Authors (including presenting author) :
MA YC(1)(2)(3)
Affiliation :
(1)Registered Nurse in A&E Department, Pamela Youde Nethersole Eastern Hospital (2)Master of Science in Nursing (Critical Care), The Hong Kong Polytechnic University (3)Bachelor of Science in Nursing, The Hong Kong Polytechnic University
Keyword 1: :
Chest pain triage
Keyword 2: :
Triage accuracy
Keyword 3: :
Emergency department assessment
Keyword 4: :
Structured triage approach
Introduction :
Chest pain, a sign of cardiovascular diseases (CVD), is a common complaint among patients in the Accident and Emergency Department (AED) in Hong Kong, which can be caused by various disorders. Triage nurses play a crucial role in in the early identification and prioritization of patients, but accurately diagnosing chest pain and distinguishing between cardiogenic and non-cardiogenic causes can be challenging. The challenges in accurately differentiating cardiac issues through current triage guidelines have led to over-triage or under-triage. Under-triaging patients may lead to longer wait times, increased risks of adverse events and treatment delays, while over-triaging can result in overcrowding and burdening healthcare resources. Observations revealed significant gaps in waiting times for Category III and IV patients, indicating inaccurate triage resulted in delay treatments for urgent patients. Moreover, long door-to-ECG times and a lack of ECG interpretation knowledge have contributed to delayed diagnoses. These issues directly impact door-to-drug and door-to-PCI times. The identified practice gaps include the low specificity of triage guidelines and the reliance on physicians for ECG interpretation, leading to delayed care and suboptimal resource utilization. Therefore, implementing an effective triage system for chest pain is essential to prioritize patients and provide prompt intervention, addressing the challenges associated with accurately differentiating between cardiac-related and non-cardiac-related causes of chest pain.
Objectives :
This pilot study aims to enhance the accuracy and consistency of triage for patients presenting with chest pain by implementing a structured triage approach. The objectives are: 1) To introduce an objective assessment tool (Emergency Department Assessment of Chest Pain Score) to support triage nurses in differentiating between cardiac-related and non-cardiac-related causes of chest pain. 2) To strengthen triage nurse's competency in 12‑lead ECG interpretation through targeted training. 3) To evaluate the impact of the structured triage process on key time‑sensitive indicators, including door‑to‑ECG time, door‑to‑drug time, door-to-fibrinolytic therapy time and door‑to‑PCI time. The overarching goal is to improve triage accuracy, reduce delays in critical interventions and optimize resource utilization within the AED.
Methodology :
A comprehensive literature review of 23 studies was conducted to identify evidence‑based assessment tools suitable for ruling in or ruling out cardiovascular disease during the triage of chest pain patients. Among the tools evaluated, the Emergency Department Assessment of Chest Pain Score (EDACS) emerged as the most appropriate for triage application. EDACS offers a rapid, objective, and easy‑to‑use scoring system that incorporates standard triage assessment elements without requiring laboratory investigations. Multiple studies consistently demonstrate that EDACS provides superior predictive accuracy for major adverse cardiac events when compared with established tools such as TIMI, HEART, and GRACE. Its structured and objective scoring method minimizes reliance on subjective clinical judgment, enhances the differentiation between cardiac and non‑cardiac chest pain, and improves the accuracy of patient prioritization. Given its efficiency, reliability, and strong validation within triage settings, EDACS represents the most suitable tool for improving triage accuracy for chest pain patients in AED. The project was conducted in AED triage station in Pamela Youde Nethersole Eastern Hospital and included patients aged 18 years or older who presented with chest pain. Following approval from departmental leaders, a structured triage algorithm incorporating EDACS and nurse‑involved ECG interpretation was implemented. The preparation phase comprised three components: enhancement of the investigator’s knowledge, revision of the triage process, and development of training materials. Knowledge enhancement was achieved through a literature review, appraisal of existing guidelines and completion of an ECG interpretation course. The triage process was revised by establishing an objective assessment tool, creating ECG arrhythmia cue cards and updating chest pain management protocols. Training materials were developed, including Training Powerpoint and pre & post‑tests. Baseline data on triage accuracy, treatment intervals, and MACE risk were collected over one month. During implementation, nurses attended small‑group training sessions, and the new triage tools were deployed at the triage station. Post‑implementation data were compared with baseline measures to evaluate improvements in triage accuracy, treatment timeliness and risk stratification performance.
Result & Outcome :
Pre‑implementation data collected in September 2023 demonstrated substantial deficiencies in triage accuracy and time‑critical performance for chest pain patients. Among 1,064 suspected cardiac cases reviewed, 25.6% were over‑triaged, with final diagnoses such as musculoskeletal pain, epigastric pain, and heartburn. Conversely, 11.4% were under‑triaged, including cases later confirmed as STEMI, NSTEMI or chest pain with abnormal ECG findings. Time‑sensitive indicators also fell short of recommended standards. The average door‑to‑ECG time was 18.2 minutes, exceeding the 10‑minute benchmark and contributing to delays in subsequent interventions. Two patients were diagnosed with myocardial infarction approximately 95 minutes after triage due to missed abnormal ECGs, highlighting the risks associated with inaccurate triage and delayed cardiac assessment. During the seven‑week implementation period beginning in late January 2024, 594 chest pain cases were assessed using the new triage algorithm. Post‑implementation results demonstrated marked improvements. Over‑triage decreased to 11.4% and under‑triage to 5.9%, indicating enhanced accuracy. The average door‑to‑ECG time improved from 18.2 minutes to 13 minutes, largely due to increased nurse involvement in ECG interpretation. This contributed to more timely interventions. The average door‑to‑drugs time for MONA decreased from 39.2 minutes to 28.5 minutes, meeting recommended standards, with reduced maximum delays. Although the average door‑to‑fibrinolytic therapy time increased from 40.5 minutes to 64 minutes, this was associated with a higher number of resuscitation cases; importantly, the average remained within the acceptable treatment window. The average door‑to‑PCI time also improved significantly, decreasing from 56.4 minutes to 36.2 minutes. Overall, the introduction of objective assessment tools and enhanced nurse‑led ECG interpretation reduced both over‑ and under‑triage while improving resource utilization. Improvements in door‑to‑ECG, door‑to‑drugs, and door‑to‑PCI times supported earlier identification of cardiac events, more prompt treatment, and timelier reperfusion, thereby strengthening patient outcomes and the quality of emergency care. Following the demonstrated success of the 2023 Master’s project, the initiative was reviewed at the Departmental Management Committee meeting in late 2025. With support, the project was approved for reactivation and expansion into a larger‑scale pilot study within the Hospital Authority. The extended study will be conducted from late 2025 through 2026, transitioning from an academic project to a formal clinical pilot aimed at broader implementation and evaluation across emergency care settings.
