1. Coyle, Amanda L. PhD, RN, FNP-BC

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IN THE PAST 20 years, episodic care centers have experienced rapid growth.1Episodic care centers include the ambulatory care centers of retail clinics, urgent care centers, freestanding EDs, and hospital-based EDs. Such a variety of healthcare options creates both opportunities and challenges for patients as healthcare consumers. Patients need to decide the level of care and services they may need when they experience an acute illness or injury. This article will explain the challenges associated with patient self-triage with a focus on urgent care centers, and discuss how nurses can play a vital role in easing a patient's transfer from an urgent care center to the ED.


What's in a name?

A retail clinic is defined as a walk-in clinic, usually located in a pharmacy or big-box store; this type of facility is designed to treat simple acute medical disorders.2,3 Retail clinics have a well-defined list of offered services for minor illnesses, such as upper respiratory tract infections, allergy symptoms, rashes, and urinary tract infections. Staff can also perform health screenings and administer immunizations. Some of these clinics are expanding into the management of chronic medical disorders.2,3


An urgent care center is also a walk-in clinic, but it can treat a broader array of lower-complexity acute medical illnesses or injuries.4 Urgent care centers routinely manage uncomplicated sprains, fractures, and lacerations as well as acute medical conditions, such as upper respiratory tract illnesses, urinary tract infections, and low back pain.2 However, additional services offered vary widely. For example, some urgent care centers offer basic lab point-of-care testing and routine plain-film X-ray services. Others offer expanded lab and radiology services, I.V. medication and fluid therapy, intra-articular injections, routine health physicals, workers' compensation exams and follow-up care, and occupational medicine services.5


A freestanding ED is a walk-in clinic designed to treat acute medical conditions, but without all the services offered in a hospital-based ED, such as specialty care, surgery, and in-patient admission.6,7Hospital-based EDs offer the broadest array of services and are most appropriate for life- and limb-threatening injuries and illnesses.


No universal standards have been established at the community, state, or federal level regarding which facilities may use the urgent care center title or what services they may offer. A recent study also found that policies regarding freestanding ED locations, staffing patterns, and clinical capabilities varied widely from state to state.8 This can create a confusing landscape of healthcare options for patients who may be concerned with their use of time, expenditure of their healthcare dollars, and the acuity of their illness or injury. National policy advocates and professional organizations recommend that urgent care centers use standardized language when naming a center by avoiding the use of "emergency" in the title, and offer uniformity of services in order to assist the patient in deciding where best to seek healthcare for an acute illness or injury.2,6,9


Choose wisely

Urgent care centers appeal to many patients as a convenient, efficient, cost-effective solution for their healthcare needs.4,10 Major insurers may specify where to appropriately seek care for specific conditions on their websites, but the burden is often on the patient to seek out this information. Patient health literacy is essential. One urgent care professional organization lists the types of disorders that are most appropriately managed in this type of facility and cautions that EDs are to be utilized for "life- and limb-threatening situations."11 But that's where confusion can easily arise: A simple hand wound, for example, might be very appropriately managed at an urgent care center, but a complex hand wound involving a crush injury or neurovascular damage is more appropriately treated in the ED. The patient is put in the position to decide where to best seek healthcare.


In order to choose the appropriate setting for their healthcare needs, patients must self-triage at a time when emotions can be heightened due to a sudden injury or acute illness. Little research has been done on patients' abilities to appropriately self-triage.2 One benchmark report from an urgent care professional organization reported that in 2015, 3% of urgent care center patients were sent from the facility to the ED, but this was the only study of its kind, so more research on the topic is needed.12 On the other hand, researchers studying the reasons for patient visits to a retail clinic, urgent care center, and ED have determined that 13% to 27% of all ED visits could be managed outside the ED.3 The study authors caution that self-triage could grow into an even larger issue as more patients start to utilize retail clinics and urgent care centers.3


Anecdotally, I know healthcare providers who report seeing a number of acutely ill patients in the urgent care center, including patients with acute coronary syndromes, respiratory distress, sepsis, and hemodynamic instability, who require immediate transfer to an ED. When patients choose incorrectly and must be transferred to a higher level of care, they experience a treatment delay and may also assume additional deductibles and copays as well as ambulance transport expenses. More research is needed on the topic of patient self-triage.


Escalating the level of care

A nurse can play a significant role when patients walk into an urgent care center needing a higher level of care. A team of researchers has created a set of best practices for the management of a patient during transfer from an urgent care center to an ED.13 The best practice focus was on quality of care and communication. Certain key information should be obtained from the patient by the urgent care providers, including the name of the patient's primary care provider, the name of the patient's emergency contact, and medication reconciliation. Clinicians should summarize the urgent care center visit in a treatment note and give the patient written discharge instructions. This information should be communicated both verbally and in written form to an ED physician in the receiving hospital at the time of transfer. In addition, the reason for transfer, the results of any completed diagnostic studies, and the urgent care clinician's contact information should be communicated in the patient's medical record.


Though best practices for transferring patients from an urgent care center to an ED exist, one study demonstrated that they aren't often followed. ED clinicians in a convenience sample of EDs in one state reported they received very little communication from urgent care centers transferring a patient to the ED.13 This practice also requires more study.


RNs should take an active role in ensuring that such essential communication does occur. Some institutions have policies and procedures in place for patient transfer and such policies should be followed carefully. However, other institutions don't have policies and procedures in place.


Institutional policies and procedures of the transferring and receiving institution should be followed or created if they don't already exist. The RN can be instrumental in developing such policies, educating colleagues, and insuring that policies are followed. By following a systematic reporting system upon transfer, nurses can ensure that the same information is given to each receiving institution every time. Nurses should also consistently document in the patient's medical record the information that was given, the date and time, and the name of the person they reported to.


Maintaining continuity of care

The growth and popularity of urgent care centers is expanding. Currently, not much is known about the number of patients who can appropriately self-triage and choose the correct level of care. When patients do need transfer to a higher level of care, communication of vital information is essential for quality and safety. Nurses can play a key role in providing an ED with patient information that will optimize patient care.




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