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Background@#There is insufficient data on the benefits of empiric antibiotic combinations for hospital-acquired pneumonia (HAP). We aimed to investigate whether empiric antipseudomonal combination therapy with fluoroquinolones decreases mortality in patients with HAP. @*Methods@#This multicenter, retrospective cohort study included adult patients admitted to 16 tertiary and general hospitals in Korea between January 1 and December 31, 2019.Patients with risk factors for combination therapy were divided into anti-pseudomonal non-carbapenem β-lactam monotherapy and fluoroquinolone combination therapy groups.Primary outcome was 30-day mortality. Propensity score matching (PSM) was used to reduce selection bias. @*Results@#In total, 631 patients with HAP were enrolled. Monotherapy was prescribed in 54.7% (n = 345) of the patients, and combination therapy was prescribed in 45.3% (n = 286).There was no significant difference in 30-day mortality between the two groups (16.8% vs.18.2%, P = 0.729) or even after the PSM (17.5% vs. 18.2%, P = 0.913). After the PSM, adjusted hazard ratio for 30-day mortality from the combination therapy was 1.646 (95% confidence interval, 0.782–3.461; P = 0.189) in the Cox proportional hazards model. Moreover, there was no significant difference in the appropriateness of initial empiric antibiotics between the two groups (55.0% vs. 56.8%, P = 0.898). The proportion of multidrug-resistant (MDR) pathogens was high in both groups. @*Conclusion@#Empiric anti-pseudomonal fluoroquinolone combination therapy showed no survival benefit compared to β-lactam monotherapy in patients with HAP. Caution is needed regarding the routine combination of fluoroquinolones in the empiric treatment of HAP patients with a high risk of MDR.
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Background/Aims@#Most studies on hospital-acquired pneumonia (HAP) have been conducted in intensive care unit (ICU) settings. This study aimed to investigate the microbiological and clinical characteristics of non-ICU-acquired pneumonia (NIAP) and to identify the factors affecting clinical outcomes in Korea. @*Methods@#This multicenter retrospective cohort study was conducted in patients admitted to 13 tertiary hospitals between July 1, 2019 and December 31, 2019. Patients diagnosed with NIAP were included in this study. To assess the prognostic factors of NIAP, the study population was classified into treatment success and failure groups. @*Results@#Of 526 patients with HAP, 379 were diagnosed with NIAP. Overall, the identified causative pathogen rate was 34.6% in the study population. Among the isolated organisms (n = 113), gram-negative bacilli were common pathogens (n = 91), such as Pseudomonas aeruginosa (n = 25), Acinetobacter baumannii (n = 23), and Klebsiella pneumoniae (n = 21). The multidrug resistance rates of A. baumannii, P. aeruginosa, and K. pneumoniae were 91.3%, 76.0%, and 57.1%, respectively. Treatment failure was significantly associated with K. pneumoniae (odds ratio [OR], 3.50; 95% confidence interval [CI], 1.35 to 9.05; p = 0.010), respiratory viruses (OR, 3.81; 95% CI, 1.34 to 10.82; p = 0.012), hematological malignancies (OR, 3.54; 95% CI, 1.57 to 8.00; p = 0.002), and adjunctive corticosteroid treatment (OR, 2.40; 95% CI, 1.27 to 4.52; p = 0.007). @*Conclusions@#The causative pathogens of NIAP in Korea are predominantly gram-negative bacilli with a high rate of multidrug resistance. These were not different from the common pathogens of ICU-acquired pneumonia.
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Background@#Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are significant public health issues in the world, but the epidemiological data pertaining to HAP/VAP is limited in Korea. The objective of this study was to investigate the characteristics, management, and clinical outcomes of HAP/VAP in Korea. @*Methods@#This study is a multicenter retrospective cohort study. In total, 206,372 adult patients, who were hospitalized at one of the 13 participating tertiary hospitals in Korea, were screened for eligibility during the six-month study period. Among them, we included patients who were diagnosed with HAP/VAP based on the Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) definition for HAP/VAP. @*Results@#Using the IDSA/ATS diagnostic criteria, 526 patients were identified as HAP/VAP patients. Among them, 27.9% were diagnosed at the intensive care unit (ICU). The cohort of patients had a median age of 71.0 (range from 62.0 to 79.0) years. Most of the patients had a high risk of aspiration (63.3%). The pathogen involved was identified in 211 patients (40.1%). Furthermore, multidrug resistant (MDR) pathogens were isolated in 138 patients; the most common MDR pathogen was Acinetobacter baumannii. During hospitalization, 107 patients with HAP (28.2%) had to be admitted to the ICU for additional care. The hospital mortality rate was 28.1% in the cohort of this study. Among the 378 patients who survived, 54.2% were discharged and sent back home, while 45.8% were transferred to other hospitals or facilities. @*Conclusion@#This study found that the prevalence of HAP/VAP in adult hospitalized patients in Korea was 2.54/1,000 patients. In tertiary hospitals in Korea, patients with HAP/VAP were elderly and had a risk of aspiration, so they were often referred to step-down centers.
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Rare cases of Fournier gangrene (FG) possibly associated with sodium-glucose cotransporter 2 inhibitors have been reported. We present a case of a 66-year-old male patient with type 2 diabetes mellitus on oral metformin, glimepiride, and dapagliflozin therapy. He presented with pain in the perineum and scrotum for 5 days. The clinical finding, computed tomography finding, and laboratory data were matched with FG. Emergency surgical drainage, debridement of necrotic tissue, and diverting loop ileostomy formation were performed by a urologist and a surgeon. The patient had no complications from diabetes before the onset of FG, and serum glucose management was good at the onset of FG. This case shows an FG patient with good glucose management taking dapagliflozin and suggests a possible association between dapagliflozin and FG. Further evaluation and additional research on this relationship are needed.
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Background@#Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are significant public health issues in the world, but the epidemiological data pertaining to HAP/VAP is limited in Korea. The objective of this study was to investigate the characteristics, management, and clinical outcomes of HAP/VAP in Korea. @*Methods@#This study is a multicenter retrospective cohort study. In total, 206,372 adult patients, who were hospitalized at one of the 13 participating tertiary hospitals in Korea, were screened for eligibility during the six-month study period. Among them, we included patients who were diagnosed with HAP/VAP based on the Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) definition for HAP/VAP. @*Results@#Using the IDSA/ATS diagnostic criteria, 526 patients were identified as HAP/VAP patients. Among them, 27.9% were diagnosed at the intensive care unit (ICU). The cohort of patients had a median age of 71.0 (range from 62.0 to 79.0) years. Most of the patients had a high risk of aspiration (63.3%). The pathogen involved was identified in 211 patients (40.1%). Furthermore, multidrug resistant (MDR) pathogens were isolated in 138 patients; the most common MDR pathogen was Acinetobacter baumannii. During hospitalization, 107 patients with HAP (28.2%) had to be admitted to the ICU for additional care. The hospital mortality rate was 28.1% in the cohort of this study. Among the 378 patients who survived, 54.2% were discharged and sent back home, while 45.8% were transferred to other hospitals or facilities. @*Conclusion@#This study found that the prevalence of HAP/VAP in adult hospitalized patients in Korea was 2.54/1,000 patients. In tertiary hospitals in Korea, patients with HAP/VAP were elderly and had a risk of aspiration, so they were often referred to step-down centers.
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Background@#A rapid response system (RRS) contributes to the safety of hospitalized patients. Clinical deterioration may occur in the general ward (GW) or in non-GW locations such as radiology or dialysis units. However, there are few studies regarding RRS activation in non-GW locations. This study aimed to compare the clinical characteristics and outcomes of patients with RRS activation in non-GW locations and in the GW. @*Methods@#From January 2016 to December 2017, all patients requiring RRS activation in nine South Korean hospitals were retrospectively enrolled and classified according to RRS activation location: GW vs non-GW RRS activations. @*Results@#In total, 12,793 patients were enrolled; 222 (1.7%) were non-GW RRS activations.There were more instances of shock (11.6% vs. 18.5%) and cardiac arrest (2.7% vs. 22.5%) in non-GW RRS activation patients. These patients also had a lower oxygen saturation (92.6% ± 8.6% vs. 88.7% ± 14.3%, P < 0.001) and a higher National Early Warning Score 2 (7.5 ± 3.4 vs. 8.9 ± 3.8,P < 0.001) than GW RRS activation patients. Although non-GW RRS activation patients received more intubation (odds ratio [OR], 3.135; P < 0.001), advanced cardiovascular life support (OR, 3.912; P < 0.001), and intensive care unit transfer (OR, 2.502;P < 0.001), their hospital mortality (hazard ratio, 0.630; P = 0.013) was lower than GW RRS activation patients upon multivariate analysis. @*Conclusion@#Considering that there were more critically ill but recoverable cases in non-GW locations, active RRS involvement should be required in such locations.
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Rare cases of Fournier gangrene (FG) possibly associated with sodium-glucose cotransporter 2 inhibitors have been reported. We present a case of a 66-year-old male patient with type 2 diabetes mellitus on oral metformin, glimepiride, and dapagliflozin therapy. He presented with pain in the perineum and scrotum for 5 days. The clinical finding, computed tomography finding, and laboratory data were matched with FG. Emergency surgical drainage, debridement of necrotic tissue, and diverting loop ileostomy formation were performed by a urologist and a surgeon. The patient had no complications from diabetes before the onset of FG, and serum glucose management was good at the onset of FG. This case shows an FG patient with good glucose management taking dapagliflozin and suggests a possible association between dapagliflozin and FG. Further evaluation and additional research on this relationship are needed.
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Background@#Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. This disease, which is quickly spreading worldwide, has high potential for infection and causes rapid progression of lung lesions, resulting in a high mortality rate. This study aimed to investigate the effects of SARS-CoV-2 infection on renal function in patients with COVID-19. @*Methods@#From February 21 to April 24, 2020, 66 patients diagnosed with COVID-19 at Chungnam National University Hospital were analyzed; all patients underwent routine urinalysis and were tested for serum creatinine, urine protein to creatinine ratio (PCR), and urine albumin to creatinine ratio (ACR). @*Results@#Acute kidney injury (AKI) occurred in 3 (4.5%) of the 66 patients, and 1 patient with AKI stage 3 underwent hemodialysis. Upon follow-up, all 3 patients recovered normal renal function. Compared with patients with mild COVID-19, AKI (n = 3) occurred in patients with severe COVID-19, of whom both urine PCR and ACR were markedly increased. @*Conclusion@#The incidence of AKI was not high in COVID-19 patients. The lower mortality rate in SARS-CoV-2 infection compared with previous Middle East respiratory syndrome and SARS-CoV infections is thought to be associated with a low incidence of dysfunction in organs other than the lungs.
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BACKGROUND: Data on noninvasive ventilation (NIV) use in intensive care units (ICUs) are very limited in South Korea. METHODS: A prospective observational study was performed in 20 ICUs of university-affiliated hospitals from June 2017 to February 2018. Adult patients (age>18 years) who were admitted to the ICU and received NIV treatment for acute respiratory failure were included. RESULTS: A total of 156 patients treated with NIV were enrolled (mean age, 71.9±11.6 years). The most common indications for NIV were acute hypercapnic respiratory failure (AHRF, n=89) and post-extubation respiratory failure (n=44). The main device for NIV was an invasive mechanical ventilator with an NIV module (61.5%), and the majority of patients (87.2%) used an oronasal mask. After the exclusion of 32 do-not-resuscitate patients, NIV success rate was 68.5% (85/124); ICU and hospital mortality rates were 8.9% and 15.3%, respectively. However, the success rate was lower in patients with de novo respiratory failure (27.3%) compared to that of patients with AHRF (72.8%) or post-extubation respiratory failure (75.0%). In multivariate analysis, immunocompromised state, de novo respiratory failure, post-NIV (2 hours) respiratory rate, NIV mode (i.e., non-pressure support ventilation mode), and the change of NIV device were significantly associated with a lower success rate of NIV. CONCLUSION: AHRF and post-extubation respiratory failure were the most common indications for NIV in Korean ICUs. Overall NIV success was achieved in 68.5% of patients, with the lowest rate in patients with de novo respiratory failure.
Subject(s)
Adult , Humans , Critical Care , Hospital Mortality , Intensive Care Units , Korea , Masks , Multivariate Analysis , Noninvasive Ventilation , Observational Study , Prospective Studies , Respiratory Insufficiency , Respiratory Rate , Ventilation , Ventilators, MechanicalABSTRACT
BACKGROUND@#Data on noninvasive ventilation (NIV) use in intensive care units (ICUs) are very limited in South Korea.@*METHODS@#A prospective observational study was performed in 20 ICUs of university-affiliated hospitals from June 2017 to February 2018. Adult patients (age>18 years) who were admitted to the ICU and received NIV treatment for acute respiratory failure were included.@*RESULTS@#A total of 156 patients treated with NIV were enrolled (mean age, 71.9±11.6 years). The most common indications for NIV were acute hypercapnic respiratory failure (AHRF, n=89) and post-extubation respiratory failure (n=44). The main device for NIV was an invasive mechanical ventilator with an NIV module (61.5%), and the majority of patients (87.2%) used an oronasal mask. After the exclusion of 32 do-not-resuscitate patients, NIV success rate was 68.5% (85/124); ICU and hospital mortality rates were 8.9% and 15.3%, respectively. However, the success rate was lower in patients with de novo respiratory failure (27.3%) compared to that of patients with AHRF (72.8%) or post-extubation respiratory failure (75.0%). In multivariate analysis, immunocompromised state, de novo respiratory failure, post-NIV (2 hours) respiratory rate, NIV mode (i.e., non-pressure support ventilation mode), and the change of NIV device were significantly associated with a lower success rate of NIV.@*CONCLUSION@#AHRF and post-extubation respiratory failure were the most common indications for NIV in Korean ICUs. Overall NIV success was achieved in 68.5% of patients, with the lowest rate in patients with de novo respiratory failure.
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BACKGROUND: We developed an additional laser guidance system to improve the efficacy and safety of conventional computed tomography (CT)–guided percutaneous transthoracic needle biopsy (PTNB), and we conducted this study to evaluate the efficacy and safety of our system. METHODS: We retrospectively analyzed the medical records of 244 patients who underwent CT-guided PTNB using our additional laser guidance system from July 1, 2015, to January 20, 2016. RESULTS: There were nine false-negative results among the 238 total cases. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of our system for diagnosing malignancy were 94.4% (152/161), 100% (77/77), 100% (152/152), 89.5% (77/86), and 96.2% (229/238), respectively. The results of univariate analysis showed that the risk factors for a false-negative result were male sex (p=0.029), a final diagnosis of malignancy (p=0.033), a lesion in the lower lobe (p=0.035), shorter distance from the skin to the target lesion (p=0.003), and shorter distance from the pleura to the target lesion (p=0.006). The overall complication rate was 30.5% (74/243). Pneumothorax, hemoptysis, and hemothorax occurred in 21.8% (53/243), 9.1% (22/243), and 1.6% (4/243) of cases, respectively. CONCLUSION: The additional laser guidance system might be a highly economical and efficient method to improve the diagnostic efficacy and safety of conventional CT-guided PTNB even if performed by inexperienced pulmonologists.
Subject(s)
Humans , Male , Biopsy, Needle , Diagnosis , Hemoptysis , Hemothorax , Lung Neoplasms , Medical Records , Methods , Needles , Pleura , Pneumothorax , Retrospective Studies , Risk Factors , Sensitivity and Specificity , Skin , Solitary Pulmonary NoduleABSTRACT
In Korea, the Hospice, Palliative Care, and Life-sustaining Treatment Decision-making Act was enacted in February 2016 in order to ensure that the patient's self-determination in end-of-life care processes is respected. To enhance physicians' understanding of this act and to provide proper criteria for medical judgment in variety of clinical settings, consensus guidelines were published in November 2016. In this article, the characteristics of these guidelines and related issues regarding the definitions of ‘the end stage of disease’ and ‘last days of life’ and the criteria for medical judgment are presented and summarized. According to the guidelines, the term ‘end stage of disease’ refers to a state in which there is no possibility of a fundamental recovery and the symptoms are expected to worsen within months. The terms ‘the last days of life’ and ‘the final days of life’ refer to a state in which, despite treatment, the patient's condition is worsening and death is impending, with no possibility of recovery. The attending physician and another relevant specialist should both judge a patient's medical condition as either ‘end stage of disease’ for hospice/palliative care or ‘the last days of life’ for dying patient care according to the law. Caregivers should provide appropriate medical information to eligible patients for palliative or ‘end stage of disease’ care through advance care planning. Therefore, it is critically necessary that caregivers understand the legitimate process of hospice/palliative and dying patient care based on the patient's wishes and best interests. Physicians should apply these consensus guidelines to eligible patients considering their clinical course and the patients' wishes.
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In Korea, the Hospice, Palliative Care, and Life-sustaining Treatment Decision-making Act was enacted in February 2016 in order to ensure that the patient's self-determination in end-of-life care processes is respected. To enhance physicians' understanding of this act and to provide proper criteria for medical judgment in variety of clinical settings, consensus guidelines were published in November 2016. In this article, the characteristics of these guidelines and related issues regarding the definitions of ‘the end stage of disease’ and ‘last days of life’ and the criteria for medical judgment are presented and summarized. According to the guidelines, the term ‘end stage of disease’ refers to a state in which there is no possibility of a fundamental recovery and the symptoms are expected to worsen within months. The terms ‘the last days of life’ and ‘the final days of life’ refer to a state in which, despite treatment, the patient's condition is worsening and death is impending, with no possibility of recovery. The attending physician and another relevant specialist should both judge a patient's medical condition as either ‘end stage of disease’ for hospice/palliative care or ‘the last days of life’ for dying patient care according to the law. Caregivers should provide appropriate medical information to eligible patients for palliative or ‘end stage of disease’ care through advance care planning. Therefore, it is critically necessary that caregivers understand the legitimate process of hospice/palliative and dying patient care based on the patient's wishes and best interests. Physicians should apply these consensus guidelines to eligible patients considering their clinical course and the patients' wishes.
Subject(s)
Humans , Advance Care Planning , Caregivers , Consensus , Hospices , Judgment , Jurisprudence , Korea , Palliative Care , Patient Care , SpecializationABSTRACT
BACKGROUND: Malnutrition is associated with many adverse clinical outcomes. The present study aimed to identify the prevalence of malnutrition in hospitalized patients in Korea, evaluate the association between malnutrition and clinical outcomes, and ascertain the risk factors of malnutrition. METHODS: A multicenter cross-sectional study was performed with 300 patients recruited from among the patients admitted in 25 hospitals on January 6, 2014. Nutritional status was assessed by using the Subjective Global Assessment (SGA). Demographic characteristics and underlying diseases were compared according to nutritional status. Logistic regression analysis was performed to identify the risk factors of malnutrition. Clinical outcomes such as rate of admission in intensive care units, length of hospital stay, and survival rate were evaluated. RESULTS: The prevalence of malnutrition in the hospitalized patients was 22.0%. Old age (≥ 70 years), admission for medical treatment or diagnostic work-up, and underlying pulmonary or oncological disease were associated with malnutrition. Old age and admission for medical treatment or diagnostic work-up were identified to be risk factors of malnutrition in the multivariate analysis. Patients with malnutrition had longer hospital stay (SGA A = 7.63 ± 6.03 days, B = 9.02 ± 9.96 days, and C = 12.18 ± 7.24 days, P = 0.018) and lower 90-day survival rate (SGA A = 97.9%, B = 90.7%, and C = 58.3%, P < 0.001). CONCLUSION: Malnutrition was common in hospitalized patients, and resulted in longer hospitalization and associated lower survival rate. The rate of malnutrition tended to be higher when the patient was older than 70 years old or hospitalized for medical treatment or diagnostic work-up compared to elective surgery.
Subject(s)
Humans , Cross-Sectional Studies , Hospitalization , Intensive Care Units , Korea , Length of Stay , Logistic Models , Malnutrition , Multivariate Analysis , Nutrition Assessment , Nutritional Status , Prevalence , Risk Factors , Survival RateABSTRACT
BACKGROUND: Early recognition of the signs and symptoms of clinical deterioration could diminish the incidence of cardiopulmonary arrest. The present study investigates outcomes with respect to cardiopulmonary arrest rates in institutions with and without rapid response systems (RRSs) and the current level of cardiopulmonary arrest rate in tertiary hospitals. METHODS: This was a retrospective study based on data from 14 tertiary hospitals. Cardiopulmonary resuscitation (CPR) rate reports were obtained from each hospital to include the number of cardiopulmonary arrest events in adult patients in the general ward, the annual adult admission statistics, and the structure of the RRS if present. RESULTS: Hospitals with RRSs showed a statistically significant reduction of the CPR rate between 2013 and 2015 (odds ratio [OR], 0.731; 95% confidence interval [CI], 0.577 to 0.927; P = 0.009). Nevertheless, CPR rates of 2013 and 2015 did not change in hospitals without RRS (OR, 0.988; 95% CI, 0.868 to 1.124; P = 0.854). National university-affiliated hospitals showed less cardiopulmonary arrest rate than private university-affiliated in 2015 (1.92 vs. 2.40; OR, 0.800; 95% CI, 0.702 to 0.912; P = 0.001). High-volume hospitals showed lower cardiopulmonary arrest rates compared with medium-volume hospitals in 2013 (1.76 vs. 2.63; OR, 0.667; 95% CI, 0.577 to 0.772; P < 0.001) and in 2015 (1.55 vs. 3.20; OR, 0.485; 95% CI, 0.428 to 0.550; P < 0.001). CONCLUSIONS: RRSs may be a feasible option to reduce the CPR rate. The discrepancy in cardiopulmonary arrest rates suggests further research should include a nationwide survey to tease out factors involved in in-hospital cardiopulmonary arrest and differences in outcomes based on hospital characteristics.
Subject(s)
Adult , Humans , Cardiopulmonary Resuscitation , Heart Arrest , Hospitals, High-Volume , Incidence , Motivation , Patient Safety , Patients' Rooms , Pilot Projects , Quality of Health Care , Retrospective Studies , Tertiary Care CentersABSTRACT
BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) II model has been widely used in Korea. However, there have been few studies on the APACHE IV model in Korean intensive care units (ICUs). The aim of this study was to compare the ability of APACHE IV and APACHE II in predicting hospital mortality, and to investigate the ability of APACHE IV as a critical care triage criterion. METHODS: The study was designed as a prospective cohort study. Measurements of discrimination and calibration were performed using the area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow goodness-of-fit test respectively. We also calculated the standardized mortality ratio (SMR). RESULTS: The APACHE IV score, the Charlson Comorbidity index (CCI) score, acute respiratory distress syndrome, and unplanned ICU admissions were independently associated with hospital mortality. The calibration, discrimination, and SMR of APACHE IV were good (H = 7.67, P = 0.465; C = 3.42, P = 0.905; AUROC = 0.759; SMR = 1.00). However, the explanatory power of an APACHE IV score >93 alone on hospital mortality was low at 44.1%. The explanatory power was increased to 53.8% when the hospital mortality was predicted using a model that considers APACHE IV >93 scores, medical admission, and risk factors for CCI >3 coincidentally. However, the discriminative ability of the prediction model was unsatisfactory (C index <0.70). CONCLUSIONS: The APACHE IV presented good discrimination, calibration, and SMR for hospital mortality.
Subject(s)
APACHE , Calibration , Cohort Studies , Comorbidity , Critical Care , Discrimination, Psychological , Hospital Mortality , Intensive Care Units , Korea , Mortality , Prospective Studies , Respiratory Distress Syndrome , Risk Factors , ROC Curve , Tertiary Care Centers , TriageABSTRACT
BACKGROUND: Early recognition of the signs and symptoms of clinical deterioration could diminish the incidence of cardiopulmonary arrest. The present study investigates outcomes with respect to cardiopulmonary arrest rates in institutions with and without rapid response systems (RRSs) and the current level of cardiopulmonary arrest rate in tertiary hospitals. METHODS: This was a retrospective study based on data from 14 tertiary hospitals. Cardiopulmonary resuscitation (CPR) rate reports were obtained from each hospital to include the number of cardiopulmonary arrest events in adult patients in the general ward, the annual adult admission statistics, and the structure of the RRS if present. RESULTS: Hospitals with RRSs showed a statistically significant reduction of the CPR rate between 2013 and 2015 (odds ratio [OR], 0.731; 95% confidence interval [CI], 0.577 to 0.927; P = 0.009). Nevertheless, CPR rates of 2013 and 2015 did not change in hospitals without RRS (OR, 0.988; 95% CI, 0.868 to 1.124; P = 0.854). National university-affiliated hospitals showed less cardiopulmonary arrest rate than private university-affiliated in 2015 (1.92 vs. 2.40; OR, 0.800; 95% CI, 0.702 to 0.912; P = 0.001). High-volume hospitals showed lower cardiopulmonary arrest rates compared with medium-volume hospitals in 2013 (1.76 vs. 2.63; OR, 0.667; 95% CI, 0.577 to 0.772; P < 0.001) and in 2015 (1.55 vs. 3.20; OR, 0.485; 95% CI, 0.428 to 0.550; P < 0.001). CONCLUSIONS: RRSs may be a feasible option to reduce the CPR rate. The discrepancy in cardiopulmonary arrest rates suggests further research should include a nationwide survey to tease out factors involved in in-hospital cardiopulmonary arrest and differences in outcomes based on hospital characteristics.
Subject(s)
Adult , Humans , Cardiopulmonary Resuscitation , Heart Arrest , Hospitals, High-Volume , Incidence , Motivation , Patient Safety , Patients' Rooms , Pilot Projects , Quality of Health Care , Retrospective Studies , Tertiary Care CentersABSTRACT
BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) II model has been widely used in Korea. However, there have been few studies on the APACHE IV model in Korean intensive care units (ICUs). The aim of this study was to compare the ability of APACHE IV and APACHE II in predicting hospital mortality, and to investigate the ability of APACHE IV as a critical care triage criterion. METHODS: The study was designed as a prospective cohort study. Measurements of discrimination and calibration were performed using the area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow goodness-of-fit test respectively. We also calculated the standardized mortality ratio (SMR). RESULTS: The APACHE IV score, the Charlson Comorbidity index (CCI) score, acute respiratory distress syndrome, and unplanned ICU admissions were independently associated with hospital mortality. The calibration, discrimination, and SMR of APACHE IV were good (H = 7.67, P = 0.465; C = 3.42, P = 0.905; AUROC = 0.759; SMR = 1.00). However, the explanatory power of an APACHE IV score >93 alone on hospital mortality was low at 44.1%. The explanatory power was increased to 53.8% when the hospital mortality was predicted using a model that considers APACHE IV >93 scores, medical admission, and risk factors for CCI >3 coincidentally. However, the discriminative ability of the prediction model was unsatisfactory (C index <0.70). CONCLUSIONS: The APACHE IV presented good discrimination, calibration, and SMR for hospital mortality.
Subject(s)
APACHE , Calibration , Cohort Studies , Comorbidity , Critical Care , Discrimination, Psychological , Hospital Mortality , Intensive Care Units , Korea , Mortality , Prospective Studies , Respiratory Distress Syndrome , Risk Factors , ROC Curve , Tertiary Care Centers , TriageABSTRACT
We found an error in this article. The author's name should be corrected as following: from "Younsuk Koh" to "Younsuck Koh".
ABSTRACT
There is no well-stated practical guideline for mechanically ventilated patients with or without acute respiratory distress syndrome (ARDS). We generate strong (1) and weak (2) grade of recommendations based on high (A), moderate (B) and low (C) grade in the quality of evidence. In patients with ARDS, we recommend low tidal volume ventilation (1A) and prone position if it is not contraindicated (1B) to reduce their mortality. However, we did not support high-frequency oscillatory ventilation (1B) and inhaled nitric oxide (1A) as a standard treatment. We also suggest high positive end-expiratory pressure (2B), extracorporeal membrane oxygenation as a rescue therapy (2C), and neuromuscular blockage for 48 hours after starting mechanical ventilation (2B). The application of recruitment maneuver may reduce mortality (2B), however, the use of systemic steroids cannot reduce mortality (2B). In mechanically ventilated patients, we recommend light sedation (1B) and low tidal volume even without ARDS (1B) and suggest lung protective ventilation strategy during the operation to lower the incidence of lung complications including ARDS (2B). Early tracheostomy in mechanically ventilated patients can be performed only in limited patients (2A). In conclusion, of 12 recommendations, nine were in the management of ARDS, and three for mechanically ventilated patients.