title: Beyond triage: the diagnostic accuracy of emergency department nursing staff risk assessment in patients with suspected acute coronary syndromes.
abstract: OBJECTIVE
  To establish the accuracy of emergency department (ED) nursing staff risk assessment using an established chest pain risk score alone and when incorporated with presentation high-sensitivity troponin testing as part of an accelerated diagnostic protocol (ADP).
  
  
  METHODS
  Prospective observational study comparing nursing and physician risk assessment using the modified Goldman (m-Goldman) score and a predefined ADP, incorporating presentation high-sensitivity troponin.
  
  
  METHODS
  A UK District ED.
  
  
  METHODS
  Consecutive patients, aged ≥18, with suspected cardiac chest pain and non-ischaemic ECG, for whom the treating physician determined serial troponin testing was required.
  
  
  METHODS
  30-day major adverse cardiac events (MACE).
  
  
  RESULTS
  960 participants were recruited. 912/960 (95.0%) had m-Goldman scores recorded by physicians and 745/960 (77.6%) by nursing staff. The area under the curve of the m-Goldman score in predicting 30-day MACE was 0.647 (95% CI 0.594 to 0.700) for physicians and 0.572 (95% CI 0.510 to 0.634) for nursing staff (p=0.09). When incorporated into an ADP, sensitivity for the rule-out of MACE was 99.2% (95% CI 94.8% to 100%) and 96.7% (90.3% to 99.2%) for physicians and nurses, respectively. One patient in the physician group (0.3%) and three patients (1.1%) in the nursing group were classified as low risk yet had MACE. There was fair agreement in the identification of low-risk patients (kappa 0.31, 95% CI 0.24 to 0.38).
  
  
  CONCLUSIONS
  The diagnostic accuracy of ED nursing staff risk assessment is similar to that of ED physicians and interobserver reliability between assessor groups is fair. When incorporating high-sensitivity troponin testing, a nurse-led ADP has a miss rate of 1.1% for MACE at 30 days.
  
  
  BACKGROUND
  Controlled Trials Database (ISRCTN no. 21109279).
authors.affiliation: Emergency Department, Southmead Hospital, Bristol, UK School of Health and Social Care, Bournemouth University, Bournemouth, Dorset, UK.
authors.forename: Edward Watts
authors.identifier: http://orcid.org/0000-0002-2064-4618
authors.initials: EW
authors.lastname: Carlton
authors.affiliation: School of Health and Social Care, Bournemouth University, Bournemouth, Dorset, UK.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Khattab
authors.affiliation: Department of Cardiology, Sunshine Coast Hospital and Health Services, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia.
authors.forename: Kim
authors.initials: K
authors.lastname: Greaves
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis*; D015415:Biomarkers / Q000097:blood; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D004739:England; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009730:Nursing Assessment; D010147:Pain Measurement; D010820:Physicians; D011446:Prospective Studies; D018570:Risk Assessment; D014218:Triage; D014336:Troponin / Q000097:blood
chemical_list: D015415:Biomarkers; D014336:Troponin
keywords: cardiac care, acute coronary syndrome; cardiac care, diagnosis; nursing, emergency departments