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Diversions with a Purpose

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Hospitals forced to divert ambulances and board the sick in emergency department hallways shouldn't blame overcrowding on patients with runny noses and scraped knees. A September study in the Annals of Emergency Medicine found that people who present with serious conditions are so numerous that the existing crisis in emergency care stems from an abundance of genuine emergencies-not a flood of ED overuse by the uninsured, as is widely believed. The American College of Emergency Physicians contends that diverting nonemergencies to urgent-care centers will bring little wait-time relief. "The fantasy is that removing a few sore throats and earaches is going to magically get people a bed in the hospital," says ACEP spokesman Richard O'Brien, M.D., a full-time emergency physician in Scranton, Pa. Leaders at Miami's Jackson Memorial Hospital are hoping an initiative to redirect patients to primary-care providers brings relief of a different kind. Although the Annals study finds that wait times for serious cases are unaffected by a backlog of nonurgent patients, the wait times of the nonurgent are longer when they're in line behind greater numbers of emergencies. Leaders at 1,325-staffed-bed Jackson Memorial have implemented a plan to tackle the latter issue while educating patients on where to find the right kind of care. Since November 2005, a nurse practitioner stationed in the 111-bed ED has screened patients who lack clear emergency symptoms in an effort to divert inappropriate presentations to one of the hospital's 12 community-based primary-care centers around Miami-Dade County or to an on-campus clinic. "It's important not just to let patients go, but to link them to another part of the system that is more appropriate for the level of care they need," says Sandy Sears, senior vice president for ambulatory services and community health. The nurse practitioner uses an internally developed checklist to determine who should be redirected. Then, at the registration desk, a computerized appointment program assigns the patients to a time slot reserved for ER referrals at the most convenient clinic-usually on the same day. Clinic fees are waived for first-time visitors so they get into the system to be tracked via ER-to-clinic referral forms. Even though the hospital diverted 8,973 individuals from the ER to a clinic between November 2005 and August 2006, hospital leaders realize this method will not reduce ER wait times for most. Jackson's ED is still on diversion an average of 30 percent of the time, but it sees fewer repeat visits for nonemergencies, says Sears-an outcome that gives her hope for the long-term goal of helping patients find a "medical home."-Kara Olsen