Impact of medical crisis on the critical care system in South Korea

The COVID-19 crisis has highlighted the importance of intensive care units (ICUs) but also caveats, including limited space and staffing. Structuring the future critical care system on an international scale is crucial. The number of critical care beds available varies widely between countries. In Europe, there is an average of 11·5 hospital beds per 100 000 inhabitants dedicated to critical care, compared with 28 beds per 100 000 in 2010 in the USA.1Carr BG Addyson DK Kahn JM Variation in critical care beds per capita in the United States: implications for pandemic and disaster planning.JAMA. 2010; 303: 1371-1372Crossref PubMed Scopus (54) Google Scholar Although a negative correlation between number of ICU beds and mortality has been reported,2Wunsch H Angus DC Harrison DA et al.Variation in critical care services across North America and western Europe.Crit Care Med. 2008; 36 (e1–9.): 2787-2793Crossref PubMed Scopus (445) Google Scholar such a relationship might be explained by differences in demographics and severity of illness.3Wunsch H Angus DC Harrison DA Linde-Zwirble WT Rowan KM Comparison of medical admissions to intensive care units in the United States and United Kingdom.Am J Respir Crit Care Med. 2011; 183: 1666-1673Crossref PubMed Scopus (166) Google Scholar Gaudart and colleagues4Gaudart J Landier J Huiart L et al.Factors associated with the spatial heterogeneity of the first wave of COVID-19 in France: a nationwide geo-epidemiological study.Lancet Public Health. 2021; 6: e222-e231Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar reported no regional correlation between number of ICU beds and mortality in patients with COVID-19 in France. Improving the quality of critical care requires more focus on ICU care organisation, rather than simply increasing the number of ICU beds. First, the versatility of physicians (eg, anaesthesiologists, cardiologists, and surgeons) trained in critical care and able to practice in ICU is a major asset. For example, during the first COVID-19 wave in France, 7148 patients who required ICU-level care were hospitalised, which greatly exceeded the usual capacity of 5432 ICU beds. The ability to increase capacity for high-level care was made possible largely through a 65% increase in medical critical care manpower, which included physicians and residents in anaesthesiology with complete training in intensive care. This versatility also applies to nurses. As such, intensive care training is a crucial aspect of medical and nursing training and should be a component of continuing education across all specialties, rather than limited to physicians in a specific few specialties. Second, the COVID-19 pandemic has taught us to take advantage of many hospital sites outside the conventional ICU environment, to develop spaces similar to ICUs—so-called ephemeral ICUs—in case there is overflow from permanent ICUs. Rapid conversion and use of these spaces allowed for the expansion of ICU capacity by 50–95% within a few weeks in 2020.5Peters AW Chawla KS Turnbull ZA Transforming ORs into ICUs.N Engl J Med. 2020; 382: e52Crossref PubMed Scopus (68) Google Scholar Interestingly, although these spaces were not originally designed to support critical care, Taccone and colleagues6Taccone FS Van Goethem N De Pauw R et al.The role of organizational characteristics on the outcome of COVID-19 patients admitted to the ICU in Belgium.Lancet Reg Health Eur. 2021; 2100019Summary Full Text Full Text PDF Scopus (42) Google Scholar found no correlation between mortality and the ratio of newly created ICU beds to the total number of ICU beds. A clear strategy for converting and mobilising emergency ICU spaces should now be required in high-volume hospitals. Third, efforts to identify severe cases before they become life-threatening are urgently needed. Improved monitoring and implementation of artificial intelligence devices to facilitate early detection of patients at risk of severe disease, systems to call for help, and rapid response teams need to be integrated in hospital and patient workflows to streamline ICU admissions.7Vincent JL The continuum of critical care.Crit Care. 2019; 23: 122Crossref PubMed Scopus (17) Google Scholar Fourth, the pandemic has triggered initiatives to improve ICU triage efforts and ethical considerations that have a major emotional impact on the population. Resource-driven triage decisions are uncommon in North America, but are more frequent in Europe. These policies warrant further research and could be standardised for all ICUs. Guidelines reinforce the importance of establishing realistic goals for the care of critically ill patients by focusing on patient-reported outcome measures (PROMs) and instituting end-of-life care when indicated. Finally, standardisation of these ICU policies should be considered on an international scale: more homogeneity in critical care system organisation, drug procurement policies, and medical education could enable proper resource and workforce distribution to ensure improved management of future international health-care crises. Although it might seem intuitive to define ICU capacity purely by number of beds, it is crucial to consider it in terms of ICU admission streamlining, staffing, and flexibility of other hospital spaces. We declare no competing interests.

The goal of critical care is to reverse patients’ acute problems in effective and ethical ways with minimum costs. Unlike in other medical fields, the quality of Korean critical care has lagged behind that of advanced countries. Moreover, the level of critical care quality differs significantly between university hospitals. The suboptimal critical care level has multifactorial causes. The major challenge to Korean intensivists is, therefore, how to overcome barriers in the current critical care delivery system to improve outcomes for critically ill patients and reduce medical errors in error-prone Intensive Care Unit (ICUs). A long-term task force including all stakeholders should address the multifactorial barriers to better outcomes. The Korean Society of Critical Care Medicine should perform the central role to dismantle the barriers step by step with a long-term vision for a desirable critical care delivery system in our society. A capable critical care team with full-time intensivists is the most urgent requirement for proper, timely care in ICUs. Intensivists should focus on basic but essential management so scarcity of resources can be minimized. Publicity about ICU to the general public is also urgently required to draw the attention of medical policy makers to the current suboptimal level of our critical care system.

Keeping Patients Safe During Intrahospital Transport

Critical care is an expensive and limited resource in the United States. Estimates from more than a decade ago suggest that over $100 billion a year is spent on critical care services.1 Over the past two decades, the number of patients presenting to the Emergency Department (ED) requiring critical care services has increased at a much higher rate than the growth in overall ED volume.2,3 The proportion of ED patients requiring Intensive Care Unit (ICU) admission has increased 75% over the first decade of the twenty-first century. In addition to the increase in the absolute number of patients requiring critical care admission, the ED length of stay for critically ill patients increased by 60 minutes. This resulted in a total nationwide increase in critical care provided in the ED by more than threefold. This disproportionate increase in critical care time reflects both the increase in critical care volume and the increase in ED boarding of critically ill patients. Data from 2008 reported the median boarding time for a patient waiting in the ED for an ICU bed was more than 5 hours, and 30% of patients waited more than 6 hours for an ICU bed.2,3 This article is protected by copyright. All rights reserved.

Women as a Growing Force in Critical Care Medicine-the Journal, Profession, and Society.

Psychiatric management of Patients in intensive care units.

First, Do No Harm: Less Training ≠ Quality Care

The Impact of Family Engagement on Anxiety Levels in a Cardiothoracic Intensive Care Unit.

When considering the establishment of the Korean Society of Critical Care Medicine (KSCCM) in 1980, the beginning of intensive care in Korea was not behind the time. However, the level of our intensive care quality lags behind that of advanced countries. The unreasonable reimbursement system in Korea for required critical care costs staggers critical care development, along with the full time intensivist shortage problem in intensive care units (ICUs). Currently, the reimbursement rates are estimated to support around 30~50% of the cost. Due to our odd critical care reimbursement system, the more financial losses for intensive care occur, the better critical care is conducted by enhancing critical care delivery system, such as the nurse-to-bed ratio. This inappropriate critical care delivery system results in poor outcomes for our critically ill patients. Critically ill patients present many diagnostic and therapeutic problems. The need to cope with those complicated patients' problems has evolved over the last four decades into a critical care subspecialty in Western countries. The KSCCM has been the only organization in Korea that represents all professional components for critical care. After the 6 year long discussion with other related medical societies, the KSCCM launched the critical care subspecialty board under the auspice of the Korean Academy of Medical Societies on April 15th, 2008. After reviewing the applicants' carriers in critical care and their research achievements, 1,040 critical care subspecialties were born this February. Their primary specialties include Anesthesiology, Emergency Medicine, Internal Medicine, Neurology, Neurosurgery, Pediatrics, Surgery, and Thoracic Surgery. 91.7% of them are university hospital faculty members and they should renew their critical care subspecialty in every 5 years. The required items for the renewal are not easily fulfilled without working as a critical care physician. The structured critical care training program began in designated training hospitals on March 1st, 2009. Over the past few decades, the activities of intensive care units have considerably changed. Recent advances in critical care technology facilitate early detection of patients' problems. Much clinical information derived through research has been evolved as bundles of clinical managements for the indicated patients. The evidences of clinical researches show that the right application of the recommended management bundles at the right time improves patient outcomes. Therefore, the meaning of the critical care subspecialty is to perform the right care at the right time for critically ill patients. We think that the implementation of the critical care specialty and of core critical care education and training system can significantly enhance quality of critical care and patient outcomes. In order to achieve these goals, the critical care delivery system should be urgently enhanced. The enhancement includes the right compensation of critical care cost and the correction of the absurd medical law, ruling on our ICU care. The KSCCM will continuously offer a variety of activities that promote excellence in patient care, education, critical care delivery system, research, and collaboration with other countries' critical care societies. It is our hope that all critically ill patients should receive professional and humane care in Korean ICUs and the inappropriately designed health care system should not jeopardize patients' health.

Fifty Years of Critical Care Medicine: The Editors' Perspective.

Postoperative care: who should look after patients following surgery?

Meeting the needs of patients' family members becomes an essential part of responsibilities of intensive care unit physicians. The aim of this study was to evaluate the satisfaction of patients' family members using the Arabic version of the Society of Critical Care Medicine's Family Needs Assessment questionnaire and to assess the predictors of family satisfaction using the classification and regression tree method. The authors conducted a prospective study. This study was conducted at a 12-bed medical intensive care unit in Morocco. Family representatives (n = 194) of consecutive patients with a length of stay >48 hrs were included in the study. Intervention was the Society of Critical Care Medicine's Family Needs Assessment questionnaire. Demographic data for relatives included age, gender, relationship with patients, education level, and intensive care unit commuting time. Clinical data for patients included age, gender, diagnoses, intensive care unit length of stay, Acute Physiology and Chronic Health Evaluation, MacCabe index, Therapeutic Interventioning Scoring System, and mechanical ventilation. The Arabic version of the Society of Critical Care Medicine's Family Needs Assessment questionnaire was administered between the third and fifth days after admission. Of family representatives, 81% declared being satisfied with information provided by physicians, 27% would like more information about the diagnosis, 30% about prognosis, and 45% about treatment. In univariate analysis, family satisfaction (small Society of Critical Care Medicine's Family Needs Assessment questionnaire score) increased with a lower family education level (p = .005), when the information was given by a senior physician (p = .014), and when the Society of Critical Care Medicine's Family Needs Assessment questionnaire was administered by an investigator (p = .002). Multivariate analysis (classification and regression tree) showed that the education level was the predominant factor contributing to the Society of Critical Care Medicine's Family Needs Assessment questionnaire score. Society of Critical Care Medicine's Family Needs Assessment questionnaire increased (greater satisfaction) with a higher education level. Other factors of great satisfaction included the senior physician providing the information, and Acute Physiology and Chronic Health Evaluation <15. Satisfaction of intensive care unit patients' families in a Moroccan sample using the classification and regression tree was dependent on relatives' education level, communication presented by senior caregiver, and low Acute Physiology and Chronic Health Evaluation score. These data underline cultural specificities of the study and suggest that caregivers should develop structured communication programs considering satisfaction predictors.

As early as August 1974, "organ failure resuscitation ward" for critically ill patients with cardiac, respiratory or renal failure had appeared as independent medical units in China. In 1980s, the discipline of critical care medicine had experienced a rapid development, shown its superiority in both daily health care and public health emergency, also its status in the academy of medicine. On September 4th, 1989, the World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM) accepted the Chinese Association of Integrative Medicine, Society of Critical Care Medicine (TCMWMCSCCM) as an official member. In November 1989, the former State Scientific and Technological Commission approved the establishment of Critical Care Medicine in Tianjin, the first journal in the very field in China, indicating that Chinese critical care medicine has been officially accepted by the international academia and its academic status has been determined. In September 1997, the Chinese Association of Pathophysiology organized the Chinese Society of Critical Care Medicine. In March 2005, the Chinese Medical Association organized the Chinese Society of Critical Care Medicine had found. In July 2009, Chinese Association of Critical Care Physicians had found under the Chinese Medical Doctor Association. In 2008, Critical Care Medicine had been defined as secondary clinical discipline (Subject code 320.58) by Standardization Administration of the People's Republic of China. In 2009, it was listed in the first clinical discipline (Code 28). In 2001, Chinese Society of Critical Care Medicine under the Chinese Association of Pathophysiology had officially joined the WFSICCM and the Asia Pacific Association of Critical Care Medicine (APACCM), and became a member in both councils. Between 2006 and 2010, Chinese Society of Critical Care Medicine under the Chinese Association of Pathophysiology had become the presidency and member in APACCM, WFSICCM and Global Sepsis Alliance (GSA), respectively. So far, there are a number of critical care physicians from China serve as a member in international academic organizations. In ESICM LIVES 2012, held in Lisbon, Portugal, the Chinese Society of Critical Care Medicine under the Chinese Association of Pathophysiology was invited on behalf of China and gave lectures, showing the elegant demeanor of Chinese scholars. Since 2013, the Annual Congress of Chinese Society of Critical Care Medicine has set up the China-USA Joint forum and China-Europe forum. In 2018, the Chinese Society of Critical Care Medicine started a series of "Belt and Road" academic activities, signed the cooperation agreement with 18 academic community of critical care medicine from respective countries or districts along the Belt and Road, and established a long-term relation of communication and cooperation, indicating that Chinese critical care medicine has intensively participated in international communication and integration. Year 2019 is the 40th year of Chinese construction and development in critical care medicine. Today, Chinese critical care medicine is taking off. It has developed rapidly on a brand-new level, advanced on the highway of professional and standardized development, achieved a series of development and won the praise of peers around the world. Since the establishment of Chinese Society of Critical Care Medicine in March 2005, the scale of annual congresses has expanded year by year, participants increased from mere 1 000 to more than 15 000, contributions increased from hundreds to thousands, exhibiting the prosperity of Chinese critical care medicine. Meanwhile, the society has published guideline series, technical specifications and academic yearbooks, implemented Chinese Critical Care Certified Course (5C training), carried out the continue education program and grassroot education activities, set up the "lifetime achievement award", etc., to promote continuous progress and development in Chinese critical care medicine. The Chinese Association of Critical Care Physicians has greatly contributed to the promotion in critical care specialist training, also push forward the progress. In August 2018, department of critical care medicine was selected in the second batch of standardized training bases for specialists, and began recruitment in both medical and surgical critical care medicine in March 2019. The future of Chinese critical care medicine requires us to make clear the developmental blueprint of the discipline, to persevere with integration and innovation, and to meet the needs of society. Efficient and normative systems are also required in the discipline construction, talent cultivation, diagnosis and treatment system, academic construction, and intelligent application of network data. Particularly, we should vigorously carry out and promote the homogenization of critical care specialist training for talent resources reservation. We should actively promote the establishment of clinical research platforms for critical care medicine, encourage and support multicenter clinical researches. We should promote multi-channel communication in the field at home and abroad, expand the international influence of Chinese critical care medicine step by step, to promote the sustainable development of Chinese critical care medicine, to explore further forefront of modern medicine, to promote greater contribution to human health.

Critical care and the global burden of critical illness in adults

Although respiratory care is a relatively new profession, its practitioners are deeply involved in providing patient care in the critical care. In preparation for writing this article, we sought to explore the respiratory therapy manpower needs and activities designed to fulfill those needs in critical care practice. We began by delineating the historical development of respiratory care as a profession, the development of its education, and the professional credentialing system. We then conducted several literature reviews with few articles generated. We requested and received data from the American Association for Respiratory Care (AARC), The National Board for Respiratory Care (NBRC), and the Committee on Accreditation of Respiratory Care education (CoARC) relative to their membership, number of credentialed individuals, and educational program student and graduate data for 2000 through 2004. We then conducted two electronic surveys. Survey 1 was a six-item survey that examined the use of mandatory overtime in respiratory care departments. We used a convenience sample of 30 hospitals stratified by size (<or=200 beds, 201-499 beds, >or=500 beds). Survey 2 was a five-item instrument distributed by blast E-mail to the Society of Critical Care Medicine's Respiratory Care Section members and members of the RC_World list serve. This survey elicited 51 usable and non-duplicative responses from geographically and size-varied institutions. We analyzed these data in several ways from distribution analysis to one-way analysis of variance procedure and appropriate post hoc analysis techniques. Where appropriate, a matched-pairs analysis was performed and these were compared across the variables intensive care unit (ICU) beds per actual number of respiratory care practitioners (RCPs) and ICU beds per preferred number of RCPs. The data gathered from the professional organizations indicated a relatively stable attrition rate (35.2%+/-1.7-3.1%), even in the face of varying enrollments (6,231 in 2004 vs. 4,589 in 2002). In survey 1, we looked at the institution of mandatory overtime policies and their use in 30 size-stratified hospitals. Mandatory overtime was selected as a survey topic under the supposition that manpower shortages might lead to the development of such procedures and also to their utilization. Fourteen of the 30 hospitals responding indicated that they had a policy addressing mandatory over time. Of the 14 hospitals with policies, only ten had disciplinary actions specific to refusing the overtime. Seven of the 30 hospitals indicated that they used mandatory overtime monthly of more frequently. Survey 2 data revealed that there was a wide variation in bed size, number of ICUs, and number of RCP staff assigned to the ICU. Serendipitously, our 51 responding centers were distributed among small (16), medium (19), and large (16) hospitals in a manner that appeared to reflect the national distribution pattern. We were able to use these data to develop a closeness of fit diagram ICU beds to preferred numbers of RCPs (DF=48; p<.0001; RSq=0.77; RMSE=4.114). The number of beds per preferred number of RCPs was 9.445 to 1.0 while the actual bed to RCP ratio was 10.75 to 1. This article provides a short history of the development of respiratory care and its historical relationship with critical care. We have, perhaps for the first time, provided a unified data set of key demographic information from the three professional bodies guiding the development of the respiratory therapy profession. This data set provides time-linked data on admissions and graduations from the CoARC, membership numbers for the AARC, and the numbers of active credentialed RCP from the NBRC. By two focused surveys, we were able to show that while mandatory overtime is a common practice in respiratory care departments, it was not overwhelming utilized. We also learned that in most hospitals, regardless of bed size, there is a perceived need for 1.3 RCPs more than the actual staff and that it appears that the critical staffing level between actual to preferred RCP to beds is between 9 and 11 beds.