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Background Acute coronary syndrome (ACS) is a major cause of mortality, with over 80,000 annual UK admissions. 1 Many patients with ACS initially present to the emergency department (A&E) where high-sensitivity troponin (Hs-Tn) testing is vital for accurate diagnosis.2 However, overuse of Hs-Tn strains resources and delays patient care. As a result, selective testing for low-risk patients with alternative diagnoses is recommended.3 Given the importance of efficient testing within the NHS, we evaluated Hs-Tn ordering practices at a UK Major Trauma Centre.Purpose To assess Hs-Tn ordering practices for cardiac-related presentations and potential avenues for quality improvement.Methods We employed the Plan-Do-Study-Act (PDSA) methodology. Plan: We process mapped the patient journey and found that Hs-Tn was ordered at initial assessment before physician evaluation. Using structured interviews with Emergency Physicians, Nurses, Resident Doctors, and Emergency Medicine Assistants (EMA), current behaviours around ordering Hs-Tn were explored. We retrospectively analysed Hs-Tn ordering for patients with cardiac presentations over one month. Do/Study: Interview analysis suggested that the majority of Hs-Tn orders are made within 1–2 minutes of initial patient assessment. Staff suggested that standardised criteria would be helpful. Act: Standardised ordering criteria were developed and introduced to clinical staff, with guidelines displayed in key areas.Results A total of 200 patients were analysed (pre-intervention: n=100; post-intervention: n=100). In the pre-intervention group, 46% were female, with a mean age of 49.1 (16.2) years; in the post-intervention group, 51% were female, with a mean age of 54.1 (17.5) years. Chest pain was the most common presentation (54% pre-intervention, 51% post-intervention). Before the intervention, 60 patients had Hs-Tn ordered, with 27 lacking clear clinical justification in the patient’s notes. Interviews revealed that most Hs-Tn orders were influenced by pressures for expedited assessments, a safety-first approach, and ambiguity in which patients warrant a Hs-Tn order. Our intervention introduced structured criteria for triage staff on which signs and symptoms, if elicited, warranted Hs-Tn ordering. Post-intervention, Hs-Tn orders increased to 82, however, the majority of tests were ordered in accordance with the criteria.Conclusion(s) Timely ACS diagnosis relies on appropriate Hs-Tn testing. Our quality improvement project suggests that structured criteria can help improve adherence to evidence-based testing in A&E. However, challenges of triage workflow constraints and diagnostic uncertainty remain. This pilot highlighted the need for further interventions, including staff training and workflow redesign. Ongoing PDSA cycles and educational initiatives are essential for optimising NHS resources, improving patient safety, and establishing a scalable emergency care quality improvement framework.References Acute coronary syndrome in adults: scope of the problem in the UK. British Journal of Cardiology. Published online January 1, 2017. doi:10.5837/bjc.2017.s01NICE. 2 The diagnostic tests | High-sensitivity troponin tests for the early rule out of NSTEMI | Guidance | NICE. Published August 26, 2020. https://www.nice.org.uk/guidance/dg40/chapter/2-The-diagnostic-tests Gardiner FW, Zhai S. Appropriate pathology ordering? Troponin testing within an Australian emergency department. Irish Journal of Medical Science (1971 -) 2016;186(1):213–218. doi:10.1007/s11845-016-1476-9