Table 1

Fishbone analysis

Poor training and understanding of triage staffCrowded transfer route from triage to the treatment areaPatients with chest pain having to wait in queue to get registeredNo policy on management of patients with chest pain
Insufficient knowledge among staff about the importance of time-sensitive management of patients with STEMILack of adequate space in the treatment and red areasDelay in performing ECGLack of clinical policy to ensure fast-track care to patients with STEMI
Unawareness and apathy among frontline workersOccupied catheterisation lab for other proceduresDelay in communication with the cardiology team
  • STEMI, ST-elevation myocardial infarction.