A rose by any other name is still a rose. This, however, may not apply to urgent care facilities. Is an urgent care clinic by any other name still an “urgent” care facility?
Urgent care clinics are part of a system that can be referred to as acute care health facilities, which can fall in four categories:
Retail clinics: These facilities are affiliated with a store, and generally manage low-acuity illness or complaints, such as upper respiratory infections, simple rashes, and immunization requests. They are staffed by a nurse practitioner or physician assistant working solo, and have limited hours of operation, such as a CVS Minute Clinic.
Intermediate care facilities: These include physicians' offices and urgent care clinics. Most can perform routine laboratory tests including urinalysis, urine pregnancy tests, complete blood counts, blood sugars and basic chemistry, influenza and strep throat screens, and administration of intravenous fluids and nausea medications. Nonnarcotic pain medication, steroid medication, and vaccinations can also be provided.
A few of these facilities have x-rays available on-site, but most refer patients to off-site radiology centers. They are not open 24 hours each day and some not on holidays. They can take prior appointments, and are staffed by physicians, PAs, or NPs. Most urgent care centers cannot consult directly with specialists, and they refer patients to the emergency department if urgent specialist care is warranted. Some urgent care clinics are owned by hospital systems, and are generally not on the same site as the parent hospital.
There are more than 7000 urgent care clinics in the United States (Health Data Management. http://bit.ly/2qs7qn4), and they see approximately 160 million patients per year. (Becker's Clinical Leadership & Infection Control. March 9, 2016; http://bit.ly/2Ls2N3z.) Urgent care clinics have names that include words like acute care, express care, fast care, or quick care. Urgent care clinics fill the gap between doctors and the ED. (Solv. http://bit.ly/364lWAl.)
Specialty acute care facilities: These facilities are limited in scope, and include labor and delivery or birthing centers and orthopedic urgent care centers. Labor and delivery centers are usually found within a hospital, though birthing centers are usually independent.
Emergency departments: These can be specialized, such as pediatric EDs. Some may be off-site such as freestanding EDs. They can have different levels of care consistent with trauma designations, and some may not have all specialties readily available. Some patients may be transferred from one ED to a higher-level one. Emergency departments are open 24 hours each day, including holidays, and are staffed by physicians and possibly also PAs or NPs.
So how does the average layperson know which acute care facility is best suited to his needs? Any provider working in an ED must be perplexed by the dichotomy of seeing someone who presents with a stuffy nose only, while another patient is referred from urgent care with abdominal pain. Why does a patient with a potentially significant medical condition show up at an urgent care facility while a patient with a minor complaint rushes to an ED? The answer is likely multifactorial.
The decision by patients to favor a particular acute care facility can be based on a lack of knowledge of the services provided by different acute care facilities, generally faster service at an urgent care center or retail clinic, lower cost at the urgent care or retail clinic, prior experience with a particular facility, and a patient's desire to minimize his symptoms. The biggest concern for emergency physicians is the potential delay in care that can arise from a patient with a possible life-threatening condition going to a lower-level facility, which can delay appropriate care, leading to morbidity and mortality. A young woman with pelvic pain from a ruptured ectopic pregnancy and an elderly patient with abdominal pain from an abdominal aortic aneurysm can suffer morbidity or mortality if they present to an urgent care clinic instead of an ED.
A middle-aged man with complaints of abdominal pain was sent from an urgent care clinic to my ED for further evaluation. Curious, I asked the patient why he went to the urgent care clinic initially with symptoms of abdominal pain. He said he had an urgent problem and that facility was an urgent care center. His response may generate a chuckle from us ED folks, but he was not incorrect. Is it any wonder some people believe that urgent care can handle any urgent problem? The naming and reference of an acute care center as urgent care can be misleading.
The Centers for Medicare and Medicaid Services (CMS) also has issues with this nomenclature. CMS, which oversees EMTALA, does not distinguish between the words urgent and emergency. (Relias Media. May 1, 2018; http://bit.ly/2RnbJuY.) Generally speaking, an urgent care center owned by a hospital system that contracts with Medicare and provides care mainly to patients without appointments can be construed as a dedicated emergency department. (Relias Media. May 1, 2018; http://bit.ly/2RnbJuY.) Per CMS policy, dedicated ED criteria can be met if that facility is presented to the public (by name, posted signs, advertisement) as a place that provides care for an emergency medical condition on an urgent basis. (Relias Media. May 1, 2018; http://bit.ly/2RnbJuY.)
A woman in her early 30s experienced chest pain while driving on a highway in Rhode Island in 2013. She saw a sign for an urgent care center, and decided to seek medical attention at that facility. She was evaluated, diagnosed with reflux, and discharged. The patient died a short time later. The patient's family sued the hospital-owned off-site urgent care facility. The urgent care clinic had argued that there was a disclaimer stating the clinic did not manage emergency conditions on its website, but the judge upheld the lawsuit, finding that “someone driving by the clinic with an emergency medical need...would not be able to make the distinction based on signage, and certainly cannot be expected to click on the [clinic's] website before walking in with chest pain.” (Injury Claim Coach. April 3, 2019; http://bit.ly/369bCaC.) The clinic eventually changed its name from urgent care to express care. (WPRI. http://bit.ly/2Pe2RVP.) Owners and operators of these walk-in clinics do not help themselves much because they will call their businesses creative things that can promote confusion rather than clarity. (Solv. http://bit.ly/364lWAl.)
The Right Choice
The underlying mindset of providers working in urgent care is that most cases that present to those clinics are not serious. Providers may minimize the pathology, just as their patients may minimize their symptoms. A patient may seek out an urgent care clinic as opposed to an ED with the hope that nothing woeful is diagnosed. These patients may also not wish to incur the cost of an ED visit and the cost associated with possible hospitalization.
Many people have no concept of the limitations or abilities of the different acute care facilities. Some laypeople think that an urgent care clinic can treat any medical condition except cardiac arrest or trauma. Patients with stroke symptoms have shown up at urgent care. Pregnant women in labor during their third trimester of pregnancy have shown up at a freestanding ED even though the hospital with a labor and delivery unit is only five minutes away. Some of my well-educated friends refer to the freestanding ED as an urgent care center.
To change perception, the public must be educated on the roles and limitations of different acute care facilities. Effective education, however, has an associated cost. Who would be responsible for this educational venture and cost? The government, hospital systems, and medical societies like the American Medical Association all should have a role in educating the public.
Visits to an appropriate acute care facility can prevent delay in care and reduce morbidity and mortality. Three-fourths of EPs polled in 2014 reported having a patient referred from urgent care on a daily basis. (ACEP. Emergency Department wait times, crowding, and access. Updated 2016.) Besides the potential for morbidity and mortality, inappropriate visits to a lower-level acute care facility can raise health care costs. Patients seen at an urgent care facility and then sent to the ED are usually billed by both facilities. Often labs and radiology studies ordered by the urgent care clinic may not be readily available to EPs and may be repeated. On the flipside, health care costs have also been increased by inappropriate referrals to the ED by urgent care clinics. Most transfers from urgent care clinics to EDs are discharged and are unnecessary. (J Emerg Med. 2018;54:882.)
One study estimated that up to 27 percent of all ED patients can be managed at a lower-level facility with a potential cost savings of more than $4 billion. (Health Aff [Millwood]. 2010;29:1630; http://bit.ly/2PcH80m.) Another claims that retail clinics increase health care utilization and spending. (Health Aff [Millwood]. 2016;35:449; http://bit.ly/2LrmwQR.) Lower-level acute care facilities can help offset the volume of patients flooding the EDs if patients are educated on the abilities and limitations of these facilities and can self-triage to the appropriate place. This would allow EPs to focus on patients who need urgent interventions.
Getting patients to the right place is paramount. The mantras for the health care community should be: The right choice for the right patient, and an educated consumer is our best customer. (Forbes. Nov. 18, 2019; http://bit.ly/2Lno2TZ.)
Dr. Gaskinis an emergency physician at Atrium Healthcare in Charlotte, NC.