Globally, non-traumatic chest pain is a significant cause of emergency department (ED) visits, with a substantial portion of these cases ultimately being diagnosed as acute coronary syndrome (ACS) or benign conditions. In England and Wales, for instance, chest pain accounts for approximately 2.4% of ED visits (1). In China, the EMPACT study highlights the challenge of managing acute chest pain, with a focus on improving diagnostic accuracy and treatment outcomes for suspected ACS cases (2). The proportion of patients with chest pain who are ultimately diagnosed with ACS varies, but a significant number are found to have non-cardiac causes, emphasizing the importance of accurate diagnosis to avoid unnecessary interventions (3).

Guidelines recommend that an electrocardiogram (ECG) should be performed within 10 min of ED arrival for patients with suspected ACS, and troponin levels should be assessed promptly to facilitate early diagnosis and treatment (4). Delays in these critical steps can lead to missed diagnoses of ST-elevation myocardial infarction (STEMI), increased morbidity and mortality, and prolonged ED stays (5). In China, audits of tertiary centers reveal performance gaps, with regional variations in the management of ACS, such as longer onset-to-first medical contact times and differences in the use of percutaneous coronary intervention (PCI) (6). These disparities highlight the need for standardized protocols and quality improvement initiatives to enhance care delivery and outcomes (6).

Emergency nursing practice plays a critical role in patient care, often serving as the first clinical contact for patients in EDs. However, the variability in assessment quality and documentation deficits can contribute to diagnostic errors and medico-legal risks (7, 8). Frameworks like ABCDE and ISBAR are partially adopted to standardize assessments, but their inconsistent use highlights the need for more comprehensive solutions (9). The Emergency Nursing Assessment Framework (ENAF) was developed to address these issues, featuring a five-step structure: Chief Complaint, Primary Survey, Focused Assessment, Secondary Survey, and Reassessment & Communication (10). Evidence suggests that ENAF improves systematic data capture and handoff fidelity, yet it lacks an explicit focus on patient-centered clinical needs such as pain, anxiety, and informational support (10, 11). Addressing patient-centered needs is crucial, as unmet needs are linked to increased anxiety, persistent pain, and decreased patient satisfaction (12). Empirical data indicate delays in analgesia and communication deficits, particularly in chest pain cohorts (13). Local quality control data from a study hospital reveal that only 60% of ECGs are performed within 10 min, and documentation completeness is at 80 ± 10%, with bottlenecks identified in equipment distance, inconsistent reassessment, and lack of standardized prompts for pain and anxiety (14). The HIRAID framework, an evidence-based approach, has been shown to improve the accuracy of clinical documentation and enhance patient experience by providing a structured method for patient assessment and non-technical skills development (8, 11). Despite these advancements, the integration of patient-centered care into emergency nursing frameworks remains a gap that needs addressing to optimize patient outcomes and satisfaction in acute care settings (11, 15).

Nurse-led intervention in combination with a low-cost electronic template with mandatory fields, a readily accessible rapid-assessment kit and a real-time audit-feedback loop, may optimize patient outcome and satisfaction in high-volume emergency departments. The aim of this study is to determine whether implementing ENAF, compared with usual care, increases the proportion of Emergency Department patients with non-traumatic chest pain receiving a 12-lead ECG within 10 min, and to evaluate effects on door-to-troponin time, early pain relief, documentation completeness, emergency department length of stay, and 30-day major adverse cardiac events.

This before-after study achieved all prespecified objectives, demonstrating that the patient-needs-enhanced ENAF protocol produced clinically meaningful gains across multiple dimensions of chest-pain care: the proportion of patients receiving an ECG within 10 min rose by 18 percentage points, median door-to-troponin time fell by 11 min, ENAF documentation completeness improved by 10 points, and median emergency-department length of stay shortened by 0.8 h, while 30-day major adverse cardiac events and protocol-related harms remained unchanged. These effect sizes are both statistically robust and operationally significant, indicating that a low-cost, nurse-led, patient-centered workflow can simultaneously accelerate time-critical diagnostics, enhance symptom control and elevate record quality without sacrificing safety.

Our findings both corroborate and extend earlier quality-improvement work on ACS. The 18-percentage-point rise we observed in ECG ≤10 min compares favorably with the 43-percentage-point gain reported when U.S. centers created a dedicated ECG room and hired technicians (16), but it was achieved without extra staff by combining an electronic hard-stop template, a rapid-assessment kit and weekly audit feedback. Pre-hospital ECG programs likewise shorten diagnosis-to-balloon times, yet remain under-utilized even though compelling single-case reports show life-saving impact in ST-segment-elevation myocardial infarction (17). On the biomarker side, we trimmed door-to-troponin by 11 min, echoing rapid rule-out protocols that leverage high-sensitivity cardiac troponin to expedite non-ST-elevation myocardial infarction decisions (18, 19); our approach, however, embeds specimen collection into the same nursing checklist that triggers the ECG, a design choice that may explain why our effect size exceeds those of earlier Chinese chest-pain-center accreditations. Although point-of-care biomarker testing is emerging for ambulance use (20), our data show that simple in-hospital workflow redesign can deliver comparable speed gains while awaiting wider adoption of mobile assays. Importantly, we also improved symptom control and documentation completeness—dimensions often overlooked in process studies—highlighting that a unified checklist can address pain, anxiety and record quality without sacrificing timeliness.

The mechanisms underpinning these gains are consistent with Cognitive Load Theory. By imposing electronic hard stops, the ENAF template removes extraneous memory demands and guides nurses through a fixed sequence of actions, thus preventing omissions at peak workload (21, 22). Visual prompts embedded in the template and the physical co-location of ECG and blood-draw equipment further reduce intrinsic load and accelerate task initiation, mirroring experimental work in STEMI protocols (23). Continuous audit-feedback loops reinforce correct behavior and have shown durable effects in ACS QI projects (24); the sustained upward trend across three ENAF months makes a transient Hawthorne effect unlikely despite the before-after design (22).

Clinically, these results argue for scaling nurse-led ECG programs in high-volume, resource-constrained emergency departments. Cost-effectiveness analyses estimate that structured ECG deployment in urban India costs as little as US $12.65 per quality-adjusted life-year (25), while person-centered care models consistently dominate usual care on both cost and effectiveness over two- to five-year horizons (26, 27). When combined with our low-cost electronic template and audit infrastructure, such programs can be rapidly disseminated—potentially as part of national ED quality indicators or nursing curricula—and do not require physician expansion or capital-intensive technology (28, 29). Crucially, our data dispel the notion that patient-centered assessment slows critical actions; on the contrary, integrating needs appraisal into the first nursing touchpoint expedited every downstream time target and left 30-day major adverse cardiac events unchanged, underscoring both the efficiency and safety of a holistic, checklist-based approach.

The ENAF protocol is practical for high-volume EDs because it relies on existing nursing staff, an 8-h education package, a low-overhead EMR template with hard-stops, and a pre-positioned rapid chest-pain kit near triage. Implementation occurred at the unit level with no additional staff positions. The protocol was associated with an 18.2-percentage-point increase in ECG ≤10 min and a 0.8-h reduction in ED LOS, indicating improved flow without compromise in safety (30-day MACE unchanged). Although not measured formally, high template closure and checklist completion, together with improved pain relief at 30 min, suggest good acceptability. The electronic template sits within triage ENAF, triggers early ECG and pre-labels troponin at first contact, and then hands off to routine clinician decision-making within existing ACS pathways, requiring only minor workflow adjustments.

Although we did not collect cost data, the intervention was intentionally resource-light: a one-day (8-h) nurse training package, an EMR template with hard-stops, a pre-positioned “rapid chest-pain kit,” and brief weekly audit-and-feedback huddles, all delivered with existing staff and infrastructure. These features suggest low marginal costs to implement and maintain. Potential cost offsets, which require formal evaluation, include shorter ED length of stay, fewer workflow delays, and improved documentation quality. Because this study focused on process effectiveness, a future multicenter evaluation should incorporate micro-costing, time-motion, and budget-impact analyses from both hospital and payer perspectives to determine whether the protocol is cost-effective at scale.

This single-center, quasi-experimental design is subject to several limitations. First, the design is vulnerable to secular trends and residual confounding despite prespecified covariate adjustment and sensitivity checks. We cannot exclude unmeasured changes in staffing, case mix, or concurrent initiatives. Second, written informed consent was required. This may have preferentially enrolled patients able to consent, potentially limiting generalizability to populations with communication barriers or severe illness. Third, performance bias is possible because clinical staff could not be blinded to a unit-level workflow change. Fourth, timing measures relied on routine time-stamps. Although missingness was low, small clock drift and documentation variability could affect some secondary outcomes. Fifth, the study was powered for process endpoints. The 30-day MACE analysis was underpowered to detect modest safety differences, and events beyond 30 days were not assessed. Our tertiary urban setting with established informatics support may limit external validity for low-resource emergency departments. We did not collect cost data, our economic comments are therefore conceptual and highlight the need for a formal, prespecified economic evaluation in future multicenter studies. To assess reproducibility across different case mixes, ED volumes, informatics maturity, and staffing models, multicenter studies, ideally cluster-randomized or stepped-wedge designs to manage contamination, are warranted. Such trials should predefine core process and safety outcomes, capture implementation metrics, and embed a concurrent economic evaluation.

Causal confirmation and implementation guidance would benefit from multicenter cluster-randomized or stepped-wedge trials comparing ENAF with standard triage. Key priorities include prespecified subgroup analyses by HEART risk strata, arrival mode, and triage acuity to characterize heterogeneity of effect, a core outcome set for chest-pain triage covering time-to-ECG, door-to-troponin, timely analgesia, documentation quality, ED length of stay, and 90-day safety, implementation-science measures (fidelity, acceptability, time-motion) and cost-effectiveness to inform scale-up in resource-constrained settings, and development of a standardized ENAF training and competency package to enhance reproducibility across platforms and staffing models.

Embedding a concise, patient-centered clinical-needs module within the Emergency Nursing Assessment Framework markedly accelerated time-critical diagnostics for non-traumatic chest pain and elevated documentation quality without increasing adverse events, demonstrating that comprehensive assessment and rapid care are not mutually exclusive. Given its low marginal resource requirements, multicenter evaluation with an embedded economic analysis is a logical next step to establish generalizability and value.