2) MES design

The MES is an automatic alarm system that detects warning signs of disease progression or adverse events in patients and generates an appropriate awareness for primary care physicians. The MES uses the EMR and existing communication system. Figure 1 shows the design of the MES. In brief, if vital signs entered in the EMR by a patient’s nurse satisfy the criteria for MES, the MES will automatically alert the primary doctor, resident, and on-call doctor of the abnormal vital signs. MES inclusion criteria include abnormal respiration rate, oxygen saturation, heart rate, and systolic blood pressure (Table 1). The MES is not turned on by patients who agree to “do not resuscitate,” are younger than 18 years, or are admitted in the emergency room or ICU. Any doctor who receives the MES message manages the patient according to the MES manuals (Figure 2). After management, the doctor records the method of management, status of the patient, and the results of management. The doctor can then turn off the MES. The MES includes education for primary care physicians that relates to basic procedures and plans for situations such as acute respiratory distress, shock, and arrhythmia. Education was conducted periodically before and after implementing the MES.

Design of the medical emergency system (MES). When a nurse enters vital sign data into the electronic medical record system, the computer automatically analyzes this information. If vital signs meet the MES criteria, a message is automatically sent to the primary doctor, resident, and on-call doctor. A doctor who receives the message must treat the patient and chart the treatment to deactivate the MES. If the MES is not deactivated, the system will continue to send the message to the doctors. EMR: electronic medical record; SMS: short message service.

Protocol for the medical emergency system. Management flow for (A) shock, (B) hypoxemia and tachypnea, (C) tachycardia. SBP: systolic blood pressure; SpO₂: oxygen saturation; RR: respiratory rate; HR: heart rate; EMR; electronic medical record; GCS: glasgow coma scale; MES: medical emergency system; qSOFA: quick sepsis related organ failure assessment; CBC: complete blood count; diff: differential count; T.bil: total bilirubin; Cr: creatinine; ABGA: arterial blood gas analysis; EKG: electrocardiogram; CXR: chest X-ray; MAP: mean arterial pressure; ICU: intensive care unit; Tx: treatment; HAT; hypotension, altered mental status, tachypnea; BP: blood pressure; Resp: respiration; COPD: chronic obstructive pulmonary disease; PTE: pulmonary thromboembolism; CT: computed tomography; TTE: transthoracic echocardiogram; AVNRT: atrioventricular nodal reentrant tachycardia; AVRT: atrioventricular reentrant tachycardia; VT: ventricular tachycardia; VF: ventricular fibrillation; DDx: differential diagnosis; A-fib: atrial fibrillation; PSVT: paroxysmal supraventricular tachycardia. aEye response, 1–4; verbal response,1–5; motor response, 1–6.

Medical emergency system inclusion criteria

RR: respiratory rate; SpO₂: oxygen saturation; HR: heart rate; BP: blood pressure; MES: medical emergency system; ICU: intensive care unit.