Exploring the complex interactions of baseline patient factors to improve nursing triage of acute coronary syndrome

Emergency Nurses' Recognition of and Perception of Sex Differences in Acute Coronary Syndrome Symptoms

INTRODUCTION

Emergency nurses must quickly identify patients with potential acute coronary syndrome. However, no recent nationwide research has explored nurses' knowledge of acute coronary syndrome symptoms. The purpose of this study was to explore emergency nurses' recognition of acute coronary syndrome symptoms, including whether nurses attribute different symptoms to women and men.

METHODS

We used a cross-sectional, descriptive design using an online survey. Emergency nurses from across the United States were recruited using postcards and a posting on the Emergency Nurses Association website. Demographic data and participants' recognition of acute coronary syndrome symptoms, using the Acute Coronary Syndrome Symptom Checklist, were collected. Descriptive statistics and ordinal regression were used to analyze the data.

RESULTS

The final sample included 448 emergency nurses with a median 7.0 years of emergency nursing experience. Participants were overwhelmingly able to recognize common acute coronary syndrome symptoms, although some symptoms were more often associated with women or with men. Most participants believed that women and men's symptoms were either "slightly different" (41.1%) or "fairly different" (42.6%). Nurses who completed training for the triage role were significantly less likely to believe that men and women have substantially different symptoms (odds ratio 0.47; 95% CI 0.25-0.87).

DISCUSSION

Emergency nurses were able to recognize common acute coronary syndrome symptoms, but some reported believing that the symptom experience of men and women is more divergent than what is reported in the literature.

A Nationwide Study of Emergency Nurses' Triage Decisions for Potential Acute Coronary Syndrome

INTRODUCTION

This study aimed to identify the symptoms used to assess angina, determine how emergency nurses make triage decisions for potential acute coronary syndrome, and determine emergency nurses' initial actions.

METHODS

This was a cross-sectional, survey-based design. Emergency nurses were recruited through a posting on the Emergency Nurses Association website and through postcards. Measures included demographic data, assessment of angina, and the Nurses' Cardiac Triage Instrument. Data were analyzed using descriptive statistics and ordinal logistic regression.

RESULTS

A total of 414 registered nurses with a mean age of 41.7 (SD = 12.0) years participated. They were predominantly female (80.7%), had a baccalaureate degree (60.1%), and worked as a registered nurse for a median 10.0 years. Common terms used to assess angina were chest pain (79.5%), chest pressure (77.3%), chest tightness (72.9%), and chest discomfort (72.5%). The severity of chest pressure (median 5.0, interquartile range 1.0) and nature of chest pain (median 5.0, interquartile range 1.0) had the highest overall median scores to support initial cardiac triage decisions. Associated symptoms of diaphoresis, fatigue, and shortness of breath along with health history contributed to decision making.

DISCUSSION

Emergency nurses primarily used chest symptoms and health history when deciding to evaluate for acute coronary syndrome in the emergency department. Associated symptoms of diaphoresis, fatigue, and shortness of breath, along with health history, also contributed to decision making. Initial registered nurse actions were to obtain an electrocardiogram, prepare the patient for the cardiac catheterization laboratory, and notify the emergency physician of the patient's admission.

Triage Accuracy of Emergency Nurses: An Evidence-Based Review

INTRODUCTION

Accurate triage assessment by emergency nurses is essential for prioritizing patient care and providing appropriate treatment. Undertriage and overtriage remain an ongoing issue in care of patients who present to the emergency department. The purpose of this literature review was to examine factors associated with triage accuracy in the emergency department.

METHODS

We conducted an evidence-based literature review using the Cumulative Index to Nursing and Allied Health Literature, PubMed, and Embase. The search focused on peer-reviewed articles in English, available in full text, published between January 2011 and December 2021.

RESULTS

A total of 14 articles met inclusion criteria and revealed the following 3 themes for triage accuracy: triage nurse characteristics, patient characteristics, and work environment. Triage nurses' accuracy rates ranged from 59.3% to 82%, with experience in triage associated with higher accuracy. Patient characteristics influenced triage accuracy, with nontrauma patients being undertriaged and trauma patients often overtriaged. The work environment played a role, as accuracy rates varied based on shift time and patient volume. Competing systems between prehospital and ED triage posed challenges and affected accuracy during fluctuations in patient volumes.

DISCUSSION

This review underscores the complex nature of ED triage accuracy. It highlights the importance of nurse experience, training programs, patient characteristics, and the work environment in enhancing triage decision making. Enhanced understanding of these factors can inform strategies to optimize triage accuracy and improve patient outcomes.

Effect of triage training on nurses' practice and triage outcomes of patients with acute coronary syndrome

BACKGROUND

Accurate assessment and prompt management of patients with acute coronary syndrome (ACS) is a complex process for emergency department (ED) nurses and has variable clinical outcomes. The aim of the present study was to determine the effectiveness of an educational intervention on nurses' practice during the triage of patients with ACS and the triage outcomes in this group of patients.

METHODS

In this quasi-experimental study, a pretest-posttest group of 24 nurses were included by convenience sampling method and 960 patients with ACS were selected by sequential sampling during the pre-intervention (n = 480) and post-intervention (n = 480) phases. A case-based learning (CBL) intervention was performed for nurses for one month considering the role of the triage nurse according to the American College of Cardiology (ACC) and the American Heart Association (AHA) recommendations as well as the factors affecting the proper identification and management of patients with ACS. During patient triage in the pre- and post-intervention phases, the "Triage Nurse Practice Checklist" and the "Medical Electronic Records" were used to assess nurses' practice and the triage outcomes in patients, respectively.

RESULTS

The overall mean score of the triage nurses' practice and its subscales, including Primary monitoring and assessment, cardiovascular risk factors assessment, evaluation of coronary heart disease (CHD) symptoms, chest pain management, and adherence to the ACC/AHA practice guidelines were significantly improved in the post-intervention phase compared with the pre-intervention phase (p < 0.001). There was no significant difference between the triage outcomes, including in-hospital mortality within 24 hours, death in ED, hospitalization in other wards, and discharge from ED in the pre and post-intervention phases (P = 0.723).

CONCLUSION

The development of a cardiac triage-specific educational program could improve the performance of nurses in the evaluation and management of patients with ACS, but had no effect on the triage outcomes in this group of patients. We recommend a quality improvement project or a critical outcomes-based triage system to assess ACS patients' care needs in the ED.

Arterial stiffness in acute coronary syndrome as a potential triage tool: a prospective observational study

BACKGROUND

Diagnosis and percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS) are time-sensitive. Triage and algorithms identify patients at high-risk. However, additional prediction tools are warranted for prioritized care based on predicted coronary pathologies and PCI complexity. Pulse-wave velocity (PWV) is a non-invasive measurement related to cardiovascular morbidity, and their exact value in ACS evaluation is unclear.

METHODS

In patients undergoing coronary angiography (CA) and - if warranted - PCI for ACS evaluation at a tertiary university hospital in Vienna, Austria, brachial-ankle (ba)PWV and carotid-femoral (cf)PWV were prospectively measured from January 2020 to January 2021.

RESULTS

PWV was measured in 58 patients (60.3% male; 65 [61-69] years). Risk prediction scores (GRACE, CRUSADE, TIMI), cardiac enzymes, and fraction of patients with a three-vessel disease were significantly higher in the pathological PWV ranges. Adjusted for age and comorbidities, baPWV independently predicted the LAD being relevantly stenotic (crude OR=1.416 [1.143-1.755], P=0.001; adjusted OR=1.340 [1.039-1.727], P=0.024; cut-off 15.5 m/s in CART-analysis), being the culprit lesion (crude OR=1.320 [1.094-1.594], P=0.004; adjusted OR=1.311 [1.037-1.657], P=0.024; cut-off 15.5 m/s), and being totally occluded (crude OR=1.422 [1.113-1.818], P=0.005; adjusted OR=1.677 [1.189-2.366], P=0.003; cut-off 19.6 m/s). Moreover, CA or PCI complexity were associated with higher PWV.

CONCLUSIONS

Pathological PWV as a surrogate for arterial stiffness, polyvascular disease and a larger atherosclerotic burden was associated with GRACE, CRUSADE, and TIMI scores, and PCI duration and complexity. BaPWV independently predicted relevant LAD pathologies, and is suggested as a potential novel triage and prioritization tool for suspected NSTE-ACS in emergency departments.