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.
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
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.
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
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
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
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
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
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
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.
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.
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.
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
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.
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Keywords:© 2011 Lippincott Williams & Wilkins, Inc.
acute coronary syndrome; clinical decision making; emergency department; nurse triage; women