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Australian Critical Care 29 (2016) 2326

Contents lists available at ScienceDirect

Australian Critical Care


journal homepage: www.elsevier.com/locate/aucc

Research paper

Factors associated with triage assignment of emergency department


patients ultimately diagnosed with acute myocardial infarction
Kimberley Ryan BN, GradDip Nurs (Crit Care), BHSc (Nat) a, ,
Jaimi Greenslade PhD a,b,c ,
Emily Dalton BSc, BNursing a ,
Kevin Chu MBBS, MSc, FACEM a,b ,
Anthony F.T. Brown MBChB, FRCP, FRCSEd, FACEM, FCEM a,b ,
Louise Cullen MBBS, FACEM a,b,c
a
b
c

Royal Brisbane and Womens Hospital, Department of Emergency Medicine, Brisbane 4006, Australia
School of Medicine, The University of Queensland, St Lucia, 4067, Australia
School of Public Health, Queensland University of Technology, Kelvin Grove, 4059, Australia

article information
Article history:
Received 19 October 2014
Received in revised form 27 April 2015
Accepted 4 May 2015
Keywords:
Chest pain
Emergency department
Emergency nursing
Myocardial infarction
Triage

a b s t r a c t
Background: The objective of this study was to explore factors associated with the triage category assigned
by the triage nurse for patients ultimately diagnosed with acute myocardial infarction.
Methods: This was a retrospective analysis of 12 months of data, on adult emergency department patients
ultimately diagnosed with acute myocardial infarction. Data were obtained from hospital databases and
included patient demographics, patient clinical characteristics and nurses experience.
Results: Of the 153 patients, 20% (95% CI: 1427%) were given a lower urgency triage category than
recommended by international guidelines. Compared to patients who were triaged Australasian Triage
Category 1 or 2, patients with an Australasian Triage Category 35 were older (mean age 76 versus
68 years), more likely to be female (63% versus 32%), more likely to present without chest pain (93%
versus 35%) and less likely to have a cardiac history (3.3% versus 17.9%). A slightly higher proportion
of patients Australasian Triage Category 35 were triaged by an experienced nurse (50%) compared to
patients categorised Australasian Triage Category 12 (35.2%) but this nding did not reach statistical
signicance.
Conclusions: One in ve presentations was given a lower urgency triage category than recommended by
international guidelines, potentially leading to delays in medical treatment. The absence of chest pain
was the dening characteristic in this group of patients, along with other factors identied by previous
research such as being of female sex and elderly.
2015 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction
Acute Myocardial Infarction (AMI) is a leading cause of premature death and disability for Australian men and women.1 Rapid
assessment and treatment of patients with AMI is essential as
mortality associated with AMI is directly linked to time taken to
receive treatment.2,3 The initial clinical assessment for patients

Corresponding author at: Royal Brisbane and Womens Hospital, Department


of Emergency Medicine, Buttereld Street, Herston, 4006 Queensland, Australia.
Tel.: +61 7 36464629; fax: +61 7 3646 8732.
E-mail address: kimberley.ryan@health.qld.gov.au (K. Ryan).

who present to hospital emergency department (ED) occurs by a


triage ofcer. In most Western countries, the triage ofcer is a registered nurse who has specialised in emergency nursing. The key
role of the triage nurse is to accurately identify potential patients
who may have an AMI as early as possible to expedite necessary
immediate cardiac care.4
Triage is a system which allows the clinical urgency of a
presenting problem to be categorised. Similar 5-level triage systems are used in Canada (the Canada Triage and Acuity Scale),5
Europe, the United Kingdom (the Manchester Triage scale) and
Australia (the Australasian Triage Scale (ATS))6,7 (Web Appendix 1).
In Australia, experienced ED nurses complete mandatory training
from the Emergency Triage Education Kit (ETEK) and must be well

http://dx.doi.org/10.1016/j.aucc.2015.05.001
1036-7314/ 2015 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

24

K. Ryan et al. / Australian Critical Care 29 (2016) 2326

versed with the ATS. The ATS ranges from 1 to 5 with the ranking correlating with the recommended maximum time a patient
should wait for treatment. Patients categorised as ATS 1 require
immediate treatment, while patients categorised as ATS 2, 3, 4 or 5
are expected to receive medical assessment and treatment within
10, 30, 60, and 120 min respectively.8 In line with the Australasian
College of Emergency Medicine guidelines and the ETEK, a patient
presenting with symptoms suggestive of Acute Coronary Syndrome
(ACS) should be triaged as a Category 2.9,10 These symptoms may
include acute chest, epigastric, neck, jaw, or arm pain; or discomfort
or pressure without an apparent non cardiac source.11
According to the ETEK, under-triage describes the process
whereby the patient receives a triage code lower than their actual
level of urgency.10 Although Australian data are lacking, international research suggests a signicant number of patients with
AMIs are under-triaged, with one study nding up to half of all
AMI patients being assigned a lower priority triage category on
presentation.5 The reasons for under-triage of AMI patients have
not been adequately elucidated, though research suggests factors including age, sex, an absence of chest pain at triage, and
history of diabetes mellitus or heart failure make AMI harder to
recognise.1214 Given that triage is a modiable factor inuencing delays to treatment, further understanding of the determinants
of triage category in an Australian setting is an essential step in
enhancing the triage process.
1.1. Purpose of the study
This study explored the triage category assigned to patients with
myocardial infarction in a large tertiary hospital ED in Queensland, Australia. The study aim was to identify the factors associated
with the triage of patients presenting to ED with AMI. Predictors
of interest included patient demographics, clinical characteristics
and nursing triage experience.
2. Patients and methods
2.1. Study design and setting
This was an analysis of retrospective collected data on adult
patients presenting to the ED who were ultimately diagnosed with
AMI. The data were collected from the Royal Brisbane and Womens
Hospital (RBWH) between 1 June 2009 and 31 May 2010. The RBWH
is a 929 bed adult tertiary-referral teaching hospital; the RBWH
ED has an annual attendance rate of 72,000 patients over the age
of 14 years. This paper reports the ndings of a research study
that adhered to the National Statement on the Conduct of Human
Research by the Australian National Health and Medical Research
Council, and has been approved by the RBWH Human Research
Ethics Committee on the 30th April 2010.
2.2. Case selection and data collection
Patients with an AMI were identied through several sequential steps. The RBWH pathology department provided a list of
all patients who presented to the ED and had a serum troponin
I (TNI) performed as part of their emergency workup. This list
was then rened to include only those patients with a TNI value
of 0.06 mcg/L. The TNI assay used in at the RBWH during the
study period was the Beckman Coulter AccuTnI assay and 0.06
was the clinical decision cut-off point. The next step was to
undertake a review of the discharge diagnosis on the Emergency
Department Information System (EDIS) to conrm a diagnosis of
AMI for those patients. Patients with an EDIS diagnosis of Chest
Pain or Acute Coronary Syndrome (ACS) were further examined to identify whether they had a diagnosis of AMI on the

Table 1
Baseline characteristics of the cohort (n = 153).
Characteristic

n (%)

Mean SD age (years)


Male sex
English as primary language
Employment status
Employed
Pensioner
Unemployed
Other/unknown
Mode of arrival to emergency department
Own transport
Ambulance service

69.5 14.4
94 (61.4)
144 (94.1)
42 (27.5)
82 (53.6)
12 (7.8)
17 (11.1)
39 (25.5)
114 (74.5)

index admission. This initial examination was undertaken using


charts and electronic medical discharge summaries where the
diagnosis was documented by a cardiologist or general physician.
For the purposes of this study, AMI included diagnosis of AMI
(NSTEMI or STEMI) on the index admission or urgent revascularisation on index admission including coronary angioplasty, coronary
artery stenting and coronary artery bypass grafting. Exclusion criteria included pregnancy, age < 18 years and any patients transferred
to the ED from another hospital.
Once the population was identied, study data were obtained
from a number of sources. Data on patient demographics (age
and sex), presenting symptoms, cardiac history, ambulance use
and triage category were collected from the EDIS database. Presenting symptoms were categorised as typical or atypical for AMI.
Typical symptoms referred to the presence of any chest pain
during the event (present or resolved on arrival), while atypical
symptoms included dizziness, syncope, nausea or vomiting and
dyspnoea with the absence of chest pain prior to arrival or during presentation.1517 The name of the nurse who triaged the
patient was provided from the ED admission system, and the
years of nursing triage experience was then sought from the ED
Nurse Educators records. Data was de-identied prior to analysis.
2.3. Data analysis
Data were analysed using SPSS version 20. Baseline characteristics of the sample were reported. A triage category of 1 or 2 was
categorised as high urgency while a triage category of 35 was
deemed lower urgency. Standard descriptive statistics were used to
report the characteristics of the correctly triaged and under-triaged
patient groups. Chi-square tests (or Fishers exact tests where cell
sizes were small) were performed to compare dichotomous data
across triage categories. T-tests were performed to compare continuous characteristics across triage categories. There only were a
small number of patients with an ATS 35 (n = 30) and so it was not
deemed appropriate to perform multivariable analyses to identify
the independent predictors of triage category.
3. Results
There were a total of 153 patients identied with an index AMI
for analysis. The sample included 94 (61.4%) males and the mean
age was 69.5 years (SD = 14.1 years). Baseline characteristics of the
cohort are provided in Table 1 and demonstrate that the majority of the patients were English-speaking pensioners who arrived
via ambulance. One hundred and twenty three (80.4%, 95% CI:
73.286.4%) patients were provided an appropriate triage category
(ATS 12).

K. Ryan et al. / Australian Critical Care 29 (2016) 2326

25

Table 2
Patient characteristics and nursing triage experience for patients categorised as ATS 12 (n = 123) and ATS 35 (n = 30).

Male
Mean (SD) patient age, years
Arrival by ambulance
Presence of chest pain
Cardiac history
Nursing triage experience >2 years

Triage category 12 (n = 123)

Triage category 35 (n = 30)

83 (67.5%)
67.79 (13.59)
93 (75.6%)
79 (64.2%)
22 (17.9%)
43 (35.2%)

11 (36.7%)
76.33 (14.03)
21 (70%)
2 (6.7%)
1 (3.3%)
15 (50%)

<0.01
<0.01
0.53
<0.01
0.05
0.14

Data are number (%) unless otherwise indicated.

Table 2 provides nurse and patient characteristics for patients


who were categorised ATS 12 versus ATS 35. At a univariate
level, females and older individuals were less often assigned a triage
category 12. Females were older (mean = 76.56 years, SD = 14.10)
than males (mean = 65.01 years, SD = 12.12). However, the nding
that triage category 12 were younger was true both for males
and females (p = 0.31) Patients with a cardiac history and patients
with chest pain were more often assigned a triage category 12. A
slightly higher proportion of under-triaged patients were triaged by
an experienced nurse (50%) compared to correctly triaged patients
(35.2%) but this nding did not reach statistical signicance.
4. Discussion
Though the ETEK was published to help support consistency
in triage practice across Australia, the implementation of it as a
mandatory learning tool was not initiated in the RBWH DEM until
the end of 2010. Thus the collection of data in this study pre-dates
the implementation of ETEK; rather the ATS guided triage at this
time.
The appropriate triage of AMI patients to an ATS Category 1 or
2 is a challenge, irrespective of the extent of clinical nursing experience. We found that 20% of patients with an AMI were given an
ATS category of 35 and were therefore under-triaged. This important nding is an improvement on past estimates; prior research
has found that up to 50% of AMI patients were under-triaged,
when comparing to a similar tertiary hospital population in Canada
with a similar triage scale5 (Web Appendix 1). We are unable to
explain the lower rates of under-triaging at our institution; our
local practice mandates that triage nurses complete standardised
ETEK training after completing the Transition to Emergency Nursing Program over at least twelve months, and utilises a standardised
protocol for assigning triage scores. Though our results show an
improvement in triage of AMI patients, under-triage may still be a
problem; the data in this study suggests one in ve patients may
experience unnecessary delays to medical treatment.
Ninety three percent of the under-triaged group (n = 30) presented with atypical features. This nding is in line with previous
research, which suggests that despite atypical presentations for
patients with an AMI being common, such patients are often
misdiagnosed and undertreated.13,18 This group of patients have
signs and symptoms that are clinically ambiguous, and have often
occurred on a background of multiple co-morbidities.4 The undertriage of this group is therefore understandable but remains of
concern; patients who experience AMI without chest pain are signicantly more likely to have an overall longer length of stay and
are more likely to die in hospital when compared with AMI patients
with chest pain.4,13
This study supports past research that found females and the
elderly were more likely to be under-triaged.13,19 We too found that
AMI patients presenting with an absence of chest pain tended to be
older and female.18,19 Women presenting with AMI are known to
not be as easy to identify as men.15 Of the under-triaged group,

63% were female with a mean age of 76 years compared with


68 years in the correctly triaged cohort. One third of the patients
who were under-triaged were elderly patients presenting to the ED
after sustaining a fall of some kind, with an absence of chest pain.
Similar data were also found by Grosmaitrea et al.15 Ours was an
incidental nding which could help illuminate a potential underlying contributing factor in the fall. Older patients have a higher
incidence of impaired cognition and memory, which could affect
recall of symptoms when arriving at the emergency department
for triage.15
Level of triage experience has been identied previously as a
factor that may be associated with triage decisions.20 This may be
a result of experienced nurses false reliance on their ability to differentiate ambiguous clinical signs and symptoms, along with a
broader knowledge of differential diagnoses. Also, junior nursing
staff may be cautiously more protocol-oriented and refer directly
to the Australian Triage Criteria when allocating a triage category.
While our study found that a slightly lower proportion of patients
were assigned an ATS category 1 or 2 by experienced Registered
Nurses (>2 years experience), the difference was non signicant.
It is unclear why our nding differed from previous research but
it may be because it was underpowered to detect an effect. A
larger study with greater power to provide robust estimates is
required to understand whether triage experience is an important
factor.
4.1. Limitations, implications for emergency nurses, conclusions
On examining level of triage experience, we did not assess Triage
nurses total years experience as a Registered Nurse, as triage experience was only determined by date of accreditation at this facility.
Some of these nurses may have had prior Emergency experience
from other hospitals.
It is difcult to constructively critique a nurses triage allocation
for an AMI patient as the end diagnosis of AMI is determined by
a collection of clinical data gathered over the patients admission.
The symptoms presented to the nurse at the time of triage form just
one small part of the clinical picture that will ultimately inform the
nal diagnosis. Therefore, while the retrospective nature of the data
is valuable in identifying possible clinical features that are common
to the under-triaged group, this is unlikely to improve the actual
triage process at this time.
This study includes only a small number of participants and
future research would need to validate ndings in a bigger sample.
However, it should be noted that the demographic characteristics of
the sample we used are similar to AMI patients in other Australian
ED cohorts21 and to high risk ED populations in the Asia Pacic
region.22 This provides some evidence that the sample is representative of AMI patients in Australian settings. Finally, the conclusions
in this study are based on simple descriptive statistics and so we
could not provide data on independent predictors of under-triage.
Future studies with larger numbers of patients would be required
to enable multivariable analyses.

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K. Ryan et al. / Australian Critical Care 29 (2016) 2326

4.2. Implications for emergency nurses

References

This study highlights a number of the patient characteristics that


ultimately place them at risk for under-triage following AMI. In
addition, the signicance of the nding that nurses with greater
than two years experience were more likely to under-triage a
patient presenting with an AMI is unclear but warrants further
investigation. The ATS protocol is in place to guide clinicians
in triaging patients and it may serve triage nurses better with
increased referral to and reection on those guidelines. The implementation of ETEK guidelines may help to consistently guide nurses
when triaging these patients. Further, these results may suggest the
need for revised hospital protocols or enhanced clinical guidelines
within the current triage system to better capture and treat those
vulnerable patients who are presently under-served. In the RBWH
DEM nursing in-services have been utilised to highlight these outcomes and raise awareness about being mindful when triaging
patients with atypical features (age, sex, history of a mechanical
fall); all patients over 70 years who present to our department
now receive an ECG on arrival, regardless of what their presenting
problem is. Further questioning at triage to potentially elucidate if
there is an underlying cardiac cause has been suggested as a way
to improve on the clinical assessment of these patients.

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5. Conclusion
Estimates of under-triage of AMI patients in this cohort are
lower than past research yet one fth of patients are still undertriaged. This may lead to delays in medical assessment and
treatment and potentially compromise patient outcomes including
mortality. Elderly and female patients are still being under-triaged
despite prior research highlighting this issue. The absence of chest
pain in AMI is a signicant factor in under-triage. Clinical signs and
symptoms can be complex to discern against a background of comorbidities, especially in older patients. This study may assist more
experienced triage nurses to be mindful of the increased potential
for these sub-groups to present with an AMI.
Authors contributions
All authors contributed to all stages of the study, and all authors
have approved this nal version.
Acknowledgment
The Royal Brisbane and Womens Foundation (2010-kr) had
reviewed and granted $15,000 towards this research project as a
Nurse Initiative Research Grant in February 2010.
Web Appendix 1. Triage scale and maximum recommended
wait time in minutes
Scale

Category/level 1

Category/level 2

Category/level 3

Category/level 4

Category/level 5

Australasian Triage Scale


Canadian Triage and Acuity Scale
Manchester Triage Scale

0
0
0

10
15
10

30
30
60

60
60
120

120
120
240