Rationale: Accurate, early identification of patients at risk for developing acute lung injury (ALI) provides the opportunity to test and implement secondary prevention strategies. Objectives: To determine the frequency and outcome of ALI development in patients at risk and validate a lung injury prediction score (LIPS). Methods: In this prospective multicenter observational cohort study, predisposing conditions and risk modifiers predictive of ALI development were identified from routine clinical data available during initial evaluation. The discrimination of the model was assessed with area under receiver operating curve (AUC). The risk of death from ALI was determined after adjustment for severity of illness and predisposing conditions. Measurements and Main Results: Twenty-two hospitals enrolled 5,584 patients at risk. ALI developed a median of 2 (interquartile range 1-4) days after initial evaluation in 377 (6.8%; 148 ALI-only, 229 adult respiratory distress syndrome) patients. The frequency of ALI varied according to predisposing conditions (from 3% in pancreatitis to 26% after smoke inhalation). LIPS discriminated patients who developed ALI from those who did not with an AUC of 0.80 (95% confidence interval, 0.78-0.82). When adjusted for severity of illness and predisposing conditions, development of ALI increased the risk of in-hospital death (odds ratio, 4.1; 95% confidence interval, 2.9-5.7). Conclusions: ALI occurrence varies according to predisposing conditions and carries an independently poor prognosis. Using routinely available clinical data, LIPS identifies patients at high risk for ALI early in the course of their illness. This model will alert clinicians about the risk of ALI and facilitate testing and implementation of ALI prevention strategies. Clinical trial registered with www.clinicaltrials.gov (NCT00889772).

OSPITALS VARY WIDELY INquality of critical care. 1 Consequently, the outcomes of critically ill patients may be improved by concentrating care at more experienced centers. [1][2][3] By centralizing patients who are at greater risk of mortality in referral hospitals, regionalized care in critical illness may achieve improvements in outcome similar to trauma networks. 4 In 2006, the Institute of Medicine called for a regionalized, coordinated system of emergency care for high-risk patients, 5 one in which patients in most need of highintensity acute care are distributed to centers with the greatest expertise in caring for the critically ill.Current out-of-hospital triage of noninjured, critically ill patients uses dispatch criteria, 6 subjective emergency medical services (EMS) assessments, 7,8 coordination by medical command officers, 9 and patient preference. 10 In specific conditions such as coronary artery disease and stroke, out-of-hospital care providers use objective tools to triage and risk-stratify prehospital patients for early treatment and choice of destination. [11][12][13] However, these subjective and disease-specific assessments alone may not be sufficient for triage in general populations at risk of critical ill-ness. 8,[14][15][16] Future development of regionalized systems of acute care will require objective, routinely measured predictors that are associated with important clinical end points in a heterogeneous population. An objective triage tool may also identify patients for early treatment by out-of-hospital care providers.We sought to develop a tool for prediction of critical illness during out-ofhospital care in noninjured, non-cardiac arrest patients. Using a population-based cohort of EMS records linked to hospital discharge data, we hypothesized that objective,out-of-hospitalfactorscoulddiscriminate between patients who were and For editorial comment see p 797.

Objectives Administration of eicosapentaenoic acid (EPA) and docosahexanoic acid (DHA), omega-3 fatty acids in fish oil, has been associated with improved patient outcomes in acute lung injury (ALI) when studied in a commercial enteral formula. However, fish oil has not been tested independently in ALI. We therefore sought to determine if enteral fish oil alone would reduce pulmonary and systemic inflammation in patients with ALI. Design Phase II randomized controlled trial. Setting Four North American medical centers. Patients Mechanically ventilated patients with ALI ≥ 18 years of age. Interventions Subjects were randomized to receive enteral fish oil (9.75g EPA and 6.75g DHA daily) or saline placebo for up to 14 days. Measurements and Main Results Bronchoalveolar lavage fluid (BALF) and blood were collected at baseline (day 0), day 4±1, and day 8±1. The primary endpoint was BALF interleukin (IL)-8 levels. Forty-one participants received fish oil and 49 received placebo. Enteral fish oil administration was associated with increased serum EPA concentration (p<0.0001). However, there was no significant difference in the change in BALF IL-8 from baseline to day 4 (p=0.37) or day 8 (p=0.55) between treatment arms. There were no appreciable improvements in other BALF or plasma biomarkers in the fish oil group compared to the control group. Similarly, organ failure score, ventilator-free days, ICU-free days, and 60-day mortality did not differ between the groups. Conclusions Fish oil did not reduce biomarkers of pulmonary or systemic inflammation in patients with ALI, and the results do not support the conduct of a larger clinical trial in this population with this agent. This experimental approach is feasible for proof of concept studies evaluating new treatments for ALI.