Youlim Kim

Effectiveness Analysis of a Part-time Rapid Response System During Operation Versus Nonoperation*

Objectives: To evaluate the effect of a part-time rapid response system on the occurrence rate of cardiopulmonary arrest by comparing the times of rapid response system operation versus nonoperation. Design: Retrospective cohort study. Setting: A 1,360-bed tertiary care hospital. Patients: Adult patients admitted to the general ward were screened. Data were collected over 36 months from rapid response system implementation (October 2012 to September 2015) and more than 45 months before rapid response system implementation (January 2009 to September 2012). Interventions: None. Measurements and Main Results: The rapid response system operates from 7 AM to 10 PM on weekdays and from 7 AM to 12 PM on Saturdays. Primary outcomes were the difference of cardiopulmonary arrest incidence between pre-rapid response system and post-rapid response system periods and whether the rapid response system operating time affects the cardiopulmonary arrest incidence. The overall cardiopulmonary arrest incidence (per 1,000 admissions) was 1.43. Although the number of admissions per month and case-mix index were increased (3,555.18 vs 4,564.72, p < 0.001; 1.09 vs 1.13, p = 0.001, respectively), the cardiopulmonary arrest incidence was significantly decreased after rapid response system (1.60 vs 1.23; p = 0.021), and mortality (%) was unchanged (1.38 vs 1.33; p = 0.322). After rapid response system implementation, the cardiopulmonary arrest incidence significantly decreased by 40% during rapid response system operating times (0.82 vs 0.49/1,000 admissions; p = 0.001) but remained similar during rapid response system nonoperating times (0.77 vs 0.73/1,000 admissions; p = 0.729). Conclusions: The implementation of a part-time rapid response system reduced the cardiopulmonary arrest incidence based on the reduction of cardiopulmonary arrest during rapid response system operating times. Further analysis of the cost effectiveness of part-time rapid response system is needed.

Evaluation of the SpO2/FiO2 ratio as a predictor of intensive care unit transfers in respiratory ward patients for whom the rapid response system has been activated

Efforts to detect patient deterioration early have led to the development of early warning score (EWS) models. However, these models are disease-nonspecific and have shown variable accuracy in predicting unexpected critical events. Here, we propose a simpler and more accurate method for predicting risk in respiratory ward patients. This retrospective study analyzed adult patients who were admitted to the respiratory ward and detected using the rapid response system (RRS). Study outcomes included transfer to the intensive care unit (ICU) within 24 hours after RRS activation and in-hospital mortality. Prediction power of existing EWS models including Modified EWS (MEWS), National EWS (NEWS), and VitalPAC EWS (ViEWS) and SpO2/FiO2 (SF) ratio were compared to each other using the area under the receiver operating characteristic curve (AUROC). Overall, 456 patients were included; median age was 75 years (interquartile range: 65–80) and 344 (75.4%) were male. Seventy-three (16.0%) and 79 (17.3%) patients were transferred to the ICU and died. The SF ratio displayed better or comparable predictive accuracy for unexpected ICU transfer (AUROC: 0.744) compared to MEWS (0.744 vs. 0.653, P = 0.03), NEWS (0.744 vs. 0.667, P = 0.04), and ViEWS (0.744 vs. 0.675, P = 0.06). For in-hospital mortality, although there was no statistical difference, the AUROC of the SF ratio (0.660) was higher than that of each of the preexisting EWS models. In comparison with the preexisting EWS models, the SF ratio showed better or comparable predictive accuracy for unexpected ICU transfers in the respiratory wards.

Transcultural Adaptation and Validation of Quality of Dying and Death Questionnaire in Medical Intensive Care Units in South Korea

Background Providing palliative care to dying patients in the intensive care unit (ICU) has recently received much attention. Evaluating the quality of dying and death (QODD) is important for appropriate comfort care in the ICU. This study aimed to validate the Korean version of the QODD questionnaire. Methods This study included decedents in the ICUs of three tertiary teaching hospitals and one secondary hospital from June 2016 to May 2017. ICU staff members were asked to complete the translated QODD questionnaire and the visual analogue scale (VAS) questionnaire within 48 hours of patient death. The validation process consisted of evaluating construct validity, internal consistency, and interrater reliability. Results We obtained 416 completed questionnaires describing 255 decedents. The QODD score was positively correlated with the 100-VAS score (Pearson correlation coefficient, 0.348; P<0.001). An evaluation of the internal consistency presented favorable results (calculated Cronbach’s alpha if a given item exceeded 0.8 in all items). The interrater reliability revealed no concordance between doctors and nurses. Conclusions The QODD questionnaire was successfully translated and validated in Korean medical ICUs. We hope further studies that use this valuable instrument will be conducted in Korea.

Case Selection Is a Fundamental Prerequisite to the Successful Surmounting of Learning Curve of Laparoscopic Radical Hysterectomy in Early-Stage Cervical Cancer: A Matched-Case Comparison in a Single Institution.

Study Objective: To identify the lengthiest step TLH in a teaching hospital and determine which clinical factors affect the duration of this step. Design: Retrospective case series. Setting: The University of Louisville Hospital. Patients: Women undergoing an elective TLH for benign disease from January 2010 to April 2014. Intervention: TLHwas divided into five steps: (1) insertion of laparoscopic ports and adhesiolysis to restoration of normal anatomy; (2) identification of the ureter, resection of adnexal structures to transection of the round ligament; (3) transection of the round ligament to transection of the uterine artery; (4) lateralization of the uterine vessel pedicle to completion of colpotomy; and (5) completion of vaginal cuff closure. The random intercept and slope model was used to identify the lengthiest step of TLH, and the backward elimination procedure was used to evaluate which clinical factors affect this step. Measurements and Main Results: A total of 490 benign TLHs were performed; 399 recordings were identified. Of these, 264 were incomplete and excluded. The remaining 135 complete recordings were reviewed. Mean total length of TLH was 81 minutes (SD=30). The lengthiest step was colpotomy with mean duration of 24 minutes (SD=13). Uterine weight significantly increased the length of time required for colpotomy (p=.001). The primary energy source (ultrasonic scalpel vs. monopolar hook) used to perform colpotomy did not influence the length of time (p=.539, p=.583). Uterine weight (p\.001) and adhesiolysis (p=.003) significantly increased total time of TLH. Conclusion: At a teaching institution where surgeries are performed by residents and fellows, colpotomy is the lengthiest step of TLH and is influenced by uterine weight. This finding may reflect the training levels of the surgeons and the learning curve associated with these steps. Further research should focus upon simulation models and/or tools for colpotomy to increase efficiency in the operating room.