I recently saw a 7-year-old girl who was referred by her pediatrician because of a wrist injury. Two days before, she fell off a swing onto her left forearm and complained of wrist pain. She was brought to an urgent care center where a physician obtained x-rays, which did not show a broken bone, so she was discharged home. Two days later, she was still in pain and not moving her left wrist. She was brought to her pediatrician, who noted left wrist swelling and tenderness, and referred her to the Emergency Department. The ED diagnosis was a growth plate fracture of one of her wrist bones. An orthopedist was consulted and her left forearm was placed in a cast.
What happened here? Growth plate fractures occur in children and adolescents with immature skeletons. The most common type does not show up on initial x-rays. Although this is a common injury, it takes training and experience in treating children to recognize it. This girl's parents brought her to an urgent care center because it was close to their home, she was seen fairly rapidly, and the visit cost less than an ED insurance co-payment. However, since she was misdiagnosed, the subsequent visits to her pediatrician and the ED, cost them even more time and co-payments.
Urgent care centers are opening up everywhere, especially in the suburbs. To address the role of these centers in children's care, The American Academy of Pediatrics released a policy statement online today outlining its recommendations for these facilities.
Freestanding urgent care facilities, according to the AAP:
Should be capable of providing timely assessment, initial resuscitation, and stabilization and be able to initiate transfer of pediatric patients who need a higher level of care.
Define the scope of care that they can and should provide to pediatric patients.
Support and complement the medical home model, not serve as a primary care provider.
Staff with providers who have training and experience to care for children.
Participate in systems of care such as the local emergency services.
"Well-managed freestanding urgent care facilities can enhance the provision of urgent services to the children of their communities, be integrated into the medical community, and provide a safe, effective adjunct to, but not a replacement for, the medical home," states the policy.
Estimates from the Urgent Care Association of America cite about 4,500 urgent care facilities throughout the United States, where more than 150 million adult and pediatric patients are seen annually. These facilities can be owned and operated by individuals, affiliated with a health insurer, or a subsidiary of a hospital system.
They provide unscheduled visits, but may also allow appointments, for mild to moderate illnesses or injuries. Some offer non-acute services such as immunizations and pre-participation sports physical examinations. Simple x-rays and laboratory tests are offered. There is usually at least one physician on staff.
So what should you do if you child becomes acutely ill or injured? It's important to have a plan as to where you will bring your child. If your child is experiencing a true emergency, 911 should be called so the child can be transported to the nearest ED. Otherwise, the first call should still be to your child's pediatrician or primary care provider. Most pediatric and primary care offices now offer evening and weekend hours. If their office is closed, your pediatrician or primary care provider should offer an answering service where a trained provider can advise if your child can wait to get seen in their office the next day, or should be seen in the ED.
Most EDs are streamlining their processes so patients with minor illnesses and injuries are seen immediately and efficiently, in "fast track" or "fast care". This is usually a separate, designated area in the ED, with its own physician and/or provider and nursing staff. The goal for most EDs is to see such patients within a half hour, and to discharge them home within 90 minutes. Therefore, the duration for the visit may be similar to an urgent care center.
If you choose to bring your child to an urgent care center, inquire about the center's capability to care for children. Is the provider trained in assessing and treating children? What laboratory and x-ray services are available? Is the provider trained to accurately interpret the results? How is this visit communicated to your pediatrician or primary care provider? What happens if your child requires a subspecialist or hospitalization?
The bottom line in your decision as to where to take your child should be the quality of care your child receives. In a child, fever can be from something as simple as a cold or as severe as meningitis; belly pain can be from constipation or acute appendicitis. On the one hand, you would not want your child to be misdiagnosed; on the other, you would not want your child to be subjected to unnecessary, uncomfortable, or potentially risky tests. Your pediatrician, primary care provider, and experienced emergency physicians are still the experts in managing your acutely ill or injured child.
In addition to its policy statement on urgent care centers, the AAP recently released a statement concerning Retail-Based Clinics that was also covered in Healthy Kids.