title: Prospective validation of a clinical decision rule to identify patients presenting to the emergency department with chest pain who can safely be removed from cardiac monitoring.
abstract: BACKGROUND
  Most patients with chest pain in the emergency department are assigned to cardiac monitoring for several hours, blocking access for patients in greater need. We sought to validate a previously derived decision rule for safe removal of patients from cardiac monitoring after initial evaluation in the emergency department.
  
  
  METHODS
  We prospectively enrolled adults (age ≥ 18 yr) who presented with chest pain and were assigned to cardiac monitoring at 2 academic emergency departments over 18 months. We collected standardized baseline characteristics, findings from clinical evaluations and predictors for the Ottawa Chest Pain Cardiac Monitoring Rule: whether the patient is currently free of chest pain, and whether the electrocardiogram is normal or shows only nonspecific changes. The outcome was an arrhythmia requiring intervention in the emergency department or within 8 hours of presentation to the emergency department. We calculated diagnostic characteristics for the clinical prediction rule.
  
  
  RESULTS
  We included 796 patients (mean age 63.8 yr, 55.8% male, 8.9% admitted to hospital). Fifteen patients (1.9%) had an arrhythmia, and the rule performed with the following characteristics: sensitivity 100% (95% confidence interval [CI] 78.2%-100%) and specificity 36.4% (95% CI 33.0%-39.6%). Application of the Ottawa Chest Pain Cardiac Monitoring Rule would have allowed 284 out of 796 patients (35.7%) to be safely removed from cardiac monitoring.
  
  
  CONCLUSIONS
  We successfully validated the decision rule for safe removal of a large subset of patients with chest pain from cardiac monitoring after initial evaluation in the emergency department. Implementation of this simple yet highly sensitive rule will allow for improved use of health care resources.
authors.affiliation: Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.
authors.forename: Shahbaz
authors.initials: S
authors.lastname: Syed
authors.affiliation: Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.
authors.forename: Mathieu
authors.initials: M
authors.lastname: Gatien
authors.affiliation: Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Perry
authors.affiliation: Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.
authors.forename: Hina
authors.initials: H
authors.lastname: Chaudry
authors.affiliation: Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.
authors.forename: Soo-Min
authors.initials: SM
authors.lastname: Kim
authors.affiliation: Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Kwong
authors.affiliation: Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Mukarram
authors.affiliation: Departments of Emergency Medicine (Syed, Gatien, Perry, Thiruganasambandamoorthy) and Epidemiology and Community Medicine (Perry, Thiruganasambandamoorthy), University of Ottawa; Ottawa Hospital Research Institute (Perry, Chaudry, Kim, Kwong, Mukarram, Thiruganasambandamoorthy), The Ottawa Hospital, Ottawa, Ont. vthirug@ohri.ca.
authors.forename: Venkatesh
authors.initials: V
authors.lastname: Thiruganasambandamoorthy
mesh_terms: D000328:Adult; D000368:Aged; D001145:Arrhythmias, Cardiac / Q000175:diagnosis* / Q000628:therapy; D002170:Canada; D002637:Chest Pain / Q000175:diagnosis; D003661:Decision Support Techniques; D003951:Diagnostic Errors / Q000517:prevention & control; D015716:Electrocardiography, Ambulatory; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000592:standards*; D011446:Prospective Studies; D012720:Severity of Illness Index; D055815:Young Adult