The impact of a sepsis performance improvement program in the emergency department: a before-after intervention study.

PURPOSE: The latest Surviving Sepsis Campaign guidelines advocate that all hospitals use sepsis performance improvement programs. However, there is a limited evidence about how to structure such programs and what their potential impact is on sepsis management and outcomes in the emergency department (ED). In this study, we evaluated the implementation of a sepsis performance improvement program in the ED including a dedicated sepsis response team and analyzed the management and outcomes of sepsis patients before and after. METHODS: We conducted a before-after interventional study in the ED of the Amsterdam University Medical Centers, the Netherlands. The sepsis performance improvement program included regular educational meetings, daily audits and weekly feedback, a screening tool, and a dedicated multidisciplinary sepsis response team. We studied all adult patients who presented to the ED with a suspected infection and a Modified Early Warning Score (MEWS) ≥ 3 during their stay. In the postintervention phase, these patients were seen by the sepsis team. Process-related and patient-related outcomes were measured between November 2019 and February 2020 (preintervention) and December 2021-May 2022 (postintervention). RESULTS: A total of 265 patients were included in the primary study, 132 patients preintervention and 133 patients postintervention. The postintervention phase was associated with improvements in nearly all process-related outcomes, such as a shorter time to antibiotics (66 vs. 143 min; p < 0.001), increased number of lactate measurements (72.9 vs. 46.2%; p < 0.001), and improved completeness of documented MEWS scores (85.0 vs. 62.9%; p < 0.001). Except for an improvement in the number of immediate versus delayed ICU admissions (100% immediate vs. 64.3% immediate; p = 0.012), there was no improvement in the other patient-related outcomes such as 28 days mortality (14.3 vs. 9.1%; p = 0.261), during the postintervention phase. CONCLUSION: Our program stimulated physicians to make timely decisions regarding diagnostics and treatment of sepsis in the ED. Implementing the sepsis performance improvement program was associated with significant improvements in most process-related outcomes but with minimal improvements in patient-related outcomes in our cohort.

[Crystal meth - a new kid on the block]. / Crystal meth ­ een nieuwkomer.

In this article we describe epidemiological, pharmacological and clinical aspects of abuse of metamphetamines, also known as crystal meth. These aspects are illustrated by two cases of methamphetamine abuse and the complications associated with it. Metamphetamine abuse is often associated with sexual activity, a combination known as 'chemsex'. A chronic addiction to chemsex can have devastating effects on the user's social, psychological, and physical wellbeing. We describe a patient suffering from recurrent relapses in his addiction to chemsex. Acute crystal meth intoxications can result in very serious complications. We describe a patient suffering from severe neurological complications and rhabdomyolysis.

[Hypovolemic shock due to ovarian bleeding]. / Hypovolemische shock door ovariële bloeding.

BACKGROUND: Ovulation may lead to abdominal pain. It is well-known that ovulation can cause intra-abdominal bleeding. However, literature on hypovolemic shock due to an ovarian bleeding is scarce. CASE DESCRIPTION: A 30-year-old woman visited the emergency room because of acute pain of the lower abdomen. Her skin was pale, her vital signs were normal and a pregnancy test was negative. At presentation, her blood pressure decreased to 87/50 mmHg. Therefore, intra-abdominal bleeding was suspected and the gynecologist was consulted. On ultrasound, intraperitoneal fluid was seen, so we proceeded to emergency laparoscopy. During surgery, we found a bleeding corpus luteum (corpus rubrum) leading to 2.5 L of free intra-abdominal blood. The bleeding was stopped intraoperatively. CONCLUSION: A bleeding corpus luteum can lead to hypovolemic shock. Ovarian bleeding should be considered in case of shock combined with lower abdominal pain, ultrasound should be performed promptly and the gynecologist has to be consulted.

[A women with burning pain in her arms after a fall]. / Een vrouw met brandende pijn in de armen na een val.

BACKGROUND: The central cord syndrome is an incomplete spinal cord injury that can develop after a minor trauma to the cervical spinal column. CASE DESCRIPTION: A 73-year-old woman presented at our Emergency Department with pyelonephritis accompanied by weakness and a burning feeling in her arms and legs after a fall on her head. The weakness and pain did not improve during her hospital admission. On consultation with a neurologist, the patient was diagnosed with central cord syndrome. As the neurological loss of function did not resolve spontaneously, the patient underwent laminectomy and spondylodesis. Postoperatively her symptoms improved. After 22 days in hospital, the patient was discharged to a rehabilitation clinic. CONCLUSION: In older patients with pre-existing degenerative cervical spinal stenosis, central cord stenosis resulting from minor trauma can cause severe and invalidating symptoms. The early tracing and treatment of patients with this syndrome is essential in order to increase the chance of neurological and functional recovery.

[A woman with acute flank pain]. / Een vrouw met acuut ontstane flankpijn.

A 55-year-old woman presented at the Emergency Department with flank pain. She was pale, hemodynamically unstable, and had a palpable mass in her right flank. CTA of the abdomen revealed a bleeding from an angiomyolipoma of the right kidney, which was successfully treated by selective coiling of the supplying renal artery.