A clearing in the crowd: innovations in emergency services.

Emergency department overcrowding may not be so much a result of inappropriate use of the emergency department as it is a problem of the unavailability and inaccessibility of primary care services in the community. The prevailing theory that people use the emergency department because they cannot afford care elsewhere does not hold true. The vast majority of patients surveyed as part of the Emergency Services Initiative had some type of coverage, primarily Medicare or Medicaid. Without additional primary care capacity to accommodate walk-in patients and to make appointments available within one to two weeks, emergency departments will remain over-crowded. In addition to increasing primary care capacity, services must be structured to be as convenient and amenable to patient use as the emergency department. The findings of the Emergency Services Initiative supports the Preferred Primary Care Provider guidelines for the assignment of a primary practitioner or team to each patient, 24-hour telephone access for medical advice, evening and weekend hours, accommodation of walk-in patients, and the provision of nonurgent appointments within a maximum of two to four weeks. In addition, easy access to ancillary services for lab tests and X rays is beneficial for attracting patients. Patient education is also necessary. Questioning by counselors indicated that patients often do not understand that primary care settings are more appropriate than the emergency department for treatment of minor health problems. The most effective way to implement change in the health care system may not be through broad, generic prescriptions but through well-designed programs tailored to specific sites and communities. Changing staff behavior is often as challenging as changing patient behavior. Pre-project planning and communication about purpose, scope, and procedures are necessary if projects are to begin and continue smoothly. Ongoing evaluation is also key.