Use of the Emergency Department (ED) for nonurgent conditions results in increased cost and discontinuous health care. This prospective study evaluated a program (KenPAC) that required 24-hour access to a primary care physician (PCP) with ED gatekeeping responsibility. Following established criteria, medical records were reviewed for appropriateness of ED use by an urban indigent pediatric population. Emergency Department visits declined (10% to 7.6% (P = 0.00005) and inappropriate visits dropped (41% to 8%) (P < 0.00001) before KenPAC and after KenPAC, respectively. Parental experience, as judged by age and number of children, played a significant role in ED use. The institution of gatekeeping activity contributed to the reduced overall and inappropriate use of the ED.