The use of ECG by triage nurses may improve the stratification of patients with cardiological symptoms admitted to the emergency department: a prospective observational study

Abstract

Abstract Background Triage is the crucial point for overall emergency department (ED) management. Its purpose is to quickly and safely identify among the many patients arriving those who need rapid medical evaluation [1]. Present triage systems are based on symptomatic assessment and clinical impression to assess patient severity on admission to the ED. Some clinical tools that are widely validated in practice, such as ECG, could be implemented in triage to improve the stratification activity of the system [2]. Purpose To evaluate whether the use of ECG can improve nursing triage prediction for patients admitted to the ED for symptoms related to suspected cardiac pathology. Methods A prospective observational single-centered study was conducted. All patients who visited the ED for chest pain, syncope, dyspnoea or palpitation and underwent ECG at the time of triage were considered. The study was conducted by a pool of nurses who had previously received special training in ECG reading. Background characteristics, comorbidities and clinical conditions were recorded for each enrolled patient. In addition, the priority level assigned according to the application of the 5-level Manchester Triage System (1 to 5) and the level of priority after ECG performance (1 to 5) were recorded. The study outcome was composite: the presence of a major cardiac event within 6 weeks after triage, a cardiogenic syncope, the presence of a pulmonary embolism or aortic dissection, or an arrhythmia requiring specific emergency therapy [3]. The priority level assigned in triage and the priority level given after performing the ECG were compared by analysis of the receiver operating characteristic. Results A total of 1,211 patients were included in the study. Of these, 62.4% (756/1,211) presented chest pain, 13.8% (167/1,211) syncope, 18.2% (221/1,211) palpitation and 5.5% (67/1,211) dyspnoea. Overall, 10.5% (127/1,211) had a positive outcome. The concordance between triage nurses and cardiologists in detecting pathological and non-pathological ECGs presented a Cohen's kappa of 0.821 (p<0.001). ECG performed by nurses increased the patient's priority in 7.5% (91/1,211) of cases and reduced it in 39.6% (480/1,211) of cases. The discriminatory ability of the triage system before ECG was performed showed an area under the receiver operating characteristic curve of 0.708 (95% CI 0.659–0.757), whereas the discriminatory ability of triage after ECG was 0.845 (95% CI 0.808–0.883). Conclusions The use of ECG in triage can be a simple and safe tool that improves the assessment of the patient's priority when presenting to the ED for a cardiac symptom. The presence of a good diagnostic concordance and a good improvement in discriminatory ability may support the implementation of ECG in nursing triage. Funding Acknowledgement Type of funding sources: None.