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™ JUNE 2007 VOLUME 1, NUMBER 8
THE JOURNAL OF URGENT CARE MEDICINE®
www.jucm.com | The Official Publication of the Urgent Care Association of America IN THIS ISSUE
FEATURES 11 Management of Patients Presenting with Symptoms of Vulvovaginitis 19 Bouncebacks: The Case of an 18-Year-Old Male with Hand Pain 30 UCAOA Benchmarking Survey: Addressing the Data Drought DEPARTMENTS 23 Abstracts in Urgent Care 25 Insights in Images: Clinical Challenge 33 Coding Q & A 34 Health Law 35 Occupational Medicine 40 Developing Data PUBLICATION A BRAVEHEART ciprodex:Layout 1 5/17/07 12:30 PM Page 1
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Every article that has appeared in JUCM, The Journal of Urgent Care Medicine is available on our website. Simply log on to www.jucm.com and click on the Past Issue Archive button to see every issue we’ve published.
THE JOURNAL OF URGENT CARE MEDICINE resnick_0607:Layout 1 5/22/07 10:34 AM Page 3
LETTER FROM THE EDITOR-IN-CHIEF UCAOA: A Vision for the Future
he UCAOA National Conference, held • Invest in research to study outcomes, best practices, last month in Daytona Beach, FL, was an customer service initiatives and risk management tools. important milestone in the organizational Ⅲ Member Recruitment Tevolution of UCAOA: The elections con- • Realize the power of numbers—the more people we ducted at the meeting marked the second represent, the louder our voice. rotation of board seats since our founding in Ⅲ Original Research 2004, and the first board election of a new president. • Encourage original research in the field. This is critical It is critical to the success of our organization to have a rotat- to identifying urgent care as legitimate in the house of ing leadership at the board and officer levels. Our bylaws guar- medicine. antee this to ensure that we adhere to the principles of a mem- Ⅲ JUCM ber voting organization with strictly democratic governance. • Drive submissions from within the urgent care commu- As the new president, I want to express sincere thanks to Bill nity. Please submit. We can help; contact me at Meadows, MD for his visionary leadership during our first three [email protected]. years. Additional gratitude should be extended to all of our Ⅲ Organizational Management founding board members. • Continue to build a reliable and accountable corporate There is, of course, no time to celebrate our past achievements, and management structure. as they simply represent a mandate for taking it to the next level. Ⅲ Association Leadership and Thought Leader Recruitment Success breeds expectations of even greater future success. • Groom the next association leaders. Looking ahead, I would like to outline what I see as the strate- • Augment our internal leadership through the counsel gic vision of UCAOA for the next three years: of thought leaders in specialty development, healthcare Ⅲ Training services research, etc. • Target resident recruitment/program expansion. • Continue to refine core competencies. Putting the You in UCAOA • Establish training program accreditation. Without the involvement of every one of our members, we will • Develop nurse practitioner and physician assistant not succeed. The critical initiatives presented here form the back- programs. bone that supports the success we have had and hope to Ⅲ Continuing Education achieve. If you’ve read this far, that means you! • Establish new programs for developing competencies If you would like to get involved with these efforts but are in key areas, both clinical and practice management. unsure where to begin, e-mail me ([email protected]) or our Ⅲ Convention executive director, Lou Ellen Horwitz ([email protected]); • Build on tremendous past success with new, value- we can help. added benefits for new and experienced practitioners, owners and operators. • Expand clinical content. Ⅲ Benchmarking • Augment and formalize benchmarking efforts to pres- ent the most authoritative and relevant data in our in- dustry; significant investment will be made to this end. Ⅲ Accreditation Lee A. Resnick, MD • Work toward creating a powerful and universally ac- Editor-in-Chief cepted tool for identifying industry standards. JUCM, The Journal of Urgent Care Medicine Ⅲ Quality Assurance President, UCAOA
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The Official Publication of the Urgent Care Association of America June 2007
VOLUME 1, NUMBER 8
CLINICAL 11 Management of Patients Presenting with Symptoms of Vulvovaginitis Approximately 10 million office visits are attributed to vulvovaginitis annually in the U.S. Are you prepared to evaluate and treat appropriately? By James Tiongson, MD, Samuel Keim, MD, and Peter Rosen, MD
BOUNCEBACKS 9 From the Executive 19 The Case of an 18-Year-Old Male Director with Hand Pain DEPARTMENTS Not all diagnoses are obvious at first glance. What was missed in 23 Abstracts in Urgent Care the initial examination and treatment of this patient with an injury of suspicious origin? 25 Insights in Images: Clinical Challenges By Michael B. Weinstock, MD and Ryan Longstreth, MD, FACEP 33 Coding Q & A INDUSTRY NEWS 34 Health Law 35 Occupational Medicine Addressing the Data Drought 30 40 Developing Data The first UCAOA Benchmarking Survey confirmed that urgent care practitioners are hungry for data on how and what their colleagues are doing. The second report of the Benchmarking Committee moves one step closer to filling that void. By J. Dale Key
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JUCM EDITOR-IN-CHIEF Lee A. Resnick, MD Case Western Reserve University Department of Family Medicine EDITOR-IN-CHIEF University Hospitals Medical Practices Lee A. Resnick, MD [email protected] JUCM EDITORIAL BOARD EDITOR Tanise Edwards, MD, FAAEM Genevieve M. Messick, MD J. Harris Fleming, Jr. Author/editor (Urgent Care Medicine) Immediate Health Associates [email protected] Nahum Kovalski, BSc, MDCM Marc R. Salzberg, MD, FACEP CONTRIBUTING EDITORS Terem Immediate Medical Care Stat Health Immediate Medical Care, PC Nahum Kovalski, BSc, MDCM Peter Lamelas, MD, MBA, FAAEP John Shershow, MD Frank Leone, MBA, MPH MD Now Urgent Care Walk-In Urgent Care Association of America John Shufeldt, MD, JD, MBA, FACEP Medical Centers John Shufeldt, MD, JD, MBA, FACEP David Stern, MD, CPC Melvin Lee, MD NextCare, Inc. ART DIRECTOR Baptist Minor Medical Clinics; Mark D. Wright, MD Tom DePrenda Metro Memphis Physicians Group The University of Arizona [email protected] Elizabeth A. Lindberg, MD The University of Arizona
JUCM ADVISORY BOARD Michelle H. Biros, MD, MS Peter Rosen, MD 2 Split Rock Road, Mahwah NJ 07430 University of Minnesota; Harvard Medical School Editor-in-Chief, Academic Emergency David Rosenberg, MD, MPH PUBLISHERS Medicine University Hospitals Medical Practices Peter Murphy Kenneth V. Iserson, MD, MBA, FACEP, Case Western Reserve University [email protected] FAAEM School of Medicine (201) 847-1934 The University of Arizona Martin A. Samuels, MD, DSc (hon), Daniel R. Konow, PA-C, MBA FAAN, MACP Stuart Williams RediMed Harvard Medical School [email protected] Steven Lelyveld, MD, FACEP, FAAP Kurt C. Stange, MD, PhD (201) 529-4004 University of Chicago Pritzker School Case Western Reserve University Mission Statement of Medicine Robin M. Weinick, PhD JUCM The Journal of Urgent Care Medicine supports Benson S. Munger, PhD Harvard Medical School The University of Arizona the evolution of urgent care medicine by creat- ing content that addresses both the clinical prac- tice of urgent care medicine and the practice UCAOA BOARD OF DIRECTORS management challenges of keeping pace with an Lee A. Resnick, MD, President ever-changing healthcare marketplace. As the Ken Palestrant, MD, Vice President Official Publication of the Urgent Care Association Cindi Lang, RN, MS, Secretary of America, JUCM seeks to provide a forum for the exchange of ideas and to expand on the Daniel R. Konow, PA-C, MBA, Treasurer core competencies of urgent care medicine as Jim Gore, MD, Director they apply to physicians, physician assistants, and John J. Koehler, MD, Director nurse practitioners. William E. Meadows III, MD, Director JUCM The Journal of Urgent Care Medicine (JUCM) makes every Kevin J. Ralofsky, MBA, Director effort to select authors who are knowledgeable in their fields. Marc R. Salzberg, MD, FACEP, Director However, JUCM does not warrant the expertise of any author in a particular field, nor is it responsible for any statements by such David Stern, MD, CPC, Director authors. The opinions expressed in the articles and columns are those of the authors, do not imply endorsement of adver- Amy Tecosky, Director tised products, and do not necessarily reflect the opinions or Lou Ellen Horwitz, MA, Executive Director recommendations of Braveheart Publishing or the editors and staff of JUCM. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested by authors should not be used by clinicians without evaluation of their JUCM The Journal of Urgent Care Medicine (www.jucm.com) is published through a part- patients’ conditions and possible contraindications or dan- gers in use, review of any applicable manufacturer’s product nership between Braveheart Publishing (www.braveheart-group.com) and the Urgent Care information, and comparison with the recommendations of Association of America (www.ucaoa.org). other authorities.
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JUCM CONTRIBUTORS
We have a trio of installment contributed by Michael B. Wein- authors from the stock, MD, and Ryan Longstreth, MD, FACEP, Department of who are also the co-authors, along with Grego- Emergency Med- ry L. Henry, MD, FACEP, of the book Bounce- icine at the Uni- backs! Emergency Department Cases: ED Returns versity of Arizona College of Medicine to thank for our lead (2006, Anadem Publishing, www.anadem.com). clinical article (Management of Patients Presenting with Drs. Weinstock and Longstreth work together Symptoms of Vulvovaginitis, page 11) this month: James at Mt. Carmel St. Ann’s Emergency Depart- Tiongson, MD is a resident; Samuel Keim, MD, whose clin- ment in Columbus, OH as attending physi- ical practice includes work in both the ED and urgent care set- cians. Dr. Weinstock is also clinical assistant tings, is associate head and residency director of the depart- professor of emergency medicine at The Ohio State Univer- ment; and Peter Rosen, MD, is clinical professor and a sity College of Medicine and has authored The Resident’s member of the JUCM Advisory Board. Guide to Ambulatory Care, the sixth edition of which is due out In addition, we’re later this year. pleased to be able to Several other regular contributors appear here fresh off publish an overview speaking engagements at the UCAOA’s Urgent Care Nation- of the second annual al Conference in Daytona Beach, FL last month. We’re grate- report of the UCAOA ful to Frank Leone, MBA, MPH; John Shufeldt, MD, JD, Survey Committee, MBA, FACEP; and David Stern, MD , CPC, for their dual sup- led by chair J. Dale port of JUCM and UCAOA, as well as to Nahum Kovalski, BSc, Key, who authored MDCM for contributing so generously to the Abstracts in the article (page 30). Mr. Key has spent the bulk of his career Urgent Care and Insights in Images departments. gathering expertise in healthcare management, and is admin- JUCM was also well represented at the conference by our istrator of Medac, a four-location urgent care and occupation- editor-in-chief, Lee Resnick, MD, who officially took office as al health practice in Wilmington, N.C. the new president of the association. As he pointed out in You may recall in April we introduced Bouncebacks, a Daytona Beach, we want this journal to reflect the perspec- semimonthly feature that recounts actual cases in which tive of as many readers as possible; be part of it by submitting patients were seen, discharged, and then “bounced back” for an article. It’s probably simpler than you think. Send an e-mail further evaluation and treatment. June sees the second to [email protected] and we’ll discuss! ■
To Submit an Article to JUCM the name, address, and contact information (mailing address, JUCM, The Journal of Urgent Care Medicine encourages you to phone, fax, e-mail) for each author. submit articles in support of our goal to provide practical, up- Before submitting, we recommend reading “Instructions for to-date clinical and practice management information to Authors,” available at www.jucm.com. our readers—the nation’s urgent care clinicians. Articles sub- mitted for publication in JUCM should provide practical To Subscribe to JUCM advice, dealing with clinical and practice management prob- JUCM is distributed on a complimentary basis to medical lems commonly encountered in day-to-day practice. practitioners—physicians, physician assistants, and nurse Manuscripts on clinical or practice management topics practitioners—working in urgent care practice settings in should be 2,600–3,200 words in length, plus tables, figures, the United States. If you would like to subscribe, please log on pictures, and references. Articles that are longer than this will, to www.jucm.com and click on “Free Subcription.” in most cases, need to be cut during editing. We prefer submissions by e-mail, sent as Word file attach- To Find Urgent Care Job Listings ments (with tables created in Word, in multicolumn format) If you would like to find out about job openings in the field of to [email protected]. The first page should include the title of urgent care, or would like to place a job listing, log on to the article, author names in the order they are to appear, and www.jucm.com and click on “Urgent Care Job Search.”
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FROM THE EXECUTIVE DIRECTOR The Crow and the Pitcher
■ LOU ELLEN HORWITZ, MA
“A thirsty crow found a pitcher with some water in it, but goes into our current survey method, we also realize that it so little was there that, try as she might, she could not is in its infancy and currently cannot be reliably translated reach it with her beak, and it seemed as though she into national trends in urgent care—which is what the indus- try sorely needs. would die of thirst within sight of the remedy. The UCAOA Board of Directors has made this a priority for At last, she hit upon a clever plan. the coming years, and significant resources have been allo- She began dropping pebbles into the pitcher, and with cated toward using proven outside researchers to develop each pebble the water rose a little higher until at last it and execute a survey program that will incorporate the reached the brim, and the knowing bird was enabled to rigor and breadth we are all looking for. quench her thirst.” One other problem with our benchmarking survey is that Moral: Necessity is the mother of invention. it only comes out once each year. The developing of detailed questions, gathering of responses, etc., take a lot of time and effort by the Benchmarking Committee members—all volun- his Aesop fable may be familiar to many of you. Also fa- teers—so right now once a year is all that is possible. How- miliar may be the feeling that the crow is having; many of ever, the committee has come up with a new survey Tyou have asked us, why is there virtually no data about ur- medium, called QuickPolls, that will provide a way for gent care centers out there? UCAOA members and website visitors to get regular snap- Regularly, I get calls like this: shots of information on an ongoing basis. “We are working on a business plan to open a center…” UCAOA’s new QuickPolls allow us to collect and share “We are considering investing in a new startup center…” data with you more often. While they are not scientifically rig- “We are trying to restructure the staffing for our center…” orous, QuickPolls will elicit anecdotal data on a variety of top- They all start differently, but they all end the same: “…and ics to let you see what's happening in other practices across I’ve been searching the Internet for hours and can’t find any- the country. These polls will ask one multiple-choice question thing on urgent care. I did find your site, however, and and instantly share the results to date when you vote. thought I’d call….” We plan to update the QuickPolls area at least once a These folks are all staring into the pitcher in the fable. month. However, the critical element in the success of the As you may know, for the past two years UCAOA has QuickPolls will be input—the more participants in the polls, conducted informal annual surveys of our constituents, the better the results. asking questions ranging from basic demographics to The polls should take no more than 30 seconds to respond billing and staffing. This has been our way of dropping to, so we hope that you will add a reminder to your calen- rocks into the pitcher, to help raise the water level a bit. dar to visit the website at least monthly to contribute to the This month, JUCM reports the results of the latest survey current QuickPoll. (page 30). If you have questions you’d like to see asked in a future While we appreciate all of the contributions and work that QuickPoll, e-mail me and we’ll add them into the lineup for a future poll. (Bear in mind that all questions must be mul- tiple choice.) Lou Ellen Horwitz is executive director of the Urgent Care Association of America. She may be But for now, sit back and take a long cool drink of infor- contacted at [email protected]. mation from our survey report—we hope it will start some dialogue in your practice and be a refresher for you as you head into the summer. ■
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Clinical Management of Patients Presenting with symptoms of Vulvovaginitis Urgent message: As the cause of approximately 10 million office visits in the United States annually, vulvovaginitis remains a common but important complaint seen in the urgent care setting.
Jansen Tiongson, MD, Samuel Keim, MD, and Peter Rosen, MD
Introduction organisms ordinarily prevents lthough numerous eti- the growth of pathogens. ologies account for vul- Lactobacillus, the predom- vovaginitis, the vast ma- inant bacteria found in the jority of cases are due to vagina, produces glycogen Abacterial vaginosis (BV), that is broken down to form trichomoniasis, and vulvo- lactic and acetic acids, thus vaginal candidiasis (VVC). favoring the growth of nor- BV causes 40% to 50% of all mal flora over pathogens by cases, while candidiasis and maintaining a pH of 4-5. trichomoniasis account for Normal flora produce nor- 20% to 25% and 15%-20%, mal vaginal secretions that respectively.1 Other notable range from being watery causes, such as atrophic/con- thin to a whitish thick dis- tact vaginitis and sexually charge. The disruption of the transmitted diseases, are be- normal balance in the mi- yond the scope of this re- croflora of the vagina leads view. This article presents a to the symptomology as-
review of practical concepts © Brian Evans cribed to vulvovaginitis. of evaluation and manage- Women often present with ment along with supportive data from current literature varying signs and symptoms, including vaginal dis- about the three main causes. charge, malodor, irritation, and itch. Often, urgent care physicians can narrow down the differential diagnosis Pathophysiology (Table 1) based on the descriptions provided by pa- The moist vaginal environment promotes the growth of tients. Systemic illnesses, antibiotic use, diet, immuno- various organisms. However, a balance between different suppression, and sexual practices can disrupt the normal
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MANAGEMENT OF PATIENTS PRESENTING WITH SYMPTOMS OF VULVOVAGINITIS
TABLE 1. Clinical Elements of Vulvovaginitis
Bacterial Vulvovaginal Clinical Elements Trichomoniasis Vaginosis Candidiasis Vaginal malodor + +/– – Thin, gray, Vaginal discharge Green-yellow White, curd-like Symptoms homogenous Vulvar irritation +/– + +
Dyspareunia – + –
Vulvar erythema – +/– +/– Bubbles in Signs + +/– – vaginal fluid Strawberry cervix – +/– +/–
Saline wet amount
Clue cells + – –
Motile protozoa – + –
Microscopy KOH test
Pseudohyphae – – +
Whiff test + +/– –
pH > 4.5 > 4.5 < 4.5
TABLE 2. form the wet preparation and 10% potassium hydrox- Questions to Ask ide (KOH) tests. Note that the wet mount is 80%-90% sensitive for diagnosing BV, 62% for trichomoniasis, Color of discharge Hygiene practice and 22% for VVC. 5 Amount of discharge Oral contraceptive/ IUD use Duration of symptoms Bacterial Vaginosis Recent antibiotics Association with menses Epidemiology Pregnancy status History of STDs Bacterial vaginosis, caused by the overgrowth of Gard- Current and previous Other medical history nerella vaginalis, Mycoplasma hominis, and other patho- partners genic bacteria with deprivation of Lactobacillus, affects nearly 5% of college women and 60% of those with sex- ually transmitted diseases. There is an increased preva- balance in the vaginal flora, and often precipitate vul- lence among divorced women over the age of 30.1 vovaginitis. Many risk factors predispose a patient to BV. For exam- Table 2 outlines the general questions to ask during ple, an increased number of sexual partners in the prior a history and physical examination, while Table 3 lists three months, along with a history of STDs, compound laboratory tests most helpful to diagnose the specific eti- the risk of developing BV.3 ology of vulvovaginitis. Table 4 describes how to per- Furthermore, habits such as vaginal douching at least
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MANAGEMENT OF PATIENTS PRESENTING WITH SYMPTOMS OF VULVOVAGINITIS
once a week are associated with increased risk, suggest- ing that daily habits play an important role in the de- TABLE 3. velopment of BV. Oral contraceptives and IUDs not Laboratory Tests to Order only diminish the risk of pregnancy but provide protec- Pregnancy test KOH wet prep tive factors against BV.2,3 BV occurs more often in black Nitrazine pH paper KOH whiff test Caribbean women and among women of lower socioe- Urinalysis GC/chlamydia DNA 4 conomic status. Saline wet prep probe
Presentation and Diagnosis The diagnosis of BV has been classically defined by Am- sel’s clinical criteria (Table 5). Amsel’s criteria include TABLE 4. both clinical signs and symptoms and laboratory find- Performing A Saline and KOH Wet Prep ings. These criteria have been shown to be 92% sensitive in diagnosing BV. Vaginal pH has the highest sensitivity 1. Obtain sample collected from posterior fornix dur- while a positive whiff test is most specific, although a ing a speculum examination 5 false positive can be seen with trichomoniasis. 2. Test pH of sample via nitrazine strip Anderson, et al report that the presence of a malodor- 3. Place fluid on one slide with saline drop, use 400x ous vaginal discharge indicates high likelihood of BV, power microscopy to look for trichomonads, clue while its absence essentially rules out the diagnosis. cells, pseudohyphae, lactobacillus, white blood cells Furthermore, moderate- to copious thin gray homoge- 4. Place fluid on another slide and add a drop of 10% nous discharge increases the likelihood ratio (LR) from KOH. Look for pseudohyphae and perform whiff 4.1 to 14, while normal-to-mild whitish discharge low- test for a fishy/amine odor ers the LR of BV to 0.11. The study also points out the following percentages of having BV per symptomology: Ⅲ 64% with thin gray homogenous vaginal discharge TABLE 5. Ⅲ 53% changes in discharge compared to normal Amsel’s Criteria For Diagnosing Bacterial Ⅲ 32% pruritus Vaginosis (3 of 4) Finally, the absence or scant presence of Lactobacillus in addition to the presence of clue cells under mi- Ⅲ Thin homogenous vaginal discharge croscopy raises the likelihood of BV, while normal lev- Ⅲ Vaginal pH higher than 4.5 els of the normal flora significantly drop the LR to 0.021 Ⅲ Positive whiff test for amine with KOH prep (Table 1). Ⅲ Clue cells on saline wet prep (Figure 1)
Treatment The World Health Organization recommends metron- idazole as the first-line therapy for the treatment of BV A similar efficacy can be expected with the 0.75% (Table 6). Metronidazole 500 mg twice daily for seven metronidazole vaginal gel used twice daily. The gel days has been the common therapy. Some have recom- eliminates BV at a rate of 83.7% after a two-week course. mended a one-time 2 g dose of metronidazole. A ran- Fewer GI symptoms are reported with the use of the gel. domized clinical trial reported in 2000, however, A patient’s menstruation status does not change the ef- showed that the one-time 2 g regimen is only 75% ef- fectiveness of the treatment. The vaginal gel, therefore, ficacious compared with the week-long 500 mg regi- is an attractive alternative for treatment of BV.6 The oral men, which has an efficacy rate of 85%-90%. week-long formulation is still highly recommended in Finally, the alternative dosing of 375 mg three times pregnant patients.7 Clindamycin 300 mg twice daily for daily has the same efficiency as the 500 mg dose, with seven days can also be used alternatively for those intol- fewer of the gastrointestinal side effects commonly as- erant of metronidazole. sociated with the use of metronidazole. However, the compliance of a three times vs. twice Special Considerations in Pregnancy daily regimen may not be as good. BV has been associated with pre-term labor, premature
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MANAGEMENT OF PATIENTS PRESENTING WITH SYMPTOMS OF VULVOVAGINITIS
rupture of membranes, sponta- Physical examination findings of- neous abortions, chorioamnioni- “No statistical ten include an erythematous vulva tis, post-partum endometritis and and vagina and a normal cervix post-Caesarean section wound in- upon speculum examination. The fection. As mentioned above, 500 difference exists presence of both the erythema and mg orally twice daily for seven curd-like discharge supports the di- days of metronidazole has been agnosis of VVC.1 recommended for the treatment between cure With the utilization of wet saline of BV in pregnancy. At present, and KOH prep, the diagnosis of metronidazole is considered safe VVC can be rapid and accurate un- to use during pregnancy. While der microscopy. The presence of the there may be a possible associa- rates for oral branching pseudo hyphae, along tion of premature birth and con- with a normal pH of 4-5 with ni- genital hydrocephalus, a consen- trazine paper, has a sensitivity of sus has not been determined to vs. intravaginal 38%-83%. The absence of pseudo- show the link between metron- hyphae on microscopy, therefore, idazole and complications in does not exclude the diagnosis. Of- pregnancy.8-10 topical agents.” ten, VVC is diagnosed clinically. A Gram’s stain and Sabouraud’s agar Vulvovaginal Candidiasis culture both reach nearly 100% in sensitivity, but the lo- Epidemiology gistic impracticality of these tests often negates their uti- As the second most common cause of vulvovaginitis, lization in the urgent care setting.13 vulvovaginal candidiasis (VVC) affects nearly every three out of four women sometime during their lifetime. Treatment Furthermore, nearly 10% of women will experience re- A single dose of oral 150 mg fluconazole is clinically and peated attacks without any obvious precipitating factors. microbiologically efficacious in the treatment of VVC Ninety percent of cases are due to Candida albicans, but (Table 6). Fluconazole is also the recommended ther- other Candida species, such as glabrata and tropicalis, apy for recurrent attacks in the following regimen: 150 have been implicated with VVC. Major risk factors in mg every other day for three doses followed by weekly the development of VVC include previous history of 150 mg doses for six months. This therapy is effective VVC, recent utilization of broad-spectrum antibiotics, in more than 80% of women who experience recurrent diabetes mellitus, AIDS, and the use of immunosuppres- bouts of VVC.14 sive therapies.11,12 Alternatively, numerous intravaginal topical agents are available both over the counter and by prescription. Presentation and Diagnosis These agents include imidazoles (clotrimazole, micona- Much like other causes of vulvovaginitis, VVC patients zole, and terconazole) and nystatin. A recent Cochrane present with a vaginal discharge, which in candidiasis database systematic review study reports that no statis- is often described as cheesy, curd-like, and thick (Table tical difference exists between the cure rates when com- 1). The occurrence of such a discharge makes it more paring oral versus an intravaginal topical agent. How- likely to be VVC when compared to a watery discharge. ever, the study also notes that oral administration Furthermore, the presence of vulvar itching increases remains the preferred route in non-pregnant women the likelihood of VVC (LR of 1.4-3.3), compared with its due to safety, cost, and patient treatment preference. absence. Pregnant patients are advised to use the topical agents In contrast to trichomoniasis and BV, the presence of for seven days rather than oral medication, as the imi- malodor decreases the probability of diagnosis of VVC dazole topical agents have been shown to have a cure (LR 0.35). Lack of odor is consistent with candidiasis. rate of 85%-100% in pregnancy while oral drugs such as Also, unlike the other causes of vulvovaginitis, women fluconazole can be associated with GI intolerance, rash, often can self-diagnose VVC due to its classical sympto- and headache.15 Despite repeated use in some patients, mology, which shows the greatest likelihood (LR 3.5) of utilization of fluconazole and the various imidazoles having VVC based on history alone in studies reviewed. (clotrimazole, miconazole, and ketoconazole), fungal re-
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MANAGEMENT OF PATIENTS PRESENTING WITH SYMPTOMS OF VULVOVAGINITIS
TABLE 6. Treatment Options for Vulvovaginitis
First Line Alternatives Recurrent Bouts Pregnancy (non-pregnant) (non-pregnant)
Bacterial Vaginosis Metronidazole Metronidazole 375 mg N/A Metronidazole 500 mg 500 mg BID po 7 days TID po 7 days BID po 7 days Metronidazole 0.75% vaginal gel BID 7 days Metronidazole 2 g po x 1 Clindamycin 300 mg twice daily for 7 days
Trichomoniasis Metronidazole 2g po x 1 Metronidazole 500 mg N/A Metronidazole 500 mg (remember to treat BID po 7 days BID po 7 days sexual partners) Tinidazole 2 g po x 1 Vulvovaginal Fluconazole 150 mg po Miconazole 200mg Fluconazole 150 mg Any except fluconazole Candidiasis x 1 vaginal suppository every other day po for qhs x 3d 1 week, then weekly for Miconazole 2% vaginal 6 months cream qhs x 7 d Butoconazole 2% vaginal cream x 1 Terconazole 80 mg vaginal suppository qhs x 3 d Terconazole 0.4% vaginal cream qhs x 7 d Clotrimazole 2-100 mg tablets intravaginally x 3 days Clotrimazole 1% cream qhs x 14 d
sistance is rare with only 3.7%-5.7% resistance shown Laboratory testing for other STDs, therefore, remains in a study published in 2005.16 Boric acid suppositories part of the recommended workup in vulvovaginitis. may be as effective oral itraconazole in treating both Furthermore, its status as an STD increases its occur- acute and recurrent disease.17 rence among premenopausal women, with a preva- lence of 2.3% and 4% in 18-24-year-olds and 4% in Trichomonas Vulvovaginitis those 25 and older. This disease can go undetected for Epidemiology months, and while the efficacy of treatment remains With nearly 120-180 million women affected annu- high, re-infection remains very common. ally worldwide, trichomoniasis remains a common Unlike other major causes of vulvovaginitis, the cause of vulvovaginitis.18,19 Classified as an STD, Tri- prevalence of trichomoniasis seems to be associated chomonas vaginalis typically is a coinfection with other with ethnicity: prevalence is highest in blacks (6.9%) venereal disease, especially gonorrhea and chlamydia. and lowest among Caucasians (1.2%).20,21
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MANAGEMENT OF PATIENTS PRESENTING WITH SYMPTOMS OF VULVOVAGINITIS
However, the cost and availabil- TABLE 7. ity of this examination limits its Comparison of pH vs. Treatment use in the urgent care setting. For better sensitivity and specificity, a Etiology pH Treatment XenoStrip-Tv for T vaginalis test Bacterial Vaginosis > 4.5 Metronidazole can be performed. However, this Trichomoniasis > 4.5 Metronidazole test is limited due to length, and its utilization in the urgent care set- Vulvovaginal Candidiasis = 4.5 Fluconazole ting is presently impractical.22
Treatment Presentation and Diagnosis The Centers for Disease Control and Prevention recom- Like the other major causes of vulvovaginitis, trichomo- mends a single dose of 2 g of metronidazole (Table 6). niasis often presents with a vaginal discharge (Table 1). Unlike the treatment for BV, this regimen has a greater It is often described as a yellow-gray-green-frothy secre- cure rate—90%-95%—compared with the week-long tion with an unpleasant odor. Having a yellowish dis- treatment of either 250 mg TID or 375 mg BID of charge, as opposed to other colors, makes trichomoni- metronidazole. The use of a single-dose therapy in the asis 14 times more likely to be the diagnosis. Similarly, treatment of trichomoniasis increases compliance, and only 10% will present with frothy discharge. However, still provides cures. Treatment of the partner with the a recent study showed that only 42% of infected women same regimen is recommended, although further re- presented with the discharge noted above. Other symp- search should focus on developing effective partner toms suggesting trichomoniasis include malodor and treatment strategy.18 symptoms worse after menses. Unfortunately, 50% of Although the association of pre-term labor and pre- women will not present with malodor, but in the cases mature rupture of membranes is significantly lower that do, the whiff test performed under KOH prep can than that seen with BV, treatment with metronidazole be a false positive. effectively eliminates such risks during pregnancy in re- With regard to physical examination, the most spe- lation to trichomoniasis.23 cific sign of trichomoniasis is colpitis macularis, or Of note, although resistance to metronidazole still re- strawberry cervix. Described as punctuated hemorrhages mains uncommon, other azoles such as tinidazole and with occasional vesicles or papules, this finding is rarely clotrimazole cream when used topically in a seven-day detected without colposcopy, and is seen in only 22%- course have been proven to be effective alternatives.24 37% of women.1 Laboratory examinations include pH testing and wet Summary saline/KOH preparations. Speculum samples will pres- Vulvovaginitis is common in the urgent care setting. Af- ent with a pH >4.5 as well as findings of flagellated or- fected patients will present with varying degrees of ganisms under a wet saline mount. The sample should vaginal discharges and odors. After a history and phys- be read under a slide within 20 minutes of preparation ical examination, adjunctive tests such as wet prepara- to avoid deterioration of the protozoa. This method of tions, microscopy, pH, and whiff tests can easily aid in confirming Trichomonas is only 40%-60% sensitive; differentiating between the three main etiologies of thus, the absence of the protozoa under microscopy vulvovaginitis. Although laboratory tests can confirm does not necessarily rule out the disease. the diagnosis, the clinical signs and symptoms are often More sensitive and specific to diagnosing trichomo- accurate enough for diagnosis. One simple strategy is niasis is the latex agglutination test. A Trichomonas an- shown in Table 7. tibody or antigen, attached to latex beads, is mixed Special considerations must be taken with pregnant with the speculum sample. If the protozoan reacts with patients. When treated appropriately, vulvovaginitis of- the latex bead complex, then an agglutination reaction ten resolves without any sequelae in the majority of occurs. Results are available within 10 minutes to an women. ■ hour. This test is 98.8% sensitive and 92.1% specific compared with a wet mount preparation. References for this article are available at www.jucm.com.
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Bouncebacks The Case of an 18-Year-Old Male with Hand Pain Urgent message: A thorough history and physical exam are essential to positive outcomes and risk reduction when managing patients with hand injuries. Michael B. Weinstock, MD and Ryan Longstreth, MD, FACEP
ouncebacks, in which we recount scenar- as a benign problem—or patients likely to ios of actual patients who were be litigious. Examples include high-risk evaluated in and discharged discharge diagnoses such as chest pain, from an emergency depart- fever and headache, abdominal pain, up- Bment or urgent care facility set patients, patients who have issues and then “bounced back” for fur- with billing, a long wait, or unmet ex- ther treatment, appears semi- pectations, and patients who have monthly in JUCM. bounced back. Case presentations on each patient, along with Step 2 case-by-case risk manage- Review the chart before the pa- ment commentary by Gre- tient leaves the urgent care gory L. Henry, past presi- clinic. Affirm consistent docu- dent of The American mentation between the nurse/ College of Emergency Physi- tech and physician, address cians (ACEP), and discus- all documented complaints sions by other nationally rec- in H&P, confirm that the ognized experts are detailed history is accurate, review in the book Bouncebacks! © Barton Stabler / Images.com potentially serious diag- Emergency Department Cases: noses, explore abnormal ED returns (2006, Anadem findings, write a progress Publishing, www.anadem.com). note explaining the medical The focus of the JUCM series will decision-making process (if un- be a two-step process designed to improve pa- clear from the H&P), and assure tient safety and reduction in legal risk in an urgent that aftercare instructions are specific care practice: and that follow-up is timely and available. This month’s case highlights several patient care and Step 1 risk management principles. Identify high-risk patients—specifically, patients with On the surface, it seems straightforward: An 18-year- the potential for serious medical illness masquerading old presents with a hand laceration which is repaired,
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THE CASE OF AN 18-YEAR-OLD MALE WITH HAND PAIN
after which the patient is advised to follow up with a 0.5% Marcaine, prep, drape, thorough irrigation with plastic surgeon. sterile saline and explored. The extensor tendon was in- However, a closer look reveals some serious inconsis- tact, but the tendon sheath was frayed. Cleaned again tencies and missed information—not seeing the forest with 10% betadine solution. Two loose 4-0 ethilon su- for the trees, as it were. tures were placed to the skin. Ancef 1 g IM and dT. This case brings the two-step approach into clear res- Wound dressed with polysporin, adaptic and a volar olution. See how many “red flags” you can spot and if OCL splint. you would have done anything differently. Diagnosis An 18-Year-Old Male with Right Hand Pain Right hand laceration, 15 hours old, with cellulitis. Initial Visit (Note: The following is the actual documentation of the Disposition providers, including punctuation and spelling errors.) The patient was discharged to home ambulatory at 13:37. Prescription for Keflex. Referral to a plastic sur- CHIEF COMPLAINT (at 11:02): Right hand pain geon to follow up in a couple of days and return to the Time Temp Pulse ED with worsening symptoms or if unable to get in to 11:12 96.6 66 see Plastic Surgeon. Resp Syst Diast 16 110 68 Phone call to ED the next day: Patient called the next day (1 day after initial ED presentation) with complaints of HISTORY OF PRESENT ILLNESS (at 11:20): 18 swelling of the hand and fingers and pain. Has been taking year old male without a significant PMH presents with Advil because he cannot afford Rx. Advised to return to the complaints that he was messing around with some ED to be checked. friends the night before and they were close to a brick wall and a brick was loose and came down and landed on the dorsum of his right hand over the third MCP Discussion of Documentation and Risk Management joint. The injury occurred 15 hours prior to the ED Issues at Initial Visit presentation. He complains of edema and redness and Error 1 a laceration. Also c/o limited movement of the finger Error: Failure to recognize a laceration over the MCP as with pain with flexion and extension. No c/o fever, a likely clenched fist injury (CFI)/“fight bite.” The pa- chills, night sweats. No allergies. Tetanus unknown. tient provides a questionable mechanism for his injury (“a loose brick fell out of the wall”). PAST MEDICAL HISTORY/TRIAGE: Intervention: Use open-ended questions to obtain Medication, common allergies: None a clear and accurate history. A patient may be hesitant PMH: None to reveal he/she punched someone in the mouth; PSH: None once the physician builds rapport, this information may be easier to discover, leading to improved patient EXAM (at 11:23): care. Use friends and family, as well, to gather a more General: Alert and oriented, no acute distress accurate history. Ext: 1 cm laceration over the third MCP joint on the Teaching point: Don’t take the complaint at face value; dorsum and edema and erythema and swelling be- if the history and exam don’t make sense, dig deeper. tween the second and fourth metacarpal clear to the base of the metacarpals; even passive ROM of the third Error 2 MCP causes pain with both flexion and extension Error: Failure to consider tenosynovitis or deep fascial Skin: No red streaks space infection of the hand. The patient states the in- Neurovasc: Cap refill brisk. Sensation WNL jury occurred only 15 hours prior to presentation, and he had already developed erythema of the second ORDERS/RESULTS (at 11:58): XR negative for fracture through fourth metacarpals, with associated limited finger movement. The physician documented pain PROGRESS NOTES (at 12:45): Anesthetized with with passive flexion and extension of the third MCP,
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THE CASE OF AN 18-YEAR-OLD MALE WITH HAND PAIN
and an associated frayed tendon sheath. recommendations. An expensive (or even relatively Intervention: The time frame presented suggests a inexpensive in this case) medication is useless if the pa- rapidly progressing infection. Kanavel first described the tient doesn’t have the resources to obtain the medicine. four cardinal signs of flexor tenosynovitis in 1939: 1) Make sure the patient has insurance or financial means pain on passive extension, 2) tenderness along the to pay for the medicine; if not, explore other ways for flexor tendon, 3) symmetric edema of the involved fin- treatment to occur. ger, and 4) flexed resting posture of finger. Early in the Teaching point: Make sure the patient has the abil- course, a patient may not exhibit all four signs; this pa- ity to obtain the medication in a timely manner. tient initially had at least two. Consideration of this condition in the differential will An 18-Year-Old Male with Hand Pain lead to more aggressive management and improved Return Visit—Five Days Later patient outcome. Returned five days later with chief complaint of in- Teaching point: The clinical picture suggests a deeper creased hand pain and drainage after his girlfriend infection, given the time frame and physical exam find- kicked his wound. He had not filled his Keflex. ings. Hand infections are high risk and must be aggres- Temperature was 100.3 and he seemed “very uncom- sively managed. fortable,” with a grimace on his face. Had purulent drainage from the wound with ex- Error 3 treme pain on range of motion (ROM) of the metacar- Error: Primary closure of an infected wound. The pa- pophalangeal (MCP) joint and pain along the tendon. tient’s laceration and associated cellulitis with a frayed IV Unasyn (ampicillin and sulbactam) was adminis- tendon was closed primarily, 15 hours after the injury. tered and he was admitted to plastics with a tendon Intervention: All CFIs should be left open, dressed, sheath infection vs. MCP septic arthritis. and splinted in position of function. CFIs have high Taken to the OR the next morning and he was found rates of associated tenosynovitis (22%) and septic arthri- to have a large extensor tendon laceration with ex- tis (12%). Subsequently, all CFIs or potential CFIs should posed joint and pus within the joint space. be reevaluated in one to two days. Cultured Eikenella species and Strep viridans, suggest- Teaching point: Don’t perform primary closure on an ing human bite wound. infected wound (or CFI). Summary of Case and Risk Management Principles Error 4 Patients presenting with hand injuries are common in Error: Failure to prescribe the appropriate antibiotic(s). urgent care medicine and are a potentially high-risk A first-generation cephalosporin is adequate for celluli- group. To ensure patient safety and minimize medical- tis but not for infected CFIs. legal exposure, the urgent care practitioner must obtain Intervention: Most infected CFIs are polymicrobial, an accurate history and perform a thorough physical requiring both aerobic and anaerobic coverage. Staphlo- exam. coccus and Streptococcus are still the two most common Our patient was initially diagnosed with an infected causes, but other bacteria, including Eikenella, may also hand laceration; unfortunately, the potential for CFI and be cultured. This patient was prescribed Keflex deep infection was not considered. His mechanism and (cephalexin), inadequate coverage for oral flora; Aug- physical exam findings were not consistent. Clues on mentin (amoxicillin/clavulanic acid) would have been the initial visit indicated that the patient had a poten- a better choice. tially serious problem; it is unusual to develop a simple Teaching point: Choose an antibiotic appropriate for cellulitis within 15 hours of a finger laceration, and the the specific type of wound. provider noted tendon injury, with significant pain with range of motion. Error 5 Cephalexin was prescribed, which is problematic for Error: Failure to address pertinent social issues. The pa- a couple of reasons: tient called the ED the next day because he could not First, an infected fight bite is most often polymicro- afford his antibiotics and was forced to return. bial, requiring more broad-spectrum coverage, and Intervention: A good patient disposition includes as- amoxicillin/clavulanic acid (Augmentin) would be a surance that the patient can follow through with your more appropriate choice.
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A TWO-STEP APPROACH TO AVOIDING A BOUNCEBACK
Second, the patient never actually filled the prescription due to lack of financial resources. We must consider social issues when disposi- tioning patients; in the urgent care environ- ment, we have only one chance to get it right! Finally, wound care of this patient was in- appropriate; an infected wound or CFI is best managed without primary closure, due to con- cern for potential infectious complications. The patient did return with a deep hand infec- tion that required operative debridement. A quick review of the patient’s chart before he left at the initial visit may have avoided this bounceback. ■
Suggested Readings Ⅲ Basadre JO, Parry SW. Indications for surgical de- bridement in 125 human bites to the hand. Arch Surg. 1991;126:65-67. Ⅲ Bunzli WF, Wright DH, Hoang AT, et al. Current management of human bites. Pharmacotherapy. 1998. 18(2):227-234. Ⅲ Perron AD, Miller MD, Brady WJ. Orthopedic pitfalls in the ED: fight bite. Am J Emerg Med. 2002;20(2);114- 117. Ⅲ Eilbert WP. Dog, cat, and human bites: providing safe and cost-effective treatment in the ED. Emerg Med Prac. 2003;5(8):1-20. Ⅲ Callaham ML. Controversies in antibiotic choices for bite wounds. Ann Emerg Med. 1988;17(12):1321- 1330. Ⅲ Chadaev AP, Jukhtin VI, Butkevich AT, et al. Treat- ment of infected clenched-fist human bite wounds in the area of metacarpophalangeal joints. J Hand Surg. [Am] 1996;2(21):299-303. Ⅲ Harrison BP, Hilliard MW. Emergency department evaluation and treatment of hand injuries. Emerg Med Clin North Am. 1999;17:793-822. Ⅲ Mayo DD, Mayo KP, Matta A. Emergency depart- ment management of dog, cat and human bite wounds. Crit Dec Emerg Med. 2001;16(2):1-6. Ⅲ Brook I. Microbiology and management of human and animal bite wound infections. Prim Care. 2003;30(1):25-39. Ⅲ Mennen U, Howells CJ. Human fight-bite injuries of the hand. J Hand Surg. [Br] 1991;16B(3):431-435. Ⅲ Gilbert DN, Moellering RC Jr, Eliopoulos GM, et al. Eds. The Sanford Guide to Antimicrobial Therapy, 34th ed. Hyde Park, VT:2004. Ⅲ Thomas EJ, Burstin HR, O’Neil AC, et al. Patient non- compliance with medical advice after the emergency department visit. Ann Emerg Med. 1996;27(1):49-55.
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ABSTRACTS IN URGENT CARE On Radiography in Acute Bronchitis, Rehydrating Children with AGE, Declining Antibiotic Scripts in URIs, and Diagnosing Venous Thromboembolism
■ NAHUM KOVALSKI, BSc, MDCM
ach month, Dr. Nahum Kovalski will review a handful of abstracts from, or relevant to, urgent care practices and practitioners. EFor the full reports, go to the source cited under each title.
Evaluation of the Utility of Radiography in cases). A total of 246 children (92.8%) had simple radi- Acute Bronchiolitis ographs, and 17 radiographs (6.9%) were complex. To iden- Key point: Infants with typical bronchiolitis (clinically tify one inconsistent and one complex radiograph requires O2sat>92% and mild/moderate distress) do not need imaging 133 and 15 children, respectively. imaging. Of 148 infants with oxygen saturation >92% and a respi- Citation: Schuh S, Lalani A, Allen U, et al. J Pediatr. 2007;150: ratory disease assessment score <10 of 17 points, 143 (96.6%) 429-433. had a simple radiograph, compared with 102 of 117 infants URL: http://sitemaker.umich.edu/emjournalclub/article_database/ (87.2%) with higher scores or lower saturation (odds ratio, da.data/1619753/PDF/bronchiolitis_xray_j_pediatrics.pdf 3.9). Seven infants (2.6%) were identified for antibiotics pre- radiography; 39 infants (14.7%) received antibiotics post-ra- The purpose of this study was to determine the proportion diography. of radiographs inconsistent with bronchiolitis in children Infants with typical bronchiolitis do not need imaging be- with typical presentation of bronchiolitis and to compare rates cause it is almost always consistent with bronchiolitis. Risk of intended antibiotic therapy before radiography versus of airspace disease appears particularly low in children with those given antibiotics after radiography. saturation higher than 92% and mild to moderate distress. ■ The authors conducted a prospective cohort study in a pedi- atric emergency department of 265 infants aged 2 to 23 months Intravenous Dextrose During Outpatient with radiographs showing either airway disease only (simple Rehydration in Pediatric Gastroenteritis bronchiolitis), airway and airspace disease (complex bronchioli- Key point: Patients who received no IV dextrose had 3.9 tis), or inconsistent diagnoses (e.g., lobar consolidation). times the odds of having a return visit with admission The rate of inconsistent radiographs was 0.75% (two of 265 than those who received some dextrose. Citation: Levy JA, Bachur RG. Acad Emerg Med. Volume 14, Number 4:324-330 (published online before print February 12, Nahum Kovalski is an urgent care practitioner and as- sistant medical director/CIO at Terem Immediate Med- 2007). ical Care in Jerusalem, Israel. URL: http://www.aemj.org/cgi/content/abstract/14/4/324
The point of this study was to determine whether the amount
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ABSTRACTS IN URGENT CARE
of IV dextrose administered is related to a return visit with ad- Approximately 23.4 million ED visits resulted in a diagno- mission (RVA) in children with acute gastroenteritis (AGE) and sis of URI between 1993 and 2004. Although the proportion dehydration, and to determine which clinical, laboratory, of URI diagnoses remained relatively stable, a significant de- and treatment parameters are associated with an RVA. crease in provision of antibiotic prescriptions for URIs oc- The investigators performed a case control study of chil- curred during this 12-year period, from a maximum of 55% dren aged 6 months to 6 years who presented to an urban ED in 1993, to a minimum of 35% in 2004. Patients who were with AGE and dehydration and who received IV rehydration prescribed antibiotics were more likely to be white than before discharge from the ED. Cases were defined as those African American and to have been treated in EDs located in patients who had an RVA within 72 hours of an original visit the southern United States. for ongoing symptoms. Controls were defined as those pa- Antibiotic prescribing for URIs continues to decrease, a fa- tients who met inclusion criteria, but who did not have an vorable trend that suggests that national efforts to reduce in- RVA. The authors studied whether the amount of IV dextrose appropriate antibiotic usage are having some success. Nev- administered at the initial visit was related to an RVA, as well ertheless, the frequency of antibiotic treatment for URI in the as which other clinical and treatment parameters were asso- ED remains high (35%). ■ ciated with an RVA. A total of 56 cases and 112 controls were studied. Patients Current Diagnosis of Venous who had an RVA received significantly less IV dextrose Thromboembolism in Primary Care: (mean: 399 mg/kg vs. 747 mg/kg, p < 0.001) than those who A Clinical Practice Guideline from the did not have an RVA. Patients who received no IV dextrose American Academy of Family Physicians had 3.9 times greater odds of having a return visit with ad- and the American College of Physicians mission than those who received some dextrose. Controlling Key point: New evidence and recommendations may aid in for fluid volume, the amount of dextrose administered re- early diagnosis of venous thromboembolism. mained statistically significant by logistic regression; for Citation: Qaseem A, Snow V, Barry P, et al. Ann Int Med. 2007; every 500 mg/kg of IV dextrose administered, the patient 146(6):454-458. was 1.9 times less likely to have an RVA. Patients with length URL: www.annals.org/cgi/content/full/146/6/454 of symptoms less than or equal to one day were more likely to have an RVA than were those with symptom length of two This guideline summarizes the current approaches for the di- or more days. agnosis of venous thromboembolism. The importance of Administration of larger amounts of IV dextrose is associ- early diagnosis to prevent mortality and morbidity associated ated with fewer return visits requiring admission in children with venous thromboembolism cannot be overstressed. This with gastroenteritis and dehydration. ■ field is highly dynamic, however, and new evidence is emerg- ing periodically that may change the recommendations. The Declining Antibiotic Prescriptions for purpose of this guideline is to present recommendations Upper Respiratory Infections, 1993–2004 based on current evidence to clinicians to aid in the diagno- Key point: Antibiotic prescribing for URIs continues to sis of lower extremity deep venous thrombosis and pul- decrease. monary embolism. Citation: Vanderweil SG, Pelletier AJ, Hamedani AG, et al. Acad Emerg Med. Volume 14, Number 4:366-369 (published Recommendations: online before print February 12, 2007). Ⅲ Validated clinical prediction rules should be used to esti- URL: www.aemj.org/cgi/content/abstract/14/4/366 mate pretest probability of venous thromboembolism (VTE), both deep venous thrombosis (DVT) and pul- Data were compiled from monary embolism, and for the basis of interpretation of the National Hospital Am- subsequent tests. bulatory Medical Care Sur- Ⅲ In appropriately selected patients with low pretest prob- vey (NHAMCS). URI visits ability of DVT or pulmonary embolism, obtaining a high- were identified by using sensitivity D-dimer is a reasonable option, and if negative ICD-9-CM code 465.9, indicates a low likelihood of VTE. whereas antibiotics were Ⅲ Ultrasound is recommended for patients with intermediate- identified using the Na- to-high pretest probability of DVT in the lower extremities. tional Drug Code Directory Ⅲ Patients with intermediate or high pretest probability of pul- class “Antimicrobials.” monary embolism require diagnostic imaging studies. ■
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INSIGHTS IN IMAGES CLINICAL CHALLENGE: CASE 1
In each issue, JUCM will challenge your diagnostic acumen with a glimpse of x-rays, electrocardiograms, and photographs of dermatologic conditions that real urgent care patients have presented with. If you would like to submit a case for consideration, please e-mail the relevant materials and present- ing information to [email protected].
FIGURE 1
The patient is a 15-year-old boy who presents with pain in the wrist 40 minutes after stopping a soccer ball with his hand. There is no snuffbox tenderness.
View the x-ray taken (Figure 1) and consider what your diagnosis and next steps would be. Resolution of the case is described on the next page.
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INSIGHTS IN IMAGES: CLINICAL CHALLENGE 1 THE RESOLUTION
FIGURE 2
The correct reading of the x-ray is: fracture of the ulnar styloid and Salter-Harris Type 1 fracture of the distal radius, with significant displacement of the epiphysis.
Type 1 Salter-Harris fractures are distinguished by complete separation of the growth plate from the metaphysis; such fractures of the distal radius are common, though ulnar involve- ment is not.
This patient was referred to the hospital for further evaluation and treatment.
Acknowledgment: Case presented by Nahum Kovalski, BSc, MDCM.
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INSIGHTS IN IMAGES CLINICAL CHALLENGE: CASE 2
FIGURE 1 The patient is a young child with three days of constipation with a non-specific history of abdominal pain. On exam, the child was asleep. The abdomen was easily palpable and soft.
View the x-ray taken (Figure 1) and consider what your diagnosis and next steps would be. Resolution of the case is described below.
THE RESOLUTION
FIGURE 2 The finding in the left upper quadrant is a concern. The bowel is dilated and cannot be identified clearly as being the small or large bowel. Also, there is a “loop”-like form to this distended bowel.
This finding is most likely pathological and is consistent with intussusception. With such a finding, even with an asymptomatic child, it is best to refer.
Acknowledgment: Case presented by Nahum Kovalski, BSc, MDCM.
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Urgent Care Industry Addressing the Data Drought
Urgent message: The second UCAOA Benchmarking Survey takes one small step toward filling the information gap in urgent care medicine.
J. Dale Key, UCAOA Benchmarking Committee Chair
lthough the practice of Among the issues covered urgent care medicine is in the first survey were hours not a new phenomenon, of operation, ownership there is a significant ab- structure, payor data, per-pa- Asence of reliable informa- tient charges, and more. tion about the industry. While UCAOA members One first step toward fill- are the first to see the results, ing that void was initiated the association’s perspective last year when the Urgent is that the survey can play a Care Association of Amer- small role in addressing the ica’s Benchmarking Com- information needs of the en- mittee released the results of tire urgent care industry. its first-ever benchmarking survey of UCAOA mem bers An Overview and others in the industry. The latest survey was sent to Results of this year’s survey individuals representing were released during the 1,200 urgent care practices UCAOA Annual Conven- in the United States, with a
tion in Daytona Beach, FL, DePrenda Digital composite: Tom iStockPhoto.com; © Photos: response rate of 13.4%. (For last month. purposes of the survey and Both surveys share the common goal of beginning this article, a “practice” is defined as the total medical to gather data in specific areas of interest to urgent operation, while the word “clinic” will be used to de- care owners, administrators, and practitioners. More scribe a single, individual location; in other words, a rigorous study and surveys of greater depth are a pri- practice may consist of any number of clinics under the ority for UCAOA and are planned for the upcoming same practice ownership). Respondents hailed from 40 years. states, with the majority representing Florida, Michi-
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ADDRESSING THE DATA DROUGHT
gan, Ohio, Texas, California, Staffing arrangements with Georgia, and Illinois. Distribution physicians are split almost One of the important tenets 1,200 urgent care practices in the U.S. evenly between two models: of the committee’s strategy is Ⅲ employed practitioners to ask some identical questions Response rate (50%), and from year to year so, over years 13.4% Ⅲ a combination of inde- to come, trend lines might be pendent contractors (26%) identified in certain areas. Areas covered and a mix of employed One of those areas pertains Urgent care structure and organization practitioners and inde- to the corporate structure of the Facilities and operations pendent contractors (24%). practices (i.e., who owns them?). Patients and staffing A similar ratio exists among Results in 2006 indicated that Patient record charting mid-level providers, with a about 47% of the responding Financial slight advantage going to em- practices were “freestanding” Profitability ployed practitioners at 65%, and 26% were “hospital- and independent contractors or owned.” One year later, the free- mixed splitting the remaining standing practices continue to percentage. UCAOA Benchmarking Committee pull ahead of the hospital-based Some of the most eagerly an- Trina Danielsen, RN, St. Joseph Urgent Care practices, moving to 53% while in Sonoma County, CA ticipated results were the ratios hospitals fell to 23%. Kevin DiBenedetto, MD, Convenient Care, LLC of different levels of staff to each The survey also posed a new in Baton Rouge, LA other. For example, responding question about whether practices Lou Ellen Horwitz, MA, practices, on average, employ were established as for-profit or UCAOA Executive Director 3.47 physician assistants (PAs) not-for-profit ventures—and Cindi Lang, RN, DocNow Urgent Care or nurse practitioners (NPs) and 74% of respondents report that in Rochester Hills, MI 2.37 registered nurses (RNs) for their practices are for-profit. The Dale Key, Medac Health Services, PA every one physician. majority (55%) of responding in Wilmington, NC For every RN hour, there are practices are also “solo” practices, 0.46 hours of clerical staff time, meaning they are a one-site op- and there are 2.21 radiology eration. Only 9% claim more than six clinics. technician hours spent to every PA or NP hour. While And while those clinics are busy, the average num- these are complex calculations averaged over all respond- ber of patients per clinic among the respondents has ing practices, they will probably not hold true for all prac- actually declined since the 2006 survey, falling to ap- tices. Nonetheless, these results can be a good place for proximately 9,923 per clinic per year from last year’s practices to start when looking at their own ratios. figure of 15,455. The perceived drop-off in patients-per- clinic could be a statistical anomaly grounded in the Time Spent Per Patient growth of the industry, however; an increase in the Another interesting finding concerns time spent per pa- number of clinics that have been in business for a short tient by different practice staff; these data show where period of time may be driving down the overall patient the time of these individuals is going during a typical per clinic average. patient visit. Physicians at responding clinics are spending approx- Staffing Models imately 19 minutes per patient, on average. Nursing as- Of the many questions posed to UCAOA staff, board sistants claimed the most time, edging out physicians members, faculty, and forum participants, the most by only one minute, with clerical/registration staff prevalent concern staffing of urgent care practices: How bringing up third with 17 minutes. do you decide how many physicians you need? How many mid-levels? In what ratio? This year’s survey pre- The Business of Medicine sented at least a snapshot of how participating practices Another area of the survey focused on the financial side are staffed, currently. of urgent care practice. How and when are practices
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ADDRESSING THE DATA DROUGHT
charging their patients? Who’s paying for the care? Are urgent care practices profitable? The results indicate that most practices (60%) $ charge patients as a part of registration. However, who LEARN HOW TO actually pays for the care is much more spread out. With regard to governmental payors: the ma- INCREASE$ jority of respondents reported that Medicare re- ceives only about 10% of their charges, and CASH FLOW Medicaid even less. WITH$ BDA’s Private insurance is much more prevalent, with 67% of respondents billing private insurance compa- DOCUMENTATION nies between 30% and 70% of the time. Private pay AND CODING makes up less than 20% of most practices, with SPECIALISTS! workers compensation accounting for similar levels. $ To bill and collect the patient fees, the vast major- $ ity (77%) of responding practices currently use in- house staff vs. contracting with outside vendors, to SCHEDULE$ YOUR varying levels of success. Only 22% are collecting over $ 90% of their charges, and fully 41% of practices are FREE collecting 70% or less. About half of the responding $ practices offer a “prompt” pay discount (generally, no CODING$ more than 20% off if paid in full at time of service). The good news is, almost everyone who re- $ sponded is profitable, or at least breaking even (66% ANALYSIS and 20%, respectively). The bad news is, if an ur- $ $ gent care practice is not in the black yet, it may take TODAY! a while according to these results, as 30% of prac- tices responding took longer than one year to reach $$$ profitability. Almost 10% made it in less than three Contact BDA at months, however, and the results here show that (800) 783-8014 after the first clinic is profitable, the second can $$ reach profitability much more quickly—54% of to register$ for those made it in less than nine months. When it comes to reimbursement, only 16% of $your $ respondents are being reimbursed using problem- organization’s based coding. The moral of that story: Efforts to- $ ward more customized reimbursement for urgent $$ care still have a long way to go. FREE Coding Analysis. While the same could be said for benchmarking $ data specific to urgent care medicine, the UCAOA $$ surveys provide the basis for dialogue about how some practices are building on the foundation they have established. Subsequent UCAOA surveys are expected to take that initiative to the next level. ■
Note: The ability to draw broad conclusions from the results of this survey is limited by the small sample size BILL DUNBAR AND and low response rate. However, as the only available ASSOCIATES, LLC source of data, the benchmarking survey provides INNOVATIVE HEALTH CARE MANAGEMENT unique, early insights into the urgent care field. One Park Fletcher, Suite 301A 2601 Fortune Circle East Indianapolis, Indiana 46241 317.247.8014 • FAX 317.247.0499 www.billdunbar.com 32 JUCM The Journal of Urgent Care Medicine | June 2007 coding_0607:Layout 1 5/22/07 10:34 AM Page 33
CODING Q&A Injection Procedures and E/M Codes
■ DAVID STERN, MD, CPC
Can we bill an evaluation and management code A separate diagnosis is not necessary to code for the Q.along with the code for administration of an in- A.E/M with modifier 25, according to both Medicare and travenous injection? CPT rules. Although it may seem obvious to expect reimburse- A.ment in these situations, Medicare waited until 2006 Is it appropriate to employ an E/M code for each to begin reimbursing physicians for a separate E/M (99201- Q.and every time the patient visits the urgent care 99205, 99212-99215) when performed at the same time as IV center and receives an intravenous injection? drug administration. The Medicare Claims Processing Manual Not always. Two examples of situations where it would states, “Medicare will pay for medically necessary office/out- A.not be appropriate to code for an E/M: patient visits billed on the same day as a drug administration Ⅲ The patient calls the physician and reports that the mi- service with modifier 25 when the modifier indicates that a graine headache has returned and the physician instructs separately identifiable evaluation and management (E/M) the patient to come into the urgent care center to re- service was performed that meets a higher complexity level ceive another injection of prochlorperazine. of care than a service represented by CPT code 99211….For an Ⅲ If the patient simply returned, received the medication E/M service provided on the same day, a different diagnosis is from the nurse, and did not see the physician. not required.” Work values now are included in drug administration codes, For example, you should bill an E/M with modifier 25 when so there has to be a truly separate evaluation and management a patient comes in for a migraine headache and the physician (not merely an evaluation and management incidental to the determines that the best treatment is an intravenous injection procedure code) to qualify for reimbursement for an E/M code. of prochlorperazine. Even though there may be only one diag- nosis of migraine headache (ICD-9 = 346.00), it still it is appro- Could we code a 99211 (with modifier 25) for the priate to bill both for the therapeutic injection and the physi- Q.nursing evaluation? The nurse could document cian’s evaluation of the patient. the patient’s vital signs and a notation that the patient The rationale: It’s medically necessary for the provider to states that this is a “typical migraine headache.” Would evaluate the patient whether the patient is suffering from a mi- this suffice to demonstrate a nursing evaluation and graine headache or some other more serious problem (such as management? an intracranial hemorrhage, brain tumor, or meningitis). Although the documentation noted would be appro- A.priate, coding a 99211 (with modifier 25) would not be Don’t I need two separate diagnoses to code for appropriate. Medicare does not reimburse for this code (99211) Q.the E/M with modifier 25? when submitted along with an intravenous injection code. Prior to 2006, many private payors reimbursed for code 99211 when coded on the same day of an injection. David Stern is a partner in Physicians Immediate Care, with nine urgent care centers in Illinois and Oklahoma, Note: CPT codes, descriptions, and other data only are copyright 2007 American Med- and chief executive officer of Practice Velocity (www.prac- ical Association. All Rights Reserved (or such other date of publication of CPT). CPT is ticevelocity.com), a provider of charting, coding and billing a trademark of the American Medical Association (AMA). software for urgent care. He may be contacted at Disclaimer: JUCM and the author provide this information for educational purposes [email protected]. only. The reader should not make any application of this information without consult- ing with the particular payors in question and/or obtaining appropriate legal advice.
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HEALTH LAW Vicarious Liability
■ JOHN SHUFELDT, MD, JD, MBA, FACEP
t’s 8:15 on Sunday morning. This is the first morning you thering the purpose of the employer when explaining what have actually been able to sleep in since you opened the employee actions will lead to vicarious employer liability. urgent care center five months ago. Truth be told, you If the employee was on the clock, if his actions benefit the Idrank a glass (or two) of wine too many last night and are employer, if the employee is under the control of the employ- still feeling the effects this morning. However, you don’t care; er, or if an incident occurs at the employer’s location or at the you have the day off and you can slouch around till noon and authorized time of the work assignment, that will probably no one will know or care! be considered to be within the course and scope. What you don’t know is that you are about to get a phone For example, if your medical assistant goes out to mail in call because the resident manning your urgent care clinic this her tax return at lunch and runs over a person in the middle morning (who also happens to be the boyfriend of your of the street, your defense would be that she was not acting sister) just broke off a needle in a patient’s rear end while giv- under your direction. However, if she was going to the bank ing an injection. to deposit the receipts from the previous day, the aforemen- Despite your hangover, the term vicarious liability springs tioned argument would fail since presumably she was acting through the cobwebs of your cortex, as does the famous line on behalf of the business while making the deposit. from the movie Animal House: “My advice to you is to start drinking heavily.” Borrowed Servant Doctrine Vicarious liability is derivative responsibility for an agent’s A physician may also be liable if he or she has the right to con- or employee’s negligence based upon the defendant’s trol the other professional’s work and the manner in which it employer-employee or principle-agent relationship. The is performed. This is called the “borrowed servant” doctrine. responsibility is imposed when the ability to supervise, con- The determination is irrespective of whether the physician- trol, or direct the conduct of the employee or agent lies employer actually controls the manner in which work is to be with the employee or principle. performed or simply has the right to control it. This right to Put another way, physicians are liable for their own neg- control is not based on any one thing, but on a constellation ligent actions and may be vicariously liable for the negligent of facts which make up the totality of the circumstances. For actions of their employees which occur in the scope of example, you may be liable for the negligence of a resident their employment. Moreover, physicians who join a partner- who is working at your urgent care center during a residen- ship are vicariously liable for the tortuous actions of their cy-approved rotation even though you never saw nor were partners when the negligent acts are committed within the consulted on the patient in question. scope of the partnership. A physician will also be liable for the negligent acts of A physician can be held liable for the negligent or wrong- other physicians if they are engaged in a joint enterprise or ful acts of other individuals if the physician is the employer partnership which has never been legally formalized in of the individual and the employee is acting within the order to protect the physicians from the imputed liability of course and scope of his or her employment. “Course and his or her partners. Partnerships can be formal when two scope of employment” is used interchangeably with fur- individuals come together or pursue a common goal. In the absence of a formal agreement, joint ventures or partnerships may be implied by law when two or more John Shufeldt is the founder of the Shufeldt Law people pursue a business opportunity for profit. For exam- Firm, as well as the chief executive officer of NextCare, Inc., and sits on the Editorial Board of JUCM. ple, if you and a friend from residency open an urgent care He may be contacted at [email protected]. center and don’t form a business entity which offers you Continued on page 36.
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OCCUPATIONAL MEDICINE Using Education as an Occupational Health Marketing Tool
■ FRANK H. LEONE, MBA, MPH
s marketing initiatives become increasingly self-serving, Ⅲ if there is a hot new topic (e.g., a new federal or state it behooves an urgent care clinic to differentiate itself by regulation). A“playing the education card.” Should your clinic develop a seminar, remember the Why Education? following: Many employer decision-makers are still strikingly naïve Ⅲ Ask prospective participants what they want to learn about the value of a well-integrated, proactive approach to about, rather than assume that you know. Education- their company’s health and safety activities. al session topics should be market driven. Educational information does not come off as self-serv- Ⅲ Offer the seminar at a hotel, restaurant, or confer- ing and is perceived as a “kinder and gentler” form of mar- ence center. We have found that midweek, morning ses- keting. In our information-saturated world, it is imperative sions tend to be well attended. to find a way to stay in front of prospects in an unobtrusive, yet memorable manner. Education can do this. An urgent care clinic that positions itself as an educator “Providers of occupational inevitably is also viewed as an expert—an important image to foster. health services are,
Live Seminars by definition, educators.” Although invariably there is intrinsic value in providing such programs, seminars’ value vis-à-vis their opportunity cost is Ⅲ Forget the “if it is free, they will come” maxim. Charge often questionable. Seminars consume scarce financial and enough to cover expenses and create a perception of human capital—capital that may generate a greater return value. When I am invited to a “free” investment semi- to an urgent care clinic if expended on other activities, such nar, I never attend because I assume that the session is as direct sales or targeted mailings. little more than a thinly veiled sales pitch. Your Offering live seminars, however, can be valuable under clients/prospects are likely to feel the same way. certain circumstances, such as: Ⅲ Go first class. Find an attractive venue; offer quality food Ⅲ if your clinic is a recent entrant to the occupational service and recruit knowledgeable, engaging speakers. health market Ⅲ Publicize the event well in advance and through multi- Ⅲ if your clinic is far from the occupational health market ple modalities. Use direct mail, e-mail blasts, calls to leader and needs attention prime prospects, and even radio spots in appropriate markets. A big turnout makes your program look good; a dismal one has the opposite effect. Frank Leone is president and CEO of RYAN Associates Ⅲ and executive director of the National Association of If need be, throw it into fifth gear. If attendance looks Occupational Health Professionals. Mr. Leone is the author disappointing a week out, do something about it. of numerous sales and marketing texts and periodicals, and has considerable experience training medical profes- Emerging Educational Tools sionals on sales and marketing techniques. E-mail him at [email protected]. E-mail is a rapid, low-cost mode of communication. Yet,
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OCCUPATIONAL MEDICINE HEALTH LAW
there is a thin line between using e-mail to your advan- some protection (limited liability corporations, limited liabil- tage and irritating prospects with “spam.” Your clinic is ity partnerships, professional corporations, etc.) you will both less likely to overstep the boundary if your e-mail mes- be held liable for each other’s negligent actions which sages are educational in nature. Prospects are much occur in the course and scope of your partnership. more likely to open and read e-mail—and to remember In general, a provider is not liable for the negligence of the sender (a central marketing principal)—if they feel another provider if that other provider is an independent they will learn something. contractor. Typically, independent contractors work on a one- Here are some basic rules: time or on an as-needed basis. Ⅲ Your clinic is likely to see greater benefits if you e- An independent contractor relationship, unlike an employ- mail a brief (i.e., a few sentences) “educational ment relationship, does not create vicarious liability. Therefore, piece” once a week than if you send a lengthy mes- physicians are typically not liable for the negligent actions of sage twice a year. The secret of effective mass com- the independent contractors with whom they contract. munication? Keep it simple and keep repeating it. To determine if an independent contractor relationship Ⅲ Offer tangible “to do’s” (e.g., track consecutive exists, the courts will look at a number of factors, such as workdays without a reported work injury by posting whether the individual has a set schedule, gets paid at reg- the number of days in a prominent location) rather ular intervals, whether the services are integral to the busi- than trivial facts or meaningless statistics. Make ness, whether the employer furnishes training material and your prospects want to forward your e-mail to other equipment, and finally, whether or not taxes are deducted colleagues within or outside of their company. and worker’s compensation insurance is provided. Ⅲ Aggressively build your e-mail address book. Mar- keting is a numbers game—if you have 1,000 email Requisite Care addresses rather than 500, you reach twice as many One area where a physician may be liable despite the fact people, and it won’t cost you any more. that the relationship is found to be that of an independent contractor is if the contractor was hired without the requi- Website Strategies site care required. In other words, liability can attach if Many urgent care clinic websites tend to be one-dimen- the physician did not use reasonable care and discretion in sional and inherently fact-based. Use your website as an hiring the independent contractor provider. Say the provider educational tool; with the right approach, doing so may you hired to fill in for you during a vacation commits med- not even add much additional effort or cost. ical negligence; if you didn’t check the National Practition- For example, our company e-mails a “Tip of the Week” er Data Bank or your state’s medical board, you may be to thousands of occupational health professionals, includ- directly and not vicariously liable to the plaintiff. ing urgent care clinics. We have found that maintaining There are ways to mitigate your liability: a complete library of those tips, organized by subject (i.e., Ⅲ Make sure the business form you choose gives you marketing, financial management, etc.), on our com- protection; joint ventures and partnerships are not the pany’s website (www.naohp.com) is beneficial both to us vehicles to use when forming a medical practice. and to our customers and prospects; many of them ac- Ⅲ Know the individuals you are working with. Take the cess our website routinely for program management ad- time to adequately screen and train them to ensure vice and thereby become more familiar with our broader they are performing up to the standard of care. range of services. Your clinic should do the same. Ⅲ Urgent care providers, like emergency medicine providers, probably fall under the safe harbor provision Summary under the tax code and therefore can be contracted Providers of occupational health services are, by defini- with as independent contractors. tion, educators whether they are educating at the em- Finally, if you are working in a hospital or group setting ployer, individual worker, or coworker level. We are, af- and your job description places you in the realm of having ter all, not selling a hard commodity, but rather an to use “borrowed servants,” ask for indemnification for intricate concept: worker health and wellbeing. any liability you might incur as the result of derivative The nature of your educational outreach depends on negligence of institutional employees. market size, market leadership, program maturity, and The practice of medicine is challenging enough without consumer preferences. Once your clinic has defined your having to worry about the wrongful acts of others. Consult position in the market, it is advisable to craft education with an attorney to ensure that you are as protected as pos- into your broader marketing strategy. ■ sible against vicarious liability claims. ■
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Career Opportunities URGENT CARE CENTER – Salem Clinic, P.C., a TALLAHASSEE, FLORIDA. ED based Urgent 40-physician multi-specialty group located in SEATTLE WASHINGTON - Multi-specialty med- Care Position just opened up. Extremely competi- ical group seeks B/C FP, IM/Peds or ER physi- Salem, Oregon, has an opening for a part-time tive package totaling $215K plus and increases to cian for a full-time urgent care position. All or full-time family practice at our Urgent Care $275K plus. Includes CME compensation, health Center. Please forward, email or fax your CV to: Urgent Cares are located within 40 minutes of insurance for entire family, flex medical account, Connie Finicle, Salem Clinic, P.C., 2020 Capitol downtown Seattle. As a MultiCare Medical 401(k) and annual bonus. Basic urgent care in- Group physician, you will enjoy excellent com- St., NE, Salem, OR 97301. Fax: 503-375-7429 or email: [email protected]. cluding minor fractures, lacerations, URI’s, etc. pensation and benefits, flexible shifts and Work 17-18 shifts without taking call! Email CV to system-wide support, while practicing your own RAPIDLY GROWING, 1-year old, evening and [email protected] or call 904-234-7433. patient care values. Take a look at one of the weekend Urgent Care center is looking for Family Northwest’s most progressive health systems. Practice, Occupational Emergency Medicine OHIO – OUTSTANDING OPPORTUNITY in a You’ll live the Northwest lifestyle and experience BC/BE physicians, or Pediatric physician willing unique program! Well-known and respected the best of Northwest living, from big city ameni- to see minor adult problems. Urgent Care experi- health system with top academic affiliation ties to the pristine beauty and recreational ence preferred. We have a strong pediatric niche seeks family medicine physician—ER/urgent opportunities of the great outdoors. Please email for evening or after-hours care. We are looking care experience required. Teaching opportunity your CV to MultiCare Health System Provider for a doctor willing to handle both pediatric as Services at [email protected] or well as adult care, who is used to procedures. available in pioneer fellowship program. Compet- fax your CV to 866-264-2818. Website: Full-and part-time positions available. We offer a itive salary plus bonus and benefits. Upscale www.multicare.org. Please refer to opportunity competitive salary, good benefits, and bonus's communities in the Cleveland area. Lifestyle op- #513-623 “MultiCare Health System is a drug for the high producing physicians. Our facility portunity with all the amenities! Contact Linda free workplace.” has on-site blood lab, and X-ray ability. We are Jacovino, 800-365-8900, ext. 232; linda.jacovi- URGENT CARE – Family Practice. Stuart, south- located in Lakeland, on the main drag, with easy [email protected]. Ref. #658692 east Florida. Board-Certified/Board-Eligible fami- access to both Tampa and Orlando for those ly practice physician, competitive salary with wanting the feel of a medium size town without FLORIDA the hustle and bustle of large cities, yet within a productivity bonus, malpractice insurance fully Excellent Ownership/Partnership oppor- 30-40 minute drive from all the attractions, covered with great benefits, 401(k) and flexible tunities available with a well-established restaurants and shopping of the larger cities. work schedule. Martin Memorial Health Systems Urgent Care group in Tampa Bay area. is a not-for-profit, community based healthcare Fax resumes to 863-644-4992 or call Dr. Parker Contact: R. Sandhu, MD organization comprised of two hospitals, numer- at 863-646-4000.www.niteowlpediatrics.com. Phone: 813-655-4100 ous physician practices and ambulatory care MT. WEST HEALTH CENTER, P.A. is currently Fax: 813-655-1775 clinics throughout Martin and St. Lucie counties seeking physicians to join practices in EL Paso, Email: [email protected] on Florida’s Treasure Coast. Martin County of- Texas for Urgent Care Center. Excellent opportunity fers a great quality of life with excellent schools. to work with a large, established private family/ Visit our website www.mmhs.com and email urgent care practice in an autonomous manner your CV to [email protected]. with other physicians and physician assistants. Contact: Trish O’Brien Don’t miss a single issue. We offer a competitive salary and benefits package. Please contact Brisa Newberry, MBA. Phone: The Journal of Urgent Care Medicine Email your ad today! 915-217-2809; email: [email protected]; fax (800) 237-9851 • Fax (727) 445-9380 [email protected] 915-850-0546. Email: [email protected]
ORLANDO URGENT CARE OPPORTUNITY
Come to sunny Orlando and enjoy a lifestyle of year-round golf, beaches, boating, theme parks, professional sports and cultural activities. Orlando is an excellent place to raise a family with strong academic institutions including the Uni- versity of Central Florida and its future Medical School.
• Centra Care is an established hospital-owned urgent care system in Central Florida. It is well recognized throughout the community as the regional leader in high quality urgent care. • 16 centers and rapidly growing with two to four new centers opening in 2007. • Physicians enjoy working in a fast paced practice with on-site x-ray, lab and electronic medical records. • Excellent opportunity for a BC/BE Family Practice, Urgent Care or Emergency Medicine physician. • Competitive compensation, productivity bonuses, paid vacations, paid CME and malpractice insurance. • Excellent benefits’ package including health, life and Employer matched 403B For more information, please call Timothy Hendrix, MD at (407) 200-2860
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Career Opportunities
Practice in Florida! Excellent Internal Medicine We need Urgent Care physicians Family Practice Opportunities Hobart, and nurse practitioners for Indiana St. Petersburg, Melbourne, URGENT CARE CLINIC Tampa, Daytona Beach, Southern California’s leading EM opportunities at 25,000 visit ED located and Miami areas of Florida. physician-owned multi-specialty medical 35 miles south of Chicago and 15 miles group has opportunities for full-time Inter- northwest of Valparaiso. BC/BP, PC with EM Excellent income and benefits nal Medicine/Family Practice experience. Shift is 11:00am-11:00pm and pro- packages offer salary, physicians in our Long Beach and vides double coverage for BC EM physicians. partnership track and more. Los Angeles regions Candidates must be Board Certified, have a current California EPMG offers paid family medical benefits, Email CV today to incentive bonuses, excellent compensation, medical license, DEA current, paid malpractice, and more. [email protected] BLS/ACLS/PALS, suture experience preferred. We are a large, dynamic Please contact Kim Senda at or call Robert at and well-established group and offer a 800-466-3764, x338 or 800-321-2460. balanced professional and personal [email protected] lifestyle, as well as excellent compensation with Partnership Track and benefits. We have immediate openings for per diem Carolinas Healthcare System and full-time physicians for a variety of shifts. Our busy Urgent Care StatClinix Urgent Care, a growing BC Physicians needed for our expanding Clinic treats patients for anything from a Urgent Care organization in Arizona common office visit to an emergency room is seeking experienced Board-Certified network of existing and new Urgent Care visit. Our patient population includes chil- facilities throughout the Charlotte, North UC/ FP/ER physicians for dren, adults and seniors. We will current and upcoming Urgent Care Carolina area. All facilities are out-patient consider 3rd year/senior residents with let- only, open 8am-8pm, 7 days/week and have Clinics. Positions available in the ters from residency program chief Metro Phoenix area and in Northern no-call. Openings are employed positions resident or director approving moonlighting. with attractive compensation and benefits. Arizona/Show Low. Excellentopportunity for employment For more information about with a competitive compensation package. opportunities, please contact: Call Mary McGuire at 480-682-4111 Sarah Foster, Physician Recruiter or fax CV to 602-478-6293 or 800-847-5084 • Fax: 704-355-5033 Apply on line: email [email protected] [email protected] http://www.healthcarepartners.com www.statclinix.com www.carolinashealthcare.org/careers/physicians /careers/careers.asp [email protected] Please visit Reference: ACP Next available issue is Headquarters is located in our website www.rja-ads.com/jucm September with a closing of August 6th Torrance, CA 90502 for classified rates.
EMERGENCY MEDICINE/URGENT CARE WISCONSIN Marshfield Clinic is directed by 700+ physicians practicing in over 80 specialties at 40 locations in central, northern and western Wisconsin. We are seeking BC/BP Family Practice physicians at the following locations: • Eau Claire - Urgent Care • Ladysmith - Urgent Care • Marshfield - Urgent Care • Minocqua - Urgent Care • Park Falls - Emergency Dept./Urgent Care • Rice Lake - Emergency Dept./Urgent Care We offer a competitive salary and a comprehensive benefit package including: malpractice, health, life, disability, and dental insurance; generous employer contributed retirement and 401K plans; $5,800 education allowance with 10 days of CME time; four weeks vacation 1st year; up to $10,000 relocation allowance; and much more. Please contact: Sandy Heeg, Physician Recruitment, Marshfield Clinic 1000 N Oak Ave., Marshfield, WI 54449 Phone: 800-782-8581, ext. 19781 Fax: (715) 221-9779 E-mail: [email protected] Website: www.marshfieldclinic.org/recruit Marshfield Clinic is an Affirmative Action/Equal Opportunity employer that values diversity. Minorities, females, individuals with disabilities and veterans are encouraged to apply. Sorry, not a health professional shortage area.
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Career Opportunities
MEDICAL & PHARMACEUTICAL SERVICE Man- URGENT CARE - FAMILY PRACTICE ager. Pompano Beach, Florida. Full-time. Devel- op and maintain computer record management Seeking experienced, self-motivated, and congenial Board Certified Family system to store and process medical and pre- Practice physician who desires an urgent care setting. Two NEW freestanding scription data; supervise and coordinate volume process of prescriptions and automated packag- facilities located in high-traffic, highly visible locations. Provide primary care ing and dispensing assembly of multi-dose med- services on an express care basis including diagnostic radiology and moderate ications for assisted living residents and patients complexity lab services. Cross-trained support staff to handle front office and of hospitals; review prescriptions to reduce er- nursing responsibilities. Established relationship with medical staff at a local 367- rors and recommend changes, warnings and disclaimers considering patients characteristics; bed regional tertiary medical center with Level II trauma and med flight services collaborate with medical providers, department offering the full spectrum of primary care, occupational medicine, and subspecialty heads and pharmacists to implement, evaluate support. Solid hourly compensation with a comprehensive benefits package; and improve quality management programs; es- including paid malpractice insurance. Flexibility in scheduling to allow you to tablish schedules for medical and pharmacy staff. PhD in Medicine or equivalent plus 2 years enjoy a busy practice AND support a quality of life. experience required. Resume: Yuval Levy, Colo- nial Healthcare Services, 2301 NW 33 Ct #111, NO CALL OR INPATIENT RESPONSIBILITIES! Pompano Beach, FL 33069. Excellent quality of Life. Vibrant, family-oriented community offering safe, PHYSICIAN sophisticated living and amenities rare in a city this size. Breathtaking landscapes MEDIQUICK URGENT CARE and wooded rolling hill terrain amongst the many area lakes and streams. Cost of living 14-15% below the national average-one of the lowest in the United States! MidState Medical Center, a state-of-the-art community hospital serving central Connecti- Chose from public, private, or parochial schooling options along with a 4-year cut, has an opening for the right physician in university in town and two Christian colleges. Variety of the four-seasons our affiliated urgent care facility. MediQuick supporting an abundance of recreational activities for the entire family. sees 19,000 patients per year and has a stable, Easy access to larger metro areas within 2 hours or less. respected nurse and physician staff and offers strong hospital and director For more information, contact: support. Work 2-3, 12 hour shifts/week. Alyssa Hodkin Candidates should be board-certified or Phone: 800-638-7021 • Fax: 417-659-6343 Board-Eligible in Internal or Family Medicine. Email: [email protected] MidState offers competitive salaries and www.docopportunity.com benefits and is within easy driving distance of Boston, New York City, the mountains, the shoreline and Connecticut’s stimulating arts and cultural offerings. Practices for Sale FOR SALE- Lansing, Michigan. Busy and very Interested applicants may contact well established urgent care. Excellent location FOR SALE- Urgent Care/Family Practice. Free Dr. Fred Tilden, Medical Director of Emer- and reputation. Consistent volume and proto- standing 4,000–sq. ft. building, 20 years same gency Services, at 203-694-8278. cols. Consistent income. Owner would like to re- owner. Prime location in Simi Valley, California, For more information on MidState Medical tire. Financing is negotiable. Please contact Ventura County. Phone 805-583-8081. Center, and to apply on-line, visit our website at [email protected]. www.midstatemedical.org FOR SALE- northern Virginia. Independent Urgent Care/Family Clinic. Excellent location for full scale Family Practice if desired. Previously re- tired owner wants to retire for good. Appraised. Contact: Trish O’Brien Send email inquiries to [email protected] or The Journal of Urgent Care Medicine fax to 703-495-8447. Please include a brief re- (800) 237-9851 • Fax (727) 445-9380 Email: [email protected] sume.
With a circulation of 12,400 urgent care subscribers, there are plenty of reasons why your company should be a part of The Journal of Urgent Care Medicine’s 11 monthly issues. The Journal of Urgent Care Medicine is the official journal of the Urgent Care Association of America, UCAOA. Each issue contains a mix of peer-reviewed, and useful clinical and practice management articles, which address the distinct clinical and practice needs of today’s busy urgent care medicine clinician. Visit our website www.rja-ads.com/jucm for classified advertising rates or if interested in a price quote, please fax or email your advertisement to my attention. Next available issue is September, with a closing date of August 6th. Contact: Trish O’Brien (800) 237-9851 • Fax (727) 445-9380 • Email: [email protected]
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DEVELOPING DATA
CAOA’s Survey Committee has conducted two annual member surveys, to date, designed to establish benchmarks in an industry for which data have been sorely lacking. Each month in Developing Data, we Uwill share one or two tidbits from the second annual survey in an effort to help readers get a sense of what their peers are doing, and what kind of trends are developing as urgent care evolves. In this issue: If you’re planning to purchase an electronic medical record (EMR) system, when do you expect to do so? At the time of the survey, 23.7% of respondents used only an EMR system for patient charting, while another 28.7% used some combination of methods (dictation only, paper/encounter form only, and paper templates only being the other options). Come next year and the third benchmarking survey, the data are likely to look considerably different: 70.6% of respondents reported that they are considering purchase of an EMR system, with nearly half expecting to do so within the next 12 months, if not sooner.
EMR SYSTEM PURCHASE TIMETABLE
Areas covered in the UCAOA industry surveys included Next month in urgent care structures and organization, services Developing Data: offered, management of facilities and operations, patients and staffing, and financial data. UCAOA A look at how some clinics are members who have ideas for future surveys should e-mail J. Dale Key, UCAOA Survey Committee chair. employing prompt-pay discounts.
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