This article from the January 30, 2017 issue of Canadian Medical Association Journal looks at which patients with chest pain can be safely discontinued from telemetry/cardiac monitoring after an initial evaluation.  Although this article may not persuade me from discontinuing patients when we have enough monitors in the Emergency Department, but this study in conjunction with several other studies by Hollander, Lin, Singer, and Antzema convinces me that many patients being transported to the floor do not need monitors during that transport.

The Ottawa Chest Pain Cardiac Monitoring Rule states that a patient with chest pain can be removed from cardiac monitoring on initial physician assessment if the patient is currently free of chest pain and the patient’s electrocardiogram is normal or has nonspecific changes (no signs of acute ischemia, infarction, bundle branch block, prolonged QRS, QT or PR interval, left ventricular hypertrophy with strain, arrhythmia or paced rhythm).

The article provides background that chest pain accounts for up to 20 percent of all admissions and often times there are not enough monitors in the emergency department. Chest pain is a common presentation to the emergency department, with more than 8 million visits annually, and accounts for about 5%–7% of all visits to emergency departments in the United States.

Studies by Hollander, Lin, Singer, and Antzema. consistently demonstrated that arrhythmia is an uncommon and 99.4% of monitor alarms were “false,” with no actual arrhythmias.

Although the Syed CMAJ study was relatively small (796 enrollees), the authors report it was strong enough to validate.

During the derivation phase, the Ottawa Chest Pain Cardiac Monitoring Rule performed with 100% sensitivity for predicting arrhythmias.  With a conservative estimation of 96% sensitivity during the validation phase, a 3% bound on the error and 1.5%–2% prevalence in the occurrence of arrhythmias, we calculated that 683 patients would be required to validate the tool.

The study concluded that arrhythmias among patients presenting to EDs with chest pain are uncommon, and a substantial number of these patients are unnecessarily placed on cardiac monitors while more critically ill patients may be waiting for care. Based on these study results, recommendations include removing patients from cardiac monitors if they are free of chest pain at the ED assessment and if the ECG is either normal or shows only nonspecific changes.

There is a caveat that

any patient who looks unwell or has unstable vital signs needs cardiac monitoring, regardless of the rule.


Source: 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 – Ottawa-Chest-Pain-Cardiac-Monitoring-Rule-Validation-CMAJ.pdf