These kinds of clinics ease the burden on emergency rooms, since most of the patients they see might simply have a cold or the flu – not true emergencies. About 15,000 urgent-care clinics are in business in the United States and about 200 new ones open every year. That's up from about 8,000 urgent-care centers in business a decade ago. These clinics are driven by consumer demand: 85 percent of the public is otherwise healthy with only an "episodic" illness.

The reality of today is that urgent care is being practiced as a specialty in Urgent Care Centers (UCCs) and at hospital-based clinics around the United States. Patients are increasingly utilizing them. The American Academy of Urgent Care Medicine believes that we can increase the capacity of our healthcare system to handle more patients by re-directing those who could be cared for in a less intense setting than in the emergency department. Similar care in the UCC is usually more quickly provided than in the ED. The result is that a greater number of patients with needs at this level could be treated.

As well, the price of an emergency room visit is much higher than an urgent care visit. A patient, or the payer for a patient seeking care at an ED, might receive hospital and physician's bills totaling several hundred dollars. The same type of care, provided in a clinic setting, would be priced hundreds of dollars less, allowing the savings to pay for more care for this patient or others.

A recent article featured on the Raleigh-Durham News Observer web site offers tips on avoiding high emergency rooms costs. First on the list? Urgent Care. The article advises

Health-industry experts say that about half the care delivered in emergency rooms is not related to a true emergency. In situations that are not life-threatening – cuts, broken bones, cough-cold-flu symptoms – think about using an urgent care center. Bonus: Co-payments for urgent care are typically less than those for a visit to the emergency room.

The public is learning that urgent care is the better choice. It is increasingly important that we direct our efforts toward developing a safe, reliable system where patients can receive such care more efficiently and economically. And it is equally important that the physicians providing such care have the proper knowledge and training.

In order for physicians to provide the best medical care to their patients, they need the knowledge and skills required to provide a high level of care. Rather than physicians modifying previous training in family practice or emergency medicine to “fit” the unique environment of urgent care, it is better to provide training developed specifically for urgent care medicine.

The process of providing medical care to patients, given the complexity of the business and politics of modem medicine, involves many people and many disciplines. We would be better served by independently enhancing what we do best, namely, caring for our patients.

And the best way we as physicians can serve the public is to obtain the appropriate knowledge and training to suit the environment where we provide such care. If we as urgent care physicians are allowed to focus our resources on developing and fostering those practices that increase and improve medical care, we will be able to meet the needs of our patients.

The Crisis in Emergency and Acute Care in the United States - The Problem For the past several years, descriptions of the system for emergency and acute care medicine in the United States have been punctuated with phrases like “serious emergency department overcrowding,” “unraveling safety net,” and “emergency medicine in crisis.” News articles and the medical literature have identified and cataloged the root causes: increased patient volume; increased complexity and level of illness; decreased emergency department (ED) capacity due to ED closures; prolonged boarding of admitted patients in the ED due to decreased hospital bed capacity and nursing shortages; decreased reimbursement due to increasing numbers of uninsured patients and managed-care influences; EMTALA and other regulatory requirements; and decreased access to timely appointments with primary care providers, to name a few1,2,3.

Whatever the reasons, there has been a steadily increasing need for acute and emergency care services in this country.4,5 Though some might perceive the boon as “job security” for hospitals and emergency physicians, ED overcrowding is felt by many involved to be having an increasingly negative impact on patient care3,6. The problem is complex and there is disagreement regarding the relative importance of each of the causative factors. However, it is very reasonable to conclude that at least part of the crisis in emergency care is due to patients seeking care in EDs who could be safely and more economically cared-for in a clinic setting. This is confirmed in a recently published comprehensive study of the problem.7 Because of a “domino-effect” related to EDs already being at or near full capacity, caring for this group of patients creates impediments in the care of all of those who come to the ED for medical care.

Restoring the Balance
At the heart of the crisis is a basic imbalance between the supply and demand for acute and emergency care services in the United States. Looking toward the future, on the demand side it is unlikely that people will change their preferences for receiving prompt care for acutely-arising problems. Moreover, adults and children with many anxiety-provoking or uncomfortable problems – even if they aren’t emergencies – cannot and should not have to wait for future appointments. With demand expected to increase, the balance therefore must be restored from the supply side. In this regard there are two basic options: adding capacity and increasing efficiency. Unfortunately, the prevailing economic trend in supply is for EDs to be closing3,4,8. Even if one purposefully were to buck the trend and build more EDs to increase this sort of capacity, it would take quite a long time, and likely would prove unprofitable – for the same reasons that the previous EDs had closed in the first place. Adding beds to existing EDs has helped somewhat3, but adding even more beds or medical staff does not proportionally increase capacity because of ancillary service and infrastructure constraints. The system of EDs has effectively become “maxed-out.”

A different technique which would increase the efficiency of our health-care system would be to redirect those who could be cared for in a simpler setting to that setting rather than to the ED. Because similar care can be more quickly provided for these patients in a clinic than in the ED, the result would be that a greater number of patients with needs at this level of acuity could be seen per unit of physician or other health-care provider time. Though the exact number of these patients is a subject of debate, reasonable estimates of the number of ED patients who could be safely and adequately cared for in a clinic type facility range between 10% and 50%. Three diverse but authoritative sources5,7,9 have recently estimated this number to be between 20% and 40%. If these patients could be redirected from the ED, the result – in terms of the increased capacity to care for those who are redirected, as well as those who need to remain – is obvious.

In addition to these efficiency advantages, this strategy would provide cost advantages, because the price of even simple care in the ED is high relative to the same care in a clinic setting9. For example, a patient seeking care at an ED for a sprained ankle might receive hospital and physicians’ (radiologist and emergency physician) bills totaling several hundred dollars. Similar evaluation and care, provided in an urgent care clinic setting, would be priced hundreds of dollars less, allowing the savings to pay for more care for this patient or for other patients.

A final advantage is that new acute-care capacity in the form of urgent-care centers can be created much more quickly and economically than new ED capacity. A full-service urgent care clinic can be capable of caring for 70 patients a day or more and can be up and running in under six months.

What Urgent Care Medicine Has to Offer
Improved efficiency, lower cost, and the ability to quickly and economically add capacity all seem to favor urgent care medicine as part of the solution to the acute-care crisis. But what is urgent-care medicine and is it a viable part of the solution?

As a medical specialty, urgent care medicine is the care of any patient of any age who has an immediate but non-emergent medical need. It involves diagnosis through history and physical exam primarily, occasionally supplemented by simple office-based laboratory or X-ray tests. Common complaints evaluated and treated within the scope of urgent-care medicine include: cough, allergy symptoms, mild to moderate asthma, fever, many infections (sinus, ear, respiratory, skin, bladder, kidney, intestinal), rashes, wounds, soft tissue injuries, fractures, abdominal pain, and headaches. While it doesn’t necessarily include the ongoing care of chronic conditions like high blood pressure, diabetes, cancer, and heart disease, initial diagnoses of these problems are often made in the urgent care setting. In these cases, initial treatment may be started and the patient is then referred to a primary care physician or specialist for continuing care. Patients who come to an urgent care center with more severe problems are stabilized and transferred directly to the emergency room, sometimes by ambulance.

The “walk-in” basis of urgent care clinics is convenient for patients. The waiting times and overall treatment times are, on average, significantly less than that for comparable evaluation and treatment in the ED. Because there are no hospital-facility charges and the professional fees are lower, and because urgent care medicine practitioners have expertise in evaluating and treating most common complaints simply, the cost of comparable care and treatment is lower in the clinic than the ED setting9. Using clinics for the care for these common problems is therefore more efficient – a greater number of patients with needs at this level of acuity can be seen per unit of physician time and at a lower cost.

In many communities, urgent care clinics are filling the acute-care void, giving patients an option to waiting for appointments with their physicians or using the emergency room. Urgent care clinics may be freestanding buildings or may be based within hospitals. As well, some emergency departments have developed “fast-track” sections, essentially urgent care clinics within the ED. Urgent care facilities are typically open 6-7 days per week and have extended hours (e.g. 8am-8pm) compared with typical doctors’ offices. Patients are learning that urgent care clinics provide valuable services are increasingly utilizing them. Along with EDs, they have become part of the medical “safety net” upon which people are increasingly relying if they don’t have personal physicians or can’t wait or chose not to wait for regularly scheduled appointments.

Quality in Urgent Care Medicine
Physicians who have training and experience in many different specialties practice urgent care medicine. Currently there are approximately 20,000 physicians practicing urgent care medicine in the US, and there are more than 10,000 dedicated urgent care clinics in the country. As with other medical specialties, a standardization of the specialty in several regards must take place to ensure patient-care quality. Founded in 1997, the American Academy of Urgent Care Medicine (AAUCM) is an organization dedicated to the standardization and advancement of the practice of urgent care medicine. Through professional development, continuing medical education for physicians, and by supporting physician board certification through the American Board of Urgent Care Medicine, the AAUCM’s goal is to ensure excellence among practitioners of urgent care medicine. The American Board of Urgent Care Medicine uses techniques which meet or exceed those utilized by other medical specialty boards – including an application process, review of any malpractice cases, review of patient care records, and a written examination. In addition, the AAUCM is working with the American Medical Association, academic medical centers, and other groups to have the new specialty recognized and to develop residency training programs. Increasing numbers of physicians are applying for urgent care medicine board certification and are participating in this rigorous process to demonstrate their proficiency and dedication to the specialty and to their patients. As well, AAUCM has developed a program to inspect urgent care centers for criteria that reflect quality patient care, and this program will be introduced soon. The Academy’s ultimate goal is to improve the quality of urgent care medicine practice on a continuous basis, so that patients and other physicians can continue to rely on that portion of America’s “health-care safety-net” which urgent care medicine provides.

Summary
Demand for emergency and urgent care services has been increasing and is expected to do so. This increase in demand comes at a time when economic factors have caused hospitals to close EDs, which have traditionally supplied these services. Those same economic factors, closures of other EDs, and continued increasing demand are putting increasing pressure on existing EDs. Because a portion – between 20% and 40% – of patients currently using the system could be cared for in a clinic setting, it is intuitive that, with effective triage mechanisms to redirect those who could be cared for in a clinic setting, the capacity of our healthcare system would be increased. These triage mechanisms include patient education and clinical triage instruments that can be utilized within the healthcare system.

While there is no doubt that patients with critical illnesses or injuries are best cared for in the emergency department, the advantages of caring for those with simpler problems in a clinic setting are many. Capacity of this sort can be added to the healthcare system relatively quickly and economically. Because of lower overhead, lack of hospital facility charges, and lower professional fees, urgent care centers present an opportunity to provide efficient, lower-priced care to patients who present to EDs with non-emergent problems. As well, the cost savings would allow more patients to be treated per health care dollar and in most cases, the fees are low enough that uninsured patients can actually afford to pay for the care they need. The AAUCM believes that making the investment in training urgent care medicine specialists and developing mechanisms to appropriately utilize urgent care facilities will add increased efficiency and more capacity to our health care system and help meet the rising demand for acute care services currently stressing this nation’s emergency health care system.

References
1. Derlet, R.W. and J.R. Richards “Overcrowding in the Nation’s Emergency Departments: Complex Causes and Disturbing Effects” Annals of Emergency Medicine 2000:35(1):63.

2. Solberg, L. I. et al. “Emergency Department Crowding: Consensus Development of Potential Measures” Annals of Emergency Medicine 2003;42(6):824.

3. Derlet, R.W. “Overcrowding in Emergency Departments: Increased Demand and Decreased Capacity. Annals of Emergency Medicine 2002;39(4):430.

4. Booth, B. “Is this trip really necessary? Emergency departments face overcrowding” American Medical News 8 Sept 2003. Available online at: http://www.ama-assn.org/amednews/2003/09/08/prsa0908.htm.

5. McCraig, L et al. National Hospital Ambulatory Medical Care Survey: 2002 Emergency Department Summary 18 March 2004. Available online at http://www.cdc.gov/nchs/data/ad/ad340.pdf.

6. Derlet, R.W., et al. “Frequent Overcrowding in U.S. Emergency Departments” Academic Emergency Medicine 2002;8:151

7. The George Washington University Medical Center, School of Public Health and Health Services, Department of Health Policy. “Walking a Tightrope, The State of the Safety net on Ten U.S. Communities”. May 2004. Available online at: http://www.urgentmatters.org/about/sna_reports.htm.

8. Hawryluk, M. “California emergency departments close after hemorrhaging money” American Medical News 24/31 March 2003. Available online at: http://www.ama-assn.org/amednews/2003/03/24/gvsd0324.htm.

9. “Improving Access to Emergency Departments: Costs, Trends, and Solutions.” A Blue Cross and Blue Shield Association Analysis. 2003 Available online at: http://bcbshealthissues.com/relatives/100042.pdf.

Fever
Practicing UCM doctors are often confronted with the dilemma of elevated temperatures and the anxiety that is associated with this for parents. They are often asked, “Should I alternate Tylenol® with Motrin®?”

We acknowledge that acetaminophen and ibuprofen are commonly being used in an alternating manner for the management of fever. There is presently no scientific evidence that this combination is safe or achieves faster antipyresis than either agent alone. There is however evidence that the improper use of these agents may cause harm. The AAUCM has no such policy. We note that this practice is more common in younger practitioners. Until proper “controlled studies” are available, the AAUCM suggests that practitioners proceed with caution.

On another note, it has been noted that an initial 30-mg/kg acetaminophen loading dose seemed to be more effective in reducing fever that a 15-mg/kg maintenance dose. No difference had been observed regarding clinical tolerance. The data in some recent studies suggest that acetaminophen treatment of fever may be more efficient in an initial loading dose.

American Academy of Urgent Care Medicine
2813 S. Hiawassee Rd., Suite 206 Orlando, Florida 32835
Telephone: 407-521-5789