Hospital-integrated general practice: a promising way to manage walk-in patients in emergency departments Mathyas Wang MD, 1 Stefanie Wild BMed, 2 Gabriela Hilfiker BMed, 2 Corinne Chmiel MD, 3,7 Patrick Sidler MD, 6 Klaus Eichler MD MPH, 8 Thomas Rosemann MD PhD 4 and Oliver Senn MD MPH 5 1 General Practitioner, 2 Research Assistant, 3 General Internist and Researcher, 4 Professor, 5 General Internist and Senior Researcher, Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland 6 Emergency Physician, 7 General Internist and Researcher, City Hospital Waid, Zurich, Switzerland 8 Senior Researcher, Institute of Health Economics, Zurich University of Applied Sciences, Winterthur, Switzerland Keywords emergency care, implementation, out-of-hours care, primary care, self-referral, walk-in patients Correspondence Dr Oliver Senn Institute of General Practice and Health Services Research University of Zurich 8091 Zurich Switzerland E-mail: oliver.senn@usz.ch Accepted for publication: 4 July 2013 doi:10.1111/jep.12074 Abstract Rationale, aims and objectives The inappropriate use and overcrowding of emergency departments (EDs) by walk-in patients are well-known problems in many countries. The current study aimed to determine whether ambulatory walk-in patients could be treated more efficiently in a new hospital-integrated general practice (HGP) for emergency care services compared to a traditional ED. Methods We conducted a pre-post comparison before and after the implementation of a new HGP. Participants were walk-in patients attending the ED of a city hospital in Zurich. Main outcome measures were differences in total process time, time intervals between stages of care and diagnostic resources used. Results The median process time from admission to discharge was 120 minutes in the ED [interquartile range (IQR): 80–165] versus 60 minutes in the HGP (IQR: 40–90) (P < 0.001). The adjusted odds ratio of receiving any additional diagnostics was 1.86 (95% confidence interval 1.06–3.27; P = 0.032) for ED doctors versus general practitioners (GPs) when controlling for patients’ age, sex and injury-related medical problems. Conclusion The HGP is an efficient way to manage walk-in patients with regard to process time and utilization of additional diagnostic resources. The involvement of GPs in the HGPs should be considered as a promising model to overcome the inappropriate use of resources in EDs for walk-in patients who can be treated by ambulatory care. Introduction Emergency departments (EDs) in many developed countries are faced with increasing numbers of patients seeking medical help [1–6]. This leads to overcrowding of EDs with potential conse- quences that compromise patient access to care and the quality of care provided [1,2]. Several studies showed that the EDs are inap- propriately frequented due to a high rate of walk-in patients (self- referrals) and that the vast majority of these patients could be treated in an outpatient setting by a general practitioner (GP), and hospitalization was rarely necessary [7–10]. Patients in Switzer- land have direct, unlimited access to primary care physicians in an ambulatory care setting and free access to outpatient specialist treatment unless they are insured by managed care organizations with gatekeeping systems (currently <10% of the population) [7]. However, the access to hospital-based EDs is not restricted by a gatekeeping system and non-health-related factors often affect decisions whether patients seek care in an ED or with their GP [11–13]. Therefore, EDs seem to be used by patients as a substitute for GPs, especially in urban areas and during out of GPs’ office hours. In Switzerland, over 50% of ED patients were walk-ins and the amount of emergency medical visits increased with annual growth rates of 1.5–6% in the 1990s [3,7]. Data from annual reports of a representative city hospital in Zurich, Switzerland (City Hospital Waid), indicate a further increase for the most recent time periods between 2005 and 2008, reaching annual growth rates of almost 7%. This has led many hospitals and health care authorities to implement new emergency care models to overcome the inappro- priate use of the EDs and to improve cost-effectiveness. One increasingly popular model in Switzerland is a hospital-integrated general practice for emergency care services (HGP) with point-of- care diagnostics based on a team of GPs and emergency doctors supported by practice assistants. These HGPs are located within the hospitals and share certain infrastructure with the ED (e.g. administrative staff, X-ray), but are otherwise very similar to a primary care practice with regard to the organizational structure and diagnostic possibilities offered. Journal of Evaluation in Clinical Practice ISSN 1365-2753 Journal of Evaluation in Clinical Practice 20 (2014) 20–26 © 2013 John Wiley & Sons, Ltd. 20