The main difference between our study and previous studies is the criteria for activating the alert system. We used a combination of clinical and laboratory parameters and a physician order of fluid or oxygen therapy. We used an electronic alert rather than a paper-based system and applied this system in an ED setting. Our results demonstrated that the electronic alert preceded ICU referral by a median of 4.02 hours (Q1–Q3, 1.25–8.55 hours). The low
prevalence found in our study was because the alert system screened all patients who presented to the ED, not only the high-risk patients or those who presented to the ED with infection. Alert systems should focus on preventing active failures and individual errorproducing conditions [15]. Therefore, achieving a high specificity of 98.4% was important. To avoid “alert fatigue and overriding”, the alert should be followed by directing the bedside nurse to ask the physician to respond to it [16].