From the Guidelines
The Emergency Nursing Assessment (ENA) protocol for emergency department triage should prioritize patients with symptoms of acute coronary syndrome (ACS), such as chest pain, shortness of breath, or severe epigastric pain, for immediate assessment and referral for further evaluation, as outlined in the 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 guidelines 1. The ENA protocol emphasizes the importance of quickly identifying patients with potential life-threatening conditions, such as ACS, to ensure prompt intervention and improve patient outcomes.
- Key symptoms that require immediate assessment by the triage nurse include:
- Chest pain, pressure, tightness, or heaviness; pain that radiates to neck, jaw, shoulders, back, or 1 or both arms
- Indigestion or “heartburn” nausea and/or vomiting associated with chest discomfort
- Persistent shortness of breath
- Weakness, dizziness, lightheadedness, loss of consciousness
- The triage nurse should also consider the patient's medical history, including previous coronary artery bypass graft surgery, percutaneous coronary intervention, coronary artery disease, angina, or myocardial infarction, as well as risk factors such as smoking, hyperlipidemia, hypertension, diabetes mellitus, family history, and cocaine or methamphetamine use 1.
- If these symptoms are present, the triage nurse should obtain a stat electrocardiogram (ECG) and initiate the ACS protocol, which may include immediate consultation with a cardiologist or other specialist 1. The ENA protocol is designed to prioritize patients with the most urgent needs, ensuring that those with life-threatening conditions receive prompt attention and care.
- By following this protocol, emergency department staff can efficiently manage resources, reduce morbidity and mortality, and improve patient outcomes 1.
From the Research
Emergency Nursing Assessment (ENA) Protocol
The Emergency Nursing Assessment (ENA) protocol for emergency department triage is not explicitly defined in the provided studies. However, the studies discuss various triage systems used in emergency departments, including:
- The Australasian Triage Scale (ATS)
- The Manchester Triage System (MTS)
- The Canadian Triage and Acuity Scale (CTAS)
- The Emergency Severity Index (ESI) 2 These systems facilitate the categorization of emergency patients according to their disease severity and determine both treatment priority and treatment location.
Triage Systems Used in Emergency Departments
The most commonly used triage system in the United States is the five-level Emergency Severity Index (ESI), used by 56.9% of responding hospitals 3. Other studies discuss the use of electronic triage systems, such as the Electronic Canadian Triage and Acuity Scale (E-CTAS), which categorizes patients into five levels to manage patient flow and prioritize patient access to health-care services 4.
Factors Influencing Triage System Usage
The use of triage systems can be influenced by various factors, including:
- Perceived ease of use
- Perceived usefulness
- Importance of training
- Social influence
- Behavior intention
- Attitude 4 Additionally, the use of triage systems can be affected by hospital policies, nurse experience, and length of shift 5.
Implementation of Standardized Triage Systems
Implementing a standardized triage system, including vital parameters and standardized algorithms for signs and symptoms, can increase the use of vital parameters and signs and symptoms for decision making and acuity assignment 6. However, the exact effect of standardized triage systems on the decision-making process remains unclear.