Assessment of Acute Disease to Reduce Imaging Costs (QUAADRICs)

I. Inclusion criteria

• Adult (>17 years) ED patient reports a history of chest discomfort and new or worsened shortness of breath or breathing difficulty, documented in the written history of present illness or review of systems.
• Patient must understand English or have a certified translator present.
• Physician has ordered or plans to order a 12-lead electrocardiogram.
• Patient indicates the site hospital was his or her "hospital of choice" in the event of return visit within 14 days.

II. Pre-randomization exclusion criteria

• 12-lead ECG with ST deviation interpreted as acute infarction or ischemia.
• Known diagnosis of acute PE within previous 24 hours (e.g., call back for overread of a CT scan).
• "Code STEMI" patients (patients with suspected acute myocardial infarction).
• Other obvious condition or diagnosis identified by the emergency physician as mandating admission (evidence of circulatory shock, severe hypoxemia, decompensated heart failure, altered mental status, hemorrhage, sepsis syndrome, arrhythmia, trauma, unstable social or psychiatric situation, stroke, aortic disaster, pneumonia ).
• Myocardial infarction, intracoronary stent placement, or CABG within the previous 30 days.
• Known cocaine use within past 72 hours, based upon patient or laboratory report.
• Referral to the emergency department by a personal physician.
• Patients undergoing voluntary medical clearance for a detox center or any involuntary court or magistrate order.
• Computer interpretation of the 12-lead ECG containing either "ischemia" or "infarction".
• Homelessness, out-of-town residence or other condition known to preclude follow-up in 14 days.
• Patients in police custody or currently incarcerated individuals.
• Patients who know they are pregnant or in whom a pregnancy test was drawn as part of usual care and was found to be positive.

III. Post-randomization exclusions

• Positive urine cocaine test.
• Incarceration within 14 days of enrollment.
• Patient elopement from medical care (i.e., patients who leave against medical advice).