Objective To investigate the impact of grid-based management of emergency nursing processes using the HIRAID framework on emergency efficiency and prognosis in patients with acute coronary syndrome (ACS). Methods A total of 120 ACS patients admitted to The First People’s Hospital of Pingdingshan from October 2023 to October 2025 were included and divided, according to the order of admission, into a control group (n＝60, receiving conventional emergency care) and a study group (n＝60, receiving grid-based management of emergency nursing processes using the HIRAID framework in addition to the conventional care). Emergency efficiency, emergency quality, and prognosis were compared between the two groups. Results Following admission, triage time, time to first electrocardiogram, time to obtain troponin results, time to administration of anticoagulant/antiplatelet agents, catheterization laboratory activation time, and balloon dilation time in the study group were significantly shorter than those in the control group (all P＜0.05), the success rate of resuscitation in the study group was significantly higher than that in the control group (P＜0.05), the incidence of in-hospital complications, the length of hospital stay and the 30-day unplanned all-cause readmission rate were significantly lower than those in the control group (all P＜0.05). Conclusion Grid-based management of emergency nursing processes using the HIRAID framework can significantly improve clinical outcomes in patients with ACS, which can be associated with enhanced emergency efficiency and care quality.