RESEARCH
ACCURACY IN ED TRIAGE FOR SYMPTOMS OF
ACUTE MYOCARDIAL INFARCTION
Authors: Susan F. Sanders, PhD, APRN, ACNS-BC, CEN, and Holli A. DeVon, PhD, RN, FAHA, FAAN, Statesboro, GA, and Chicago, IL
Earn Up to 9.5 CE Hours. See page 367.
Introduction: More than 6 million people present to emergency
departments across the United States annually with symptoms of
acute myocardial infarction (AMI). Of the 1 million patients with AMI,
350,000 die during the acute phase. Accurate ED triage can reduce
mortality and morbidity, yet accuracy rates are low. In this study we
explored the relationship between patient and nurse characteristics
and accuracy of triage in patients with symptoms of AMI.
Methods: This retrospective, descriptive study used patient
data from electronic medical records. The sample of 286 patients was
primarily white, with a mean age of 61.44 years (standard deviation
[SD], ±13.02), and no history of heart disease. The sample of triage
nurses was primarily white and female, with a mean age of 45.46
years (SD, ±11.72) and 18 years of nursing experience. Nineteen
percent of the nurses reported having earned a bachelor’s degree.
ccurate decisions at ED triage can reduce mortality
A and morbidity, yet data indicate that accuracy rates are
low. 1,2 More than 6 million patients present to
emergency departments across the United States every year
with chest pain; 6 million more present with additional
symptoms of coronary heart disease such as dizziness, nausea,
or shortness of breath. 3 Coronary heart disease is the leading
cause of death in the US. 4 Investigating the possible reasons for
inaccuracy is necessary to improve care in these populations.
According to the Emergency Severity Index (ESI), 5
patients are assigned a triage level based on the following
scale: level 1, resuscitation needed; level 2, emergent; level 3,
Susan F. Sanders, Member, Coastal Empire Chapter, is Assistant Professor,
School of Nursing, Georgia Southern University Statesboro, GA.
Holli A. DeVon is Associate Professor, College of Nursing, University of
Illinois at Chicago, Chicago, IL.
Supported by a Spring 2011 Kaiser Permanente Evidence-Based Research Award.
For correspondence, write: Susan F. Sanders, PhD, APRN, ACNS-BC, CEN,
School of Nursing, Georgia Southern University, PO Box 8158, Statesboro,
GA 30460; E-mail: sfsanders@georgiasouthern.edu.
J Emerg Nurs 2016;42:331-7.
Available online 4 March 2016
0099-1767
Copyright © 2016 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2015.12.011
July 2016 VOLUME 42 • ISSUE 4
Results: Emergency nurse triage accuracy was 54%. Patient race
and presence of chest pain were significant predictors of accuracy.
Emergency nurse age was a significant predictor of accuracy in triage,
but years of experience in nursing was not a significant predictor.
Discussion: Of the 9 variables investigated, only patient race,
symptom presentation, and emergency nurse age were significant
predictors of triage accuracy. Inconsistency in triage decisions may
be due to other conditions not yet explored, such as critical thinking
skills and executive functions. This study adds to the body of
evidence regarding ED triage of patients with symptoms of AMI.
However, further exploration into decisions at triage is warranted to
improve accuracy, expedite care, and improve outcomes.
Key words: Triage; Accuracy; Gender; Race/ethnicity; AMI;
Experience
urgent but stable and can safely wait in the waiting room;
level 4, nonurgent; and level 5, referable to another care
provider such as a clinic setting. The American College of
Cardiology (ACC) and the American Heart Association
(AHA) recommend that certain goals be met for patients
presenting to the emergency department with symptoms
suggestive of acute myocardial infarction (AMI): obtain an
electrocardiogram (ECG) within 10 minutes of arrival; have
a patient evaluated by a health care provider within 10
minutes; and initiate thrombolytics within 30 minutes or
percutaneous coronary intervention within 90 minutes of
arrival. 6 To meet these goals requires that a patient be
triaged as level 2 and moved to an area for initiation of care.
The time to ECG may be beyond the control of the
emergency nurse when staffing is low; however, a decision
to allow the patient to wait in the waiting room with a level
3 designation violates the ACC and AHA standards.
Determining the severity of illness and urgency of care
required are the main functions of the emergency nurse in
the triage role. Triage level designation is a subjective
decision based on input from several sources. In preliminary
triage decision making, triage is not always straightforward,
and diagnostic tests may be limited. Along with data
collected during a brief nursing assessment, the nurse elicits
other information such as medical history and accompany-
ing signs and symptoms. Nurses in the triage role have the
WWW.JENONLINE.ORG 331
RESEARCH/Sanders and DeVon
responsibility of identifying patients with cardiac emergen-
cies who need prompt care.
Literature Review
In studies that used designs such as retrospective electronic
medical record (EMR) review, written vignettes, comput-
erized visual vignettes, and direct observation of triage to
investigate ED triage, accuracy rates from 40% to 70% were
found. 2,7–9 Investigating the ability to predict hospital
admission is another design used in studies aimed at
identifying accurate decision making by emergency nurses. 1
Nursing research has continued to identify inaccuracies in
triage decisions. 7,8,10 Urgent cases assigned nonurgent
status may place patients at risk for delayed treatment and
poor outcomes. Patients may be judged by the triage nurse
as not having a medical emergency when one exists. When
this situation occurs, the patient is said to be undertriaged,
meaning the patient was assigned a lower triage level than is
actually warranted. 11 Patients are also sometimes over-
triaged—that is, assigned a triage level higher than
necessary—which may cause a stable patient to be seen
ahead of a patient with an emergent medical need. For
persons with AMI, the consequences may be permanent
cardiac muscle damage and even death. It is important to
note that a possible limitation in studies of triage decisions is
that a correct decision is multifaceted. Most patients
presenting to the emergency department have not yet
received a differential diagnosis at the point of triage. A
patient experiencing immediate life-threatening symptoms
suggestive of AMI may be deemed correctly triaged when
given a level 1 instead of a level 2 designation. 5
The association of patient characteristics and
triage accuracy has been investigated by nurse researchers
with varying results. Females were more often triaged
incorrectly in numerous studies, 7,8 as were nonwhite
patients. 13 Younger patient age has been noted to decrease
triage accuracy. 13,14 In a study of cardiac triage decision
making, registered nurses (RNs) were found to hold cultural
biases and stereotypes. Specific cues utilized in triage
decision making included patient demographics, attitudes,
perceptions, and cultural beliefs. 15
Researchers investigating factors that affect patient
outcomes identified RN education level and years of
experience as significant variables. 16 Benner and Tanner 17
hypothesized that novice RNs are hesitant and slow in
assessment of patients in their care and experienced RNs are
rapid and fluid in problem solving in patient situations.
Although the work of Benner and Tanner 17 emphasized
stages of knowledge from novice to expert, it is unclear
whether these stages influence emergency nurse triage
332 JOURNAL OF EMERGENCY NURSING
accuracy. Results are mixed from studies in which the
correlation between experience, education, and accurate
decision making in triage has been investigated. 1,2,11
The AHA depicts classic AMI symptoms as central
chest discomfort that may be described as pressure, fullness,
squeezing, or pain with radiation to the arms, neck, jaw,
back, and abdomen. 6 These symptoms may be accompa-
nied by shortness of breath, nausea, lightheadedness, and
sweating. 13 The ED triage decision is made more difficult
because patients present with varying symptoms, some of
which are considered to be typical of AMI and some
atypical. The patient who presents with a classic set of signs
and symptoms suggestive of AMI (ie, clutching the chest,
short of breath, pale, and diaphoretic) will undoubtedly be
immediately recognized by the emergency nurse and result
in a level 1 or 2 triage designation.
However, not all patients present with easily recogniz-
able symptoms, and symptom presentation may vary by
gender and race/ethnicity. 13,18–20 Previous studies have
found the incidence of a classic set of symptoms during an
AMI to be as low as 27%. 13,14 Less typical symptoms may
have an impact on triage decisions, 21,1 highlighting the
complexity of patient assessment and the variations in
individuals. In studies of patients with unstable angina and
AMI, symptoms of acute coronary syndrome were
identified as chest pressure, chest discomfort, chest pain,
shoulder pain, arm pain, upper back pain, lightheadedness,
shortness of breath, sweating, unusual fatigue, nausea,
palpitations, and indigestion. 22 Patients presenting with
symptoms that are not classic may present a more difficult
challenge for the emergency nurse.
Studies identify limited accuracy in triage level
designations and the inability of the emergency nurse to
consistently identify patients with symptoms of possible
AMI. 7,10–15,1,22,23 Therefore, the purpose of this study was
to explore the relationship between patient and RN
characteristics and the accuracy of triage in patients with
symptoms suggestive of AMI, as well as to identify the
patient and nurse characteristics that predict triage accuracy
in this patient population.
Methods
This retrospective, descriptive study used patient data from
EMRs. Information from EMRs for a convenience sample
of patients presenting for ED care was used in data
collection. To obtain the demographic characteristics,
emergency nurses who were noted as making the triage
decisions in the EMRs included in the study were invited to
VOLUME 42 • ISSUE 4 July 2016

participate via completion of a questionnaire once written
informed consent was obtained.
The study was conducted at a 660-bed regional health
care system operating emergency departments at 2 sites in
the Southeastern United States. At the time of this study,
site 1 logged approximately 50,000 ED visits a year, and site
2 logged approximately 32,000 ED visits a year. Combined,
the 2 sites employed 92 emergency nurses and evaluated
approximately 2200 patients for AMI per year. Triage role
assignment was made by the ED charge nurse at the start of
each shift. No set protocol was used for assignment of duty
areas. New graduates were not assigned to the triage role.
After institutional review board approval was obtained
from both the university and the health care system, a query
list of patient records was generated for review and possible
study inclusion. Inclusion criteria were patients at least 21
years old with symptoms suggestive of AMI. Exclusion
criteria included (1) patients who were in critical condition,
required resuscitation, or had a severely altered level of
consciousness; (2) patients arriving via ambulance; and (3)
patients with a documented traumatic event. Patients
arriving via ambulance were excluded from the study
because of the potential bias associated with the triage nurse
having prior knowledge of the patient’s status. In addition,
we sought to limit the heterogeneity of the sample to reduce
potential confounders such as preliminary diagnosis, ECG
data, or physical status of the patients. Variables of interest
including the patient’s chief complaint taken from the first
triage note, final diagnosis, triage level assigned, patient
gender, patient age, patient race/ethnicity, and emergency
nurse were obtained from the EMR. Symptoms included in
the study were those identified by the AHA along with the
more vague symptoms of unusual fatigue, nausea, palpita-
tions, and indigestion. 21 Records were chosen based on
these symptom presentations at triage, not final diagnosis of
AMI. We were interested in determining if characteristics of the
patient or nurse were predictors of triage accuracy in patients
with symptoms suggestive of AMI. This determination included
the “rule out” patient as well as the “rule in” patient. Accuracy
was determined based on whether patients with symptoms
suggestive of AMI, not the final diagnosis, excluding those in
need of resuscitation, were assigned a level 2 triage designation.
EMR review occurred first, and then information
regarding emergency nurse characteristics was obtained via
use of a questionnaire from consenting emergency nurses.
Anonymity was not possible because nurses’ names were
noted in the EMR, but confidentiality was preserved in the
following manner: Data were coded and entered into an
electronic data file. All data sets were de-identified. The data
were stored in a locked file cabinet and on a password- and
firewall-protected computer.
July 2016 VOLUME 42 • ISSUE 4
Sanders and DeVon/RESEARCH
Power analysis 24 suggested that a minimum sample size
of 113 patient triage decisions was needed for a maximum
of 9 predictor variables, a medium effect size, and an α of
less than 0.05 with a power of 0.80. The possible predictor
variables were sex, age, and race/ethnicity of the patient and
sex, age, race, education level, and years of general nursing
experience of the emergency nurses, along with years of
specific emergency nursing experience. A medium effect size
was chosen based on a review of studies evaluating accuracy
in ED triage. 12–15 A 2-tailed P value of ≤ .05 was considered
significant for all analyses. Descriptive statistics were
assessed for patients and nurses. Frequencies and percent-
ages were calculated for the patient characteristics of sex,
race/ethnicity, marital status, and medical history. Cross-
tabulation procedures between cases with and without
missing values and the dependent measures were all
nonsignificant. Inferential statistics were then conducted.
These analyses included Pearson’s correlations and logistic
regression. Because we were looking only at accuracy, the
decision made by the triage nurse was the unit of analysis.
Two logistic regression procedures were conducted. RN
level of education data was missing in 90 cases; therefore,
only 196 cases were included in the regression model.
Accordingly, 2 logistic regression procedures were conducted,
one with level of education and one without level of
education. Because level of education did not significantly
predict accuracy of triage level designation, only the findings
of the second logistic regression procedure, which does not
include the education variable, are presented.
Results
Patients (N = 283) were between 26 and 95 years old with a
mean age of 61.44 years (standard deviation [SD], ± 13.02).
The majority of patients were white (67.1%); 31.1% were
African American, and 0.8% were of another race/ethnicity.
There was nearly an equal number of women (51.9%) and
men (48.1%). Most of the patients were nonsmokers
(74.6%). Forty-eight percent of the patients had a body
mass index greater than 29. One third (30.4%) of the
patients had diabetes, and 43.1% reported a history of
cardiac disease. A majority of the patients (88.7%) reported
experiencing chest pain in addition to their other symptoms
at triage. Clinical characteristics of the sample are presented
in Table 1.
Triage level designations from 286 EMRs were
investigated, representing 66 emergency nurses. Forty of
66 emergency nurses participated in the study, for a
response rate of 60.6%. Characteristics of nurses not
participating in the study were not included in the
WWW.JENONLINE.ORG 333
RESEARCH/Sanders and DeVon

regression model. The range of number of triages conducted
per emergency nurse was 1 to 22, with 5 emergency nurses
in the study triaging 10 or more patients. The triage role was
randomly assigned by the charge nurse, with only new
graduates not being assigned to the role; therefore, all levels
of experience were represented in the sample. Emergency
nurse level of education data were missing in 90 of the triage
cases; therefore, only 196 triage cases were included in the
regression model. Little’s Missing Completely at Random
test was conducted, which indicated that the missing data
were in a random pattern and not statistically significant.
The majority of emergency nurses were female
(70.3%), and all who reported their race were white. The
age of emergency nurses ranged from 26 to 64 years, with a
mean age of 45.46 years (SD, ± 11.72). Years of general
nursing experience ranged from 3 to 35 years, with a mean
of 17.96 years (SD, ± 10.43). Years of emergency nursing
experience ranged from 3 to 35 years, with a mean of 10.98
years (SD, ± 8.51). A large number of nurses reported
having earned an associate’s degree (45.6%), and the
remainder reported that their highest degree was a BSN
(19.1%). A small proportion of emergency nurses were
categorized as diploma nurses (3.5%).
A total of 155 cases (54.1%) had an appropriate triage
designation of level 2 required for a patient with symptoms
suggestive of AMI. Nonwhite patients were more likely to
receive an accurate triage level than were white patients
(odds ratio [OR] = 2.07, P = .010). Patients who
experienced chest pain were more likely to receive an
accurate triage level than were patients who experienced
symptoms of AMI other than chest pain (OR = 2.55, P =
.022). Neither patient gender nor patient age was a
predictor of accuracy of triage in this study sample. Sex
and race were separate variables and were not entered into
the regression model testing the interaction of the two.
The age of the emergency nurse was a predictor of
accuracy in triage. The older the emergency nurse, the
greater the likelihood that the triage level designation was
accurate. Neither level of education nor years of experience
predicted accuracy of triage level designation. Results are
presented in Table 2. Because only 12 of the emergency
nurses in this sample were male and 100% of the emergency
nurses were white, the variables of gender and race of the
emergency nurse were not included in data analysis.
Discussion

The correct triage level designation can be crucial in

TABLE 1 determining how quickly an ECG is obtained and how
Patient characteristics quickly the patient is examined by a health care provider;
Variable No. (%) thus, an accuracy rate of 54% is concerning. Previous
studies of triage accuracy have identified low triage accuracy
Gender
rates. 7,10–15,1,22,23 Of the 9 patient and emergency nurse
Male 136 (48.1)
variables investigated, only patient race, symptom presen-
Female 147 (51.9) tation, and emergency nurse age were significant predictors
Race/ethnicity of triage accuracy.
White 190 (67.1) African American patients in this study were more
African American 88 (31.1) likely to be accurately triaged, which may be partially due to
Hispanic or Latino 1 (0.4) the higher burden of heart disease risk born by African
Multiracial 1 (0.4) Americans. 25 Race/ethnicity was noted to be a significant
Missing 3 (1.1) contributor in a study of pain-related assessments, with
Marital status older African-American women perceived by RNs as having
Single 31 (11) and expressing more pain. 26 Although accuracy of triage
Married 168 (59.4) level designation in that study was not identified, the visual
portrayal of pain by patients was noted as a significant
Divorced 41 (14.5)
decision point.
Widowed 40 (14.1)
Age biases were identified in studies of triage decisions
Missing 3 (1.1) when considering an AMI diagnosis. 13,14,27 Neither the sex
Current smoker 72 (25.4) nor the age of the patient was found to be a significant
Diabetes 86 (30.4) predictor of triage accuracy in this study. This finding is
Previous cardiac disease 122 (43.1) contrary to previous studies identifying male gender and
Chest pain at triage 251 (88.7) patient age as a predictor of accurate triage level
designation. 13,14,27

334 JOURNAL OF EMERGENCY NURSING VOLUME 42 • ISSUE 4 July 2016


TABLE 2
Logistic regression model with predictors of accuracy in triage
Variable B (CI 95%)
Patient
Male sex –0.37
Nonwhite patient 0.73 (0.181-1.28)
Chest pain 0.94 (1.66-3.13)
Registered nurse
Older age 0.07 (0.98-2.52)
Years of experience –0.03
Years of ED experience –0.05
CI, Confidence interval; OR, odds ratio; SE, standard error.
* Significance noted. Overall model χ2 = 25.44; P = .001.
Older age of the emergency nurse was found to be a
significant predictor of accuracy in triage level designation
of patients with symptoms suggestive of AMI, but years of
experience was not a significant predictor. It is possible that
older emergency nurses have better critical thinking skills
and are able to synthesize history and clinical presentation.
It is also possible that older emergency nurses may have
personal or family experiences with cardiac-related events,
leading to the more accurate triage level designation for
patients triaged. Years of experience and older age did not
necessarily go hand-in-hand, because years of experience
was not a predictor of accuracy in triage of patients with
symptoms suggestive of AMI. It is possible that nurses may
have chosen emergency nursing after years in another field.
Studies have consistently failed to identify links between
experience in nursing and accuracy in triage level
designations. 11,15,27
Although studies identify education level as having a
positive effect on overall patient outcomes, 16 nurse
education was not a predictor of accuracy in triage level
designations in this study. Nearly half of the patients in this
study (N = 139) were triaged by an emergency nurse with
an associate’s degree or diploma as their highest level of
education.
In this study, patients reporting chest pain were more
likely to be accurately triaged. Chest pain is the hallmark
symptom of cardiac ischemia, and thus it is not surprising that
patients in this study who reported chest pain were triaged
correctly. However, patients presenting with AMI are known
to experience multiple symptoms, 13,18,21 and many patients do
not experience chest pain, 13 which may put patients without
chest pain at risk for delayed treatment or missed diagnosis. 13,14
The decision from the emergency nurse standpoint that
includes “Would you give up your last bed for this patient?”
July 2016 VOLUME 42 • ISSUE 4
Sanders and DeVon/RESEARCH
SE Wald OR
0.26 2.07 0.69
0.28 6.58 2.07
0.41 5.24 2.55
0.03 4.34 1.07
0.03 0.53 0.98
0.27 0.04 0.95
is certainly on the minds of nurses in the triage role. The
catalyst for this work was the concern that patients may have
a poor outcome as a result of lengthy waits in the
waiting room. Does the nurse well-trained in ESI make a
difference? Does education and experience improve accuracy
in these patients?
The ESI 5-level system defines level 3 as “urgent but
stable to wait in the waiting room.” 5 The emergency
departments in this study frequently acquired a long line of
“level 3s” with no re-sorting within that level. Thus,
assigning a level 3, 4, or 5 for a patient with symptoms
suggestive of AMI was deemed inaccurate for the purposes
of this study, specifically because of the need to get an ECG
within 10 minutes of arrival and be assessed rapidly.
Investigating the possible reasons a patient is more likely
to be left in the waiting room to wait was at the heart of
this study.
Limitations
A limitation of this study is that data were gathered by
retrospective EMR review. Patients may have reported
additional symptoms that were not documented by the
emergency nurse at the time of triage. Missing information
also may have led to the exclusion of some EMRs in the
study, because data collection was dependent on the
emergency nurse documentation of a chief complaint.
Another limitation was the lack of demographic
information from nurses who did not participate in the
study, which resulted in 90 patient cases being excluded.
Forty of 66 emergency nurses participated in the study. The
response rate of 60.6% is considered a relative strength of
the study. Although 90 patient cases were excluded, the
WWW.JENONLINE.ORG 335
RESEARCH/Sanders and DeVon
study sample was well powered (n = 283 patient triage
designations) to detect significant, relevant variables.
This study was limited to patients arriving by a private
vehicle or public transportation. Patients arriving via
ambulance were excluded from the study because of the
potential bias associated with the triage nurse having prior
knowledge of the patient’s status. In addition, we sought to
limit the heterogeneity of the sample in order to reduce
potential confounders such as preliminary diagnosis, ECG
data, or physical status of the patients.
Implications for Emergency Nurses
A majority (88.7%) of the sample of patients in this study
reported chest pain at triage. A study of patients with vague
symptoms, combined with risk factors such as diabetes and
hypertension, and without chest pain at presentation would
be helpful in further research of triage. With the advent of
excellent computer programs for ED documentation,
protocols created from best practice could be embedded
in the triage assessment to trigger an alert based on signs
and symptoms.
Studies using a second method of capturing symptoms
at triage such as direct observation of triage, in conjunction
with the EMR data search, would be beneficial in validating
symptom presentations.
Strategies that will improve accuracy should be
explored and implemented, such as targeted educational
interventions aimed at increasing awareness of AMI
multisymptom presentations. These strategies could include
scenario-based sessions using actors or educational comput-
er software programs. An exploration of emergency nurse
perceptions of the AMI patient population may give insight
into nurse biases. Processes to improve triage skills such as
immediate review and feedback, clinical case reviews, and
documentation reviews could be beneficial. There is little
evidence of the role that ED orientation of the novice nurse
and the experienced nurse plays in accuracy of triage. Studies
that examine this possible predictor of accurate triage decisions
in the emergency department are needed.
Conclusion
This study adds to the body of evidence regarding accuracy
in ED triage of patients with symptoms of AMI. Accuracy
of triage designation in this study was 54%. Only patient
race (nonwhite), presence of chest pain, and older age of the
emergency nurse were significant predictors of triage
accuracy. Additional research with a more heterogeneous
336 JOURNAL OF EMERGENCY NURSING
sample of nurses is needed to determine both patient and
organizational outcomes of an inaccurate triage designation.
REFERENCES
1. Ryan K, Greenslade J, Dalton E, Chu K, Brown AF, Cullen L. Factors
associated with triage assignment of emergency department patients
ultimately diagnosed with acute myocardial infarction. Aust Crit Care.
2016;29(1):23-26.
2. Bonzi M, Fiorelli E, Angaroni L, et al. Predictive accuracy of triage
nurses evaluation in risk stratification of syncopy in the emergency
department. Emerg Med J. 2014;31:877-881.
3. National Hospital Ambulatory Medical Care Survey. Ten leading principle
reasons for Emergency Department visits, by patient age and sex: United
States, 2011. http://www.cdc.gov/nchs/data/ahcd/nhames_emergency/
2011_ed_web_tables.pdf. Accessed February 12, 2016.
4. Heron M. Deaths: leading causes for 2011. Natl Vital Stat Rep.
2015;64(7):1-96.
5. Gilboy N, Tanabe P, Travers D, et al. Emergency Severity Index (ESI): A Triage
Tool for Emergency Department Care, Version 4, Implementation Handbook,
Rockville, MD: Agency for Healthcare Research and Quality; 2011.
6. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA
guideline for the management of ST-elevation myocardial infarction: a
report of the American College of Cardiology Foundation/American
Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol.
2013;61:e78-e140.
7. Kuhn L, Page K, Rolley JX, Worrall-Carter L. Effect of patient sex on
triage for ischaemic heart disease and treatment onset times: a
retrospective analysis of Australian emergency department data. Int
Emerg Nurs. 2014;22:88-93.
8. Ravn-Fischer A, Caidahl K, Hartford M, et al. Community-based
gender perspectives of triage and treatment in suspected myocardial
infarction. Int J Cardiol. 2012;156(2):139-143.
9. Atzema CL, Schull MJ, Tu JV. The effect of a charted history of
depression on emergency department triage and outcomes in patients
with acute myocardial infarction. Can Med Assoc J. 2011;183:663-669.
10. 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;53:736-745.
11. Chen S, Chen J, Ng C, Chen P, Lee P, Chang W. Factors that influence
the accuracy of triage nurses’ judgment in emergency departments.
Emerg Med J. 2010;27:451-455.
12. López L, Wilper AP, Cervantes MC, Betancourt JR, Green AR.
Racial and sex differences in emergency department triage assessment
and test ordering for chest pain, 1997–2006. Acad Emerg Med.
2010;17(8):801-808.
13. Canto AJ, Kiefe CI, Goldberg RJ, et al. Differences in symptom
presentation and hospital mortality according to type of acute
myocardial infarction. Am Heart J. 2012;163(4):572-579.
14. Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex
with myocardial infarction symptom presentation and in-hospital
mortality. JAMA. 2012;307(8):813-822.
15. Arslanian-Engoren C. Explicating nurses’ cardiac triage decisions.
J Cardiol Nurs. 2009;24(1):50-57.
VOLUME 42 • ISSUE 4 July 2016

16. Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education
and hospital mortality in nine European countries: a retrospective
observational study. Lancet. 2014;383(9931):1824-1830.
17. Benner P, Tanner C. Clinical judgment. How expert nurses use
intuition. Am J Nurs. 1987;87:23-31.
18. McSweeney JC, O’Sullivan P, Cleves MA, et al. Racial differences in
women’s prodromal and acute symptoms of myocardial infarction. Am J
Crit Care. 2010;19:63-73.
19. DeVon HA, Burke LA, Nelson H, Zerwic JJ, Riley B. Disparities in patients
presenting to the emergency department with potential acute coronary syndrome: it
matters if you are Black or White. Heart Lung. 2014;43(4):270-277.
20. Kirchberger I, Heier M, Kuch B, Wende R, Meisinger C. Sex differences
in patient-reported symptoms associated with myocardial infarction
(from the population-based MONICA/KORA Myocardial Infarction
Registry). Am J Cardiol. 2011;107(11):1585-1589.
21. Devon HA, Rosenfeld A, Steffen AD, Daya M. Sensitivity, specificity,
and sex differences in symptoms reported on the 13-item Acute
Coronary Syndrome Checklist. J Am Heart Assoc. 2014;3(2):e000586.
July 2016 VOLUME 42 • ISSUE 4
Sanders and DeVon/RESEARCH
22. Kamali A, Söderholm M, Ekelund U. What decides the suspicion of
acute coronary syndrome in acute chest pain patients?. BMC Emerg Med.
2014;14(1):9.
23. Wilper AP, Woolhandler S, Lasser KE, et al. Waits to see an emergency
department physician: U.S. trends and predictors, 1997-2004. Health
Aff. 2008;27:w84-w95.
24. Soper D. A-priori sample size calculator for multiple regression. http://
www.danielsoper.com/statcalc3/calc.aspx?id=1. Accessed February 3,
2016.
25. Hirsh AT, George SZ, Robinson ME. Pain assessment and
treatment disparities: a virtual human technology investigation. Pain.
2009;143:106-113.
26. Atzema CL, Austin PC, Tu JV, Schull MJ. ED triage of patients with
acute myocardial infarction: predictors of low acuity triage. Am J Emerg
Med. 2010;28:694-702.
27. Garbez RO, Carrieri-Kohlman V, Stotts NA, Chan GK, Neighbor ML.
Factors influencing patient assignment to level 2 and level 3 within the
5-level ESI triage system. J Emerg Nurs. 2011;37:526-532.
WWW.JENONLINE.ORG 337
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.