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Introduction Chest pain is a common cause of emergency department (ED) attendance and places significant pressure on clinical capacity. Structured risk stratification tools such as the Troponin-only Manchester Acute Coronary Syndrome (T-MACS) score can support safe early discharge of very low-risk patients. At Wrightington, Wigan and Leigh Teaching Hospitals (WWL), the local chest pain pathway incorporates T-MACS but does not currently implement the ‘very low-risk’ discharge arm. This Quality Improvement Project aimed to assess current practice, documentation quality, and the potential impact of introducing the very low-risk T-MACS pathway on service efficiency and patient flow.Methods A retrospective review of 50 adult patients presenting with chest pain to the ED or Same Day Emergency Care was conducted in September 2025. Documentation completeness for history, investigations and T-MACS variables was assessed. An ‘optimistic’ T-MACS calculation was performed assuming undocumented features were absent, allowing comparison between calculated risk categories and actual clinical management. A 30-day safety outcome review was undertaken. An estimated impact analysis was performed using audit findings and NHS England Trust-level emergency attendance data (annual and monthly activity for September 2025) to estimate the potential reduction in observation time if the very low-risk arm were implemented.Results Key elements of chest pain history were frequently undocumented, preventing formal T-MACS calculation in 70% of cases. Using optimistic scoring, 48% of patients were classified as very low risk. Despite this, 63% of these patients underwent prolonged ED observation for repeat troponin testing rather than early discharge. Extrapolation of audit findings suggests that approximately 372 patient-hours of observation time per month could be avoided. Thirty-day follow-up demonstrated no major adverse cardiac events, supporting the safety of current practice while highlighting inefficiencies related to conservative management of very low-risk patients.Conclusion Incomplete documentation limits the effective use of structured risk stratification tools such as T-MACS. As a result, very low-risk chest pain presentations are frequently managed through observation and repeat testing despite meeting criteria for early discharge. Introducing the very low-risk discharge arm, alongside improved documentation, could improve ED capacity and patient flow without compromising safety. This baseline audit forms the foundation for a prospective closed-loop Quality Improvement Project. Implementation is currently underway, with re-evaluation and 30-day safety outcomes expected in April 2026.Abstract 87 Figure 1Proportion of patients where TMACS score could not be calculated