To compare the diagnostic accuracy of emergency department (ED) physicians with the World Health Organization (WHO) case definition in a large community-based SARS (severe acute respiratory syndrome) cohort.

This was a cohort study of all patients from Hong Kong’s Amoy Garden complex who presented to an ED SARS screening clinic during a 2-month outbreak. Clinical findings and WHO case definition criteria were recorded, along with ED diagnoses. Final diagnoses were established independently based on relevant diagnostic tests performed after the ED visit. Emergency physician diagnostic accuracy was compared with that of the WHO SARS case definition. Sensitivity, specificity, predictive values and likelihood ratios were calculated using standard formulae.

During the study period, 818 patients presented with SARS-like symptoms, including 205 confirmed SARS, 35 undetermined SARS and 578 non-SARS. Sensitivity, specificity and accuracy were 91%, 96% and 94% for ED clinical diagnosis, versus 42%, 86% and 75% for the WHO case definition. Positive likelihood ratios (LR+) were 21.1 for physician judgement and 3.1 for the WHO criteria. Negative likelihood ratios (LR–) were 0.10 for physician judgement and 0.67 for the WHO criteria, indicating that clinician judgement was a much more powerful predictor than the WHO criteria.

Physician clinical judgement was more accurate than the WHO case definition. Reliance on the WHO case definition as a SARS screening tool may lead to an unacceptable rate of misdiagnosis. The SARS case definition must be revised if it is to be used as a screening tool in emergency departments and primary care settings.

To determine the rate of bacterial meningitis among febrile infants in the emergency department (ED) who have pyuria detected in an initial catheterized urine specimen.

This retrospective chart review, conducted at the Hospital for Sick Children, Toronto, Ont., involved all children aged 0 to 3 months who presented to the ED with fever and pyuria (≥10 white blood cells/mm3) over a 3-year period. Cerebrospinal fluid (CSF) was evaluated using standard methods, and the rate of meningitis in children with pyuria was determined.

The study sample included 211 infants with fever and pyuria — 79 of these under 1 month of age. Eighty-one percent (171/211) had positive urine cultures, and 143 underwent lumbar puncture to rule out meningitis. Of these, 140 CSF samples were culture negative and 3 grew coagulase negative Staphylococcus — 2 because of contamination and 1 because of a ventriculo-peritoneal shunt infection. Both children with CSF contamination grew Escherichia coli in the urine. The rate of bacterial meningitis in the study sample was 0% (95% confidence interval, 0%–2.6%).

In this study of febrile children under 90 days of age with fever and pyuria, the incidence of concurrent meningitis was 0%. This suggests that recommendations for mandatory lumbar puncture in such children should be reconsidered. However, until larger prospective studies define a patient subset that does not require CSF analysis, it is prudent to rule out meningitis, administer parenteral antibiotics for urinary tract infection, and admit for close observation.

Standard learning objectives enable residency directors to develop effective programs and evaluate residents based on key goals and parameters. While standards are important for ensuring basic competence, the usual process has little flexibility to address the unique needs and desires of a given resident. Our objective was to determine whether the expectations of off-service residents rotating through an emergency department (ED) rotation were being met.

We developed a 144-item questionnaire using a 5-point Likert scale and surveyed 25 off-service residents at the beginning and end of their ED rotation. The survey was divided into 3 sections: presentations, skills and diagnoses.

The results demonstrate that certain expectations are consistently underachieved while others represent individual variations.

We propose a learner-centred approach to ensure an optimal emergency educational experience for all trainees.