Table 1

Fishbone analysis

People	Place	Process	Policy
Poor training and understanding of triage staff	Crowded transfer route from triage to the treatment area	Patients with chest pain having to wait in queue to get registered	No policy on management of patients with chest pain
Insufficient knowledge among staff about the importance of time-sensitive management of patients with STEMI	Lack of adequate space in the treatment and red areas	Delay in performing ECG	Lack of clinical policy to ensure fast-track care to patients with STEMI
Unawareness and apathy among frontline workers	Occupied catheterisation lab for other procedures	Delay in communication with the cardiology team