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FEBRUARY 2015 UCCOP Confidence Is a Sign of the Right Fit FEBRUARY 2015 ™ VOLUME 9, NUMBER 5 THE JOURNAL OF URGENT CARE MEDICINE® www.jucm.com The Official Publication of the UCAOA and UCCOP PUBLICATION BRAVEHEART A Confidence is a sign of the right fit. Urgent Care and Occupational Medicine are a great pair—that bring some colorful management dilemmas. AgilityUC is perfectly fitted for facilities that audaciously plan to excel at both. Streamline workflow demands. Flaunt your efficiency with a single billing system. One record per patient keeps PHI secure from workers' compensation data. Be cool, everything's covered. Learn more at nhsinc.com Software for Urgent Care nhsinc.com The Art of the Right Fit.™ © 201 Net Health. All Rights Reserved. LETTER FROM THE EDITOR-IN-CHIEF Evaluating Chest Pain in Urgent Care— “Catch 22 and the Three Bears”: Part 1 hat can Joseph Heller and Goldilocks way to the ED or gets into an accident, what will be your teach us about managing no-win situ- defense then? All patients presenting to an urgent care Wations in urgent care? As it turns out, if should have an evaluation that is reasonable for their clin- you look under the covers of Baby Bear’s ical condition. Ⅲ bed, you might find something meaning- Step 2: Determine whether the patient is stable or ful, perhaps even something that’s “just unstable. A patient with chest pain who is clinically unsta- right.” Take the classic no-win situation when patients present ble (e.g., the patient has altered responsiveness, has sig- to urgent care with chest pain. Without a definitive and reli- nificant bradycardia or hypoxia, has hypotension) should able test to guide our decision making, we are stuck with the trigger the initiation of emergency protocols regardless of ultimate “damned if you do, damned if you don’t” moment: underlying cause. If, on the other hand, the patient is clin- Either send everyone with chest pain to the emergency ically stable, then a reasonable and systematic evaluation department (ED) or roll the dice and send some of them should follow without bias or emotion. Ⅲ home. Neither option is very good. One is “too hot” and one is Step 3: Decide whether a transfer is necessary. There “too cold.” We cannot continue to ignore the problem; nor can should, of course, be several hard stops in the evaluation we continue to complain about it. that will trigger urgent or emergency transfer. These will Alternatively, there may be an approach that’s “just right,” vary on the basis of the equipment and testing avail- or at least “just right enough.” The fact is that the behavior and able but would include things like ST-segment elevation decision making of most clinicians is driven by the desire to myocardial infarction and an elevated level of cardiac eliminate risk, an idyllic fantasy that simply does not exist. In enzymes (e.g., troponin I). It should also be clear that all the absence of risk elimination, we would all agree that risk patients with “typical” chest pain and/or evidence of reduction with a realistic eye toward minimizing false positives ischemic changes on electrocardiograms belong in the and false negatives is our ultimate goal. So what does the ED or catheterization laboratory. Ⅲ evidence tell us, and how can we apply the evidence to our Step 4: Decide whether the patient can go home. This daily routine in a way that reflects best practice? Although most is perhaps the most challenging step of them all. Although rejectionists among us would say that there is no evidence that it may be easy to identify patients who obviously belong defends a balanced approach to managing chest pain in urgent in the ED (as described in step 3), it is, conversely, extremely care, the reality reflects otherwise. Several clinical decision challenging to determine which of the remaining chest- tools, along with a few diagnostic tests, can minimize the risk pain presentations can be managed more routinely on an of bad outcome and the risk associated with false alarms. Con- outpatient basis. In next month’s column, I will examine sider the following approach: this step in detail, including an evidence-based paradigm Ⅲ Step 1: The first step to evaluating patients with a for sending some chest-pain patients home safely and ■ complaint of chest pain in urgent care is to actually according to a reasonable standard of care. evaluate them. As absurd as that may sound, the prac- tice of “pre-triaging” patients with chest pain to the ED before completing an evaluation is commonplace in urgent care. Patients are told by front-desk personnel that “we don’t see chest pain” and are then referred directly to the ED. In an unrealistic effort to eliminate risk, the urgent care has taken on immeasurable risk by not pro- Lee A. Resnick, MD, FAAFP viding a clinical evaluation. If the patient collapses on the Editor-in-Chief, JUCM, The Journal of Urgent Care Medicine www.jucm.com JUCM The Journal of Urgent Care Medicine | February 2015 1 ™ The Official Publication of the UCAOA and UCCOP February 2015 VOLUME 9, NUMBER 5 CLINICAL 8 Medication Issues in Urgent Care Patients with multiple medical conditions likely take multiple long-term medications. In the face of polypharmacy, clinicians must be on guard against adverse drug reactions and drug allergies. Jasmeet Singh Bhogal, MD PRACTICE MANAGEMENT IN THE NEXT ISSUE OF JUCM A 50-year-old man who can’t make it through the 22 A Process Approach to day without taking a nap… a 32-year-old new mother Differentiating Your Urgent who is tired… an 82-year-old woman who has been exhausted for 2 weeks. Up to 7% of Americans expe- Care Brand by Ensuring That rience fatigue, costing employers more than $130 Patients Leave Satisfied billion each year. Next month’s cover story helps the urgent care practitioner wade through an extensive If your urgent care center is to thrive, you have differential diagnosis with a streamlined approach to differentiate it from other centers. How? Promise and deliver a good patient experience. to diagnosis and management while staying alert for red flags for life-threatening problems. Alan A. Ayers, MBA, MAcc DEPARTMENTS CASE REPORT 7 From the UCAOA CEO 28 Serious Pathology 32 Health Law Masquerading as Chronic 34 Abstracts in Urgent Care Back Pain 36 Coding Q&A 40 Developing Data Chronic back pain, a common urgent care presentation, can mask major disease. Urgent CLASSIFIEDS care providers cannot assume previous 38 Career Opportunities diagnoses are correct. Jessica Hoffmann, MS-4, and John Shufeldt, MD, JD, MBA, FACEP www.jucm.com JUCM The Journal of Urgent Care Medicine | February 2015 3 JUCM EDITOR-IN-CHIEF Joseph Toscano, MD Lee A. Resnick, MD, FAAFP San Ramon (CA) Regional Medical Center Chief Medical and Operating Officer Urgent Care Center, Palo Alto (CA) Medical WellStreet Urgent Care Foundation President, Institute of Urgent Care Janet Williams, MD, FACEP EDITOR-IN-CHIEF Medicine Rochester Immediate Care Lee A. Resnick, MD Assistant Clinical Professor, Case Western [email protected] Mark D. Wright, MD Reserve University MANAGING EDITOR Department of Family Medicine University of Arizona Medical Center Katharine O’Moore-Klopf, ELS [email protected] JUCM ADVISORY BOARD ASSOCIATE EDITOR, PRACTICE MANAGEMENT JUCM EDITORIAL BOARD Alan A. Ayers, MBA, MAcc Alan A. Ayers, MBA, MAcc Michelle H. Biros, MD, MS CONTRIBUTING EDITORS Concentra Urgent Care University of Minnesota Sean M. McNeeley, MD Tom Charland Kenneth V. Iserson, MD, MBA, FACEP, John Shufeldt, MD, JD, MBA, FACEP Merchant Medicine LLC FAAEM David Stern, MD, CPC The University of Arizona MANAGER, DIGITAL CONTENT Richard Colgan, MD Brandon Napolitano University of Maryland School of Medicine Gary M. Klein, MD, MPH, MBA, CHS-V, [email protected] Jeffrey P. Collins, MD, MA FAADM ART DIRECTOR Harvard Medical School mEDhealth advisors Tom DePrenda Massachusetts General Hospital Benson S. Munger, PhD [email protected] Tracey Quail Davidoff, MD The University of Arizona Accelcare Medical Urgent Care Emory Petrack, MD, FAAP Kent Erickson, MD, PhD, DABFM Petrack Consulting, Inc.; Unlimited Patient Care Center, PLLC Fairview Hospital 120 N. Central Avenue, Ste 1N Ramsey, NJ 07446 Thomas E. Gibbons, MD, MBA, FACEP Hillcrest Hospital Doctors Care Cleveland, OH PUBLISHERS William Gluckman, DO, MBA, FACEP, Peter Rosen, MD Peter Murphy [email protected] • (201) 529-4020 CPE, CPC Harvard Medical School FastER Urgent Care Stuart Williams David Rosenberg, MD, MPH [email protected] • (201) 529-4004 David Gollogly, MBChB, FCUCP University Hospitals Medical Practices CLASSIFIED AND RECRUITMENT ADVERTISING (New Zealand) Case Western Reserve University [email protected] College of Urgent Care Physicians School of Medicine Pete Murphy - (201) 529-4020 • Stu Williams - (201) 529-4004 Wendy Graae, MD, FAAP Martin A. Samuels, MD, DSc (hon), Mission Statement PM Pediatrics FAAN, MACP JUCM The Journal of Urgent Care Medicine supports the evolution of urgent care medicine by creating content that addresses both the clinical practice of urgent care medicine Nahum Kovalski, BSc, MDCM Harvard Medical School and the practice management challenges of keeping pace with an ever-changing healthcare Terem Emergency Medical Centers marketplace. As the Official Publication of the Urgent Care Association of America and Kurt C. Stange, MD, PhD the Urgent Care College of Physicians, JUCM seeks to provide a forum for the exchange Peter Lamelas, MD, MBA, FACEP, Case Western Reserve University of ideas and to expand on the core competencies of urgent care medicine as they apply FAAEP to physicians, physician assistants, and nurse practitioners. Robin M. Weinick, PhD MD Now Urgent Care Medical Centers, Inc. Affiliations RAND JUCM The Journal of Urgent Care Medicine (www.jucm.com) is published through a partnership Melvin Lee, MD, CCFP, RMC between Braveheart Group, LLC (www.braveheart-group.com) and the Urgent Care Asso- FastMed North Carolina ciation of America (www.ucaoa.org).
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