Radio/walkie use is regularly utilized to enhance speed of communication between the triage nurse and other staff members. The rapid response of others responding to radio communication demonstrates effective teamwork within the department. The organization also uses a language translation service that is readily available at all times; this assists in expediting identification of patients experiencing CP symptoms.

The organization has a substantial number of contract employees that are not considered core staff due to high turnover rates; these employees struggle with learning every process in detail due to their short tenures. There are more novice staff members in the department who are inexperienced in utilizing the ESI tool and unfamiliar with the triage workflow process. Patient boarding, a common occurrence in EDs, is also a regular obstacle that often leaves no available space to complete timely EKGs for other patients.

Providing staff with structured training and education on the ESI triage tool could assist with patient throughput by improving triage accuracy. A partially modified triage workflow process for patients presenting with CP by establishing an EKG suite could reduce delays and improve patient outcomes if they are experiencing a major cardiac adverse event; the modification would include completing registration after obtaining an EKG rather than at time of arrival. A modified triage workflow process could improve patient experience ratings, a measurable quality metric used by the Centers for Medicare and Medicaid Services (CMS) for hospital reimbursement [19].

A threat to the implementation of the project is the use of agency personnel to fill as needed staffing gaps. These individuals are external to the facility and only work one or two shifts in the department every four to eight weeks or longer. The effort to mitigate this threat is recommending the agency personnel not work in the triage role. If this is unavoidable, then it is recommended that these individuals receive frequent reminders of the modified triage workflow process. Another threat is the variability of patient flow; during times of high patient arrival, staff tend to move the EKG machines around the department. This then causes waste of time as staff members must look for an EKG machine. The mitigation effort for this threat is to clearly label the EKG machine dedicated for the triage suite and educate staff that it should never be removed from the space. A third threat is variations in patient descriptions of symptoms. Effort to mitigate missing cardiac related complaints is to include commonly used terms and phrases for CP such as “chest pressure” and “chest tightness” to name a few.

A sequence of tasks in a process, including both physical and mental chores occurring sequentially or simultaneously, that must be accomplished for a specified objective to be deemed executed [1][4].

This is similar to workflow; however, it includes specific clinical activities that culminates in overall patient care [5].

A critical clinical workflow process used for prioritizing patients based on the severity of their presenting symptoms or condition [2]. When implemented effectively, this process assists in reducing preventable medical errors [3].

Planned tasks, such as provider orders or practice standards, which are not performed as intended; preventable medical errors can also include an erroneously implemented plan of care [4].

A standardized triage tool commonly used throughout the world to measure severity of presenting symptoms and prioritize patient care upon arrival to the ED [2].

A common test completed in EDs that evaluates electrical impulses through the heart and assists in early identification of cardiac abnormalities or events such as MI [22].

The elapsed time between patient arrival to the ED to completion of the initial EKG measured in minutes [20].

An umbrella term used to identify a collection of disorders involving the heart and blood vessels leading to the heart and brain [6].

A type of life-threatening CVD commonly referred to as a heart attack [8]. A heart attack occurs when circulation of blood to the heart stops and results in oxygen starvation [10].

A specific type of heart attack requiring immediate identification and percutaneous coronary intervention for optimal patient outcomes [10].

Clinical workflow is comprised of numerous tasks that when disrupted increases the risk that preventable medical errors will occur [5]. Variables that can influence the triage workflow include patient volume, staff training, and interruptions [3]. The ESI is a valid and reliable tool used in the triage clinical workflow process to measure acuity of patient symptoms and determine immediate resource requirements [15][16]. Adequate training on specific tools increases the usage during the triage process [2], and triage accuracy improves with the use of valid and reliable tools such as the ESI [17]. Efforts should be made to utilize the ESI to improve triage accuracy and reduce the frequency of clinical workflow interruptions.

It was noted that patient boarding in the ED has different definitions, but the overall premise is the same: patients do not leave the department in a timely manner after the decision to admit is made [31]-[34]. Patient boarding interferes with clinical workflow by reducing the amount of readily available resources during triage and routine care [20][24]-[30].

Some of the basic physical resources necessary during the triage process for patients experiencing CP include an area that provides privacy, a stretcher, and an EKG machine. The authors reported in their study that less than 60% of patients had a DTE completed within the goal of 10 minutes [20]; the primary contributing factor (49.3%) to obtain a timely EKG was unavailability of a bed. The lack of resources noted in a separate study indicated an increase in ED wait times exceeding 3 hours [25]. In another study, insufficient material resources (76.7%) were also identified as the top cause for missed nursing care [24]. Another study similarly reported lack of material resources as the most common reason (92.5%) for rationed nursing care [29]. Physical resources were noted as the main reason for medical errors in the aforementioned studies, but they ranked second or lower in other reports as a major cause. Specific to the project, studies recommend having the required resources always available to minimize the effects on DTE times; they include a dedicated area, EKG machine, and stretcher [2][20][25][35]. Efforts should be made to ensure the basic physical resources are immediately available in an EKG suite for patients presenting with CP.

One study revealed that insufficient staff was the most significant cause for rationed care amongst nurses [30]. This was also reported as the main reason for missed nursing care in another study [26]. Human resources were the second leading cause for nursing errors according to other studies; it was reported in one article that insufficient staff contributed to 65.5% of rationed care [24] whereas another reported it accounted for 68.7% of their results [29]. Efforts should be made to ensure staffing levels are adequate.

A common theme noted in the literature was the inclusion of additional contributors to medical errors. The studies varied in their reports of significance; however, the commonality was that the identified factors still increased the likelihood of a medical error occurring. A breakdown in communication was identified in multiple studies [24][26][29][36][37]. Poor teamwork was another cause for medical errors [24][29]. Efforts should be made to promote effective communication and teamwork.

One limitation of the literature review regarded the lack of available data strictly dedicated to the triage clinical workflow process focused on CP patients. The studies provided cumulative insight on the triage process in EDs for patients with all complaints [2][3][15]-[17]. Other studies related to DTE time were primarily concerned with patients experiencing STEMI and data beyond the scope of this project related to percutaneous coronary interventions [11][12][38]. Additional studies, not dedicated to the ED, were included to highlight the importance of effective workflows [5][23]-[30][34][37]. Another limitation encountered was the exclusion of pediatric patients, identified as anyone under the age of 18 years old, in the reviewed literature. This group was excluded from the project; however, consideration was still given during the literature review because this patient population is considered part of the general ED population with the potential to present with a complaint of CP. This presented a possible gap in knowledge for pediatric patients.

Another limitation was the inconsistent use of terms or phrases in the reviewed literature. It was noted that similar definitions were used to describe preventable medical errors, missed nursing care, missed care, and rationed nursing care. These terms are applicable to numerous healthcare fields; use in the search of literature generated a wealth of information not relevant to the project. This resulted in several of these terms being excluded as part of the literature search strategy.

A possible gap in knowledge revolved around if a singular intervention reduced DTE time. The literature addressed triage. However, triage is a process that involves multiple tasks with the potential to be disrupted during any of them. It was noted in one study that goal DTE time was not achieved even after interventions were implemented [35]; this was the only study that mentioned failure to achieve the benchmark standard time even though there was an improvement in the overall DTE time.

The review of literature provided evidence that supports the need for effective and efficient triage, a clinical workflow process found in EDs, to assist in reducing preventable medical errors [3]-[5]. The literature revealed using a valid and reliable triage tool improved triage accuracy [17]. It was also reported that when training was provided, the use of triage tools increased [2]. Several studies suggested having the necessary resources readily available at all times to help mitigate the issues created by patient boarding; this included a dedicated area, EKG machine, and stretcher [2][20][25][35]. The following PICOT question was developed from recommendations in the literature: For newly arriving walk-in patients with chest pain in the emergency department, will use of the Emergency Severity Index and implementation of an electrocardiogram triage suite compared to current practice reduce door-to-EKG time within 8 weeks? Training on the use of the ESI triage tool and implementation of an EKG triage suite are two evidence-based interventions extracted from the literature that support the project goal. The project aim was to assist staff at the practice site consistently meet the benchmark standard DTE time of 10 minutes established in the evidence-based CP guideline jointly produced by the AHA and the ACC [9]. Implementing these interventions were intended to improve the triage clinical workflow process to influence patient outcomes as guided by the Donabedian model.

The purpose of this quality improvement project was to investigate if reviewing the ESI with the ED team and implementing an EKG suite would improve the triage clinical workflow and decrease the DTE time for newly arriving walk-in patients presenting to an ED with a cardiac related complaint of CP. The reality of the situation at the project site was that clinical workflow obstacles exist because of common dilemmas like overcrowding and boarding in EDs which decreases available resources necessary to care for newly arriving patients; this in turn increased the risk of preventable medical errors occurring [20]. At the practice site, the average DTE time in the second quarter of 2025 for this specific patient population was 18.27 minutes which exceeds the benchmark standard time. A DTE time exceeding 10 minutes for patients experiencing CP is considered a preventable medical error as it is an evidence-based practice standard established in the CP guideline [9]. Cardiac related CP can occur in any patient population without regard to demographics at any time of day. While CP is not always due to a cardiac source, it can be fatal if it is [10]. The goal of this project was to improve the triage clinical workflow by ensuring ED staff were trained on using the ESI and always had the necessary space and equipment readily available for adult patients presenting to the department with CP to reduce DTE time. This in turn allowed for prompt identification of major adverse cardiac events like STEMI to improve quality of care and patient outcomes [9][11][12].

The specific question the scholarly project aimed to address in PICOT format was: For newly arriving walk-in patients with chest pain in the emergency department, will use of the Emergency Severity Index and implementation of an electrocardiogram triage suite compared to current practice reduce door-to-EKG time within 8 weeks? The PICOT question is related to the clinical problem of disruptions in the triage clinical workflow due to ED overcrowding and patient boarding that results in preventable medical errors such as the untimely attainment of an EKG for walk-in patients with complaints of CP. The obstacles that contributed to the inefficient triage workflow process included inadequate training on the ESI tool, no consistently available space, and lack of a dedicated EKG machine.

The intervention, or independent variable, for this quality improvement project had two parts. First, it included training for registered nurses (RNs) on use of the ESI tool. The triage nurse used the ESI level and chief complaint to prioritize patients requiring an EKG. The second portion of the intervention was the establishment of an EKG suite. The EKG suite was a repurposed triage room. It consisted of a stretcher and a dedicated EKG machine. The suite remained stocked with extra supplies such as EKG paper, electrodes, and clippers. The data collection approach included retrospective chart review prior to the intervention implementation and post implementation specific to patients presenting with a cardiac chief complaint of CP. The measure under evaluation, also known as the dependent variable, for the project was DTE completion time.

The project had a quantitative quasi-experimental methodology which was useful in observing if there was a causal effect from an intervention [18]. A volunteer unit secretary collected de-identified data for a specific amount of time before the intervention was implemented. Similarly, de-identified data was collected for the same amount of time post implementation of the intervention by the same volunteer. The difference between CP patients’ arrival times to the ED and EKG completion time allowed for the derived outcome measure, DTE time, to be calculated. From this data, descriptive statistics and inferential statistics were then applied to determine project success.

The scholarly project was conducted in a pre-intervention and post-intervention design. This design method allowed for evaluation of the outcome measure prior to implementation of the intervention and post implementation [18]. The pre-intervention and post-intervention data was collected by retrospective chart review of the electronic health record prior to the intervention implementation and post implementation specific to patients presenting with a cardiac related chief complaint of CP. The measure the student evaluated was time. The first tracked time was patient arrival time to the ED (arrival time). This was the time the patient checked in to the ED via kiosk or their information directly taken by the staff member serving as the receptionist in the triage area. The second tracked time was EKG completion time. As the name implies, this was the time that the EKG was completed. In most situations, the arrival time was automatically populated in the electronic health record whereas the EKG completion time was manually entered by the technician into the electronic health record. Adjustments to the arrival time would have been required if a patient delayed checking in for evaluation; this is discussed further in the inclusion criteria. The difference between the arrival time and EKG completion time was the outcome measure for the proposed project: DTE time. A unit secretary voluntarily collected data directly from the electronic health record through an embedded triage audit report providing both arrival time and EKG completion time. No identifying patient information was gathered during the data collection process. All data was de-identified.

The practice setting for this project was an ED at tertiary hospital and accredited CP center located in a major metropolitan area of Texas in the U.S. The ED consisted of 20 individual patient rooms, 2 triage rooms, 1 treatment/procedure room, 8 vertical three spaces, and 5 rapid intake areas. The ED also had the capability to accommodate an additional 14 hall beds for a total of 50 patient care areas when patient boarding was necessary. The average daily census fluctuated between 80-115 patients per day. Department productivity levels allowed for 26 staff members to be scheduled in a 24-hour period. This included a combination of dayshift, mid-shift, and night-shift employees. The staffing matrix consisted of RNs, licensed vocational nurses, advanced paramedics, and unit secretaries. The care providers in the ED at any given time consisted mostly of RNs, and it is this group that mainly impacted the triage clinical workflow process. Therefore, the focus of the project involved primarily nurses who were assigned to the triage area.

The specific population was walk-in patients presenting to the ED with a cardiac related complaint of CP. At the practice site, there were an average of 10 walk-in patients a day that arrived with CP due to CVDs. Nonrandom, purposive sampling was used which allowed for criteria to be established for participation [18]. A free, online sample size calculator (see Appendix D) was used for power analysis to determine the appropriate a-priori sample size of 102. A unit secretary volunteer collected unpaired data for several days before and after implementation of the intervention. The volunteer included all qualifying samples from the pre- and post-intervention groups, collecting data until both sample sizes were sufficient at 51 each.

Criteria for inclusion for the patient population included “newly arriving” defined as presenting to the ED less than 30 minutes before checking in. On occasion, patients have decided to delay checking in. The 30-minute window allows for capture of these patients without significantly distorting data. The delayed check-in can directly impact the mean DTE time because the arrival time for these patients is adjusted to reflect the true arrival time; this time is the moment the patient physically enters the ED rather than the time they decide to check in for evaluation. While it is rare for CP patients to postpone seeking care while physically in the ED waiting room, it has been observed by staff at the practice site. The 30-minute window was established to mitigate the impact on the DTE time from extensive delays because the impact is not the result of inadequate ESI training or the triage process in place in these situations. No patients experiencing CP delayed checking in for this project.

Additional inclusion criteria for the patient population included: 1) age 18 years or older, 2) any gender, 3) identification as walk-in, 4) triage classification as cardiac related, 5) any ESI level, and 6) complaint of CP or variations like chest pressure, discomfort, and tightness. Exclusion criteria for the project included patients brought in via emergency medical services (EMS) or by peace officers. Additional exclusion criteria included cardiac related or potentially cardiac related complaints without CP; these included complaints such as high blood pressure, dizziness, short of breath, and palpitations. For the patient population, obtaining informed consent was not necessary since obtaining an EKG for these individuals is a standard and routine practice. Additionally, collected data was not patient specific, but generalized to a group with a defined complaint. All data was de-identified. No personal identifiable information was collected.

One way to maintain confidentiality is through anonymous data collection [18]. Data specific to the quality improvement project was retrospectively collected with the assistance of a department unit secretary. Data was collected using a triage audit report within the electronic health record that included all patients with a cardiac related complaint of CP triaged by any RN. The volunteer removed any information that could be used to identify participants, both RNs and patients, to maintain anonymity and ensure confidentiality.

Project planning was implemented because it is considered the blueprint, or guide, which steers the project while identifying necessary tools, parameters, and establishes necessary timelines leading to the overall success of a project [44]. Various tools were used in planning of the project such as budgets, a SWOT analysis, and a work breakdown structure. Project planning assisted the team in thinking systematically by identifying how various pieces of the project influenced another. This led to the development of the PICOT question presented in the project by establishing a clear goal with a measurable outcome which are considered project success factors [45].

Communication is considered a vital component of project planning and implementation; it is imperative to disseminate “the right information, at the right time, with the right people, and in the right format” [14]. The method of communication exchange is equally important. Individuals should be versed in the chosen communication strategy especially if it requires a specific skill or knowledge base to understand the relayed message [46]. Throughout the project, methods of effective communication included in-person interaction, teleconferences, and electronic mail correspondence to create and sustain a dynamic team dedicated to the project’s success.

Organization support was gained through a top-down approach from internal stakeholders. The internal stakeholders included the Assistant Chief Nursing Officer and Director of Emergency Services who were presented with an overview of the project and how it could potentially lead to financial gain and improved patient outcomes. Financial gain was identified in the form of cost-avoidance through minimizing the risk that the organization could lose accreditation as a CP center; accreditation is granted by the ACC which is an external stakeholder. A description of cost-avoidance is circumventing future costs as a result of practice or process changes [14].

Cost-avoidance was also highlighted through maintaining a stream of revenue by fostering trust in the community, an external stakeholder, as an accredited CP center; this is because current and future patients have a choice on where to seek care. The benefit of cost-effectiveness was also emphasized because implementing a cost-efficient intervention has “the potential to reduce disease burden” [14]. This was proposed through measuring the mortality rates of STEMI patients. While measuring STEMI mortality rates was not part of this scholarly project, it is a key performance indicator measured and tracked by the organization’s quality department. A reduction in mortality rate is one indication of improvements in patient outcomes [12]. Support was then obtained from the staff members, additional internal stakeholders, directly involved in the project by presenting value in the form of improved patient outcomes and patient satisfaction. The risks and benefits associated with both internal and external stakeholders drive the sustainability of the project.

Members of the project team included the DNP student, project chair, committee member, content expert, and a unit secretary volunteer. The student’s role was self-assigned as the author and project manager. A project manager should have critical thinking skills and problem-solving abilities manifested in effective communication to drive the project forward [46]; this was evident by the student’s responsibility in selecting relevant team members to assist with the project. Aside from developing the team, the student was responsible for project planning, staff training and education, implementation, monitoring for consistency and opportunities to reinforce the modified triage workflow, evaluation of project progression, and data analysis. The project chair and committee member were assigned to the project team, and they possessed valuable knowledge in the development of the project focus and organization of the project manuscript. The unit secretary volunteer collected raw data that was then purged of personal identifiable information; this allowed for the preservation of data confidentiality and anonymity. The content expert provided insight on the clinical problem and feasibility of the project interventions for sustainability. Each of these individuals contributed to the success of the project through an interconnected team approach by providing insight, presenting different avenues to consider, offering guidance, and task assistance.

The factors necessary to make the project a success included adequate time to educate staff on the evidence-based interventions and elements of the EKG suite. These elements consisted of a suitable area to convert to an EKG suite, a dedicated stretcher for the space, and an EKG machine specifically for the suite. Additionally, a volunteer ensured the confidentiality and anonymity of participants during data collection. A triage audit report embedded within the electronic health record allowed for data collection during a specified time period pre and post intervention. There were two budgetary needs addressed which the student was able to self-fund. One budget was for staff education prior to implementation (see Appendix E); the second budget was for the project portion to include post-project presentation material (see Appendix F). While there was no immediate financial gain from project implementation, patient satisfaction was stressed for timely evaluation of CP. A patient’s negative perception about a hospital’s quality of care could result in the spread of undesirable opinion via word-of-mouth leading up to $400,000 in lost revenue over the span of an individual’s life [47].

At the practice site, lack of training on use of the ESI and insufficient resources impeded the triage clinical workflow. Part of the intervention for this quality improvement project included educating RNs employed in the ED on using the ESI. These nurses then utilized the ESI tool to assign a triage level to patients upon arrival to the ED that was used in conjunction with the patient’s chief complaint to prioritize patients experiencing CP and required an EKG. The second portion of the intervention was the establishment of an EKG suite. Workflow disruptions occur when the individual performing the EKG must waste time searching for a suitable place to perform the EKG or waste time searching for the actual EKG machine. These issues were both mitigated by creating a specified space with dedicated equipment strictly for EKG completion.

The EKG suite was created by repurposing a triage room. It consisted of a stretcher, a dedicated EKG machine, and was stocked with basic supplies needed to complete an EKG such as paper, electrodes, and clippers. Patients identified by the triage nurse requiring an immediate EKG were escorted to the suite for EKG completion. Once the EKG was obtained, the patient was then moved to the next appropriate care area. This ensured the EKG suite was nearly immediately available for another patient. It was noted that dedicated space and equipment are recommended interventions from previous research to help reduce DTE times [25]. One study specifically recommended having a dedicated EKG machine and EKG technician in the triage area of the ED [35]. Another study recommended not just having a machine but included a demarcated space specifically for EKG completion [20]. Due to the feasibility of having a dedicated EKG machine and demarcated space in the triage area for timely DTE completion, they constituted a combined intervention, the EKG suite, for the project.

Prior to implementation of the project, a letter of cooperation (seeAppendix G) was obtained from the organization. Specifically, the letter was obtained from the Director of Emergency Services who possessed approval authority for the project from the organization’s Chief Nursing Officer. The student was required to submit a request for an Institutional Review Board (IRB) through Oklahoma Wesleyan University (OKWU) for approval. An exempt IRB determination (see Appendix H) was granted for the project. The practice site did not require an additional IRB. Since this project consisted of a process change that is already a standard of care, no informed consent was necessary.

The first part of the implementation phase included staff education (see Appendix I). The ED RNs received education during shift huddle over the span of a week. Shift huddle occurred twice a day, once in the morning and once in the evening. The education and training consisted of reviewing the ESI and modification to the triage clinical workflow process with implementation of the EKG suite. Establishment of the EKG suite took no longer than 45 minutes. It involved removing unnecessary items such as an infant scale and extra chairs and replacing them with the stretcher, EKG machine, and other necessary items.

A unit secretary voluntarily conducted retrospective chart reviews utilizing a triage audit report tool embedded in the electronic health record to collect pre-intervention and post-intervention data specific to patients presenting with a cardiac chief complaint of CP. The collected data were times; the first was patient arrival time and second was EKG completion time. Data integrity was maintained through establishing clear criteria, utilizing a single volunteer, and providing the volunteer with easy-to-follow instructions on how to access the triage audit report tool. Data was exported to a portable document format file, a type of electronic document, where any personal identifiable information was then erased. The raw data, void of personal identifiable information, was then printed and provided to the student. The electronic versions were deleted. The student reviewed the data for completeness before utilizing Microsoft Excel and IBM SPSS Statistics version 26 for calculations and statistical analysis. The printed data was protected and securely stored, locked in a filing cabinet, at the project site in the ED manager’s office when not in use. The ED manager’s office was always locked; this served as an additional safety measure. Human subject protection was ensured by maintaining ethical standards through adherence to the Health Insurance Portability and Accountability Act where no personal identifiable information was collected on patients or RNs participating in the project.

The ESI scale is a valid and reliable tool used in triage to measure severity of symptoms and necessary resources to treat a patient presenting to the ED [15][16]. The ESI has been shown to have a significant inter-rater reliability rating as demonstrated by Cohen’s Kappa score of 0.75, yielded an average sensitivity of 74.3%, and indicated specificity of 94.4% [15]. This tool is publicly available and is integrated into the electronic health record at the project site. Data was collected from the electronic health record and included timestamps for patient arrival and EKG completion times. Data was collected retrospectively utilizing a triage audit report tool embedded in the electronic health record.

There were two noteworthy limitations throughout the project. One limitation of this project was the high turnover rate at the practice site. There were fewer experienced RNs who are considered proficient in triage compared to the number of inexperienced staff. Effort to mitigate the impact on the project included recommending not assigning new hires to the triage role until they received proper education. This was because the inexperience and lack of education had the potential to result in inconsistent ESI level assignment if inexperienced staff misidentify the chief complaint due to the variability in patients’ description of symptoms. An effort to mitigate this involved posting a list of phrases in the triage area that patients commonly use to describe CP such as discomfit, pressure, and tightness. Another limitation of the project was from a data entry perspective. The EKG completion times were manually entered into the electronic health record which were later collected. If the times were incorrectly entered, this could interfere with the results. To mitigate this, staff were reminded to verify data entries were correct before saving to the electronic health record.

Human subject protection was promoted through maintaining ethical standards. Prior to the start of the project, the DNP student completed mandatory human subject protection training (see Appendix J). The student abided by the Health Insurance Portability and Accountability Act to ensure privacy and security of data was protected for staff and patient information throughout the project. Data was confidentially collected by a unit secretary voluntarily. The unit secretary expunged any personal identifiable information such as patient names, ages, date of birth from all records provided to the student to maintain anonymity. Only times were collected for the project. The project fostered the principles of respect, justice, and beneficence through integration of Kingdom nursing and embracing a Christian worldview regarding the concept of love for all without regard to demographics of any kind [48]. Love in this sense does not include romantic emotions, but it refers to actions and behaviors that improve the wellbeing of others [49]. This included fostering consistency in the triage process to promote health equity by ensuring all patients who met the inclusion criteria for CP received the same high-quality care [50][51].

The project was subjected to an IRB for approval through OKWU and was granted an exempt review. The project site did not require an additional IRB. A letter of cooperation was obtained from the organization which granted permission to conduct the project. All data will be stored securely for seven years from the project’s approval date and then destroyed per OKWU’s policy.

The pre-intervention and post-intervention data sets were first evaluated for completeness to ensure necessary elements were available to calculate DTE time. Microsoft Excel was used for data organization. The DTE times were manually calculated by the student using the arrival times and EKG completion times; these singular times were then organized from shortest to longest for the student to view the data spread (see Appendix K). The descriptive statistic measure of central tendency, mean, was then calculated for the two raw data sets using the appropriate formula function in Excel. This provided limited insight into the project results to indicate if a change had occurred. The student observed the pre-intervention DTE mean was higher than the reported 2025 second quarter DTE mean. This prompted the student to complete a data dispersion comparison with a box and whisker chart using Excel that highlighted data outliers. The box and whisker graph was chosen because it is regarded as a widely accepted tool used in the identification of outliers [52]. Due to the possibility of the outliers indicating errors in the entered EKG times, the two longest outliers were removed from both groups. Removing the outliers was considered an appropriate corrective measure to enhance the overall data quality [53], and the student completed analysis for the adjusted data. The mean for each data set was again calculated during statistical analysis through a one-tail Welch’s t-test.

IBM SPSS Statistics version 26 was used to calculate the one-tail Welch’s t-test. This parametric test was used because the project outcome measure provided interval data. The Welch’s t-test was also chosen for the unpaired data because it was assumed the sample variances were unequal. The data analysis technique aligns with the project design and PICOT question because two unpaired data sets were collected to compare their means after an intervention had been implemented; this is the basis for the Welch’s t-test. The level of statistical significance used for the quantitative analysis was a-priori (p < 0.05).

The ED had a fluctuating average daily census between 80 - 115 patients per day, and the department productivity levels allowed for up to 26 staff members to be scheduled in a 24-hour period. The staffing mix that influenced the triage process consisted of RNs, licensed vocational nurses, and advanced paramedics. RNs comprised the largest group of care providers within the ED at any given time and had the most influence on the triage clinical workflow process. It was for this reason that the focus of the education portion of the project primarily involved all RNs assigned to the triage area.

The participants were those identified as newly arriving walk-in patients to the ED with a cardiac related complaint of CP. The practice site had an average daily census of 10 walk-in patients a day with CP symptoms due to CVDs. An a-priori total sample size of 102 was calculated for power analysis using a free, online sample calculator. Fifty-one de-identified nonrandom, purposive samples were collected both pre- and post-intervention by a unit secretary volunteer. Inclusion criteria for the patient population consisted of “newly arriving” defined as checking in to the ED within 30 minutes of arrival to the facility. The following were additional inclusion criteria: 1) age 18 years or older, 2) any gender, 3) identification as walk-in, 4) triage classification as cardiac related, 5) any ESI level, and 6) complaint of CP or variations like chest pressure, discomfort, and tightness. Specific demographic data regarding staff or patients was not collected to ensure privacy and confidentiality.