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Review Article

Ethics
When ethics is not enough: institutional governance of critical care allocation under crisis conditions: Ho Kyung Sung, Ungki Jung, Kyungdo Lee; Acute Crit Care. 2026;41(2):213-225. Published online May 28, 2026; DOI: https://doi.org/10.4266/acc.001872

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Abstract PDF Supplementary Material

Ethical principles such as maximizing benefit, fairness, and procedural justice are frequently invoked in discussions on critical care resource allocation during public health emergencies. The coronavirus disease 2019 (COVID-19) pandemic, however, demonstrated that the mere presence of ethical principles does not ensure their operation in real-world crisis settings. In Lombardy and New York, allocation decisions defaulted to individual clinicians under extreme pressure. This review examines the institutional and governance prerequisites for ethical allocation of critical care resources during surge conditions. Rather than proposing normative allocation criteria, we analyze how ethical principles are translated—or fail to be translated—into practice through institutional arrangements. Using Ontario, Canada, as an empirical reference point, we conduct a comparative analysis of crisis standards of care, governance structures, regional coordination mechanisms, data infrastructures, and legal protections that support collective decision-making in critical care. We propose a multilevel analytical framework comprising three interdependent levels: national and governance, hospital and regional operations, and individual clinical application. Across international experiences, failures in critical care allocation arise when key functions are absent or misaligned across these levels, concentrating ethical, legal, and emotional burdens on frontline clinicians. Applying this framework to the Korean context, we identify structural gaps in crisis standard activation, governance authority, coordination mechanisms, and institutional decision-making capacity, indicating that ethical allocation is not solely a moral challenge, but a systems-level governance problem requiring institutional preparedness beyond ethical consensus.

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Towards Distributive Justice in Life-Sustaining Care: Navigating the Structural Determinants of Patient Preference
Ungki Jung, Ho Kyung Sung, Kyungdo Lee
Korean Journal of Medical Ethics.2026; 29(2): 99. CrossRef

Original Articles

Pulmonary
The Ability of the Acute Physiology and Chronic Health Evaluation (APACHE) IV Score to Predict Mortality in a Single Tertiary Hospital: Jae Woo Choi, Young Sun Park, Young Seok Lee, Yeon Hee Park, Chaeuk Chung, Dong Il Park, In Sun Kwon, Ju Sang Lee, Na Eun Min, Jeong Eun Park, Sang Hoon Yoo, Gyu Rak Chon, Young Hoon Sul, Jae Young Moon; Korean J Crit Care Med. 2017;32(3):275-283. Published online August 31, 2017; DOI: https://doi.org/10.4266/kjccm.2016.00990

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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.

Citations

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Physiology and health assessment, risk balance, and model for end-stage liver disease scores: Postoperative outcome of liver transplantation
Raquel Hohenreuther, Andresa Thomé Silveira, Edison Moraes Rodrigues Filho, Anderson Garcez, Bruna Goularth Lacerda, Sabrina Alves Fernandes, Claudio Augusto Marroni
World Journal of Transplantation.2025;[Epub] CrossRef
Ongoing crisis across the HIV care continuum: high mortality among PWH admitted to the ICU in an urban safety-net hospital in the South
Elisa M. Pichlinski, Kyle H. Saysana, Anna E. Moscowitz, Daniel N. Maxwell, Matthew J. Leveno, Helen L. King, Ank E. Nijhawan
AIDS Care.2025; 37(5): 802. CrossRef
Performance of ROX index in predicting reintubation rate of postextubation high-flow nasal cannula therapy in patients with hypercapnic respiratory failure
Suzan Salama, Doaa M. Magdy, Hamed F. Qenawy, Sahar R. Mahmoud
The Egyptian Journal of Chest Diseases and Tuberculosis.2025; 74(2): 229. CrossRef
The American Society of Anesthesiologists Physical Status Classification Versus Acute Physiology and Chronic Health Evaluation II for Predicting Perioperative Outcomes in Surgical Patients
Laltanpuii Sailo, Saidingpuii Sailo, Rajani Thabah, Jaideep Sonowal, Sunny Aggarwal
Cureus.2025;[Epub] CrossRef
Comparison of APACHE II and APACHE IV Scores in Predicting Mortality in the Surgical ICU (SICU) of a Tertiary Care Hospital - A Prospective Study
Prashanta Swami Pujar, Pavithra P, Sachin ., Prajwal RK
International Journal of Health Sciences and Research.2025; : 192. CrossRef
DYNAMICS OF WILLEBRAND FACTOR AND APACHE II SEVERITY SCORES IN ELDERLY PATIENTS WITH BURN INJURIES AND SIRS WHEN USING A COMBINATION OF QUERCETIN AND POVIDONE IN INTENSIVE CARE
O. I. Bondarenko, P. A. Kyiko
Kharkiv Surgical School.2025; (2): 295. CrossRef
Circadian rhythms of vital signs are associated with in-hospital mortality in critically ill patients: A retrospective observational study
Zhengning Yang, Xiaoxia Xie, Xu Zhang, Lan Li, Ruoxue Bai, Hui Long, Yanna Ma, Zhenliang Hui, Yujie Qi, Jun Chen
Chronobiology International.2023; 40(3): 262. CrossRef
Characteristics and outcomes of patients admitted to adult intensive care units in Hong Kong: a population retrospective cohort study from 2008 to 2018
Lowell Ling, Chun Ming Ho, Pauline Yeung Ng, King Chung Kenny Chan, Hoi Ping Shum, Cheuk Yan Chan, Alwin Wai Tak Yeung, Wai Tat Wong, Shek Yin Au, Kit Hung Anne Leung, Jacky Ka Hing Chan, Chi Keung Ching, Oi Yan Tam, Hin Hung Tsang, Ting Liong, Kin Ip Law
Journal of Intensive Care.2021;[Epub] CrossRef
Evaluation and Validation of Four Scoring Systems: the APACHE IV, SAPS III, MPM0 II, and ICMM in Critically Ill Cancer Patients

Indian Journal of Critical Care Medicine.2020; 24(4): 263. CrossRef

The Usefulness of a Triage Kit for Detecting Abused Drugs: Myoung Kwan Kwak, Won Young Kim, Hui Dong Kang, Jae Ho Lee, Bum Jin Oh, Won Kim, Kyoung Soo Lim; Korean J Crit Care Med. 2009;24(2):75-79.; DOI: https://doi.org/10.4266/kjccm.2009.24.2.75

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BACKGROUND
The recovery and outcome of intoxicated patients depends on the kind of drugs they took and the total time of their initial management. The purpose of this study is to evaluate the usefulness of a Triage drug kit for detecting abused drugs.
METHODS
From 2003 Feb. to 2003 July, we studied the patients who visited the emergency department with suspicious drug intoxication. In this case, we used a Triage drug kit for 134 patients with drug intoxication or who were clinically suspected of taking illegal drugs, with 30 of the patients initially admitting the substance they had used. The kit is an immunoassay kit for qualitative testing drug metabolites in urine. To compare with those cases of the preceding year, we studied 104 patients with drug intoxication that was detected between February 2002 and July 2002.
RESULTS
Overall, 60% of the 30 cases who did not know what substance they abused and tested positive for, and 33% of the 27 cases with suspected intoxication confirmed their substance abuse. The positive rate for benzodiazepine use was the highest (46.7%), and there were no positive results regarding amphetamine, methamphetamine or cocaine. An appropriate antidote was administered significantly more frequently in the group for which we used the kit.
CONCLUSIONS
A Triage drug kit is probably useful for diagnosing acute drug intoxication and for identifying the causative substance. However, the time required to decide whether or not a patient should be admitted is not reduced. If the kit can detect the frequently abused drugs in Korea, it will be helpful for treating drug intoxicated patients.

Citations

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Clinical features of adolescents with suicide attempt and the factors associated with their outcomes: poisoning versus non-poisoning
Myoung Hoon Lee, Jae Ho Jang, Jin-Seong Cho, Woo Sung Choi, Jea Yeon Choi
Pediatric Emergency Medicine Journal.2020; 7(2): 85. CrossRef
Evaluation of the Triage TOX Drug Screen Assay for Detection of 11 Drugs of Abuse and Therapeutic Drugs
Hae In Bang, Mi-Ae Jang, Yong-Wha Lee
Annals of Laboratory Medicine.2017; 37(6): 522. CrossRef

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