The early 1980s witnessed the growth and expansion of urgent care as a permanent key player in the American healthcare system. To date, more than 7,000 urgent care centers in the United States provide care for more than 160 million patients a year.1 In practice, no set or minimal standards have been established, either at federal or state levels, for the scope of services provided.
Nurses beginning a career in urgent care will experience a lively, dynamic, and fast-paced care environment. RNs call upon their critical thinking skills and experience to assess patients in every age group and with a great range of health disorders. Multitasking, focusing on detail, and meticulous record-keeping skills are needed for urgent care RNs to deliver the quality of care and efficiency demanded.
This article explores the events, issues, and trends that guided this new model of care into its niche and discusses how nurses fit into this particular healthcare landscape.
Convenience is king
The continuing shortage of primary care providers has in recent years limited patients' access to primary care services.2 In addition, the need for more immediate or urgent care is genuine, and events requiring care often occur outside traditional medical office hours—evenings, weekends, and holidays. Urgent care's universal offer of direct, hands-on care with swift attention to unpredictable minor illnesses and injuries is therefore highly appealing to many patients. The most common problems managed at urgent care centers are influenza and influenza-like illnesses, acute sinusitis, acute exacerbations of asthma and other respiratory problems, acute pharyngitis, acute otitis media, rashes and skin infections, accidental eye splashes and eye infections, sprains and fractures, suturing of minor lacerations, and treatment for superficial and partial-thickness burns.3
The convenience of high-quality, efficient service by healthcare providers and nurses on duty outside of traditional office hours, along with the prospect of going straight home and feeling better quickly, is what draws patients to an urgent care center over a traditional physician office. Most centers are strategically located in well-lit shopping plazas and strip malls in urban and suburban areas. They're generally well advertised locally and clearly signed with ample on-site parking. Many feature physician biographies and work schedules on their websites. The facilities often have charging ports for personal electronic devices and free Wi-Fi. Patient-focused perks such as these have helped drive this new industry into a gap between primary care and the ED.
Waiting it out
A 2014 survey revealed that the average wait time for primary care physician appointments across major metropolitan areas was 19.5 days.4 The longest recorded wait that year—66 days—took place in Boston, Mass. The shortest wait time—5 days—was in Dallas, Tex. In 2017, the wait-time survey was repeated and showed that times had increased by 30% over the previous 3 years.5
The Affordable Care Act (ACA) has significantly expanded patients' access to primary care. Under the ACA, millions of previously uninsured patients acquired new healthcare policies within a remarkably brief period. These newly insured patients presented additional demands to primary care resources, which were already challenged to provide basic care within reasonable waiting times.6
Wait times in the emergency care landscape have been equally long. In December 2016, District of Columbia patients with minor illnesses or injuries spent up to 4 hours in the ED. The Dakotas, Mississippi, and Iowa had the shortest ED wait times in the nation—around 2 hours for nonurgent complaints.7
The Urgent Care Association of America (UCAOA) benchmarking survey indicated that 69% of patients at urgent care centers had wait times of less than 20 minutes; 28% of patients waited between 21 and 40 minutes; and only 3% waited longer than 40 minutes.8 This is impressive and appealing, but only an estimate. In reality, wait times at an urgent care center may vary depending on patient volume, which can increase greatly during influenza or allergy season. Most urgent care centers have adopted a triage system and will see patients with more obviously serious conditions first, similar to the process used in most EDs. However, the health issues presented in an urgent care setting are generally far less serious and more consistently predictable.
Health insurance plans won't likely cover a visit to the ED for minor problems. The prudent layperson standard applies only when one anticipates serious health impairment and a valid need for emergency care. In these cases, insurance coverage is based on current symptoms, such as chest pain, as opposed to the final diagnosis. The American College of Emergency Physicians supported the prudent layperson standard for many years until it was codified into the ACA in 2010.9 However, when seeking care for more obvious low-acuity conditions, the patient may be liable for much higher than expected out-of-pocket expenses for ED visits.10
Added to the facility charge, which hospitals may apply for use of the ED, patients may be billed separately by attending physicians who aren't in their insurance network. Some physicians, although contracted by an in-network hospital, may be out-of-network providers under some insurance plans. Patients may incur additional charges for medications, miscellaneous supplies, and additional diagnostic procedures.
Patients sometimes choose to go to urgent care centers with a serious illness or injury. If the condition can't be appropriately diagnosed and treated at the center, transfer to an ED, possibly by ambulance, will be required. This results in a delay of care and treatment. Unfortunately, the patient will likely receive separate bills from the urgent care center, ED, and emergency medical services (EMS) for their transportation to the ED. It isn't customary for insurance policies to cover both urgent care and emergency care for the same illness on the same date.
The Emergency Medical Treatment and Labor Act (EMTALA) of 1986 is a federal law that requires anyone coming to a Medicare-participating hospital's ED with an emergency medical condition to be stabilized and treated regardless of insurance status or ability to pay.11 In 2003, new regulations extended the reach of EMTALA to any off-campus facility that provides care for emergency medical conditions on an urgent, nonappointment basis, such as an urgent care center. This is known as the New EMTALA Final Rule.12
Urgent care centers will always stabilize critically ill patients to the extent of their resources while calling immediately for EMS transport. However, for routine and lower-acuity health concerns, urgent care centers aren't limited under any similar mandate, either at federal or state levels.
Many urgent care centers publish a list of accepted insurance companies and specific plans within those companies. They commonly participate with Medicare, Medicaid, and often with Tricare, the healthcare program for uniformed service members and their families around the world, and will file claims for patients.13 It isn't uncommon, however, for an urgent care center to be an out-of-network provider for some patients, resulting in higher patient co-pays.
Typically, urgent care centers use a flat-rate billing system and charge the same fee for any illness or injury. However, some centers use a two- or three-tiered system according to the severity of the patient's condition. Centers with expanded on-site facilities, such as lab and X-ray, will usually bill separately for these services. Some centers offer self-pay plans to patients not covered by an insurance plan in which the center participates. Discounted rates typically apply and a total visit cost, inclusive of most services, is often capped.14 Patients coming to these centers know exactly what to expect before they agree to be seen.
Choosing the right care
Providers want patients to be well informed about their options for accessing healthcare. Adequate patient education is key to making appropriate choices. Many urgent care centers now publish online guidelines to help patients choose the appropriate provider: urgent care, primary care, or ED.15 Many major insurance companies furnish advice and guidelines for their subscribers. Patients should be reminded that they should always call 911 if they think they're experiencing a medical emergency.16
Urgent care continues to evolve in the healthcare landscape. Perhaps it will soon be suitably dubbed “unscheduled care.” Medical literature often refers to urgent care as “episodic” due to the resolution of an illness or injury during a single visit, usually with no follow-up required.17 Urgent care centers are keen to see patients return to the facility, but with a different problem on subsequent visits. By contrast, primary care providers give priority to continuity of care, supporting the patient's journey through chronic, longer-term, or more complicated health problems. Primary care often integrates and coordinates specialist care for the patient, whereas urgent care seldom gets involved beyond designating a straightforward referral for transition of care.
Most urgent care centers are equipped to treat patients of all ages, but many new centers are designed and designated exclusively for pediatrics. Urgent care centers are also now frequently commissioned to offer expanded and more extensive services than the typical primary care medical office. They may have lab facilities, radiology departments, physical therapy resources, and even pharmacies onsite for exclusive use by the center. Staff frequently administer I.V. fluids for rehydration and I.V. antibiotics. Many centers also offer occupational health services, such as school and employment physicals, drug screenings, or health and wellness programs. Some urgent care centers treat unexpected job-related injuries and handle workers' compensation and other commercial insurance accounts.18
The role of an RN in urgent care is unique and unconventional. Nurses generally function as staff supervisors and case managers. RNs work in close partnership with providers to facilitate a smooth, seamless flow of patients through the center. Strong communication skills and proficiency with electronic medical records are essential for frequent patient status updates, ensuring that patients are seen efficiently and wait times are minimal.
RNs in urgent care are skilled team leaders, and are typically experienced at delegating many aspects of patient care to unlicensed assistive personnel (UAP). The delegating nurse will retain accountability for these numerous duties and for evaluating the competency of all individuals performing them.19 RNs will exercise professional judgment strictly in accordance with their relevant Nurse Practice Act, and will remain active participants in implementation and evaluation of care plans.
Written instructions designated as standing orders may be prepared by healthcare providers and clearly designated for patients with specific signs and symptoms or sets of signs and symptoms.20 For example, at many centers, instructions given to UAP will state under which set of circumstances and under what conditions specific lab tests, X-rays, peak expiratory flow rate measurements, and visual acuity screenings or hearing evaluations should be prescribed. The UAP will enter these orders into a computer. Each order will then be reviewed by a nurse. As that's being done, specimen labels can be printed, while the lab and radiology departments prioritize their workload. This system of work is intensely challenging. Again, nursing judgment and critical thinking must be exercised within the context of the employing facility's model of nursing practice and consistent with the nurse's scope of practice.
Nurses may help provide staff continuity in this healthcare setting. Locum tenens is a Latin phrase that translates to “hold a place for” or temporarily “substitute” for. Locum tenens physicians are often contracted by urgent care centers to cover illness, vacation, or any other potential gaps in patient care, but locum tenens physicians may not share the commitment level of permanent staff.21 Nurses often have to contend with these staffing complications.
Nurses are increasingly called on to adapt to wider clinical teams, which may include locum tenens physicians, travel nurses, and as-needed staff. Response to workforce issues may require adjustments to working relationships, with closer cooperation for care delivery. Nurses can and do take the lead in supporting successful, integrated teams within a huge range of clinical settings. The quality of communication and partnership between temporary providers and nurses certainly influences the quality of patient care. Healthcare disciplines must collaborate for the mutual goal of providing safe, quality patient care.22
The UCAOA was founded in 2004 and represents all professionals working in urgent care.23 Its mission includes advocating and advancing urgent care as a sound and sustainable healthcare option. The UCAOA offers learning opportunities and e-learning resources in support of professional development for nurses with an interest in urgent care.
A new path to primary care
With increasing popularity, primary care services are becoming available at urgent care facilities. One center, with three locations in the Chicago suburbs, offers walk-in urgent care, or primary care by appointment.15 All physicians onsite are Board Certified in Family Medicine. Another, with six locations north of Los Angeles, offers all of the basic primary care services, and will see patients with significant health issues on recurrent visits.24 The physicians onsite at a center with several mid-Atlantic locations offer primary care to patients on a walk-in basis, 7 days a week.3
Is primary care within the scope of urgent care nursing? The National Advisory Council on Nurse Education and Practice advocates for the role of nursing to provide “accountability for primary care needs across [various] settings...they [nurses] assess health needs, develop health plans, provide care, educate patients, coordinate transitions, and manage chronic diseases.”22
Urgent care for all ages continues as a response to healthcare needs in local communities. The demands for basic primary care services are equally significant. Nurses will thus be challenged to support a diverse range of primary care resources across borders that may not always be clearly defined.
Cooperation, not competition
Should you advocate urgent care for your patient? Although the boundaries between primary care, urgent care, and emergency care aren't consistently clear, the right choice is ultimately the patient's responsibility. Urgent care nurses are on the front lines of helping patients choose appropriate care options. Understanding and clarifying local area facilities and capabilities for healthcare is an important part of urgent care nursing practice.
Urgent care is a tempting alternative for patients with a view to convenience, lower costs, and shorter wait times, and is projected to increase by 5.8% each year through 2018.25 However, the mission of urgent care is cooperation, not competition, with community healthcare providers.17 There's good evidence that primary care and urgent care practices do collaborate for quality care outcomes.17 It's now common practice for records of urgent care visits, including lab and X-ray results, to be seamlessly forwarded to a primary care provider. Patients are routinely referred to their provider if follow-up care is needed after they've been seen at the center.
In the future, will primary care offices eventually expand their scope of services? Will EDs, in time, limit their services to addressing only serious illnesses and injuries? Time will tell as legislation evolves. If urgent care is here to stay, it must remain a distinctive and cost-effective participant with demonstrable benefits for health and wellness, as well as decreased costs and convenience.