Impact of triage nurses' recognition of acute coronary syndrome on door-to-balloon time at a Northern Jordanian Tertiary Hospital

Background: Early diagnosis and treatment of Acute Coronary Syndrome (ACS) is very important to decrease morbidity and mortality. Triage nurses play a key role in early identification; however, undertriage remains an issue in the Jordanian emergency departments. The Unified National Chest Pain Protocol was implemented in Jordan to standardize ACS care, but there is limited data on its adherence in real-world settings. 
Objective: To assess how triage nurses’ recognition of ACS affects door-to-balloon (D2B) time and clinical outcomes at Princess Basma Hospital, a new tertiary care facility in Northern Jordan. 
Methods: A retrospective cohort study was conducted at Princess Basma Hospital. Data collection included accuracy of triage nurse in identifying ACS, time metrics (door-to-ECG, door-to-balloon), patient demographics, and clinical outcomes. Multivariate logistic regression identified predictors of prolonged D2B time (>90 minutes).
Results: Among 320 ACS patients (mean age 58.4±12.6 years, 54.6% male), 42.8% were under-triaged by emergency triage nurses. Under-triaged patients experienced significantly longer door-to-ECG times (median 12 vs. 6 minutes, p<0.001) and door-to-balloon times (median 108 vs. 72 minutes, p<0.001). Only 48.2% of under-triaged patients met the recommended D2B target of ≤90 minutes, compared to 82.4% of accurately triaged patients (p<0.001). Under-triage was independently associated with prolonged D2B time (aOR=4.82, 95% CI: 2.68–8.66, p<0.001). Patients with prolonged D2B had higher in-hospital mortality (12.4% vs. 4.2%, p=0.008) and longer hospital duration (median 7 vs. 4 days, p<0.001). 
Conclusion: Emergency nurses’ under-triage of ACS patients is associated with significant delays in diagnosis and treatment, including prolonged D2B time. These findings highlight the importance of optimized triage education and compliance to the Unified National Chest Pain Protocol to improve ACS outcomes.