Urgent care just for children.
The daycare calls and tells you that your 18-month-old is running a fever. What are your options? It used to be that all you could do was try to get an appointment with your child’s primary care provider. If there were no appointments available, you could wait a day or take your child to the local ED. Now the options are growing. Pediatric providers are offering evening hours for sick visits. There are retail clinics in stores, such as Walmart, that will see patients without appointments. There are a large and growing number of urgent care clinics. In some locations, there are pediatric urgent care clinics.
So where to take an 18-month-old? Same day and after hours visits with the pediatrician are the preferred option for low acuity problems, but these slots can fill up quickly. In addition, parents want the convenience of on-demand care that a primary care clinic may not be able to provide.
Available Options
Retail-based clinics are usually staffed by PAs or NPs. They can see low complexity problems however some may not be comfortable with very young children and might have a minimum age limit.
Generic urgent care clinics are usually staffed by physicians, but typically not by pediatricians. There is variability in providers’ comfort levels with very young children. Staff may or may not be proficient in procedures, such as establishing venous access in children. Pediatric urgent cares are not as prevalent, but are typically staffed by pediatric-trained providers and have nurses and/or assistants that are accustomed to working with children.
ED vs. Urgent Care
A recent study by Montalbano and colleagues compared urgent care and ED visits in pediatric Medicaid patients.[1] They examined 5,925,568 acute care visits of patients under the age of 19 years in a multi-state database. The top three diagnoses were the same in both the urgent care and ED setting. These were upper respiratory infection, otitis media and fever. The rate of return visits was higher for ED patients than for urgent care patients at every level of severity. The costs of providing care in the urgent care setting were lower. This study makes a pretty good argument for choosing the urgent care for our 18-month-old patient.
So what about children whose care originates in urgent care centers but who end up in the ED? Is that a significant enough problem to warrant starting out in the ED in the first place?
McCarthy and colleagues did a retrospective chart review of 109 patients < 21 years of age that were transferred to an urban, academic ED from an urgent care setting.[2] Eighty-five percent were discharged from the ED. Twenty-seven percent were sent home without utilizing any ED resources at all. The most common reason for transfer was “GI illness.” It is not clear what ED resources were provided in the ED referred group who were then discharged.
Olympia and colleagues also took a recent look at ED referrals from urgent care centers.[3] Their study was a prospective, observational study of urgent care referrals to an ED in a rural area of central Pennsylvania. They looked at 455 patients under the age of 21. Eighty-three percent of the patients referred to the ED from urgent cares were discharged home. Seventy-six percent of these referrals were considered “essential.” A panel was convened to decide a priori what referrals would be considered essential. The panel determined that urgent cares would not be able to perform certain actions. Among these were blood tests; ecgs, radiographs; procedures such as IV placement, dislocation reduction and splinting of fractures or dislocations, and incision and drainage of abscesses. They therefore determined that patients who received these interventions in the ED were essential referrals.
This is not to suggest that all urgent cares are unable to provide these services. The study does not discuss what constituted an urgent care. Retail clinics might not be able to provide these services and many urgent cares with non-pediatric providers might struggle to get IV access, labs or perform interventions on infants and small children. A pediatric urgent care would likely be able to provide many or all of these services. Maybe rural Pennsylvania is simply lacking in pediatric urgent care centers?
After finding out that the pediatrician’s same-day slots are filled, you decide to take your toddler to the local pediatric urgent care center. Your child is non-toxic appearing, fully immunized and otherwise healthy, and the pediatric-trained staff at the urgent care are comfortable making a disposition without any unnecessary blood testing. Urine was not indicated, as the fever is low grade and the child is a circumcised male. It is the case however, that the staff are equipped and able to obtain a catheterized urine specimen in a toddler if the situation calls for it.
Conclusion
Not all urgent cares are alike when it comes to their capability to handle pediatric patients. Look for contemporary pediatric urgent care centers that are staffed with pediatric emergency physicians and pediatric NPs and PAs, are able to provide IV access and can perform simple procedures. Facilities that cater to children typically create a network with PCPs and EDs in the area to ensure prompt follow up or seamless ED referral.[4]
With the spread of pediatric-specific urgent care centers, it may be possible to see some real decompression of the demand on emergency departments. And it will likely come with a lower price tag as well.
References:
- Montalbano A, Rodean J, Kangas J, et al. Urgent care and emergency department visits in the pediatric Medicaid population. Pediatr. 2016;137(4).
- McCarthy JL, Clingenpeel JM, Perkins Am, Eason MK. Urgent care transfers to an academic pediatric emergency department. Pediatr Emerg Care. 2018:34(3).
- [1] Olympia RP, Wilkinson R, Dunnick J, et al. Pediatric referrals to an emergency department from urgent care centers. Pediatr Emerg Care. 2018;34 (12).
- 4 Saidinejad M, Audrey P, Gausche-Hill M, et al. Consensus statement on urgent care centers and retail clinics in acute care of children. Pediatr Emerg Care. 2019 35:138-142