The association between mode of arrival, presence of medical referral, and outcomes in patients presenting to the emergency department with chest pain: A historical cohort study

• Arrival mode and referral status influence ED outcomes in chest pain patients. • EMS arrivals had highest admission, mortality, LOS, and readmission rates. • Medically referred patients had the lowest rate of heart-related diagnoses. • Self-arrival and EMS were independently associated with increased admission odds. • Community-based referral pathways may reduce ED admissions and improve outcomes. Chest pain is a common reason for emergency department (ED) visits, yet the impact of arrival mode and medical referral status on hospital admission and clinical outcomes remains unclear. This study evaluated their influence on ED patients with chest pain. A retrospective cohort study analyzed adults presenting with chest pain between January 2022 and June 2024. Patients were categorized as self-arrival without referral (SA), self-arrival with medical referral (MR), or arrival via emergency medical services (EMS). Primary outcome was hospital admission; secondary outcomes included 30-day mortality, prolonged length of stay (LOS), heart-related diagnoses, and readmission rates. Among 12,164 ED visits, hospital admissions were highest in the EMS group (29.9 %) compared to SA (21.0 %) and MR (17.1 %; p < 0.001). After adjustment, EMS and SA groups had greater odds of admission (adjusted ORs: 1.66 and 1.54, respectively; p < 0.001). EMS patients had the highest 30-day mortality (0.8 %), prolonged LOS (43.0 %), and readmission rates (8.0 %). Heart-related diagnoses at discharge were lowest in the MR group (21.7 % vs. 32.0 % in SA; p < 0.001). Medical referral was associated with lower admissions and better outcomes. Optimizing community-based diagnostics may improve triage and reduce ED burden.