Impact of institutional case volume on intensive care unit mortality

The primary aim of this review is to explore current knowledge on the relationship between institutional intensive care unit (ICU) patient volume and patient outcomes. Studies indicate that a higher institutional ICU patient volume is positively correlated with patient survival. Although the exact mechanism underlying this association remains unclear, several studies have proposed that the cumulative experience of physicians and selective referral between institutions may play a role. The overall ICU mortality rate in Korea is relatively high compared to other developed countries. A distinctive aspect of critical care in Korea is the existence of significant disparities in the quality of care and services provided across regions and hospitals. Addressing these disparities and optimizing the management of critically ill patients necessitates thoroughly trained intensivists who are well-versed in the latest clinical practice guidelines. A fully functioning unit with adequate patient throughput is also essential for maintaining consistent and reliable quality of patient care. However, the positive impact of ICU volume on mortality outcomes is also linked to complex organizational factors, such as multidisciplinary rounds, nurse staffing and education, the presence of a clinical pharmacist, care protocols for weaning and sedation, and a culture of teamwork and communication. Despite some inconsistencies in the association between ICU patient volume and patient outcomes, which are thought to arise from differences in healthcare systems, ICU case volume significantly affects patient outcomes and should be taken into account when formulating related healthcare policies

Changes in the incidence of cardiopulmonary resuscitation before and after implementation of the Life-Sustaining Treatment Decisions Act

Background The Life-Sustaining Treatment (LST) Decisions Act allows withholding and withdrawal of LST, including cardiopulmonary resuscitation (CPR). In the present study, the incidence of CPR before and after implementation of the Act was compared. Methods This was a retrospective review involving hospitalized patients who underwent CPR at a single center between February 2016 and January 2020 (pre-implementation period, February 2016 to January 2018; post-implementation period, February 2018 to January 2020). The primary outcome was monthly incidence of CPR per 1,000 admissions. The secondary outcomes were duration of CPR, return of spontaneous circulation (ROSC) rate, 24-hour survival rate, and survival-to-discharge rate. The study outcomes were compared before and after implementation of the Act. Results A total of 867 patients who underwent CPR was included in the analysis. The incidence of CPR per 1,000 admissions showed no significant difference before and after implementation of the Act (3.02±0.68 vs. 2.81±0.75, P=0.255). The ROSC rate (67.20±0.11 vs. 70.99±0.12, P=0.008) and survival to discharge rate (20.24±0.09 vs. 22.40±0.12, P=0.029) were higher after implementation of the Act than before implementation. Conclusions The incidence of CPR did not significantly change for 2 years after implementation of the Act. Further studies are needed to assess the changes in trends in the decisions of CPR and other LSTs in real-world practice

Institutional case volume and mortality after aortic and mitral valve replacement: a nationwide study in two Korean cohorts

Background : There are only a handful of published studies regarding the volume-outcome relationship in heart valve surgery. We evaluated the association between institutional case volume and mortality after aortic valve replacement (AVR) and mitral valve replacement (MVR). Methods : Two separate cohorts of all adults who underwent AVR or MVR, respectively, between 2009 and 2016 were analyzed using a Korean healthcare insurance database. Hospitals performing AVRs were divided into three groups according to the average annual case volume: the low- ( 70 cases/year). Hospitals performing MVRs were also grouped as the low- ( 40 cases/year). In-hospital mortality after AVR or MVR were compared among the groups. Results : In total, 7875 AVR and 5084 MVR cases were analyzed. In-hospital mortality after AVR was 8.3% (192/2318), 4.0% (84/2102), and 2.6% (90/3455) in the low-, medium-, and high-volume centers, respectively. The adjusted risk was higher in the low- (OR 2.31, 95% CI 1.73–3.09) and medium-volume centers (OR 1.53, 95% CI 1.09–2.15) compared to the high-volume centers. In-hospital mortality after MVR was 9.3% (155/1663), 6.3% (94/1501), and 2.9% (56/1920) in the low-, medium-, and high-volume centers, respectively. Compared to the high-volume centers, the medium- (OR 1.97, 95% CI 1.35–2.88) and low-volume centers (OR 2.29, 95% CI 1.60–3.27) showed higher adjusted risk of in-hospital mortality. Conclusions : Lower case volume is associated with increased in-hospital mortality after AVR and MVR. The results warrant a comprehensive discussion regarding regionalization/centralization of cardiac valve replacements to optimize patient outcomes

Impact of institutional case volume of solid organ transplantation on patient outcomes and implications for healthcare policy in Korea

Solid organ transplantation is distinguished from other high-risk surgical procedures by the fact that it utilizes an extremely limited and precious resource and requires a multidisciplinary team approach. For several decades, institutional experience, as quantified by center volume, has been shown to be strongly associated with patient outcomes and graft survival after solid organ transplantation. The United States has implemented a minimum case volume requirement and performance standards for accreditation as a validated transplantation center. Solid organ transplantation in Europe is also governed by the European Union, which monitors patient outcomes and organ allocation. The number of solid organ transplantation cases in Korea is increasing, with patient outcomes comparable to international standards. However, Korea has outdated regulations regarding hospital facilities, and performance indicators including patient outcomes after transplantation are not monitored. Therefore, centers perform solid organ transplantation with no meaningful oversight. In this review, data regarding the impact of institutional case volume of kidney, liver, lung, and heart transplantation are summarized, followed by a description of current transplantation center regulations in the United States and Europe. The basis for the necessity of adequate transplantation center regulations in Korea is presented

Sympathetic stimulation increases the blood flow through the in situ right gastroepiploic artery graft after off-pump coronary artery bypass graft surgery

OBJECTIVE: The right gastroepiploic artery is gaining popularity as an in situ arterial graft for coronary artery bypass surgery. Unlike the internal thoracic artery, the right gastroepiploic artery is a visceral artery and has a vasoconstrictive tendency in response to sympathetic stimulation. We hypothesized that blood flow through the in situ right gastroepiploic arterial graft might be compromised after sympathetic stimulation. METHODS: Thirty patients scheduled for off-pump coronary artery bypass surgery using the left internal thoracic artery and the right gastroepiploic artery as in situ arterial grafts were enrolled. Blood flow through both arteries was measured by transit time flow before (T1), during (T2), and after noradrenalinee infusion (T3). RESULTS: After sympathetic stimulation, blood flow of both the right gastroepiploic artery (30.1+/-13.9 mL/min at T1 vs 36.2+/-17.5 mL/min at T2; P = 0.001) and left internal thoracic artery grafts (37.3+/-19.1 mL/min at T1 vs 41.8+/-18.2 mL/min at T2; P = 0.01) was increased significantly. However, blood flow in proportion to cardiac output increased only in the right gastroepiploic artery graft (P = 0.01). CONCLUSIONS: Sympathetic stimulation increases, rather than compromises, blood flow through the right gastroepiploic artery graft after coronary revascularization