Problems faced by the urban emergency department in providing rapid triage and intervention for the patient with suspected acute myocardial infarction.

Widespread application of thrombolytic therapy has increased the importance of rapid triage and intervention for the patient who seeks treatment in the emergency department (ED) for suspected acute myocardial infarction. It has been suggested that all patients with acute myocardial infarction who might benefit from thrombolytic therapy should receive treatment within the first "golden hour" of arrival at the hospital ED. Busy urban medical centers, particularly public hospitals serving a large proportion of indigent patients, face special challenges in attempting to meet this goal. ED overcrowding, in part caused by patient "dumping," and diminishing governmental financial support have created an environment in which rapid triage and treatment are difficult. Because only 4% to 5% of all patients who are seen in the ED with chest pain actually require thrombolytic therapy, there is negative reinforcement for the triage nursing staff. The busy urban ED environment also creates greater litigation potential for the physician and nurse. Problems created by the busy ED environment can be minimized by providing adequate nursing staff, standing orders and protocols for evaluation of the patient with chest pain, equipment for an immediate electrocardiogram, and a thrombolytic drug stock in the ED. Hospital administrators must recognize the unique problems created in the ED when inpatient beds are unavailable. The hospital must also have efficient bed turnover and a community-wide plan for dealing with patients when the ED "closes" to incoming ambulance traffic. Governmental entities must recognize the consequences of their actions in curtailing health care benefits for those who cannot afford care in private hospitals.