title: Gatekeepers: a missed opportunity for safe transport.
abstract: OBJECTIVE
  To assess whether contact with a health care provider or gatekeeper increases the use of an ambulance for patients with acute chest pain.
  
  
  METHODS
  A convenience sample of adults > or =40 years of age presenting with a chief complaint of chest pain were interviewed by trained personnel regarding transport used to come to the ED. The study was performed at the ED of an urban university hospital. Patients with hemodynamic instability and those receiving thrombolytics or emergency angioplasty were excluded. Patients were asked about access to a primary health care provider and contact with a provider regarding this ED visit, including instructions given for transportation.
  
  
  RESULTS
  Of the 450 interviewed patients, 42% arrived by ambulance. Those who had contact with a health care provider prior to the ED visit were less likely to come by ambulance than those without contact, 31% vs 51% (p < 0.001). Of the patients who had cardiac enzymes obtained to work up for their chest pain, 34% with health provider contact vs 57% without health provider contact arrived by ambulance (p < 0.001). Of those with acute myocardial infarction, 30% with health provider contact vs 66% without health provider contact came by ambulance (p < 0.03). Patients who recalled transport instructions from their providers tended to follow those instructions. The majority of patients who recalled no specific transport instructions arrived by personal automobile.
  
  
  CONCLUSIONS
  Of patients presenting to an ED for evaluation of chest pain, those who made contact with a health care provider were less likely to arrive via ambulance.
authors.affiliation: Department of Emergency Medicine, University of Rochester Medical Center, NY, USA. sandra_schneider@urmc.rochester.edu
authors.forename: S M
authors.initials: SM
authors.lastname: Schneider
authors.forename: D J
authors.initials: DJ
authors.lastname: Cobaugh
authors.forename: N F
authors.initials: NF
authors.lastname: Leahey
mesh_terms: D000328:Adult; D000368:Aged; D000552:Ambulances / Q000706:statistics & numerical data*; D002637:Chest Pain; D004630:Emergencies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006801:Humans; D008329:Managed Care Programs; D008875:Middle Aged; D009518:New York; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D014187:Transportation of Patients; D014600:Utilization Review