Responding to COVID-19: how an academic infectious diseases division mobilized in Singapore.

BACKGROUND: On January 30, COVID-19 was declared a Public Health Emergency of International Concern-a week after Singapore's first imported case and 5 days before local transmission. The National University Hospital (NUH) is Singapore's third largest hospital with 1200 beds, heavy clinical workloads, and major roles in research and teaching. MAIN BODY: With memories of SARS still vivid, there was an urgent requirement for the NUH Division of Infectious Diseases to adapt-undergoing major reorganization to face rapidly changing priorities while ensuring usual essential services and standards. Leveraging on individual strengths, our division mobilized to meet the demands of COVID-19 while engaging in high-level coordination, strategy, and advocacy. We present our experience of the 60 days since the nation's first case. During this time, our hospital has managed 3030 suspect cases, including 1300 inpatients, 37 confirmed cases, and overseen 4384 samples tested for COVID-19. CONCLUSION: Complex hospital adaptations were supported by an unprecedented number of workflows and coordination channels essential to safe and effective operations. The actions we describe, aligned with international recommendations and emerging evidence-based best practices, may serve as a framework for other divisions and institutions facing the spread of COVID-19 globally.

Risk Factors for Emergency Department Unscheduled Return Visits.

BACKGROUND AND OBJECTIVES: This study aims to identify reasons for unscheduled return visits (URVs), and risk factors for diagnostic errors leading to URVs, with comparisons to data from a similar study conducted in the same institution 9 years ago. MATERIALS AND METHODS: This retrospective study included adult patients who attended the emergency department (ED) of a tertiary hospital in Singapore between January 2014 and June 2014, with re-attendance within 72 h for the same or similar complaint. The primary outcome was wrong or delayed diagnoses. Secondary outcomes include admission to the ED observation unit or ward on return visit. Findings were compared with the previous study performed in 2005 to identify trends. RESULTS: Of 67,422 attendances, there were 1298 (1.93%) URVs from 1207 patients (median age 34, interquartile range 24 to 52 years; 59.7% male). The most common presenting complaint was abdominal pain (22.2%). One hundred ninety-one (15.8%) patients received an initial wrong or delayed diagnosis. Factors (adjusted odds ratio; 95% CI) associated with this were: presenting complaints of abdominal pain (2.99; 2.12-4.23), fever (1.60; 1.1-2.33), neurological deficit (4.26; 1.94-9.35), and discharge without follow-up (1.61; 1.1-2.26). Among re-attendances, 459 (38.0%) required admission. Factors (adjusted odds ratio; 95% CI) associated with admission were: male gender (1.88; 1.42 to 2.48); comorbidities of diabetes mellitus (2.07; 1.29-3.31), asthma (5.23; 1.59-17.26), and renal disease (7.48; 2.00-28.05); presenting complaints of abdominal pain (1.83; 1.32-2.55), fever (3.05; 2.10-4.44), and giddiness or vertigo (2.17; 1.26-3.73). There was a reduction in URV rate compared to the previous study in 2005 (1.93% versus 2.19%). Abdominal pain at the index visit remains a significant cause of URVs (22.2% versus 25.1%). CONCLUSIONS: Presenting complaints of neurological deficits, abdominal pain, fever, and discharge without follow-up were associated with wrong or delayed diagnoses among URVs.

Emergency Department Management of Sepsis Patients: A Randomized, Goal-Oriented, Noninvasive Sepsis Trial.

STUDY OBJECTIVE: The noninvasive cardiac output monitor and passive leg-raising maneuver has been shown to be reasonably accurate in predicting fluid responsiveness in critically ill patients. We examine whether using a noninvasive protocol would result in more rapid lactate clearance after 3 hours in patients with severe sepsis and septic shock in the emergency department. METHODS: In this open-label randomized controlled trial, 122 adult patients with sepsis and serum lactate concentration of greater than or equal to 3.0 mmol/L were randomized to receive usual care or intravenous fluid bolus administration guided by measurements of change of stroke volume index, using the noninvasive cardiac output monitor after passive leg-raising maneuver. The primary outcome was lactate clearance of more than 20% at 3 hours. Secondary outcomes included mortality, length of hospital and ICU stay, and total hospital cost. Analysis was intention to treat. RESULTS: Similar proportions of patients in the randomized intervention group (70.5%; N=61) versus control group (73.8%; N=61) achieved the primary outcome, with a relative risk of 0.96 (95% confidence interval [CI] 0.77 to 1.19). Secondary outcomes were similar in both groups (P>.05 for all comparisons). Hospital mortality occurred in 6 patients (9.8%) each in the intervention and control groups on or before 28 days (relative risk=1.00; 95% CI 0.34 to 2.93). Among a subgroup of patients with underlying fluid overload states, those in the intervention group tended to receive clinically significantly more intravenous fluids at 3 hours (difference=975 mL; 95% CI -450 to 1,725 mL) and attained better lactate clearance (difference=19.7%; 95% CI -34.6% to 60.2%) compared with the control group, with shorter hospital lengths of stay (difference=-4.5 days; 95% CI -9.5 to 2.5 days). CONCLUSION: Protocol-based fluid resuscitation of patients with severe sepsis and septic shock with the noninvasive cardiac output monitor and passive leg-raising maneuver did not result in better outcomes compared with usual care. Future studies to demonstrate the use of the noninvasive protocol-based care in patients with preexisting fluid overload states may be warranted.

Obesity, asthma prevalence and IL-4: Roles of inflammatory cytokines, adiponectin and neuropeptide Y.

BACKGROUND: Obesity is associated with asthma risk and severity, but the underlying biological mechanisms are poorly understood. We hypothesized that cytokine markers of systemic inflammation, and adiponectin and neuropeptide Y (NPY) markers of immuno-modulating and neurohormonal regulation are involved in the obesity-asthma association. METHODS: We explored the relationships between body mass index (BMI), C-reactive protein (CRP), IL-6, TNF-α, adiponectin and NPY with asthma prevalence and IL-4 levels in 70 youth with asthma and 69 age- and gender-matched healthy controls using cross-sectional and longitudinal data. RESULTS: Mean BMI level was higher among patients with asthma than healthy controls (p < 0.001). In logistic regression models controlling for potential confounders, independent associations with asthma prevalence were found for obesity (p = 0.001), increasing tertiles of CRP (linear trend p < 0.001), IL-6 (linear trend p < 0.001) and lowest and highest tertiles of TNF-α (quadratic trend p < 0.05), increasing adiponectin (linear p = 0.022) and decreasing tertiles of NPY (linear trend p = 0.001). Among patients with asthma, NPY level was positively correlated with adiponectin (p < 0.05) and TNF-α (p < 0.05), and levels of NPY and IL-6 were significantly associated with IL-4 level at baseline and 1-year follow-up. CONCLUSIONS: The obesity-asthma association was not explained by systemic inflammation. Specifically, CRP, TNF-a, IL-6, NPY and adiponectin were independently associated with asthma prevalence. NPY and IL-6 were associated with IL-4 marker of allergic airway inflammation in asthma and should be further investigated as prognostic markers of asthma outcomes.

IDSA/ATS minor criteria aid pre-intensive care unit resuscitation in severe community-acquired pneumonia.

The effect of employing severity scores to identify severe community-acquired pneumonia (SCAP) cases for early aggressive resuscitation is unknown. Optimising pre-intensive care unit (ICU) care may improve outcomes in patients at risk of SCAP. We conducted a before-and-after study of patients classified into control and intervention groups (January 2004 to December 2007 and January 2008 to December 2010, respectively). Our intervention was two-pronged, using the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) minor criteria to identify SCAP for aggressive emergency department resuscitation. Patients with SCAP, defined as those with three or more IDSA/ATS minor criteria, were targeted. Differences in mortality, triage and compliance with emergency department resuscitation were compared between the groups. The hospital mortality rate was lower in the intervention versus the control group (5.7% versus 23.8%, p<0.001). On multivariate analysis, the intervention group was associated with lower mortality (OR 0.24, 95% CI 0.09-0.67). ICU admission rates decreased from 52.9% to 38.6% (p=0.008) and inappropriately delayed ICU admissions decreased from 32.0% to 14.8% (p<0.001). There was increased compliance with the aggressive resuscitation protocol after the intervention. A combined intervention, using a pneumonia score to identify those at risk of SCAP early and an aggressive pre-ICU resuscitation protocol may reduce mortality and ICU admissions.

Using systematic change management to improve emergency patients' access to specialist care: the Big Squeeze.

BACKGROUND: Delayed access to specialist care for emergency patients is associated with increased risk of morbidity and mortality, and increased patient anxiety. OBJECTIVES: (1) To provide timelier access to inpatient and urgent outpatient specialist care for emergency patients. (2) To influence multiple stakeholders to modify their traditional practices and sustain changes. SETTING: National University Hospital of Singapore, an academic medical centre with 997 beds in Singapore and over 34 sub-specialties. METHODS: A set of six interventions was implemented to meet three goals: (1) provide timely access to urgent outpatient specialist care requested by the emergency department ED; (2) increase early inpatient discharges (in order to better match timing of emergency admissions); and (3) provide earlier defined care by inpatient specialists at the ED. An eight-step organisational change management plan was implemented to ensure all specialties complied with the changes. RESULTS: The goals were achieved. (1) Specialist outpatient appointments given within the timeframe requested by the ED doctor increased from 51.7% to 80.8%. (2) Early discharges increased from 11.9% to 26.6% and were sustained at 27.2%. (3) 84% of eligible patients received earlier defined specialist care at the ED. The change management achieved excellent clinician compliance rates ranging from 84% to 100%. However the median wait for admission remained unchanged. CONCLUSION: The interventions reduced the time for ED patients to access specialist outpatient and inpatient care. The systematic organisational change management approach resulted in sustained compliance.

Implementation of early goal-directed therapy and the surviving sepsis campaign resuscitation bundle in Asia.

OBJECTIVE: To examine the impact of implementing sepsis bundle in multiple Asian countries, having 'team' vs. 'non-team' models of patient care. DESIGN: Prospective cohort study. SETTING: Eight urban hospitals, five countries in Asia. PARTICIPANTS: Adult patients with severe sepsis or septic shock. INTERVENTIONS: Implementation was divided into six quartiles: Baseline, Education and four Quality Improvement quartiles. MAIN OUTCOME MEASURES: Quarterly bundle compliance and in-hospital mortality with respect to bundle completion and implementation model. METHODS: In the team model, the implementation was championed by intensivists, where the bundle was completed in the intensive care unit. The non-team model led by emergency physicians completed the bundle in the emergency department as part of standard care. RESULTS: Five hundred and fifty-six patients were enrolled. The overall in-hospital mortality rate was 29.9%, and 67.1% of the patients had septic shock. Compliance to the bundle was 13.3, 26.9, 37.5, 45.9, 48.8 and 54.5% over the six quartiles of implementation (P < 0.01). With team model, compliance increased from 37.5% baseline to 88.2% in the sixth quartile (P < 0.01), whereas hospitals with a non-team model increased compliance from 5.2 to 39.5% (P < 0.01). Crude in-hospital mortality was better in the patients who received the entire bundle (24.5 vs. 32.7%, P = 0.04). Bundle completion was associated with crude in-hospital mortality reduction (odds ratio 0.67, 95% confidence interval 0.45-0.99), but this survival benefit disappeared after adjustment for confounding variables. CONCLUSIONS: Through education and quality improvement efforts, initially low sepsis bundle compliance was improved in Asia. A team model was more effective in achieving bundle compliance compared with a non-team model.

A multinational randomised study comparing didactic lectures with case scenario in a severe sepsis medical simulation course.

BACKGROUND: Medical simulation has been used to teach critical illness in a variety of settings. This study examined the effect of didactic lectures compared with simulated case scenario in a medical simulation course on the early management of severe sepsis. METHODS: A prospective multicentre randomised study was performed enrolling resident physicians in emergency medicine from four hospitals in Asia. Participants were randomly assigned to a course that included didactic lectures followed by a skills workshop and simulated case scenario (lecture-first) or to a course that included a skills workshop and simulated case scenario followed by didactic lectures (simulation-first). A pre-test was given to the participants at the beginning of the course, post-test 1 was given after the didactic lectures or simulated case scenario depending on the study group assignment, then a final post-test 2 was given at the end of the course. Performance on the simulated case scenario was evaluated with a performance task checklist. RESULTS: 98 participants were enrolled in the study. Post-test 2 scores were significantly higher than pre-test scores in all participants (80.8 ± 12.0% vs 65.4 ± 12.2%, p<0.01). There was no difference in pre-test scores between the two study groups. The lecture-first group had significantly higher post-test 1 scores than the simulation-first group (78.8 ± 10.6% vs 71.6 ± 12.6%, p<0.01). There was no difference in post-test 2 scores between the two groups. The simulated case scenario task performance completion was 90.8% (95% CI 86.6% to 95.0%) in the lecture-first group compared with 83.8% (95% CI 79.5% to 88.1%) in the simulation-first group (p=0.02). CONCLUSIONS: A medical simulation course can improve resident physician knowledge in the early management of severe sepsis. Such a course should include a comprehensive curriculum that includes didactic lectures followed by simulation experience.

Outcome effectiveness of the severe sepsis resuscitation bundle with addition of lactate clearance as a bundle item: a multi-national evaluation.

INTRODUCTION: Implementation of the Surviving Sepsis Campaign (SSC) guidelines has been associated with improved outcome in patients with severe sepsis. Resolution of lactate elevations or lactate clearance has also been shown to be associated with outcome. The purpose of the present study was to examine the compliance and effectiveness of the SSC resuscitation bundle with the addition of lactate clearance. METHODS: This was a prospective cohort study over 18 months in eight tertiary-care medical centers in Asia, enrolling adult patients meeting criteria for the SSC resuscitation bundle in the emergency department. Compliance and outcome results of a multi-disciplinary program to implement the Primary SSC Bundle with the addition of lactate clearance (Modified SSC Bundle) were examined. The implementation period was divided into quartiles, including baseline, education and four quality improvement phases. RESULTS: A total of 556 patients were enrolled, with median (25th to 75th percentile) age 63 (50 to 74) years, lactate 4.1 (2.2 to 6.3) mmol/l, central venous pressure 10 (7 to 13) mmHg, mean arterial pressure (MAP) 70 (56 to 86) mmHg, and central venous oxygen saturation 77 (69 to 82)%. Completion of the Primary SSC Bundle over the six quartiles was 13.3, 26.9, 37.5, 45.9, 48.8, and 54.5%, respectively (P <0.01). The Modified SSC Bundle was completed in 10.2, 23.1, 31.7, 40.0, 42.5, and 43.6% patients, respectively (P <0.01). The ratio of the relative risk of death reduction for the Modified SSC Bundle compared with the Primary SSC Bundle was 1.94 (95% confidence interval = 1.45 to 39.1). Logistic regression modeling showed that the bundle items of fluid bolus given, achieve MAP >65 mmHg by 6 hours, and lactate clearance were independently associated with decreased mortality - having odds ratios (95% confidence intervals) 0.47 (0.23 to 0.96), 0.20 (0.07 to 0.55), and 0.32 (0.19 to 0.55), respectively. CONCLUSIONS: The addition of lactate clearance to the SSC resuscitation bundle is associated with improved mortality. In our study patient population with optimized baseline central venous pressure and central venous oxygen saturation, the bundle items of fluid bolus administration, achieving MAP >65 mmHg, and lactate clearance were independent predictors of outcome.

Primary spontaneous pneumothorax--the role of the emergency observation unit.

OBJECTIVE: The objective of this study was to compare an expedited 24-hour management pathway against traditional inpatient ward management of patients with primary spontaneous pneumothorax (PSP) and recurrent spontaneous pneumothorax (RSP). METHOD: This was a retrospective chart review of all patients who presented with either PSP or RSP to an urban tertiary university hospital in 2007. RESULTS: Eighty-two patients were included in the study, of which approximately a third (27) were managed in the emergency department observation unit (EDOU). Five of the EDOU patients were admitted to the ward. Emergency department observation unit treatment failures as defined by recurrences within a week were comparable to those managed in the ward. One of 5 PSP patients receiving only oxygen therapy managed in the EDOU had their pneumothorax recur within a week on discharge, whereas none of the 15 receiving needle aspiration recurred within a week. For the RSP patients managed in the EDOU, 1 of 3 managed with oxygen therapy alone and discharged recurred within a week, whereas with needle aspiration, 1 of 4 recurred within a week. The success rate of aspiration in our study was comparable with that of published rates (75% versus 50%-60%). CONCLUSIONS: Small to moderate PSPs can be safely and efficiently managed within 24 hours in an EDOU.

Management of acute pyelonephritis in the emergency department observation unit.

INTRODUCTION: This study aimed to assess the effectiveness of the emergency department observation unit (EDOU) for patients with acute pyelonephritis in a Singapore tertiary academic medical centre. METHODS: We reviewed the clinical records of consecutive patients who presented with pyelonephritis between 1 July 2012 and 31 October 2014 to collect information on demographics, symptoms, signs, laboratory and radiological results, treatment, and clinical outcomes. RESULTS: Of 459 emergency department (ED) patients who were identified as having pyelonephritis, 164 (35.7%) were managed in the EDOU. Successful management in the EDOU was achieved in 100 (61.0%) patients. Escherichia coli was the predominant (64.6%) micro-organism in urine cultures and was positive in 106 patients. Patients diagnosed with acute pyelonephritis who were successfully managed in the EDOU had a lower incidence of nausea (32.0% vs. 60.9%, p < 0.001) and vomiting (15.0% vs. 50.0%, p < 0.001) compared to those who were not successful. CONCLUSION: EDOU is useful for both observation and treatment of patients with acute pyelonephritis. Urine cultures are sufficient for the identification of the culprit micro-organism. Patients who present with prominent symptoms of vomiting should have routine administration of antiemetics, while consideration for second-line antiemetics is recommended for those with persistent symptoms.

Diagnostic utility, safety, and cost-effectiveness of emergency department-initiated early scheduled technetium-99m single photon emission computed tomography imaging followed by expedited outpatient cardiac clinic visits in acute chest pain syndromes.

Conventional emergency department (EMD) approach to triaging acute chest pain syndromes may lead to unnecessary admissions, resulting to in-hospital bed occupancy and increased healthcare costs. We explore the diagnostic utility of early (less than a week) outpatient scheduled single photon emission computed tomography (SPECT) in intermediate-risk chest pain subjects who presented to EMD with non-diagnostic electrocardiogram and negative serum troponin level. Additionally, we intend to study the safety and cost-effectiveness of such a strategy. We conduct a prospective, non-randomized study of 108 subjects who fit the inclusion criteria. After SPECT studies, all subjects were evaluated in the cardiac clinic within 2 weeks of EMD visits. Final diagnosis of coronary artery disease and subsequent disposition to standard medical therapy or follow-on angiography were decided by incorporating pre-test clinical data and SPECT results. Adverse events defined as myocardial infarction and cardiac death was tracked between EMD visit and eventual therapy (either medical therapy or coronary revascularization). Finally, cost-effectiveness was determined based on estimated cost and days of hospitalization saved between standard strategies of ward admission for further evaluation versus the present early outpatient SPECT-based workflow. Among 108 subjects (mean age 58 years, 59% male) included for analysis, 82 (76%) had normal perfusion status. There was no statistical difference in baseline characteristics and prior ischemic heart disease history between groups. In the 26 abnormal perfusion subjects, seven had follow-on coronary angiography in which three were found to have significant stenotic coronary lesions, but only one had intervention performed. There was an unscheduled coronary angiography in the normal perfusion group that yielded normal coronary anatomy. There was no adverse clinical event in both groups. Compared with standard strategy, early outpatient SPECT initiated by EMD physicians followed by cardiac clinic evaluation resulted in 2.9 days of hospitalization or $781.23 saved per patient per EMD visit. EMD-initiated early SPECT studies followed by cardiac clinic evaluation in intermediate-risk acute chest pain syndromes with non-diagnostic ECG and negative serum troponin levels carries excellent diagnostic and therapeutic utility, in addition to being safe and cost-effective.

Response and Lessons Learnt Managing the COVID-19 Crisis by School of Medicine, National University of Singapore.

This article was migrated. The article was marked as recommended. Background: Healthcare professionals are playing an important role in the recent COVID-19 outbreak. It is crucial that the health systems maintain their ability to train students and residents during this time. However, there is a paucity of literature on the measures taken by higher education institutions to ensure academic continuity. The aim of this article is to share the systematic measures that were taken during the COVID-19 pandemic by Yong Loo Lin School of Medicine, National University of Singapore. Methods: We discussed our multi-faceted approach to protect students, staff and patients/ standardized patients during the COVID-19 outbreak that occurred during a pivotal time in the school's academic calendar. Results: Our approach to ensuring academic continuity and quality were based on best practices in the following areas: 1) A coordinated leadership and management process 2) Prioritising safety for all stakeholders 3) Dissemination of information amongst the stakeholders in a transparent and efficient way, and 4) Maintaining the rigour and quality of training. Conclusion: The initiatives were implemented as we leveraged on the available infrastructure and the collective team efforts of all involved. Further research will be done to evaluate the usefulness of these measures. We hope that this article would be a useful reference for other schools as they evaluate their pandemic preparedness in the event that the COVID-19 outbreak affects their country or similar crisis event in the future.

Neuropeptide Y associated with asthma in young adults.

OBJECTIVE: Neuropeptide Y, a widely circulating neurotransmitter, plays a pivotal role in energy balance, immunomodulation and asthma, and several NPY polymorphisms are promising genetic risk factors for asthma and obesity. We explored the associations of candidate NPY gene polymorphisms with prevalent asthma and its relationship with obesity in young adult asthma patients free of other chronic medical morbidity. METHODS: Five common gene variants of NPY (rs16147 (-399T/C), rs17149106 (-602G/T), rs16140 (+1000C/G), rs5573 (+1201A/G), rs5574 (+5327C/T)) previously validated to account for most of the NPY expression in vitro and in vivo were investigated in 126 physician-diagnosed asthma patients without other chronic medical morbidity and 182 healthy controls (21-35years). Plasma levels of NPY, adiponectin, and CRP were determined using ELISA, and IL-6 was measured by Luminex in a subgroup of 70 patients and 69 age- and sex-matched healthy controls. RESULTS: In logistic regression models controlling for gender and obesity, the CT genotype of rs5574 (OR=0.54, 95%CI: 0.30-0.89) and the GT genotype of rs17149106 (OR=5.58, 95%CI: 1.09-28.54) were significantly associated with asthma. No significant interaction between NPY SNP polymorphisms and obesity were detected. Plasma NPY level was correlated with adiponectin levels (p<0.05). Compared with the healthy controls, patients with asthma had higher BMI (p<0.001), adiponectin (p<0.05), IL-6 (p=0.001) and CRP (p<0.001), and lower NPY levels (p<0.01). CONCLUSIONS: The CT genotype of rs5574 and the GT genotype of rs17149106 are significantly associated with prevalent asthma.

Psychiatric comorbidities in Asian adolescent asthma patients and the contributions of neuroticism and perceived stress.

PURPOSE: Psychiatric comorbidity is reported to be common among adolescents with asthma, but little is known about its underlying psychological factors. OBJECTIVE: This study explored the profile of anxiety and depressive comorbidities among adolescents with well-controlled and poorly controlled asthma and the contribution of neuroticism and perceived stress. METHODS: The Revised Child Anxiety and Depression Scale, Neuroticism subscale of Big Five Inventory, Perceived Stress Scale, and Asthma Control Test were administered to 198 adolescents (aged 12-19 years) with well-controlled (n = 137) and poorly controlled asthma (n = 61) as well as 171 healthy neighborhood controls. RESULTS: Adolescents with poorly controlled asthma, compared with well-controlled asthma patients and healthy controls, had higher scores of depression (p = .006), panic attacks (p = .002), total anxiety (p = .038), and total internalizing symptoms (p = .017), after adjusting for gender, age, ethnicity, smoking status, and family housing type. Adolescents with asthma had higher neuroticism (p = .025), perceived stress (p = .022), and body mass index (p = .006) and lower self-rated health (p < .001) than healthy controls. No significant differences in psychiatric comorbidity scores were observed after accounting for differences in underlying psychological and physical factors. Among asthma patients, increased asthma control was associated with decreased scores of psychiatric comorbidity (p < .01), but the association was not significant after allowing for decreased neuroticism and perceived stress. CONCLUSIONS: The diagnosis of asthma and poor asthma control in adolescents is associated with excess psychiatric comorbidity, which is likely due to increased neuroticism and perceived stress.

Feasibility of introduction and implementation of the Surviving Sepsis Campaign bundle in a Singapore emergency department.

OBJECTIVES: The Surviving Sepsis Campaign has been shown to improve the outcome of patients with severe sepsis or septic shock in Europe and North America. We aim to examine the impact of implementing the severe sepsis resuscitation bundle as part of standard care at the National University Hospital Emergency Department (ED) and assess its feasibility in Singapore. MATERIALS AND METHODS: Adult patients presenting to the ED with severe sepsis and septic shock from 1 July 2008 to 31 December 2009 were included. Implementation of the bundle was divided into six quartiles: Baseline, Education and four Quality Improvement quartiles. The primary outcome of interest was bundle compliance. Other clinical outcomes include mortality and difference in treatment between the two groups. RESULTS: One hundred and seventeen patients were included. The median age was 58 years and the median APACHE II score was 20. The overall in-hospital mortality was 26.5%. Compliance to all items of the bundle was 0, 10, 24, 24, 7 and 40%, respectively, over six quartiles. Patients who received the entire bundle had a crude mortality of 11.1%, which is 18.2% lower than those who received only some or none of the bundle components. Patients receiving the entire bundle tend to receive about 1 litre more intravenous fluids in the ED. CONCLUSION: There was zero compliance to the severe sepsis resuscitation bundle at baseline. Quality improvement initiatives resulted in better compliance and outcome for patients, showing that such a protocol of management is feasible in a typical Singapore ED.