title: Referral practice among Swiss and non-Swiss walk-in patients in an urban surgical emergency department.
abstract: OBJECTIVE
  To assess the relationship between nationality, gender and age and use of health services among patients visiting an urban university hospital emergency department (ED).
  
  
  BACKGROUND
  ED crowding is an increasingly significant national and international problem. Overcrowding has many potential detrimental effects, including frustration for patients and ED personnel and greater risk of poor outcomes. This is partially caused by the growing numbers of visits by so called "walk-in patients" with minor problems.
  
  
  METHODS
  From May 1, 2007 to May 31, 2008, sociodemographic information was collected prospectively from 6955 male and 4303 female patients at Inselspital, University Hospital Bern, Switzerland, who had requested our emergency services for non-urgent problems. A stratified sample of 1173 patients was taken for further analysis of referral by a general practitioner (GP) and having a GP at all.
  
  
  RESULTS
  In all, 26% of visits were by foreign nationals. Only 57% of these were registered with a GP, compared to 83% of Swiss nationals (p <0.0001). Swiss patients referred themselves to us in 87%, compared to 97% self-referrals among foreigners (p <0.0001). Between 7:00 pm and 7:00 am, our ED was significantly more often visited by non-Swiss patients (p <0.0001). Foreign patients were significantly younger than Swiss patients (median age 45, range 1-98 years versus age 35, range 2-89 years, p <0.0001).
  
  
  CONCLUSIONS
  Nationality is associated with greater use of ED services for non-urgent problems. Several explanations are conceivable for this. Clinical and policy efforts must address barriers to GP care, since in the long term the GP provides better and more cost-effective care for patients with minor complaints.
authors.affiliation: Leitender Arzt Notfallmedizin, Universitätsspital Bern, Notfallzentrum, 3010 Bern, CH.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Clément
authors.forename: Adrian
authors.initials: A
authors.lastname: Businger
authors.forename: Luca
authors.initials: L
authors.lastname: Martinolli
authors.forename: Heinz
authors.initials: H
authors.lastname: Zimmermann
authors.forename: Aristomenis K
authors.initials: AK
authors.lastname: Exadaktylos
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012017:Referral and Consultation; D013503:Surgery Department, Hospital / Q000706:statistics & numerical data*; D013557:Switzerland; D014171:Transients and Migrants / Q000706:statistics & numerical data*; D014505:Urban Population; D055815:Young Adult