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Final Summary Paper

Caroline Kissam

Bon Secours Memorial College of Nursing

NUR 4242-DL1 Synthesis of Nursing Practice

Trina Gardner, MSN, RN

October 29, 2022

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Final Summary Paper

Introduction

Calls for active chest pain is a common issue we deal with in our cardiology triage

department. As a large cardiology clinic with 17 cardiologists we take an average of 200 triage

calls a day. Despite the fact that we are not set up to deal with emergencies in the clinic, our

patients still call us instead of going to the hospital when they are having active chest

pain. Chest pain could be an active myocardial infarction which needs to be assessed and treated

as soon as possible to prevent injury and death, so it is imperative that we triage these calls

efficiently and accurately. Our triage department consists of 5 nurses, LPNs and RNs, and we

have found that there is no consistency with how these nurses assess, document and treat active

chest pain calls. Some attempt to assess the situation to determine if it is an actual emergency

and others don’t ask any questions and instruct the patient to go to the emergency room. In some

cases these calls are not emergencies and may not even require treatment. In either case accurate

assessment and treatment is important not only for the patient but to help utilize health care

resources in the most appropriate and cost-effective way.

To address this issue I have done two PDSA cycles on using a chest pain triage template

and decision tree to help make triage calls for active chest pain be conducted in a more timely

and accurate way. I created a template that is essentially an EPIC smart phrase the nurse can

quickly pull into the phone call note. It has a set of physician approved assessment questions to

help guide the call and document important information that will help the provider and/or the

nurse make treatment decisions. The template will save the nurse documentation time as well as

help guide the patient interaction as patients often get off-topic without realizing that some issues

may not be pertinent to the assessment of the chest pain. Once the data is collected the nurse can
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refer to the decision tree to determine the next step. The decision tree is color coded with true

emergency/911 symptoms listed in the red column and less serious symptoms listed in

descending order with instructions on how to address them. Each PDSA cycle was conducted by

one triage nurse on one to two patients. After the first cycle we discussed how useful the

template was and what changes could be made to make the template easier to implement and

more helpful for the triage nurse and the providers who ultimately make the diagnosis and

treatment decisions. Changes were implemented after the first cycle and tested in cycle

two. This paper will discuss outcome of this PDSA project for telephone triage of chest pain.

Background

Because we are a large cardiology practice chest pain is one of the most common calls

our triage department receives, and these calls often lead to an emergency room visit. Studies

show that chest pain is second leading cause of emergency room visits in the United States(Sax

et al., 2018). There are many causes of chest pain. Some are life threatening and require urgent

treatment in a hospital setting and some are not serious and can be treated in an outpatient setting

or even resolved with an over the courter medication. Chest pain is often over treated which can

lead to misuse of ambulance services and emergency room services, which increases costs for

both the health care system and patients. It also makes it more challenging for patients that have

true emergencies like acute coronary syndrome to receive treatment. In a study done in similar

setting in the Netherlands where triage calls are taken by nurses who are supervised by

physicians, 46.2% of serious adverse events documented were related to unrecognized acute

cardiovascular problems such as myocardial infarctions, cardiac arrest, stroke and ruptured

aneurysms(Erkelens et al., 2022).

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We are aware that there are inconsistencies in the way our triage team evaluates and

documents triage calls for chest pain. We have several examples of calls where patients report

having active chest pain where the triage nurse referred the patient directly to the ER without

asking any assessment questions. Later we discovered that these patients didn’t require urgent

treatment. Fortunatly we have not had triage situations where patients having Acute Coronary

Syndrome received less care than was required. To manage this issue we created a telephone

triage template utilizing the smart phrase tool in our EPIC electronic medical record system that

prompts the nurse to collect certain data to help the provider assess the level of intervention

needed to treat the chest pain. We also developed a decision tree that would assist the nurse in

recognizing symptoms of true life threatening emergiences such as myocardial infarctions that

need urgent treatment. We performed two PDSA cycles completed by one triage nurse and

utilized qualitative data obtained by interviewing the nurse after each cycle and discussion with

the physician and the manager to determine if the tool was useful and lead to appropriate

resolutions to the patients issue.

Method

The triage template and decision tree were created with input from the project team: a

triage nurse, the lead cardiologist, and the clinical manager. The initial version of the template

was reviewed with team. I asked the nurse to utilize the tools for one chest pain triage call and

provide feed back on if they helped her in documenting, assessing, determining the next steps in

addressing the patient’s chest pain. The nurse had not used a triage template before this

test. She reported that the tool was helpful in making sure she collected all the information

needed to properly assess the chest pain and document the call. She suggested that I add smart

phrase that would pull in the patients current medication list and cardiac history that has already
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been reported in the electronic medical record, so she would have all the information on the same

screen and not have to toggle back and forth between different sections of the chart. I took her

feedback and made those additions to the template prior to cycle two. Those changes were

reviewed by the physician and the clinical manager. The nurse was asked to utilize the amended

template on one or two chest pain calls. I reviewed the second set of calls with the project team

to determine if the tools were useful and what the next steps should be. The nurse reported that

the tools were very useful and that she felt the more she used the tools the more comfortable she

would be using them and that ultimately it would make the response to chest pain triage calls

more timely and the treatment more appropriate.

Results

The team agreed that the feedback was positive and that another test should be done

utilizing the rest of the triage nurses taking at least one call using the tools and data on patient

outcomes would be necessary to know if the tools made a positive impact on the telephone triage

of chest pain. Overall the team felt like the tools helped to standardize the process and that this

would improve patient outcomes and help us utilize resources appropriately. Additional calls

and review of medical records would be required to determine the full effect the tools have on

patient care and outcomes. Ultimately the practice wants to create templates and decision trees

for other common cardiac problems such as atrial fibrillation, hypertension and heart failure.

This process has facilitated very good conversations in our practice and strengthened staff

relationships. Physicians don’t usually work closely with other staff members on process

improvement, so this project created an opportunity for that. My mentor was very supportive but

let me drive this project. She provided great feedback without taking over. Overall it was a

great experience and I hope that we will continue to perfect this project.
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Conclusion

Telephone triage of chest pain is mostly conducted by nurses with physician

supervision. If not done properly it can lead to inappropriate use of health care resources and

inappropriate treatment for patients. The worst case scenario is that patients can be harmed

without proper assessment. In this project we created a documentation template and decision

tree to guide the triage nurse through collecting all the information needed to make a proper

treatment decision. Two PDSA cycles were done and the team that included a physician, the

triage nurse, the clinical manager and I determined that the template was useful and more cycles

should be done utilizing more triage nurses and additional chest pain calls along with medical

records review to determine if patient outcomes were improved.

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References

Alotaibi, A., Body, R., Carley, S., & Pennington, E. (2021). Towards enhanced telephone triage

for chest pain: a Delphi study to define life-threatening conditions that must be identified.

BMC Emergency Medicine, 21(1), 158. https://doi.org/10.1186/s12873-021-00553-w

Erkelens, D., Rutten, F., Wouters, L., Kirk's, H., Poldervaart, J., de Groot, E., Damoiseaux, R.,

Hoes, A., & Swart, D. (2022). Missed acute coronary syndrome during telephone triage

at out-of-hours primary care: lessons from a case-control study. Journal of Patient Safety,

18(1), 40–45. https://doi.org/10.1097/PTS.0000000000000799

Erkelens, D., Wouters, L., Swart, D., Damoiseaux, R., de Groot, E., Hoes, A., & Rutten, F.

(2019). Optimization of telephone triage of callers with symptoms suggestive of acute

cardiovascular disease in out-of-hours primary care: observational design of the Safety

First study. BMJ Open, 9(7), Article e027477. https://doi.org/10.1136/bmjopen-2018-

027477

Sax, D., Vinson, D., Yamin, C., Huang, J., Falck, T., Bhargava, R., Amaral, D., & Reed, M.

(2018). Tele-triage outcomes for patients with chest pain: Comparing physicians and

registered nurses. Health Affairs, 37(12), 1997–2004.

https://doi.org/10.1377/hlthaff.2018.05079