***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: Objective To explore the causes of failure to activate the rapid response system ( RRS ) . The organisation has a recognised incidence of staff failing to act when confronted with a deteriorating patient and leading to adverse outcomes . Design A multi- method study using the following : a point prevalence survey to determine the incidence of abnormal simple bedside observations and activation of the rapid response team by clinical staff ; a prospect i ve audit of all patients experiencing a cardiac arrest , unplanned intensive care unit admission or death over an 8-week period ; structured interviews of staff to explore cognitive and sociocultural barriers to activating the RRS . Setting Southern Health is a comprehensive healthcare network with 570 adult in-patient beds across four metropolitan teaching hospitals in the south-eastern sector of Melbourne . Measurements Frequency of physiological instability and outcomes within the in-patient hospital population . Qualitative data from staff interviews were thematically coded . Results The incidence of physiological instability in the acute adult population was 4.04 % . Nearly half of these patients ( 42 % ) did not receive an appropriate clinical response from the staff , despite most ( 69.2 % ) recognising their patient met physiological criteria for activating the RRS , and being ‘ quite ’ , or ‘ very ’ concerned about their patient ( 75.8 % ) . Structured interviews with 91 staff members identified predominantly sociocultural reasons for failure to activate the RRS . Conclusions Despite an organisational commitment to the RRS , clinical staff act on local cultural rules within the clinical environment that are usually not explicit . Better underst and ing of these informal rules may lead to more appropriate activation of the RRS 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 UNLABELLED RATIONALE , AIMS & OBJECTIVE : Tools for the assessment of the quality of research studies tend to be specific to a particular research design ( e.g. r and omized controlled trials , or qualitative interviews ) . This makes it difficult to assess the quality of a body of research that addresses the same or a similar research question but using different approaches . The aim of this paper is to describe the development and preliminary evaluation of a  quality assessment tool that can be applied to a method ologically diverse set of research articles . METHODS The  16-item quality assessment tool ( QATSDD )  was assessed to determine its reliability and validity when used by health services research ers in the disciplines of psychology , sociology and nursing . Qualitative feedback was also gathered from mixed- methods health research ers regarding the comprehension , content , perceived value and usability of the tool . RESULTS Reference to existing widely used quality assessment tools and experts in systematic review confirmed that the components of the tool represented the construct of ' good research technique ' being assessed . Face validity was subsequently established through feedback from a sample of nine health research ers .  Inter-rater reliability was established through substantial agreement between three review ers when applying the tool to a set of three research papers ( κ = 71.5 % ) , and good to substantial agreement between their scores at time 1 and after a 6-week interval at time 2 confirmed test-retest reliability . CONCLUSIONS The QATSDD shows good reliability and validity for use in the quality assessment of a diversity of studies , and may be an extremely useful tool for review ers to st and ardize and increase the rigour of their assessment s in review s of the published papers which include qualitative and quantitative work Rapid response systems ( RRS ) have been widely endorsed and adopted by hospital systems in industrialized countries to respond to deteriorating patients outside the intensive care unit ( ICU ) [ 1 ] . There is face validity in the idea that a system that promotes early recognition of deterioration and the implementation of time-critical interventions would save lives . Recent systematic review s point to the potential effectiveness of RRS , but important caveats need to be considered [ 2–4 ] . The vast majority of studies included in these analyses were before – after studies with no contemporaneous control ( Table 1 ) [ 2 , 3 ] . Whilst this methodology is simple to implement and underst and , the absence of a control group limits causal inference . The observed effects may be due to changes in case-mix , referral patterns , or overall improvements of ward-based care over time independent of an RRS . It is often unclear from the reported studies whether there were other interventions occurring at the same time . Bristow and colleagues performed a controlled before– after study comparing an  intervention hospital  to  two control hospitals  contemporaneously [ 5 ] . This methodology can account for secular trends , but does not completely account for baseline differences . Hospitals may experience changes not attributable to the intervention and not accounted for by regression techniques . The unadjusted analysis suggested benefit from implementation of the RRS , but the adjusted analysis yielded conflicting results [ 5 ] . After adjustment one control hospital performed worse while the other performed better than the RRS hospital . This suggests that the observed treatment effect of the RRS may be significantly attributable to observed and unobserved baseline imbalances . The interrupted time series ( ITS ) conducted by Howell and colleagues is a more robust methodology [ 6 ] . Their study of an RRS in an academic center found a reduction in unexpected mortality [ patients without a do not attempt resuscitation ( DNAR ) order ] , but no reduction in overall hospital mortality [ 6 ] . The reasons for this observation are unclear . About 8 % of RRS activations led to a DNAR order , but it is unlikely that increased utilization of DNAR orders would completely account for the observed difference in expected and overall hospital mortality . The ITS design does not account for time-varying confounders and other unmeasured events unrelated to the study intervention . For example , the introduction of the RRS may have coincided with a general increased utilization of DNAR orders independent of the RRS . This study utilized the patient ’s usual care team and m and ated communication with the patient ’s treating physician within 1 h of activation using explicit criteria [ 6 ] . This raises the possibility that the RRS acted as a substitute for timely senior clinical input from the usual care team [ 7 ] . Priestley and Hillman performed experimental evaluations of RRS [ 8 , 9 ] . Rapid response systems are applied at a system level and individual patient r and omization risks contamination between control and intervention participants in the same system . Priestly and colleagues used a stepped wedge design where each hospital ward was r and omly allocated consecutive time points to implement the RRS such that at the end of the trial all wards had implemented the intervention [ 8 , 10 ] . This methodology is attractive when end users believe an intervention is beneficial because all participating sites end up with the intervention and only the timing of implementation varies . Unfortunately , this study did not record measurements at each time interval so we can not address the * Correspondence : ritesh.maharaj@kcl.ac.uk 1 Department of Intensive Care , Kings College London , Denmark Hill , London SE5 9RS , UK Full list of author information is available at the end of the The Early Warning Score ( EWS ) is a simple physiological scoring system suitable for bedside application . The ability of a modified Early Warning Score ( MEWS ) to identify medical patients at risk of catastrophic deterioration in a busy clinical area was investigated . In a prospect i ve cohort study , we applied MEWS to patients admitted to the 56-bed acute Medical Admissions Unit ( MAU ) of a District General Hospital ( DGH ) . Data on 709 medical emergency admissions were collected during March 2000 . Main outcome measures were death , intensive care unit ( ICU ) admission , high dependency unit ( HDU ) admission , cardiac arrest , survival and hospital discharge at 60 days . Scores of 5 or more were associated with increased risk of death ( OR 5.4 , 95%CI 2.8 - 10.7 ) , ICU admission ( OR 10.9 , 95%CI 2.2 - 55.6 ) and HDU admission ( OR 3.3 , 95%CI 1.2 - 9.2 ) . MEWS can be applied easily in a DGH medical admission unit , and identifies patients at risk of deterioration who require increased levels of care in the HDU or ICU . A clinical pathway could be created , using nurse practitioners and /or critical care physicians , to respond to high scores and intervene with appropriate changes in clinical management OBJECTIVE To study the rate of documentation of vital signs in the period before the occurrence of an adverse event or emergency team call and to measure the effect of introducing the medical emergency team ( MET ) system on the rate of such documentation . METHODS During a cluster , r and omised trial of the MET in 23 Australian hospitals , we collected the data on lowest systolic blood pressure , highest and lowest respiratory rate and heart rate from 15min to 24h before an adverse event ( cardiac arrest , death or unexpected intensive care unit admission ) or emergency team call . We derived the document of these vital signs ( yes/no ) from the numerical values recorded . We used analytically weighted and r and om-effect regression models to examine the association between non-documented ( missing ) vital signs , hospital characteristics and MET allocation , and to examine their trend over time . RESULTS We found marked variability in documentation , with a high proportion of missing vital signs in some hospitals . Close to 77 % of patients suffering adverse events had at least one vital sign missing immediately before the event . Allocation to a MET system was associated with significantly increased documentation of respiratory rate and blood pressure before emergency team review ( P<0.01 ) as well as an improvement in documentation over time ( P<0.01 ) . At all stages and for both MET and control hospitals , the respiratory rate was the least commonly documented vital sign ( P<0.01 ) . CONCLUSIONS The documentation of vital signs in the period before adverse events was commonly incomplete with a particular deficiency in the documentation of the respiratory rate . Introduction of a MET system was associated with improvement in the rate of documentation of vital signs AIMS AND OBJECTIVES To evaluate the relationship between  nurse demographics  and correct identification of clinical situations warranting specific nursing actions , including activation of the medical emergency team . BACKGROUND If abnormal physiology is left untreated , the patient may develop cardiac arrest . Nurses in general wards are those who perceive any clinical deterioration in patients . DESIGN A descriptive , quantitative design was selected . METHODS An anonymous survey with 13 multiple choice questions was distributed to 150 r and omly selected nurses working in general medical and surgical wards of a large tertiary hospital in Athens , Greece . After explanation of the purpose s of the study , 94 nurses ( response ratio : 62 % ) agreed to respond to the question naire . RESULTS Categories with the greatest nursing concern were patients with heart rate<40/minute , an atypical thoracic pain , foreign body airway obstruction and bronchial secretions , respiratory rate<5/minute and heart rate=100/minute . However , almost 50 % of nurses were able to accurately identify the critical nursing action for patients with respiratory rate<4/minute , 72 % for patients with airway obstruction and 73 % for patients with chest pain . Nurses who had graduated from a four-year educational programme identified clinical situations that necessitated medical emergency team activation in a significantly higher rate and also scored significantly higher in questions concerning clinical evaluation than nurses who had graduated from a two-year educational programme . CONCLUSION Activation of the medical emergency team is influenced by factors such as level of education and cardiopulmonary resuscitation courses attendance . RELEVANCE TO CLINICAL PRACTICE Graduating from a four-year educational programme helps nurses identify emergencies . However , irrespective of the educational programme they have followed , undertaking a basic life support or advanced life support provider course is critical as it helps them identify cardiac or respiratory emergencies BACKGROUND AND OBJECTIVE To conduct a pilot study to compare the frequency of errors that accompany single vs. double data extraction , compare the estimate of treatment effect derived from these methods , and compare the time requirements for these methods . METHODS Review ers were r and omized to the role of data extractor or data verifier , and were blind to the study hypothesis . The frequency of errors associated with each method of data extraction was compared using the McNemar test . The data set for each method was used to calculate an efficacy estimate by each method , using st and ard meta-analytic techniques . The time requirement for each method was compared using a 
    Output:
    
The escalation of care process highlighted the influence of cultural barriers and personal judgment on RRS activation .
Mainly , delayed team calls were factors strongly associated with the increased risk of unplanned admissions to the intensive care unit and length of stay , hospital length of stay and mortality , and 30-day mortality .
Conclusions A combination of factors affects the timely identification and response to sudden deterioration by general ward staffs , leading to suboptimal care of patients , delayed or failed activation of RRS teams , and increased risks of worsening outcomes .