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ClearRounds Health · Cardiology · Quick Reference

Chest Pain — Nurse Phone Triage Algorithm

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A nurse phone-triage decision tree for chest-pain calls: screen for an emergency, gather the story, then disposition (911/ED, urgent ED, or routine) using the "not improving / when concerned" rule.

Last reviewed

Pending initial clinical review

Sources / guidelines to verify

  • Schmitt-Thompson telephone-triage protocols (chest pain)
  • AAACN Scope & Standards of Practice for Professional Telehealth Nursing
  • 2021 AHA/ACC Chest Pain Guideline (principles)
  • Adopt / adapt as your practice’s own approved protocol
Disclaimer: Educational reference only. Not a substitute for clinician judgment, local protocols, or current guideline review.

One-page algorithm

Print this or pull it up at the desk. Educational — verify against the sources above and adopt as your practice’s approved protocol.

Chest pain nurse phone-triage decision algorithmScreen for an active emergency first (call 911 or go to the ED). If not an emergency, gather the full story and home vitals. If pain is ongoing and not improving, or the story or vitals are concerning, advise the ED. If clearly non-cardiac and stable with no red flags, route routine with return precautions. When uncertain, default up to the ED. Document and give return precautions on every call.YESNOYESNOYESNOPatient calls — chest painActive pain NOW + any red flag?sweating · breathless · arm/jaw · faint· tearing pain · looks/sounds very unwellCALL 911 / GO TO ED NOWthen notify the providerGather the full story + home vitalsOngoing & not improving —or story / vitals concerning?ADVISE THE ED (urgent)Clearly non-cardiac & stable?reproducible / positional · no red flagsROUTINEcallback / schedule + return precautionsUNCERTAIN → DEFAULT UPED / urgent provider contactFor every call:document · give return precautions · notify the provider per your workflow (don’t pull them out)Go to the ED (911 or urgent)Routine / home with precautionsAligned with Schmitt-Thompson & AAACN telephone-triage standards · adapt as your practice’s own protocolEducational — does not replace clinical judgment or institutional protocols.
Chest pain — nurse phone-triage decision flow. On the phone, when in doubt, send to the ED.

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ClearRounds Health · Cardiology — Chest Pain — Nurse Phone Triage Algorithm Quick Reference · Last reviewed: Pending initial clinical review · Educational reference only. Not a substitute for clinician judgment, local protocols, or current guideline review.