Urgi-care centers and multi-physician practices have attempted to meet the need of today’s patient by allowing a drop-in approach for unexpected medical needs. This has been very successful and very helpful for patients who did not want to wait for hours in an emergency room for non-emergent care. It also is of benefit to patients who have not yet established a relationship with a primary physician, or who have developed an urgent but not emergent need outside of office hours. This system can work very well if the patient has a primary physician (PCP) who is apprised of this urgent care; with that knowledge, the PCP can work with the patients to manage their own care. If there is no coordination of care, problems can develop.

Patients who come and go whenever they feel the need of treatment may consider an urgent care or walk-in practice as their “treating physician.” They may not have any other doctor, or they may see specialists in the same casual manner. If the facility is unaware that they are the de facto primary caregiver for this patient, there can be a lack of continuity of care just as if the patient were going to the emergency room on a sporadic basis. This represents a liability risk for the facility.

A patient who is seen in this fashion may not see the same doctor at each visit, especially if the practice or clinic is large. In keeping with the “urgent” nature of each visit, practitioners and staff may document less and may fail to follow up on the tests they have suggested. Bluntly stated, the episodes of care may lack connection, causing redundancies and missed opportunities; and even when there is an attempt to give appropriate treatment, it may not be documented.

Following are several urgent care cases/scenarios:

Case 1 An elderly man with Type II diabetes was seen in an urgent care facility for early signs of neuropathy in one of his great toes. His foot was carefully examined and a thorough history was taken of his diabetes; documentation was good. No other systems were assessed, however. Specifically, his neurological orientation was not carefully evaluated. Since he was not accompanied by any family members, there was no one else to get his history from or to give instructions to. The patient took his discharge instruction sheet and left. He never followed up on the discharge instructions; he forgot them due to his early stage dementia. By the time his children, who lived out of town, caught on to his “foot problems” the neuropathy was seriously advanced, he had problems with infections, and he had to have part of his toe amputated.

Case 2 A woman frequented an urgent care facility over a period of years, presenting about once every year or two. She was seen by various physicians of the center for a number of complaints. Frequently she was asked to return for further testing regarding one problem or another, but she invariably did not come back as scheduled. When she did return, it would be for another issue, and she usually managed to evade any ordered tests beyond routine blood work, which could be done without advance preparation. She saw other physicians, usually specialists, in between her visits to the urgent care center and had several surgeries throughout the years. Ultimately, on a visit to another treating facility, she was found to have an advanced cancer which may have been diagnosed by one or more of the many tests or exams she evaded.

RECOMMENDATIONS:

For Patient Check-in and Evaluation

û        Triage of walk-ins should be done by a physician, NP, or PA;[i] this triage must be done within the first minutes of the patient’s arrival just as if the facility was an emergency department.

û        Pull and review their old chart. For ease of review, an up-to-date case summary sheet at the beginning of the record can be a help.

û        Do not assume you remember the patient from prior visits; ask necessary questions again.

û        Do the appropriate, not minimal, physical exam and document it.

û        Use critical thinking in your decision-making process, and document that decision process; treat each patient as the missed diagnosis case you are determined to avoid.

û        Utilize strict protocols for rule-out MIs, fractures,[ii] and meningitis; the care of patients who fall into these and similar categories should be carefully documented.

Documentation

û        Patient history and physical exam, to include mental status evaluation, must be clearly and completely documented.

û        Documentation of critical thinking in the diagnostic process must include rule-outs.

û        Vital signs, pulse oximetry, and neuro checks as appropriate must be done and recorded for specific types of care.

û        Written discharge instructions should be reviewed with the patient, and family as appropriate, by the physician, NP, or PA;[iii] care should be taken to use interpreters if necessary and document their use.

Policies and Procedures

û        Have a tracking system in place to ensure that the patient follows through on their care plan.

û        Shift change hand-off procedures should be well developed and formal; they should apply to all levels of caregiver.[iv]

û        Policy/procedure should carefully limit telephone advice and discourage telephone orders.[v]

General Issues

û        Signage, facility documents given to the public, and the organization’s website (if one is utilized) should clearly state the type of practice it is; documents and website should include disclaimer language which explains that the care given is urgent in nature and is not to be considered on-going health management. For those urgent care facilities that provide worker's compensation treatment, the wording will have to be altered appropriately.

û        If the facility is strictly urgent care, all admission and discharge paperwork should have disclaimers, which state that the facility only provides care on an urgent basis and that all patients should seek health management from a qualified PCP.

û        If the patient is a walk-in without a regular physician, the patient should be given materials on finding a PCP or choose to be followed by a physician of the practice that has just treated them; it should be clearly documented in their chart that they were seen and will be continuing care with the practice or that they were seen as urgent care only and have been given materials instructing them about finding a PCP.