Secondary Logo

Journal Logo

Triaging Women With Acute Coronary Syndrome: A Review of the Literature

Kuhn, Lisa DipAppSci(Nurs), EmergCert, GradDip(Nurs), MHlthSci(Nurs), RN; Page, Karen MN, DN, BEd, GradDipAdvNurs(CritCare), RN; Davidson, Patricia M. PhD, MEd, BA, RN; Worrall-Carter, Linda PhD, BEd, CoronaryCareCert, RN

The Journal of Cardiovascular Nursing: September-October 2011 - Volume 26 - Issue 5 - p 395-407
doi: 10.1097/JCN.0b013e31820598f6
ARTICLES: Triage With Acute Coronary Syndrome
Free

Aims and Objectives: This article analyzes the literature describing factors affecting nurses' triage of emergency department (ED) patients with potential acute coronary syndrome (ACS), with particular attention paid to gender-based differences.

Introduction: Acute coronary syndrome is one of the most time-critical conditions requiring ED nurse triage. This literature review will provide examination of how triage nurses prioritize patients with possible ACS, reflecting on challenges specifically associated with evaluating women for ACS in the ED. The article presents a description of the research findings that may help improve the timely revascularization of ACS in women.

Methods: An electronic search of EBSCOhost CINAHL, Health Source Nursing Academic Edition, MEDLINE, Psychology and Behavioral Sciences Collection databases, online theses, the Cochrane Library, the Joanna Briggs Institute, and National Guideline Clearinghouse resources were used to identify all relevant scientific articles published between 1990 and 2010. Google and Google Scholar search engines were used to undertake a broader search of the World Wide Web to improve completeness of the search. This search technique was augmented by hand searching these articles' reference lists for publications missed during the primary search.

Results: Review of the literature suggests factors such as patient age, sex, and symptoms at ED presentation affect the accuracy of nurses' triage of ACS, particularly for women. However, research examining delays due to ED triage is scant and has predominantly been undertaken by one researcher. Little research has examined triage of ACS specifically in women.

Conclusions: The literature search revealed a small number of articles describing challenges associated with nurse triage of women with ACS. Although most of this published research is North American, the themes uncovered are well supported by broader international research on acute assessment and management of women's ACS. These include the following: gender-based differences in the presentation of ACS can preclude early identification of ACS, advanced patient age often correlates with missed or delayed diagnosis of ACS, and there appears to be a general bias against managing women for ACS in parity with men's disease.

Relevance to Practice: Early reperfusion therapy is critical for optimal health outcomes in ACS. Triage nurses are ideally placed to minimize time to treatment for ACS. An understanding of the issues related to clinical decision making and triage allocation of women with ACS at triage is necessary to ensure appropriate treatment.

Lisa Kuhn, DipAppSci(Nurs), EmergCert, GradDip(Nurs), MHlthSci(Nurs), RN PhD Candidate, Faculty of Health Sciences, School of Nursing and Midwifery, Australian Catholic University; and St Vincent's Centre for Nursing Research, St Vincent's Public Hospital, Melbourne, Australia.

Karen Page, MN, DN, BEd, GradDipAdvNurs(CritCare), RN Associate Professor of Research, Faculty of Health Sciences, School of Nursing and Midwifery, Australian Catholic University; and St Vincent's/ACU Centre for Nursing Research, St Vincent's Public Hospital, Melbourne, Australia.

Patricia M. Davidson, PhD, MEd, BA, RN Professor of Cardiovascular and Chronic Care, School of Nursing and Midwifery, Curtin University of Technology, Sydney, Australia.

Linda Worrall-Carter, PhD, BEd, CoronaryCareCert, RN Professor and Director of Nursing Research, Faculty of Health Sciences, School of Nursing and Midwifery, Australian Catholic University; and St Vincent's/ACU Centre for Nursing Research, St Vincent's Public Hospital, Melbourne, Australia.

The authors wish to acknowledge support received by Ms Kuhn in the form of an Australian Postgraduate Award with stipend administered by Australian Catholic University and a grant from the Royal College of Nursing, Australia National Research and Scholarship Fund.

The authors have no conflicts of interest to report.

Correspondence Lisa Kuhn, DipAppSci(Nurs), EmergCert, GradDip(Nurs), MHlthSci(Nurs), RN, VECCI Building, Locked Bag 4115, Fitzroy MDC 3065, Level 4, 486 Albert St, East Melbourne 3002, Australia (l.kuhn@bigpond.net.au).

Emergency department (ED) triage nurses are the first health professionals to evaluate patients within many acute health systems and therefore are in a strong position to influence health outcomes.1 These nurses are ideally placed to enhance outcomes for patients with time-sensitive conditions because of their responsibility for assessing acuity or urgency of illness and assigning the order in which patients receive ED care.2,3 For the management of acute coronary syndrome (ACS), ED nurses are integral to determining the time to revascularization.4,5

As the entry point for patients coming into hospital systems via the ED, the triage role is central to the efficient delivery of emergency care6,7 and paramount to patient safety.2,6,8,9 However, this role is often undertaken in crisis-driven3 and chaotic10 settings. Decisions are made in the context of significant time constraints, crowded waiting rooms, and high patient anxiety.

Arrival at a triage decision is recognized to be a dynamic process.11 It is formulated based on patients' chief complaints, clinical histories, general states of well-being, and signs and symptoms.7 Vital and other physiological signs may not be used as often to inform decisions as some recommend.7 Competing demands on ED nurses have been found to cause them to rely on "pattern recognition" to reach triage acuity decisions.12 Because assigning lower triage scores than required for ACS risks unnecessarily delaying treatment and increasing cardiac muscle damage, examination of issues affecting triage of these conditions is essential to all reliant on or involved in cardiovascular nursing.

Little is known about how ED triage nurses formulate decisions related to possible ACS and the factors that influence these. This article reviews issues arising from the literature involving clinical decision making at ED triage for assessment and management of women for ACS.

Back to Top | Article Outline

Literature Search Methodology

An advanced search using the EBSCOhost interface was undertaken for CINAHL, Health Source Nursing Academic Edition, MEDLINE, and Psychology and Behavioral Sciences Collection databases using the following terms in Boolean Phrase search modes: triage (triag*), women (female* or wom* or gender* or sex) and heart disease (heart or coronary or myocardial or cardi*). This was supplemented with electronic searching of online thesis listings, Cochrane Library Systematic Reviews, Joanna Briggs Institute databases, and the National Guideline Clearinghouse to identify other relevant articles not published in professional journals. Articles selected included adult population samples, which were peer reviewed and published in English. Google and Google Scholar search engines were also used to undertake a broader search of the World Wide Web to improve completeness of the search. The search technique was augmented by hand searching reference lists for publications missed during the primary search.

The review was focused on articles involving ED nursing triage of women's ACS from 1990 to March 2010. Articles were included if they pertained to ED nurse triage of women's heart disease or clinical decision making related to ACS of either sex at the time of nursing triage.

When searching subject headings in CINAHL EBSCOhost, 308 results were returned. All citations were reviewed to ascertain those relevant to the current literature review. Seventeen of these records were retrieved in full, having ruled out all others because they failed to relate sufficiently to the topic of nurse triage for ACS or examined other conditions such as respiratory disease and traumatic injuries. Many also described nonprimary ED decision-making processes and were excluded. Six articles were found to be relevant.13-18 An electronic search was then undertaken using the same terms in the Ovid MEDLINE (MeSH) database. This was narrowed in the same manner as described for EBSCOhost and uncovered 4 additional articles. One of these met the requirements for this review.19 Searches of the National Guideline Clearinghouse, Cochrane Systematic Reviews and Joanna Briggs Institute databases, and Google and Google Scholar search engines failed to locate additional articles. A review of online theses identified one further article meeting the review requirements.20 Retrieved article reference lists searched for articles missed in the electronic searches failed to yield any more suitable references.

The search strategy identified 8 articles meeting the search criteria (Table). The search included articles that were prospective randomized controlled trials, observational studies, literature reviews, meta-analyses, theses, and published conference abstracts.

TABLE

TABLE

TABLE

TABLE

Back to Top | Article Outline

Literature Search Results

The articles highlighted through the search that met the inclusion criteria are listed in the Table. All but one were written by the same lead author (Arslanian-Engoren) and emanated from the United States, including the thesis. The other study was conducted across multiple sites in Canada.

Back to Top | Article Outline

Literature Review Findings

Research articles are grouped by similar methods in the current section to enable description and synthesis of their findings and explication of themes. The earliest record relevant to triage of women's heart disease by Arslanian-Engoren20 highlighted in this search was her doctoral dissertation. Her work covers a 10-year period and incorporates a number of different techniques. For her thesis, the author used a cross-sectional quantitative approach augmented with qualitative interviews to examine relationships between ED triage staff, knowledge, and experience, as well as patient sex, patient cues, and triage decisions. Using identical clinical vignettes in which only patient sex was changed, Arslanian-Engoren found older patients more likely to be allocated higher triage acuity scores for presentations suggestive of heart disease. She found acute myocardial infarction (AMI) was more easily differentiated in men, with women more often being assigned triage acuity scores for perceived respiratory and gallbladder diseases.20

Two of the studies by Arslanian-Engoren were qualitative.13,18 The researcher used focus group methodology to explore triage decision-making processes of ED nurses for men and women with cardiac illness. Both studies analyzed data from 12 participants, and although they did not state where or when the sessions were conducted, there was variation in sex balance, suggesting that some aspects of the studied groups had changed. Similar methodology allowed some comparison of how the triage nurses' knowledge and decisions related to ACS changed over time.

The earlier study found ED nurses were knowledgeable of the differences in sex-specific presentations, but were unable to apply this knowledge to middle-aged women's presentations with ACS.13 The ED nurse participants held differing perceptions of significance and likelihood of women seeking care for AMI than they did men.13 In the more recent study, Arslanian-Engoren18 reported the nurse participants who took part in another focus group study remained knowledgeable about differences in ACS presentation related to age and sex, but prone to hold cultural biases and stereotypes that interfered with clinical decision making at triage. Assessment of urgency status and subsequent triage categorization was assigned to patients according to their chief complaints, demographic features, and history, in addition to the participants' own attitudes, perceptions, beliefs, knowledge, and clinical experience. Triage decisions were formulated using a number of important patient cues including general appearance, vital signs, cardiac history, chest pain, and mode of transportation to the ED. Hence, issues remained similar over an extended period for these sample groups.

Other research reported by Arslanian-Engoren14-17 used clinical vignette questionnaires to expose patient cues used by triage nurses to predict ACS in women and men. The first of the studies using surveys involved a mailed questionnaire with 3 clinical vignettes, sent to 500 emergency nurses (response rate, 52%; 260 respondents). The vignettes were 3 identical scenarios, which were developed in pairs, male or female.14 Participants ranked up to 5 cues from the information provided on a visual analog scale from least (0 mm) to most (100 mm) for relevance in the triage decision. They were then asked to rate how urgently the vignette patients should be evaluated (0, nonurgent; 100, urgent) on a 100-mm visual analog scale and whether patients should be admitted (and if so, to a general ward, electrocardiograph [ECG]-monitored bed, or intensive care unit) or discharged home. Multiple regression analysis was used to determine if cue relevancy scores could predict triage urgency. The researcher concluded ED triage nurse sex bias and ageism could account for disparities uncovered in triage decisions for middle-aged women with vignettes suggestive of heart disease.14 This was at odds with the contribution from the author's dissertation already described; that increased patient age resulted in higher triage score allocation.20

In another study reported several years later, the same researcher evaluated 108 triage decisions, which were determined as necessary for medium effect size using a power calculation for 8 predictor variables (α = .05, power = 0.80) to evaluate triage nurse accuracy of prediction for admission for ACS.15 Analysis of these data found no differences based on patient sex, race, or age, but found that the overall accuracy for admission prediction for ACS was poor.15

Findings published in the following article contradicted the absence of sex bias in ACS triage.16 Using a power calculation for 15 predictor variables, it was determined that 952 subjects were required (small effect size, α = .05, power = 0.80). A total of 840 usable questionnaires were returned, meaning the study was underpowered according to the stated power analysis. The researcher asserted that different cues were used by ED nurses to determine clinical inferences for complaints suggestive of ACS based on patient sex. Female clinical vignette patients with ACS were more likely than male vignettes to be assigned suspected diagnoses of cholecystitis than ACS, despite identical symptoms.16

The researcher's subsequent article, copublished with a colleague, reported a 28% response rate to the mailed questionnaires.17 The researchers developed a genetic algorithm to predict nurses' triage decisions for ACS with reported success. They described a genetic algorithm as a form of computing, which "establishes simple heuristic rules for making a prediction of outcome, evaluates the correctness of these rules, changes or evolves these rules, and evaluates the correctness of the new rules."17(p83) They used this to determine if triage nurses applied different reasoning and rules to formulate triage decisions for men and women with suspected ACS. The results of this study showed that triage nurses did use different prediction rules when triaging male and female clinical vignette patients for ACS. The cues they used for both sexes were similar, but were combined differently to formulate their decisions.

The final article listed in the Table describes a retrospective analysis of a population-based cohort of 3088 patients with AMI admitted to 102 Ontarian acute care hospitals for 9 months to March 2001.19 Outcome measures were low-acuity triage scores using the Canadian Triage and Acuity Scale for these patients and its association with delays in arrival to treatment time (door to ECG and door to administration of fibrinolysis). The researchers found half of the patients with AMI were given inappropriately low Canadian Triage and Acuity Scale scores, and this was associated with significant delays in acquisition of ECGs and administration of fibrinolysis. They reported that being male had a positive and independent effect on patient median door-to-ECG time for ACS, in comparison to being female (P = .05). The researchers reinforced that ED triage was an important factor limiting performance on key measures of quality for AMI.19

Back to Top | Article Outline

Discussion

A number of themes have emerged from the literature search. First, presentation differences between men and women with ACS, such as chest pain and symptoms generally, may affect the quality of nursing assessment. Second, advanced patient age can be associated with inconsistency when triaging patients with possible ACS, and finally, there appears to be a pervasive sex bias when decision making for women with ACS in the ED. The thematic contributions from the literature search are placed in the context of broader literature relating to assessment and management of women's ACS, where it fits with the highlighted themes.

Because of the small number of articles and different methodologies used in their development, it is not feasible to provide in-depth analysis of themes from this literature alone. Other scientific articles are used to build on themes arising from the reviewed literature and inform the issue of triage of women's ACS on arrival at EDs in the current section. Exploration and synthesis of uncovered themes will be provided here, which will lead into Summary and Recommendations for Future Research, informing avenues of further research aimed at improving women's access to timely management for ACS in the ED.

Back to Top | Article Outline

Presentation Differences Between Women and Men With ACS

Two articles uncovered in this review reveal difficulties associated with recognition of symptoms of ACS in women by triage nurses.13,20 This is consistent with much of the literature published regarding symptoms of women's ACS, which has reported significantly different presentations between the sexes.21 Although there is some discord,22 literature generally supports the presence of differences in symptoms23-26 or in the proportion of symptoms experienced.27

A significant proportion of women have right-sided chest and arm pain.28 Others report no pain at all.29 Cardiovascular events in women are often heralded by nonspecific symptoms, making differentiation from other physiological and functional etiologies for them and ED personnel problematic.26 In a qualitative study by McSweeney and Crane,30 37 of 40 participants revealed prodromal symptoms occurred from 3 weeks to 2 years prior to their ACS events. McSweeney and colleagues31 examined women's symptoms both prodromally (before onset) and acutely (concurrent with onset) for ACS. They described a set of prodromal symptoms for ACS specific to women including unusual fatigue, sleep disturbance, shortness of breath, weakness, anxiety, and chest discomfort.31 Acutely, women are more likely to present with complaints of unusual fatigue, dyspnea, dizziness, cold sweats,31 nausea,23 weakness, and indigestion.32,33 Prominent throat, neck, and jaw pains have also been reported acutely.34

Back to Top | Article Outline

Atypical Nature of Women's Symptoms for ACS

Time from arrival to assessment and management for women with ACS in the ED setting tends to be delayed, compared with men's according to numerous studies.35-37 Women's tendency to experience "atypical" symptoms and signs for ACS is believed to account for much of the time delays.38 Typical chest pain in ACS has been historically defined by men's experiences of ACS.39 Some claim this has resulted from past overrepresentation of men in studies related to heart disease.40-42 Symptoms reported to occur are more likely to reflect the male pattern for ACS,43-45 as are treatments based on evidence from these findings.46

Back to Top | Article Outline

Chest Pain Is Central to Early ACS Assessment

Chest pain is an important symptom examined in the context of early ACS assessment because it is considered the "hallmark" characteristic of the syndrome's presentation.21 A number of decision algorithms for predicting ACS in EDs rely on chest pain as a major predictor of the syndrome.47-49

Using chest pain as the key descriptor for assessing women's ACS in the ED is problematic for a variety of reasons. First, a proportion of women do not present with complaints of chest pain when experiencing ACS, and this may be higher than in men. A recent meta-analysis, for instance, calculated that 37% of women and 27% of men diagnosed with AMI fail to present with chest pain.21 Hence, chest pain should not be the only chief complaint considered when assessing patients for ACS, particularly women. Second, if patients do not present with chest pain and this is the symptom most likely to "trigger" suspicion for ACS in the minds of triage nurses and other emergency clinicians, it is difficult to gauge how many ACS episodes have been missed. Emergency department triage nurses have been found to rely on pattern recognition when formulating clinical decisions,12 and if the patient presentations do not fit the pattern, serious disease may be overlooked altogether, increasing the time to initiation of any treatment and quantity of permanent myocardial damage.

Another challenge for triage nurses may be that even when the symptom is present, descriptors of chest pain can differ markedly between sexes.50 One research group argued men and women both experienced chest pain equally, but, on finding perceptions of chest pain differed between the sexes, proposed a framework based on psychosocial, biological, physiological, and anatomical differences to explain how symptoms manifest.32 This is problematic when applying current understandings of "typical" chest pain because ACSs are more easily differentiated in men.51 When it is described as triage personnel anticipate it to be, chest pain provides useful diagnostic cues for the time-sensitive ACSs.16,17

Back to Top | Article Outline

Triage Inconsistencies in ACS Related to Advanced Patient Age

Triage score allocation for ACS has been found to be inconsistent in articles highlighted in this review because of patient age.14,20 Advanced age may lead to both higher and lower triage score allocation for ACS than required for optimal patient outcome. In her thesis, Arslanian-Engoren20 reported that older patients were more often allocated higher acuity triage scores than younger patients. This contradicts other research, however, which report triage acuity levels negatively correlate with increased patient age.14,52-55 Hence, older age tends to attract lower triage allocation for ACS presentations, which can be detrimental to early revascularization and prevention of cardiac damage.

Possible bias against patients of advanced age has been examined for its potentially negative ramifications in ACS in other studies. A recent study by Han et al53 found that clinical practice for ACS in the ED did not reflect best available evidence for the elderly. They found that older patients suffered significantly higher 30-day mortality risk for ACS, but received less testing, reflecting an age bias.53 Magid et al54 argue that it is plausible the lower application of evidence-based treatment is partially responsible for the poorer outcomes in older-age patients with AMI. As women tend to present with their first ACS event 8 to 10 years older than their male counterparts,56 the likelihood of undertriage (assigning lower than expected triage acuity score) for this patient population is potentially greater. Some researchers have noted particularly high ACS mortality rates in women 65 years or older.52,57 Shaw and colleagues58 described patients with heart disease who had combined old age and female sex as becoming victims of inequality.

Advanced age brings with it an increased range of comorbidities such as type 2 diabetes mellitus, hypertension, and chronic arthritic diseases.59 As women are more likely to experience ACS after menopause, they are likely to have accrued more comorbid illnesses than men by the time the syndrome manifests.60,61 Increased comorbidities have previously been used to explain differences in ACS management provided to men and women patients.62

Interestingly, recent studies have shown advancing age in women and men leads to diminished perception of chest pain in ACS.23,25 This may be pertinent to the identification of ACS in newly presenting older patients of either sex, when assessed by ED triage personnel. They showed that such presentations were associated with the administration of fewer evidence-based treatments such as revascularization and pharmacotherapy. This, they proposed, led to greater hospital morbidity and higher mortality in this patient group, which included older women and men.23,25 Similar results were found in a large study (n = 10 783) across 10 hospital EDs in the United States.63 Coronado et al63 concluded that heart failure, age, female sex, and diabetes were most often associated with painless ACS. They found that patients who did not experience chest pain with ischemia were less likely to be admitted to coronary care units, but suffered increased hospital mortality.63

Back to Top | Article Outline

Sex-Related Influences From ED Triage to Ongoing Assessment and Management

Literature featured during the current review purports that women are assessed and managed differently than men for ACS during ED triage.13,16,19,20,64 Available research supports evidence of an ongoing and pervasive international bias against women's ACS management from the time of triage, which negatively affects their treatment through the remaining ED trajectory of care.

In a North American study, Lehmann et al65 found a bias against women presenting to EDs with new-onset chest pain, even when their symptoms were similar to their male counterparts'. The timeliness to treatment and outcomes for women were also reported to be poor in Ireland with women experiencing longer in-hospital treatment delays than men for ACS in Dublin EDs.66 The interval from time of triage to physician review for women was 30 minutes, compared with 20 minutes for men. This delay may have induced delays to intervention in subsequent intervals; median door-to-needle time was 70 minutes for women and 52 minutes for men (P = .02). Women also waited longer to receive aspirin and were transferred to the coronary care unit an average of 1 hour later than men (P ≤ .0001). It has been shown that women are more likely to be discharged prematurely from EDs with ACS.67 A number of researchers have closely examined time to treatment for patients with ACS in the ED.19,65,66,68 All have found issues of inequity of ACS management, which have constituted quantifiable bias against women's treatment for ACS.

Literature indicates that there are significant differences in assessment and management of women throughout the care pathway in acute hospital settings, beyond EDs.60,66,67,69 The problem is not new; the phrase "Yentl syndrome" was coined almost 20 years ago in a New England Journal of Medicine article outlining sex bias in treatment for women's heart disease.70 It has since been invoked to illustrate finding that even when clinical and nonclinical predictors of admission were controlled for, women were significantly less likely to be admitted to hospital for chest pain or to have diagnostic tests than men.71

Research continues to show women are less likely to undergo revascularization procedures than men.36,67,72-74 Women also receive less evidence-based pharmacotherapy than men, including anticoagulation, β-blockade, statins, and antiplatelet drugs.36,75,76 Swedish researchers compared outcomes for women and men with chest pain or other symptoms suggestive of AMI who had normal ECGs.77 Men were admitted to coronary care units more readily than women, and although women developed less AMIs, they had equivalent in-hospital mortality as men and during their first year subsequent to this presentation.77

Jneid and colleagues36 believe less aggressive administration of therapy is likely part of the reason women are more prone to experience premature death when admitted with ST-elevation myocardial infarction than men. Contemporary research has shown that inadequate use of evidence-based management for women's ACS also occurs in Australia,74 where although knowledge among physicians is good, application of evidence to practice is inconsistent or poor.78

Back to Top | Article Outline

Summary and Recommendations for Future Research

The current literature review describes the triage of women patients with ACS in the ED. All but 1 of the 8 articles revealed challenges. The article that differed most from the others15 was itself, contradicted a year later in a similar but larger study by the same researcher.16 Since the early publication of the longitudinal Framingham study acknowledging that heart disease is in fact an important cause of mortality and morbidity in women,79 research has continued to show the global heart disease burden for them is not diminishing at the same rate as men's.80 It remains the greatest killer of women worldwide.81

Literature uncovered through this review indicates the urgency of women's ACS is neither always recognized nor managed with parity to that of men.67,69,82 The importance of women's heart disease remains underestimated by health professionals.43,83,84 This underestimation is said to be partly responsible for the underrecognition and undertreatment of heart disease in women in hospitals.62

Back to Top | Article Outline

Underestimation of Prevalence of Women's ACS

Emergency department clinicians have been shown to underestimate women's ACS risk,13,36,64 which can have dire consequences at the stage when most can be done to prevent myocardial cell damage. Timely reperfusion for ACS has positive effects on patient mortality and morbidity.85 Yet, in a recent large study in the United States (n = 78 000), it was found that women with AMI presenting to EDs received less early aspirin, β-blockade, reperfusion, and timely reperfusion than men.36 They also received less cardiac catheterization and revascularization procedures after AMI.36,86 Similar disparities against women are identified in numerous studies internationally.67,72-74,87-89

Despite acknowledging that time to treatment is a critical factor in ACS,85,90 there is very little research addressing time delay from the time affected patients present to the triage desk. Triage is a developing concept91 in a relatively new specialty.92 Research of the role has intensified in the last decade in recognition of the effect triage nurse decisions have on subsequent ED care.9 The primary aims of triage are to ensure patients with life-threatening conditions are assessed accurately and managed expeditiously.93

Themes arising from the literature reveal sex-related differences for ACS treatment at ED triage, most likely due to underestimation of the prevalence of the syndromes in women.20,13 Extensive evidence supports women are treated differently for ACS during ED and inpatient trajectories of care. Some researchers have labeled this "gender bias"94,95 and believe it is responsible for many disparities experienced by women.40 Themes from this literature review suggest a number of reasons women may be undertreated for ACS in the ED, likely related to differences in symptoms, age, comorbid illness, and an unwillingness to accept ACS to be so prevalent in women. The themes suggest women's sex may influence their triage and subsequent assessment and management for ACS, but they do not portray an intentional bias against women. In fact, it has been shown if either a man or woman presents to an ED with ACS, time to treatment may be delayed if he/she does not fit the "pattern" expected for a patient with ACS.96 Chest pain, for instance, is seen to be central to accurate assessment of ACS; Brieger and colleagues75 found that patients who failed to present with the requisite chest pain with ACS had delayed treatment and worse outcomes, regardless of their sex.

Back to Top | Article Outline

Assessment of ACS Is Based on Men's Experiences

Literature illustrates that women's ACS is often not anticipated by many ED triage nurses.20,13 Even if the nurses are knowledgeable about the syndrome's symptoms in women,16 they are less likely to triage according to expected category for ACS if the pattern of presentation is different than men's. This is not surprising, given that most research has historically involved male participants.97 Despite concerted efforts by investigators, particularly in the United States,41 to include more women in cardiovascular trials, some continue to argue that women's cardiovascular health remains underresearched.40,41,69 This has led to what has been called a "gender-neutral" understanding of heart disease.98 Women are assumed to present with the same symptoms as men and the same therapeutic needs. Lockyer98 calls for health professionals to "develop a clearer understanding of the nature of CHD [coronary heart disease] as it affects women and develop an evidence base that underpins…" it.98(p162) There is much scope for research to understand how to convert knowledge of differences in ACS presentation in women into consistent evidence-based practice. Research needs to be undertaken to determine if it is possible to improve access to timely management for women with ACS through further increasing awareness of the syndrome among ED triage nurses and their colleagues, or if behavior is better modified in a different way. Research has previously shown that changes on 12-lead ECGs are predictive of increased cardiovascular events and mortality in women who are asymptomatic,99 so it may be useful to promote performing more ECGs in women who present to EDs with a broader range of complaints.

Back to Top | Article Outline

Pattern Recognition for ACS

Emergency department triage nurses operate under conditions of ongoing time constraint and often in rapidly changing settings. To enable them to function in their role and assess all patients as they present to the ED, they need to be able to formulate decisions promptly. One of the methods they use to do this is by pattern recognition.12 Arslanian-Engoren17 labeled these prediction rules. She argued that triage nurses use "cues" to enable them to formulate clinical inferences to predict likelihood of patients presenting with ACS.16 Patients whose complaints, physical attributes, age, sex, and comorbid conditions fit certain patterns for illnesses are assigned a triage category based on the probability they are experiencing a particular condition. Cioffi2 calls this a probability judgment. A patient who is experiencing an ACS should be given a high triage score to enable early revascularization and reperfusion of ischemic myocardium. However, for a triage nurse to judge it probable the patient is having this condition, he/she needs to recognize a pattern or series of cues to enable the formulation of the triage judgment or inference. Symptoms including chest pain and demographic features such as patient sex, age, and comorbid illness all trigger probability judgments necessary to come to an appropriate triage decision, only if they are anticipated as possible cues for ACS. If the triage nurse does not arrive at this judgment, identification of ACS may be overlooked or delayed.

Regardless of a triage nurse's knowledge or intention to expedite all patients with ACS appropriately, preconceived notions such as expected prevalence of ACS in women affect triage nurse decisions. This was evident in several of the studies located in the literature review.13,16,20 Despite being knowledgeable of women's ACS experiences, triage nurses were unable to associate ACS with middle-aged women.13 Identical presentations elicited different responses from triage nurses based on patient sex.20

Future research is required to ascertain if it is possible to increase ED triage nurse awareness of the range of cues for ACS and when it is necessary to delve further into a patient's presentation to avoid missed or delayed recognition of time-sensitive conditions. The use of pattern recognition is an important adjunct to the triage nurse's advanced assessment skills because it enables rapid categorization for commonly presenting illnesses, such as ACS. While it is important to retain the ability to triage large numbers of patient arrivals in a shift, the evidence that not all ACS presentations are the same needs to be built into clinical assessment. Research needs to show how triage nursing can be undertaken with expedience, while reducing the risk of overlooking what does not fit the usual mold for ACS.

Back to Top | Article Outline

Limitations

An extensive search of multiple resources revealed a small number of scientific articles seeking to better understand primary ED triage decisions for women presenting to EDs with possible ACS, making meaningful comparison difficult. The prime limitation of the literature review was that most of the research and therefore discussion were provided by 1 lead author (Arslanian-Engoren). Although this work is valuable and examination of the subject would be limited without it, this may portray a singular view of the subject. This researcher has, however, used various methods that have been well explicated and arrived at similar conclusions. Hence, her research in this area is of great value.

A second limitation is that investigation was limited to North American EDs. Issues affecting these EDs may differ from others internationally. Each was done using 5-tier triage scales (0, lowest urgency, to 5, highest urgency). Such triage scales have been described as the most valid and reliable methods for stratifying patients for clinical urgency.100,101 Similar 5-tier scales are also used in the United Kingdom, Australia, and New Zealand,102 which may increase the comparability and relevance of these findings in these countries also.

Although some objectives were similar, there was no consistency across study designs, which meant comparable conclusions could not be reached. Multiple methodologies were used; hence, meta-analysis could not be undertaken. A number of studies were qualitative in nature, and results were not generalizable beyond the participant groups described. Sample sizes in the focus group studies were small,13,18 which is suitable for this methodology.103

Table

Table

Back to Top | Article Outline

Implications for Practice

A number of research projects have addressed delays to reperfusion for patients with ACS in EDs.104-107 These have included studies to measure and/or improve door-to-reperfusion times for patients managed in EDs with potential ACS.108 Considering the primary role triage nurses play in expediting management for all ED patients, particularly those with time-sensitive conditions such as ACS, studies specifically examining cardiac triage decisions in women and men are surprisingly rare. Canadian researchers recently determined that more than half of all patients with ACS failed to reach benchmark times for reperfusion.19 The situation may be deteriorating, with only 40% of patients reportedly undertriaged in the early 1990s.109

The implication is that there is a great deal to be done in terms of ACS management for women at the time of ED triage internationally. Evidence is not being applied satisfactorily to practice.110 Despite increasing research efforts aimed at redressing shortages of evidence for women's heart disease,73 there appear to be a number of gaps in the literature related to this issue. There are no recent reports evaluating triage category allocation and patient outcomes for ACS. Little is known about current ED nursing knowledge of women's ACS, or how nurses make decisions at ED triage for patients of either sex with possible ACS outside North America.

Strategies need to be devised, tested, and evaluated to ensure that women's presentations for ACS, even when atypical, are evaluated and expedited appropriately. To do this, the authors recommend a systematic suite of studies to examine current knowledge base requirements, assessment practice, and process-related constraints to accurate assessment of ACS in women at various management time points. This would include studies using various designs such as case study, staff survey, and medical record audit with mixed quantitative and qualitative methodologies to ensure not only breadth but also depth to this important area of research. With the benefit of thorough understanding and stakeholder input, evidence would be more readily implemented into ED practice.

Back to Top | Article Outline

REFERENCES

1. Gerdtz MF, Collins M, Chu M, et al. Optimizing triage consistency in Australian emergency departments: the Emergency Triage Education Kit. Emerg Med Australas. 2008;20(3):250-259.
2. Cioffi J. Decision making by emergency nurses in triage assessments. Accid Emerg Nurs. 1998;6(4):184-191.
3. Fry M, Burr G. Using a survey tool to explore the processes underpinning the triage role: a pilot study. Australas Emerg Nurs J. 2001;4(1):27-31.
4. Considine J, Ung L, Thomas S. Triage nurses' decisions using the National Triage Scale for Australian emergency departments. Accid Emerg Nurs. 2000;8(4):201-209.
5. Olsson SE, Ohlsson M, Ohlin H, et al. Decision support for the initial triage of patients with acute coronary syndromes. Clin Physiol Funct Imaging. 2006;26(3):151-156.
6. CENA. Position Statement: Triage Nurse. Burwood, New South Wales, Australia: College of Emergency Nursing Australasia Ltd.; 2009.
7. Gerdtz MF, Bucknall TK. Triage nurses' clinical decision making. An observational study of urgency assessment. J Adv Nurs. 2001;35(4):550-561.
8. Cioffi J. Triage decision making: educational strategies. Accid Emerg Nurs. 1999;7(2):106-111.
9. Considine J, Botti M, Thomas S. Do knowledge and experience have specific roles in triage decision-making? Acad Emerg Med. 2007;14(8):722-726.
10. Gerdtz MF, Bucknall TK. Why we do the things we do: applying clinical decision-making frameworks to triage practice. Accid Emerg Nurs. 1999;7(1):50-57.
11. Andersson AK, Omberg M, Svedlund M. Triage in the emergency department-a qualitative study of the factors which nurses consider when making decisions. Nurs Crit Care. 2006;11(3):136-145.
12. Fry MM. Triage Nursing Practice in Australian Emergency Departments 2002-2004: An Ethnography. Sydney, Australia: Department of Family and Community Health Nursing, Faculty of Nursing, University of Sydney; 2004.
13. Arslanian-Engoren C. Gender and age bias in triage decisions. J Emerg Nurs. 2000;26(2):117-124.
14. Arslanian-Engoren C. Gender and age differences in nurses' triage decisions using vignette patients. Nurs Res. 2001;50(1):61-66.
15. Arslanian-Engoren C. Do emergency nurses' triage decisions predict differences in admission or discharge diagnoses for acute coronary syndromes? J Cardiovasc Nurs. 2004;19(4):280-286.
16. Arslanian-Engoren C. Patient cues that predict nurses' triage decisions for acute coronary syndromes. Appl Nurs Res. 2005;18(2):82-89.
17. Arslanian-Engoren C, Engoren M. Using a genetic algorithm to predict evaluation of acute coronary syndromes. Nurs Res. 2007;56(2):82-88.
18. Arslanian-Engoren C. Explicating nurses' cardiac triage decisions. J Cardiovasc Nurs. 2009;24(1):50-57.
19. Atzema CL, Austin PC, Tu JV, Schull MJ. Emergency department triage of acute myocardial infarction patients and the effect on outcomes. Ann Emerg Med. 2009;53(6):736-745.
20. Arslanian-Engoren CM. The Triaging of Men and Women for Coronary Artery Disease: Knowledge, Experience, or Bias [thesis]. Ann Arbor, MI: The University of Michigan; 1999.
21. Canto JG, Goldberg RJ, Hand MM, et al. Symptom presentation of women with acute coronary syndromes: myth vs reality. Arch Intern Med. 2007;167(22):2405-2413.
22. Comeau A-C. A Comparison of Typical and Atypical Symptom Presentation in Acute Coronary Syndromes [M.N.]. Alberta, Canada, University of Alberta; 2003.
23. Arslanian-Engoren C, Patel A, Fang J, et al. Symptoms of men and women presenting with acute coronary syndromes. Am J Cardiol. 2006;98(9):1177-1181.
24. Goldberg RJ, O'Donnell C, Yarzebski J, Bigelow C, Savageau J, Gore JM. Sex differences in symptom presentation associated with acute myocardial infarction: a population-based perspective. Am Heart J. 1998;136(2):189-195.
25. Milner KA, Vaccarino V, Arnold AL, Funk M, Goldberg RJ. Gender and age differences in chief complaints of acute myocardial infarction (Worcester Heart Attack Study). Am J Cardiol. 2004;93(5):606-608.
26. Shaw LJ, Bairey Merz CN, Pepine CJ, et al. Insights from the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) study: part I: gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies. J Am Coll Cardiol. 2006;47(3 suppl S):S4-S20.
27. DeVon HA, Zerwic JJ. Symptoms of acute coronary syndromes: are there gender differences? A review of the literature. Heart Lung. 2002;31(4):235-245.
28. Albarran J, Durham B, Gowers J, Dwight J, Chappell G. Is the radiation of chest pain a useful indicator of myocardial infarction? A prospective study of 541 patients. Accid Emerg Nurs. 2002;10(1):2-9.
29. Shlipak MG, Elmouchi DA, Herrington DM, Lin F, Grady D, Hlatky MA. The incidence of unrecognized myocardial infarction in women with coronary heart disease. Ann Intern Med. 2001;134(11):1043-1047.
30. McSweeney JC, Crane PB. Challenging the rules: women's prodromal and acute symptoms of myocardial infarction. Res Nurs Health. 2000;23(2):135-146.
31. McSweeney JC, Cody M, O'Sullivan P, Elberson K, Moser DK, Garvin BJ. Women's early warning symptoms of acute myocardial infarction. Circulation. 2003;108(21):2619-2623.
32. DeVon HA, Ryan CJ, Ochs AL, Shapiro M. Symptoms across the continuum of acute coronary syndromes: differences between women and men. Am J Crit Care. 2008;17(1):14-24; >quiz 25>.
33. Dracup K, McKinley SM, Moser DK. Australian patients' delay in response to heart attack symptoms. Med J Aust. 1997;166:233-236.
34. Philpott S, Boynton PM, Feder G, Hemingway H. Gender differences in descriptions of angina symptoms and health problems immediately prior to angiography: the ACRE study. Appropriateness of Coronary Revascularisation Study. Soc Sci Med. 2001;52(10):1565-1575.
35. Hasdai D, Lev EI, Behar S, et al. Acute coronary syndromes in patients with pre-existing moderate to severe valvular disease of the heart: lessons from the Euro-Heart Survey of acute coronary syndromes. Eur Heart J. 2003;24(7):623-629.
36. Jneid H, Fonarow GC, Cannon CP, et al. Sex differences in medical care and early death after acute myocardial infarction. Circulation. 2008;118(25):2803-2810.
37. Kudenchuk PJ, Maynard C, Martin JS, Wirkus M, Weaver WD. Comparison of presentation, treatment, and outcome of acute myocardial infarction in men versus women (the Myocardial Infarction Triage and Intervention Registry). Am J Cardiol. 1996;78(1):9-14.
38. Patel H, Rosengren A, Ekman I. Symptoms in acute coronary syndromes: does sex make a difference? Am Heart J. 2004;148(1):27-33.
39. Pilote L, Dasgupta K, Guru V, et al. A comprehensive view of sex-specific issues related to cardiovascular disease. CMAJ. 2007;176(6):S1-S44.
40. Lockyer L, Bury M. The construction of a modern epidemic: the implications for women of the gendering of coronary heart disease. J Adv Nurs. 2002;39(5):432-440.
41. Blauwet LA, Redberg RF. The role of sex-specific results reporting in cardiovascular disease. Cardiol Rev. 2007;15(6):275-278.
42. Redberg RF. Gender differences in acute coronary syndrome: invasive versus conservative approach. Cardiol Rev. 2006;14(6):299-302.
43. Clancy M. Chest pain units. BMJ. 2002;325(7356):116-117.
44. Lockyer L. Women's interpretation of their coronary heart disease symptoms. Eur J Cardiovasc Nurs. 2005;4(1):29-35.
45. Stramba-Badiale M, Priori SG. Gender-specific prescription for cardiovascular diseases? Eur Heart J. 2005;26(16):1571-1572.
46. Jochmann N, Stangl K, Garbe E, Baumann G, Stangl V. Female-specific aspects in the pharmacotherapy of chronic cardiovascular diseases. Eur Heart J. 2005;26(16):1585-1595.
47. Boufous S, Kelleher PW, Pain CH, et al. Impact of a chest-pain guideline on clinical decision-making. Med J Aust. 2003;178(8):375-380.
48. Fesmire FM, Hughes AD, Fody EP, et al. The Erlanger chest pain evaluation protocol: a one-year experience with serial 12-lead ECG monitoring, two-hour delta serum marker measurements, and selective nuclear stress testing to identify and exclude acute coronary syndromes. Ann Emerg Med. 2002;40(6):584-594.
49. Selker HP, Beshansky JR, Griffith JL, et al. Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia. A multicenter, controlled clinical trial. Ann Intern Med. 1998;129(11):845-855.
50. Albarran JW, Clarke BA, Crawford J. 'It was not chest pain really, I can't explain it!' An exploratory study on the nature of symptoms experienced by women during their myocardial infarction. J Clin Nurs. 2007;16(7):1292-1301.
51. Pepine CJ. Ischemic heart disease in women. J Am Coll Cardiol. 2006;47(3 suppl S):S1-S3.
52. Gibler WB, Armstrong PW, Ohman EM, et al. Persistence of delays in presentation and treatment for patients with acute myocardial infarction: the GUSTO-I and GUSTO-III experience. Ann Emerg Med. 2002;39(2):123-130.
53. Han JH, Lindsell CJ, Hornung RW, et al. The elder patient with suspected acute coronary syndromes in the emergency department. Acad Emerg Med. 2007;14(8):732-739.
54. Magid DJ, Masoudi FA, Vinson DR, et al. Older emergency department patients with acute myocardial infarction receive lower quality of care than younger patients. Ann Emerg Med. 2005;46(1):14-21.
55. Tricomi AJ, Magid DJ, Rumsfeld JS, et al. Missed opportunities for reperfusion therapy for ST-segment elevation myocardial infarction: results of the Emergency Department Quality in Myocardial Infarction (EDQMI) study. Am Heart J. 2008;155(3):471-477.
56. Bassand JP, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: the Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology. Eur Heart J. 2007;28(13):1598-1660.
57. Grzybowski M, Zalenski RJ, Ross MA, Bock B. A prediction model for prehospital triage of patients with suspected cardiac ischemia. J Electrocardiol. 2000;(33 Suppl):253-258.
58. Shaw M, Maxwell R, Rees K, et al. Gender and age inequity in the provision of coronary revascularisation in England in the 1990s: is it getting better? Soc Sci Med. 2004;59(12):2499-2507.
59. Jani SM, Montoye C, Mehta R, et al. Sex differences in the application of evidence-based therapies for the treatment of acute myocardial infarction: the American College of Cardiology's Guidelines Applied in Practice projects in Michigan. Arch Intern Med. 2006;166(11):1164-1170.
60. Dey S, Flather MD, Devlin G, et al. Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events. Heart. 2009;95(1):20-26.
61. Turris SA, Finamore S. Reducing delay for women seeking treatment in the emergency department for symptoms of potential cardiac illness. J Emerg Nurs. 2008;34(6):509-515.
62. Di Cecco R, Patel U, Upshur R. Is there a clinically significant gender bias in post-myocardial infarction pharmacological management in the older (>60) population of a primary care practice? BMC Fam Pract. 2002;3(1):8.
63. Coronado BE, Pope JH, Griffith JL, Beshansky JR, Selker HP. Clinical features, triage, and outcome of patients presenting to the ED with suspected acute coronary syndromes but without pain: a multicenter study. Am J Emerg Med. 2004;22(7):568-574.
64. Ahlstrom F, Goransson KE, von Rosen A. Does gender matter at triage? Australas Emerg Nurs J. 2007;10(4):202-203.
65. Lehmann JB, Wehner PS, Lehmann CU, Savory LM. Gender bias in the evaluation of chest pain in the emergency department. Am J Cardiol. 1996;77(8):641-644.
66. O'Donnell S, Condell S, Begley C, Fitzgerald T. In-hospital care pathway delays: gender and myocardial infarction. J Adv Nurs. 2005;52(1):14-21.
67. Kaul P, Chang WC, Westerhout CM, Graham MM, Armstrong PW. Differences in admission rates and outcomes between men and women presenting to emergency departments with coronary syndromes. CMAJ. 2007;177(10):1193-1199.
68. Brown DW, Xie J, Mensah GA. Electrocardiographic recording and timeliness of clinician evaluation in the emergency department in patients presenting with chest pain. Am J Cardiol. 2007;99(8):1115-1118.
69. Mikhail GW. Coronary heart disease in women. BMJ. 2005;331(7515):467-468.
70. Healy B. The Yentl syndrome. N Engl J Med. 1991;325(4):274-276.
71. Johnson PA, Goldman L, Orav EJ, et al. Gender differences in the management of acute chest pain. Support for the "Yentl syndrome". J Gen Intern Med. 1996;11(4):209-217.
72. Radovanovic D, Erne P, Urban P, Bertel O, Rickli H, Gaspoz JM. Gender differences in management and outcomes in patients with acute coronary syndromes: results on 20,290 patients from the AMIS Plus Registry. Heart. 2007;93(11):1369-1375.
73. Rosenfeld AG. State of the heart: building science to improve women's cardiovascular health. Am J Crit Care. 2006;15(6):556-566; >quiz 567>.
74. Walters DL, Aroney CN, Chew DP, et al. Variations in the application of cardiac care in Australia. Med J Aust. 2008;188(4):218-223.
75. Brieger D, Eagle KA, Goodman SG, et al. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Chest. 2004;126(2):461-469.
76. Vinson DR, Magid DJ, Brand DW, et al. Patient sex and quality of ED care for patients with myocardial infarction. Am J Emerg Med. 2007;25(9):996-1003.
77. Karlson BW, Herlitz J. Hospitalisations, infarct development, and mortality in patients with chest pain and a normal admission electrocardiogram in relation to gender. Coron Artery Dis. 1996;7(3):231-237.
78. Chew DP, Amerena J, Coverdale S, Rankin J, Astley C, Brieger D. Current management of acute coronary syndromes in Australia: observations from the acute coronary syndromes prospective audit. Intern Med J. 2007;37(11):741-748.
79. Kannel WB, McGee DL. Diabetes and glucose tolerance as risk factors for cardiovascular disease: the Framingham study. Diabetes Care. 1979;2(2):120-126.
80. Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics-2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119(3):480-486.
81. World Health Organization. Cardiovascular diseases. http://www.who.int/cardiovascular_diseases/en/. Accessed July 16, 2008.
82. Anand SS, Xie CC, Mehta S, et al. Differences in the management and prognosis of women and men who suffer from acute coronary syndromes. J Am Coll Cardiol. 2005;46(10):1845-1851.
83. Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111(4):499-510.
84. Rosenfeld AG. State of the heart: building science to improve women's cardiovascular health. Am J Crit Care. 2006;15(6):556-566.
85. Berger PB, Ellis SG, Holmes DR Jr, et al. Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb) trial. Circulation. 1999;100(1):14-20.
86. Peterson ED, Shah BR, Parsons L, et al. Trends in quality of care for patients with acute myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006. Am Heart J. 2008;156(6):1045-1055.
87. Jneid H, Thacker HL. Coronary artery disease in women: different, often undertreated. Cleve Clin J Med. 2001;68(5):441-448.
88. Milcent C, Dormont B, Durand-Zaleski I, Steg PG. Gender differences in hospital mortality and use of percutaneous coronary intervention in acute myocardial infarction: microsimulation analysis of the 1999 nationwide French hospitals database. Circulation. 2007;115(7):833-839.
89. Vaccarino V, Rathore SS, Wenger NK, et al. Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002. N Engl J Med. 2005;353(7):671-682.
90. Nallamothu B, Fox KAA, Kennelly BM, et al. Relationship of treatment delays and mortality in patients undergoing fibrinolysis and primary percutaneous coronary intervention. The Global Registry of Acute Coronary Events. Heart. 2007;93(12):1552-1555.
91. McCallum Pardey TG. The clinical practice of Emergency Department Triage: application of the Australasian Triage Scale-an extended literature review. Part 1: evolution of the ATS. Australas Emerg Nurs J. 2006;9:155-162.
92. Jelinek GA, Cameron PA, Murray LM. Emergency medicine. Med J Aust. 2002;176(1):11.
93. ACEM. Guidelines for implementation of the Australasian Triage Scale in Emergency Departments. Melbourne, Victoria, Australia: Australasian College for Emergency Medicine; 2000.
94. Bergelson BA, Tommaso CL. Gender differences in clinical evaluation and triage in coronary artery disease. Chest. 1995;108(6):1510-1513.
95. Daly C, Clemens F, Lopez Sendon JL, et al. Gender differences in the management and clinical outcome of stable angina. Circulation. 2006;113(4):490-498.
96. Washington DL, Bird CE. Sex differences in disease presentation in the emergency department. Ann Emerg Med. 2002;40(5):461-463.
97. Lee PY, Alexander KP, Hammill BG, Pasquali SK, Peterson ED. Representation of elderly persons and women in published randomized trials of acute coronary syndromes. JAMA. 2001;286(6):708-713.
98. Lockyer L. Women's interpretation of cardiac symptoms. Eur J Cardiovasc Nurs. 2008;7(3):161-162.
99. Denes P, Larson JC, Lloyd-Jones DM, Prineas RJ, Greenland P. Major and minor ECG abnormalities in asymptomatic women and risk of cardiovascular events and mortality. JAMA. 2007;297(9):978-985.
100. Tanabe P, Gimbel R, Yarnold PR, Adams JG. The Emergency Severity Index (version 3) 5-level triage system scores predict ED resource consumption. J Emerg Nurs. 2004;30(1):22-29.
101. Zimmermann PG. The case for a universal, valid, reliable 5-tier triage acuity scale for US emergency departments. J Emerg Nurs. 2001;27(3):246-254.
102. Gerdtz MF, Considine J, Sands N, et al. Emergency Triage Education Kit. Canberra, Australia: The Australian Commonwealth Department of Health and Ageing, Commonwealth Government of Australia; 2007.
103. Patton MQ. Qualitative Research & Evaluation Methods. 3rd ed. London, UK: Sage Publications; 2002.
104. Boden WE, Eagle K, Granger CB. Reperfusion strategies in acute ST-segment elevation myocardial infarction: a comprehensive review of contemporary management options. J Am Coll Cardiol. 2007;50(10):917-929.
105. Bradley EH, Herrin J, Wang Y, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006;355(22):2308-2320.
106. Pearlman MK, Tanabe P, Mycyk MB, Zull DN, Stone DB. Evaluating disparities in door-to-EKG time for patients with noncardiac chest pain. J Emerg Nurs. 2008;34(5):414-418.
107. Trigo J, Gago P, Mimoso J, Santos W, Marques N, Gomes V. In-hospital delay in ST-segment-elevation myocardial infarction after Manchester Triage. Rev Port Cardiol. 2008;27(10):1251-1259.
108. Henry TD, Unger BT, Sharkey SW, et al. Design of a standardized system for transfer of patients with ST-elevation myocardial infarction for percutaneous coronary intervention. Am Heart J. 2005;150(3):373-384.
109. Higgins GL 3rd, Lambrew CT, Hunt E, et al. Expediting the early hospital care of the adult patient with nontraumatic chest pain: impact of a modified ED triage protocol. Am J Emerg Med. 1993;11(6):576-582.
110. Tu JV, Khalid L, Donovan LR, Ko DT. Indicators of quality of care for patients with acute myocardial infarction. CMAJ. 2008;179(9):909-915.
Keywords:

acute coronary syndrome; clinical decision making; emergency department; nurse triage; women

© 2011 Lippincott Williams & Wilkins, Inc.