 % sensitivity and 99 % specificity . All patients scoring greater than 10 suffered cardiac arrest . CONCLUSION Risk factors for cardiac arrest have been identified , quantified and formulated into a table of activation criteria to help predict and avert cardiac arrest by alerting a clinical response . A grade d clinical response has result ed in a tool that has both sensitivity and specificity for cardiac arrest Abstract Objective . To document the characteristics and 
    Output:
    
The positive results of before-after trials likely reflects secular trends and biased outcome ascertainment , as the improved outcomes they reported were of similar magnitude to those of the control group in the RCT .