The AAUCM encourages physicians to refer any patient who indicates that he or she may be victims of domestic violence to a provider or facility that specializes in the counseling, management and treatment of domestic violence, if such a provider or facility is available. If no such provider or facility is available, the patient should be encouraged to follow up with his or her primary care physician.

The AAUCM encourages physicians to obey any local, state or federal laws requiring the reporting of suspected abuse in children, adolescents or the elderly. However, any such laws should affirm the authority of physicians to use appropriate clinical judgment in reporting cases of suspected domestic violence. Those laws should also protect the physician from liability for compliance with the law when the reporting of violence was in good faith.

If the physician is not required to do so by the law, the AAUCM encourages physicians to recommend any such patient report the violence to proper law enforcement officials.

The AAUCM does recognize the autonomy of a competent adult to decline any treatment or referral and acknowledges the concept of doctor-patient confidentiality in such cases.

Delivery of care to uninsured persons
The American Academy of Urgent Care Medicine (AAUCM) encourages physicians to provide a reasonable amount of charity care to patients without insurance. It is believed that charity care is both an ethical and civic responsibility. However, the AAUCM opposes any governmental or regulatory mandates that stipulate a specified amount of charity care to be rendered. It is up to each individual provider to determine how much charity care is reasonable.

The AAUCM believes that physicians have an ethical obligation to provide care for patients presenting with emergency conditions, regardless of their insurance status or ability to pay, even if that care is just stabilization of their condition until the Emergency Medical System (EMS) personnel have arrived.

The AAUCM supports the development of charitable immunity laws in those states that have not already passed such laws.

Delivery of Care to Undocumented Persons
The American Academy of Urgent Care Medicine (AAUCM) opposes any federal, state or local initiative, law or regulation requiring the refusal of care by physicians, other health care providers, or health care facilities, to undocumented persons. The AAUCM also opposes any requirement or burden on the physician, other health care provider or health care facility to prove a person’s legal citizenship status, or to report said persons to immigration authorities.

Meningococcal Conjugate Vaccine Meningococcal
(Groups A, C, Y and W-135)
Conjugate Vaccine (MCV-4)
AAUCM Endorses Meningococcal Vaccine for Adolescents and College Freshmen The American Academy of Urgent Care Medicine recommends routine vaccination of young adolescents with MCV4 at the pre-adolescent visit (11-12 year old). Introducing a recommendation for MCV4 vaccination in young adolescents (11-12 years old) may strengthen the role of the pre-adolescent visit and have a positive effect on vaccine coverage in adolescence. AAUCM recommends that young adolescents see a healthcare provider at age 11-12 for a routine preventive visit, at which time appropriate immunizations and other preventive services should be provided. For those who have not previously received MCV4, we recommend vaccination before high school entry (~15 years old) as the most effective strategy towards reducing meningococcal disease incidence in adolescence and young adulthood. Within 3 years, the goal is routine vaccination with MCV4 of all adolescents beginning at 11 years of age. The AAUCM recognizes that vaccine supply may be an issue in the first few years after licensure of MCV4. Other adolescents who wish to decrease their risk of meningococcal disease may elect to receive vaccine. College freshman who live in dormitories are at higher risk for meningococcal disease compared to other people of the same age. Because of the feasibility constraints in targeting freshmen in dormitories, colleges may elect to target their vaccination campaigns to all matriculating freshmen. The risk for meningococcal disease among non-freshmen college students is similar to that for the general population of similar age (18-24 years). However, the vaccines are safe and immunogenic and therefore can be provided to non-freshmen college students who want to reduce their risk for meningococcal disease. Meningococcal disease is caused by bacteria that infect the bloodstream and the linings of the brain and spinal cord, causing serious illness. Every year in the United States, 1,400 to 2,800 people get meningococcal disease. Ten to 14 percent of people with meningococcal disease die, and 11-19 percent of survivors have permanent disabilities (such as mental retardation, hearing loss, and loss of limbs). The disease often begins with symptoms that can be mistaken for common illnesses, such as the flu. Meningococcal disease is particularly dangerous because it progresses rapidly and can kill within hours. Disease caused by meningococcal bacteria kills about 300 people each year in the United States. The vaccine is highly effective. However, it does not protect people against meningococcal disease caused by “type B” bacteria. This type of bacteria causes one-third of meningococcal cases. More than half of the cases among infants aged <1 year are caused by “type B,” for which no vaccine is available in the United States. The new meningococcal vaccine was licensed by the U.S. Food and Drug Administration (FDA) on January 14, 2005 for use in people 11-55 years of age. It is manufactured by Sanofi Pasteur and is marketed as Menactra™.

The Role of Nurse Practitioners and Physician Assistants in Urgent Care Medicine
Nurse practitioners and physician assistants are capable of providing valuable services in the practice of urgent care medicine. Healthcare systems that utilize these providers must develop explicit, written policies and procedures in accordance with the state laws and regulations that relate to this practice. In conjunction with this guidance, the American Academy of Urgent Care Medicine (AAUCM) recommends the following:

Training, Experience, and Credentialing
The nurse practitioner or physician assistant should have appropriate training and experience in the provision of urgent care medicine services and the performance of procedures specific to the specialty prior to beginning practice. Healthcare systems that utilize nurse practitioners and physician assistants should develop standards based on the requirements and scope of the practice setting. These systems should employ effective credentialing methods for verifying these qualifications and develop standards for interval re-credentialing.

Scope of Practice
Healthcare systems that utilize nurse practitioners and physician assistants should clearly define the scope of practice for these providers – including the direct evaluation and treatment of patients with various symptoms and medical needs, performance of procedures, telephonic and email communications with patients and pharmacies, and other tasks related to patient care.

Supervisory Relationships
Supervisory relationships between physicians and nurse practitioners and between physicians and physician assistants must be defined prior to beginning practice. Healthcare systems should determine, for each activity within the scope of practice, the number of nurse practitioners or physician assistants that can be supervised by a single physician and the level of direct or indirect physician supervision which is required.

Independent Practice
The expertise of nurse practitioners and physician assistants is most properly utilized in conjunction with a supervising physician qualified to provide urgent care medicine services.1 In the majority of circumstances, this requires the presence of a physician within the urgent care medicine facility. AAUCM recognizes that certain healthcare systems, e.g., rural or underserved areas, may utilize nurse practitioners or physician assistants in independent practice, as permitted by law. In these situations, the supervising physician must be available immediately by telephone and otherwise available promptly (within 5-10 minutes) to arrive in person to assist in the care of patients.

Continuing Education
Nurse practitioners and physician assistants should participate regularly in continuing education, at a minimum as required to maintain certification, regarding topics in the field of urgent care medicine. As members of the clinical team, nurse practitioners and physician assistants should participate in quality improvement and other practice-enhancing activities along with physicians.

Development, Revision, and Approval of Policies and Procedures
Healthcare systems should employ effective methods for developing policies and procedures for the role of these providers within the system. These methods should include consideration of applicable laws and regulations, the needs of the patients and community, the balance between the demand for services with the resources of the system, and the level of expertise of the providers and physicians involved. Policies and procedures relating to these providers should be developed in conjunction with representatives of the providers and be approved after broad review and comment by those whom they will affect. Final approval should be made in writing from representatives of the healthcare system, of the physician supervisors, and of the nurse practitioners and physician assistants. These policies and procedures should be reviewed periodically, ideally at least annually and on an as-needed basis if changes in the healthcare system or state laws and regulations might require a change in them. After periodic review and any revisions, the policies and procedures should undergo broad review and approval as above.

References
1. AAUCM Policy and Procedure Statement “Board Certification in Urgent Care Medicine”, approved April 12, 2004.

Definition of Ambulatory/Urgent Care Medicine
Ambulatory/Urgent Care Medicine is a medical specialty which comprises the evaluation and care of patients with acute illnesses and injuries. These patients may be of either gender, of any age, with medical problems relating to any organ system. For this reason, the scope of Ambulatory/Urgent Care Medicine overlaps in some way with each of the other medical specialties, though its focus is on acutely-arising complaints resulting from disorders of a non-life-threatening nature. Despite the overlap, there is a uniqueness of practice that defines Ambulatory/Urgent Care Medicine, with a distinct knowledge base, skill set, and breadth of experience.

The broad scope of Ambulatory/Urgent Care Medicine is similar to that of Family Practice and Emergency Medicine, though there are important differences which characterize each specialty. Ambulatory/Urgent Care Medicine differs from Family Practice due to its dedicated focus on the rapid diagnosis and treatment of acute medical conditions. Ambulatory/Urgent Care Medicine differs from Emergency Medicine with regard to its focus on the non-life-threatening portion of the spectrum of acute illness and injury, as well as its out-of-hospital setting, without ready access to extensive laboratory testing, advanced imaging (e.g., CT scanning and ultrasound), extended patient observation, and specialty consultation.

Physicians practice Ambulatory/Urgent Care Medicine in many settings, including free-standing offices, hospital-based clinics, and emergency department “fast-tracks”. The specialty includes a strong emphasis on diagnosis by thorough but focused medical history and physical examination, without reliance on extensive laboratory testing or advanced imaging. Physicians in the specialty can provide complete medical care for most patients who present to an Ambulatory/Urgent Care Medicine setting. In those other cases where it is determined, after initial evaluation by the Ambulatory/Urgent Care Medicine physician, that a patient requires additional care, the physician facilitates follow-up or referral to a specialist, transfer to an emergency department, or direct hospitalization (with inpatient care by a consultant), as indicated. The specialty of Ambulatory/Urgent Care Medicine does not include surgery (other than wound repair and skin lesion removal), the care of inpatients, or the continuity medical care of chronic medical problems.

Compared with standard office practices, Ambulatory/Urgent Care Medicine facilities are typically open extended hours, weekends, and many holidays, providing increased access to medical care for patients. Ambulatory/Urgent Care Medicine is part of the “front line” of medicine and shares status with emergency medicine as being part of patients’ “health-care safety net” in this country.