A systematic review of the barriers and facilitators influencingemergency department nurses' competency and adherence totriage protocols for acute myocardial infarction

Abstract

Acute Myocardial Infarction (AMI) continues to be one of the leading causes of mortality and disability worldwide and remains a major public health concern. Timely recognition and appropriate emergency department (ED) triage play a decisive role in reducing treatment delays and improving survival outcomes. Emergency department nurses serve as the first point of clinical contact and are responsible for the rapid assessment, prioritisation, and initiation of evidencebased triage protocols for patients presenting with suspected AMI. Their competency in recognising both typical and atypical clinical manifestations, performing early electrocardiographic assessment, and activating institutional chest pain pathways directly influences door-to-electrocardiogram (ECG) time, reperfusion therapy, and overall patient prognosis. Despite the availability of internationally accepted triage protocols and clinical guidelines, variations in emergency nursing competency and adherence remain common. Factors such as overcrowded emergency departments, workforce shortages, limited clinical experience, inadequate continuing education, increasing patient acuity, and organisational barriers frequently compromise the implementation of evidence-based AMI triage practices. Furthermore, atypical clinical presentations among women, older adults, and patients with diabetes mellitus increase the risk of delayed diagnosis and inappropriate triage categorisation. This systematic review synthesises the available evidence regarding barriers and facilitators influencing emergency department nurses' competency and adherence to triage protocols for acute myocardial infarction. The review demonstrates that simulation-based education, structured competency assessment, multidisciplinary collaboration, clinical decision support systems, protocol standardisation, mentorship programmes, and continuous quality improvement initiatives significantly improve nursing performance and protocol compliance. These interventions contribute to earlier ECG acquisition, timely activation of reperfusion pathways, and improved patient outcomes. Overall, strengthening emergency nursing competency requires a comprehensive systems-based approach combining professional education, evidence-based clinical protocols, technological support, organisational commitment, and continuous performance evaluation. Improving emergency nurses' adherence to standardised AMI triage protocols has the potential to minimise treatment delays, enhance patient safety, reduce mortality, and improve the overall quality of emergency cardiovascular care