September 2007 Volume 1, Number 10

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™ SEPTEMBER 2007 VOLUME 1, NUMBER 10

THE JOURNAL OF URGENT CARE MEDICINE®

www.jucm.com | The Official Publication of the Urgent Care Association of America IN THIS ISSUE

FEATURES 13 Managing Heat Illness in Urgent Care 21 Bouncebacks: The Case of a 33-Year-Old Male with Abdominal Pain DEPARTMENTS 27 Insights in Images: Clinical Challenge 35 Abstracts in Urgent Care 39 Health Law 41 Coding Q & A 43 Occupational Medicine 48 Developing Data PUBLICATION A BRAVEHEART Ad_Spread_Sized:Layout 1 8/18/07 9:44 PM Page 1

*T IMPORTANT SAFETY INFORMATION VIGAMOX® solution is indicated for the treatment of bacterial conjunctivitis caused by susceptible strains of the following organisms: Corynebacterium species‡, Micrococcus luteus‡, Staphylococcus aureus, S. epidermidis, S. haemolyticus, S. hominis, S. warneri‡, Streptococcus pneumoniae, Streptococcus viridans group, Acinetobacter lwoffi i‡, Haemophilus infl uenzae, Haemophilus parainfl uenzae‡, Chlamydia trachomatis ( ‡effi cacy for this organism was studied in fewer than 10 infections). VIGAMOX® solution is contraindicated in patients with a history of hypersensitivity to moxifl oxacin, to other fl uoroquinolones, or to any of Licensed to Alcon, Inc. by Bayer HealthCare AG. ©2007 Alcon, Inc. 7/07 VIG07512 JA Ad_Spread_Sized:Layout 1 8/18/07 9:44 PM Page 2

Get rid of the pink in a blink.*

VIGAMOX® solution erases 99% of Streptococcus pneumoniae pathogens in vitro in as little as an hour.1*† †In vitro data are not always indicative of clinical success or microbiological eradication in a clinical setting.

*The dosing of VIGAMOX® solution is one drop in the affected eye(s) 3 times daily for 7 days. s the components in this medication. NOT FOR INJECTION. VIGAMOX® solution should not be injected m subconjunctivally, nor should it be introduced directly into the anterior chamber of the eye. In patients receiving systemically administered quinolones, including moxiﬂ oxacin, serious and occasionally fatal s hypersensitivity (anaphylactic) reactions have been reported, some following the ﬁ rst dose. As with s other anti-infectives, prolonged use of VIGAMOX® solution may result in overgrowth of non-susceptible d organisms, including fungi. The safety and effectiveness of VIGAMOX® solution in infants below 1 year h of age have not been established. The most frequently reported ocular adverse events were conjunctivitis, f decreased visual acuity, dry eye, keratitis, ocular discomfort, ocular hyperemia, ocular pain, ocular pruritus, subconjunctival hemorrhage, and tearing. These events occurred in approximately 1%–6% of patients. Please see brief summary of prescribing information on adjacent page. Vigamox PI & Call for Art House Ad:Layout 1 8/22/07 10:04 AM Page 1

(moxifl oxacin hydrochloride ophthalmic and, where appropriate, fl uorescein staining. solution) 0.5% as base Patients should be advised not to wear contact DESCRIPTION: VIGAMOX® (moxifl oxacin HCl lenses if they have signs and symptoms of ophthalmic solution) 0.5% is a sterile ophthalmic bacterial conjunctivitis. solution. It is an 8-methoxy fl uoroquinolone Information for Patients: Avoid contaminating anti-infective for topical ophthalmic use. the applicator tip with material from the eye, CLINICAL PHARMACOLOGY: fi ngers or other source. Microbiology: Systemically administered quinolones including The following in vitro data are also available, moxifl oxacin have been associated with but their clinical signifi cance in ophthalmic hypersensitivity reactions, even following a single infections is unknown. The safety and dose. Discontinue use immediately and contact effectiveness of VIGAMOX® solution in treating your physician at the fi rst sign of a rash or allergic ophthalmological infections due to these reaction. microorganisms have not been established in Drug Interactions: Drug-drug interaction studies adequate and well-controlled trials. have not been conducted with VIGAMOX® solution. The following organisms are considered In vitro studies indicate that moxifl oxacin does not susceptible when evaluated using systemic inhibit CYP3A4, CYP2D6, CYP2C9, CYP2C19, or breakpoints. However, a correlation between the CYP1A2 indicating that moxifl oxacin is unlikely to in vitro systemic breakpoint and ophthalmological alter the pharmacokinetics of drugs metabolized effi cacy has not been established. The list by these cytochrome P450 isozymes. of organisms is provided as guidance only in Carcinogenesis, Mutagenesis, Impairment assessing the potential treatment of conjunctival of Fertility: Long term studies in animals infections. Moxifl oxacin exhibits in vitro minimal to determine the carcinogenic potential of inhibitory concentrations (MICs) of 2 μg/ml or less moxifl oxacin have not been performed. However, (systemic susceptible breakpoint) against most ≥ in an accelerated study with initiators and ( 90%) of strains of the following ocular pathogens. promoters, moxifl oxacin was not carcinogenic Aerobic Gram-positive microorganisms: in rats following up to 38 weeks of oral dosing Listeria monocytogenes at 500 mg/kg/day (approximately 21,700 times Staphylococcus saprophyticus the highest recommended total daily human Streptococcus agalactiae ophthalmic dose for a 50 kg person, on a mg/kg Streptococcus mitis basis). Streptococcus pyogenes Moxifl oxacin was not mutagenic in four bacterial Streptococcus Group C, G and F strains used in the Ames Salmonella reversion Aerobic Gram-negative microorganisms: assay. As with other quinolones, the positive Acinetobacter baumannii response observed with moxifl oxacin in strain Acinetobacter calcoaceticus TA 102 using the same assay may be due to the Citrobacter freundii inhibition of DNA gyrase. Moxifl oxacin was not Citrobacter koseri mutagenic in the CHO/HGPRT mammalian cell Enterobacter aerogenes gene mutation assay. An equivocal result was Enterobacter cloacae obtained in the same assay when v79 cells were Escherichia coli used. Moxifl oxacin was clastogenic in the v79 Klebsiella oxytoca chromosome aberration assay, but it did not Klebsiella pneumoniae induce unscheduled DNA synthesis in cultured Moraxella catarrhalis rat hepatocytes. There was no evidence of Morganella morganii genotoxicity in vivo in a micronucleus test or a Neisseria gonorrhoeae dominant lethal test in mice. Proteus mirabilis Moxifl oxacin had no effect on fertility in male Proteus vulgaris and female rats at oral doses as high as 500 mg/ Pseudomonas stutzeri kg/day, approximately 21,700 times the highest Anaerobic microorganisms: recommended total daily human ophthalmic dose. Clostridium perfringens At 500 mg/kg orally there were slight effects on Call for Fusobacterium species sperm morphology (head-tail separation) in male Prevotella species rats and on the estrous cycle in female rats. Propionibacterium acnes Pregnancy: Teratogenic Effects. Other microorganisms: Pregnancy Category C: Moxifl oxacin was not Articles Chlamydia pneumoniae teratogenic when administered to pregnant rats Legionella pneumophila during organogenesis at oral doses as high as Mycobacterium avium 500 mg/kg/day (approximately 21,700 times Mycobacterium marinum the highest recommended total daily human Mycoplasma pneumoniae ophthalmic dose); however, decreased fetal Clinical Studies: body weights and slightly delayed fetal skeletal The Journal of Urgent Care Medicine In two randomized, double-masked, multicenter, development were observed. There was no controlled clinical trials in which patients were evidence of teratogenicity when pregnant dosed 3 times a day for 4 days, VIGAMOX® solution Cynomolgus monkeys were given oral doses as (JUCM), the Official Publication of the produced clinical cures on day 5-6 in 66% to 69% high as 100 mg/kg/day (approximately 4,300 of patients treated for bacterial conjunctivitis. times the highest recommended total daily human Urgent Care Association of America, is Microbiological success rates for the eradication ophthalmic dose). An increased incidence of of the baseline pathogens ranged from 84% to smaller fetuses was observed at 100 mg/kg/day. 94%. Please note that microbiologic eradication Since there are no adequate and well-controlled looking for a few good authors. does not always correlate with clinical outcome in studies in pregnant women, VIGAMOX® solution anti-infective trials. should be used during pregnancy only if the INDICATIONS AND USAGE: VIGAMOX® solution potential benefi t justifi es the potential risk to is indicated for the treatment of bacterial the fetus. Physicians, physician assistants, and conjunctivitis caused by susceptible strains of the Nursing Mothers: Moxifl oxacin has not been following organisms: measured in human milk, although it can be nurse practitioners, whether practicing presumed to be excreted in human milk. Caution Aerobic Gram-positive microorganisms: ® Corynebacterium species* should be exercised when VIGAMOX solution is Micrococcus luteus* administered to a nursing mother. in an urgent care, primary care, hospital, Staphylococcus aureus Pediatric Use: The safety and effectiveness of Staphylococcus epidermidis VIGAMOX® solution in infants below 1 year of age Staphylococcus haemolyticus have not been established. or office environment, are invited to sub- Staphylococcus hominis There is no evidence that the ophthalmic Staphylococcus warneri* administration of VIGAMOX® solution has any mit a review article or original research Streptococcus pneumoniae effect on weight bearing joints, even though oral Streptococcus viridans group administration of some quinolones has been Aerobic Gram-negative microorganisms: shown to cause arthropathy in immature animals. for publication in a forthcoming issue. Acinetobacter lwoffi i* Geriatric Use: No overall differences in safety Haemophilus infl uenzae and effectiveness have been observed between Haemophilus parainfl uenzae* elderly and younger patients. Submissions on clinical or practice Other microorganisms: ADVERSE REACTIONS: Chlamydia trachomatis The most frequently reported ocular adverse *Effi cacy for this organism was studied in fewer events were conjunctivitis, decreased visual management topics, ranging in length than 10 infections. acuity, dry eye, keratitis, ocular discomfort, CONTRAINDICATIONS: VIGAMOX® solution ocular hyperemia, ocular pain, ocular pruritus, from 2,500 to 3,500 words are wel- is contraindicated in patients with a history subconjunctival hemorrhage, and tearing. These of hypersensitivity to moxifl oxacin, to other events occurred in approximately 1-6% of patients. quinolones, or to any of the components in this Nonocular adverse events reported at a rate of come. The key requirement is that the medication. 1-4% were fever, increased cough, infection, otitis WARNINGS: media, pharyngitis, rash, and rhinitis. article address a topic relevant to the NOT FOR INJECTION. Rx Only VIGAMOX® solution should not be injected Manufactured by Alcon Laboratories, Inc. real-world practice of medicine in the subconjunctivally, nor should it be introduced Fort Worth, Texas 76134 USA directly into the anterior chamber of the eye. Licensed to Alcon, Inc. by Bayer HealthCare AG. In patients receiving systemically administered U.S. PAT. NO. 4,990,517; 5,607,942; 6,716,830 urgent care setting. quinolones, including moxifl oxacin, serious and ©2003, 2004, 2006, Alcon, Inc. occasionally fatal hypersensitivity (anaphylactic) reactions have been reported, some following the fi rst dose. Some reactions were accompanied by Reference: Please e-mail your idea to cardiovascular collapse, loss of consciousness, 1. Data on fi le. Alcon Laboratories, Inc. angioedema (including laryngeal, pharyngeal JUCM Editor-in-Chief or facial edema), airway obstruction, dyspnea, urticaria, and itching. If an allergic reaction to moxifl oxacin occurs, discontinue use of the drug. Lee Resnick, MD at Serious acute hypersensitivity reactions may require immediate emergency treatment. Oxygen [email protected]. and airway management should be administered as clinically indicated. PRECAUTIONS: General: As with other anti-infectives, prolonged He will be happy to discuss it use may result in overgrowth of non-susceptible organisms, including fungi. If superinfection with you. occurs, discontinue use and institute alternative therapy. Whenever clinical judgment dictates, the patient should be examined with the aid of magnifi cation, such as slit-lamp biomicroscopy, resnick_0907:Layout 1 8/22/07 5:17 PM Page 3

LETTER FROM THE EDITOR-IN-CHIEF Lessons Learned

etween sticky ribs and spicy BBQ Whether you are giving a lecture or talking with a patient, sauce, I mingled with the future gen- the first key to success is to know your audience. Under- eration of doctors at the annual AAFP stand their needs, their agenda, their language, and their BResidents and Students Conference in cultural background. Kansas City. I was reminded of several The two features of daily life most lacking for a resident very important things: or med student are fun and money. Hence the free stuff and Ⅲ I am old video games. Merely a simple technique to attract visitors Ⅲ I didn’t just finish my residency to your booth. Everyone knows it and everyone accepts it. Ⅲ I need to get a “MySpace” account and learn how to “IM.” A cultural norm with no apologies necessary. In addition to my mini-mid-life crisis, my booth was dead. You give me food and a free neck massage and I’ll listen I was sure there would be crowds of people interested in about your program. urgent care and options for additional training. What was I In the end, an exchange of real information takes place, doing wrong? and you get several grateful, interested candidates. I decided to leave my booth and walk around a bit to see The rest of the show, I hung out at the “cool” booths and what other exhibitors were doing to attract people to their met dozens of residents interested in urgent care and fel- booth. The tricks of the trade: free food and other seem- lowship training. ingly “worthless” giveaways. Everything from kielbasa and Please submit your ideas for booth attractions for next roasted almonds to stopwatches, stuffed animals, and mini year’s conference to [email protected]. lava lamps. There was even a booth that brought their own BFN (bye for now). “Wii” video game for the students to play. How could a crowd of “academics” stoop so low just to dupe some “unsuspecting” students to visit their booth?

Know Your Audience Knowing there must be a lesson in all this, I retreated to my lonely booth, barren of popcorn, a dartboard or gleaming Harley Davidson (yes, a family medicine residency from Wis- consin shipped one in—and yes, they had a very busy Lee A. Resnick, MD booth). Editor-in-Chief What I realized is a lesson I have preached to the students, JUCM, The Journal of Urgent Care Medicine residents, and fellows repeatedly: Know your audience. President, UCAOA

Join the Discussion You’ll note on page 8 of this month’s issue of JUCM that we’ve begun publishing Letters to the Editor. If you have questions on an article you’ve read here, thoughts about the state of urgent care in general—or, as Dr. Resnick suggested, ideas on how to draw attention to the UCAOA booth at conferences—share them with us (and, by extension, with your colleagues) in an e-mail to [email protected].

Whenever possible and appropriate, we will reply or seek out a reply from an authoritative party—in this case Dr. Kent Knauer, author of the lead clinical article in our July/August issue.

www.jucm.com JUCM The Journal of Urgent Care Medicine | September 2007 3 Ad_FullPage_Sized 3/21/07 3:35 PM Page 1

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The Official Publication of the Urgent Care Association of America September 2007

VOLUME 1, NUMBER 10

CLINICAL 13 Managing Heat Illness in Urgent Care

The advent of September means increased risk of heat illness in many—not just the elderly or those with specific risk factors, but younger athletes, as well. Are you prepared to differentiate among the various diagnoses and to treat accordingly? By Bridget Dyer, MD, Samuel Keim, MD, and Peter Rosen, MD

BOUNCEBACKS 8 Letters to the Editor 21 The Case of a 11 33-Year-Old Male From the Executive with Abdominal Pain Director DEPARTMENTS A 33-year-old man presents with abdominal pain and is discharged without a definitive 27 Insights in Images: diagnosis. Would your treatment and advice Clinical Challenges regarding follow-up ensure the best possible outcome—and minimize 35 Abstracts in Urgent Care your malpractice exposure? 39 Health Law By Ryan Longstreth, MD, FACEP and Michal B. Weinstock, MD 41 Coding Q & A 43 Occupational Medicine Next month in JUCM: An original article on evaluation and treatment of urinary tract infections and pyelonephritis, as well 48 Developing Data as a look at Derm Diagnoses from actual urgent care case files.

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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 practice 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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LETTERS TO THE EDITOR Regarding Insect Bites and Stings

The take-home message is that the rare presence of severe pain or tenderness, or systemic symptoms such as fever or chills, suggests the complication of infection.

To the Editor: Thank you for your timely journal. I read with interest the article on bites and stings by Dr. Knauer. It was very informative and reviewed all of the important tips on caring for bites and stings except one: Brown re- To the Editor: cluse spiders have a very well demarcated geographical area After reading the article on how rare cellulitis is after a wasp and there have been no documented bites outside of that area. sting (Challenges in Assessing and Treating Insect Bites and I have seen many of my colleagues here in North Carolina Stings, Kent A. Knauer, MD, JUCM, July/August 2007), I won- misdiagnosis serious methicillin-resistant Staph aureus in- der if there are any cases where cellulitis happened only seven fections as brown recluse bites. Brown recluse spiders do not hours after the sting (swelling was 8 cm beyond sting site and live in North Carolina. I have testified to such in a case in first signs of cellulitis appeared as red patches with little red Florida and read some articles about people in Michigan who streaks two hours after occurrence) and was spreading at a tried to sue their family doctor for diagnosing cellulitis and rate of about 1 cm an hour along the lymphatic system and then having the emergency physician erroneously call it the veins. brown recluse spider bites. There are no brown recluse spi- (This is actually a scenario that just happened to me per- ders in Michigan, either. sonally on August 3, 2007 after five wasp stings.) Please remind your readers to be very careful not to miss Beatrice Sirakaya the diagnosis of cellulitis, especially MRSA cellulitis, by think- Instructor, Department of Biochemistry and ing the symptoms are the result of a brown recluse bite out- Molecular Biology side of the geographic domain of that spider. Pennsylvania State University Christian Madsen, MD, FAADEP ProMed Minor Emergency Center Dr. Knauer responds: In my 20 years of practice, I have seen Charlotte, NC only one case of an infectious complication from a sting. It happened to be the husband of a nurse from our organ- Dr. Knauer responds: I believe that it is true that the number ization. I saw him the next day after a honeybee sting on the of reported recluse bites in North America exceeds the esti- forearm. He had no allergic response, but had increased pain mated population. Unfortunately, rare things do happen. and swelling at the site. What seemed unusual to me was the extreme tenderness and pain apparent on exam. Ultrasound proved an abscess, and it was drained by a sur- geon an hour later. He recovered completely within a few days on a cephalosporin. I guess this is an example of “never say never.”

If you have thoughts on an article that appeared in JUCM, The Journal of Urgent Care Medicine (or on issues relevant to urgent care in general), please express them in a Letter to the Editor via e-mail to [email protected] or by “snail mail” to: Editor, JUCM, 2 Split Rock Road, Mahwah NJ 07430.

8 JUCM The Journal of Urgent Care Medicine | September 2007 www.jucm.com Ad_FullPage_Sized:Layout 1 6/18/07 8:00 AM Page 1

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JUCM CONTRIBUTORS

With school back in session and the calendar already flipped from August to September, summer is over in many ways. Cli- matically speaking, however, we’re still in the midst of the proverbial “dog days;” temperatures and humidity may creep well past comfortable for another month or so, just as football season and cross country races kick into high gear. What better time, then, to take a look at optimal treatment of patients presenting to urgent care with symptoms of heat syndromes, which can range in severity from mild discomfort to life-threatening?

We’re pleased to Department Cases: ED Returns (2006, Anadem Publishing, publish an orig- www.anadem.com). In this issue, the authors begin an analy- inal article on sis of how data from studies of patients who "bounced back" that topic (Man- for additional care after discharge might best be used to aging Heat Ill- identify high-risk patients. Drs. Weinstock and Longstreth ness in Urgent Care, page 13) by Bridget Dyer, MD, Samuel work together at Mt. Carmel St. Ann’s Emergency Department Keim, MD, and Peter Rosen, MD, all of the Department of in Columbus, OH as attending physicians. Dr. Weinstock is also Emergency Medicine at the University of Arizona College clinical assistant professor of emergency medicine at The of Medicine. Dr. Dyer's areas of clinical interest include inter- Ohio State University College of Medicine and has authored national emergency medicine, heat illness, medical education, The Resident’s Guide to Ambulatory Care, the sixth edition of and undocumented border crossers. Dr. Keim, whose clinical which is due out later this year. practice includes work in both the ED and urgent care settings, Finally, we continue to be indebted to contributing editors is associate head and residency director of the department. Nahum Kovalski, BSc, MDCM; Frank Leone, MBA, MPH; John Dr. Rosen is clinical professor and a member of the JUCM Shufeldt, MD, JD, MBA, FACEP; and David Stern, MD for Advisory Board. sharing their expertise in administering quality care in the In addition, we bring you the urgent care setting, in the marketing of occupational medicine third installment of the Bounce- services, health law, and coding. backs series (page 21), con- If you would like to submit an article or you have something tributed by Ryan Longstreth, to say about an article you read in this or any other issue of MD, FACEP and Michael B. JUCM, we invite you to contact our editor-in-chief, Lee Weinstock, MD—also co-authors, along with Gregory L. Resnick, MD via e-mail at [email protected]. Share what’s on Henry, MD, FACEP, of the book Bouncebacks! Emergency your mind! ■

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 submitted 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 ‘Quality’ and Urgent Care’s Hierarchy of Needs

■ LOU ELLEN HORWITZ, MA

’ve been visiting some urgent care centers lately, and—paradox- lobby would be so much nicer if we could rip out that wall and add ical as it may be—one thing they all have in common is that they a plasma TV screen and have fresh flowers delivered", or, "It's time Iare all very different from one another. we got our staff into some effective communication training." Some are large, glamorous affairs with fireplaces and tropical On the other hand, if your needs are aligned along the bottom fish; some are in older buildings in need of renovation; some have row of the hierarchy because you’re still struggling to break even the feel of a solo physician practice; some have virtually all of their every month, you are probably focusing only on getting patients medical equipment tucked invisibly (and silently) away; and in the door and keeping your costs down so you can afford to then some have an array of equipment and paperwork center make the payroll and keep up with the payments to the bank. stage, in bustling work areas. Most of you are probably somewhere in between. The wide variety made me think of the choices that patients must make when deciding where to go for episodic healthcare The ‘Q’ Factor needs. When I talk with the average member of the public, one So where does that leave quality of care? At what point in the hi- of the main concerns over opting to visit an urgent care center erarchy does that become your primary focus? With so little reg- is whether they will receive quality care at “one of those centers.” ulation of urgent care centers and very few centers going through Whether a giant fish tank equals quality healthcare is cer- any kind of accreditation process, where does our industry stand tainly not up for debate. But that’s not to say that it doesn’t on the quality curve? matter; patients’ perception can affect what they choose to As we all know, in the seven years since the release of the In- disclose when you take their history, whether they will even stitute of Medicine’s To Err is Human: Building A Safer Health Sys- stick around to see someone, whether they will return in the tem*, hospitals have been blanketed with quality programs; future—and what they will tell their friends (aka your poten- new associations, consultants, training programs, books, task tial patients). forces, job functions, and news stories have been created solely to If you aren’t paying attention to what your center feels like focus on quality healthcare delivery in the hospital setting. when patients walk in the door, you should ask an honest friend With the public so well-educated now on the risks associated to come in and give you a candid opinion. with healthcare errors, is it any wonder they have concerns about the quality of healthcare they will receive in your center, Appearances Can Be Expensive regardless of how different the environment is from the local ED? The most impressive centers had one thing in common: money. The question then falls squarely on all of our shoulders: What In any business, there seems to be a definite ordering of ba- are we doing about that concern? sic necessities, similar to Maslow’s hierarchy of needs. For our part, UCAOA is forming a select committee to address If you are at the top level of the hierarchy—if the more basic this issue. That committee will be chaired by Dr. Donald F. Dil- needs have been met, in other words—you’re thinking, “our lahunty, president of PrimaCare Medical Centers. We will share our plans with you in an upcoming issue of JUCM. In the meantime, I encourage UCAOA members to use the Lou Ellen Horwitz is executive director of the Urgent Care Association of America. She may be Forums section of the association website (www.ucaoa.org/ contacted at [email protected]. forum/index.php) to share your own efforts with all of us. ■

* The Executive Summary of To Err is Human: Building a Safer Health System is available at no charge on the National Academies Press website at www.nap.edu/catalog/9728.html.

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Clinical Managing Heat Illness in Urgent Care

Urgent message: The urgent care provider’s most critical role in heat illness is to identify risk factors and the cause, to cool and hydrate the patient, assess for complications, and educate the patient in the hope of preventing a more serious exposure.

Bridget Dyer, MD, Samuel Keim, MD, and Peter Rosen, MD

Introduction Physiology eat illness occurs when As the core temperature ex- external heat conditions ceeds the hypothalamic set and internal heat pro- point, heat avoidance behav- duction overwhelm the ior is induced, and both sym- Hability of the body to dis- pathetic and parasympa- sipate heat. Evaporation of thetic tones are augmented. sweat is the most effective Increased sympathetic way to dissipate heat; when tone increases cardiac output, the humidity is high, evapo- supporting cutaneous and ration is compromised. Cal- skeletal muscle vasodilata- culations that are based on tion, allowing for radiation both temperature and hu- of heat, delivering plasma for midity, such as the heat in- sweat and oxygen for exer- dex, are a more robust way of tion, with contraction of determining heat stress than splanchnic circulation. ambient temperature alone.1 Parasympathetic tone mod- Elevated humidity can cause u lates sweating, increasing to even moderate temperatures 2.5 liters per hour in an accli-

to be dangerous, especially DePrenda Tom Composite: © Photoresearchers.com/iStockPhoto.com. mated person during strenu- to persons at high risk. ous exercise.3 Heat shock Internal heat production depends on both the level of proteins (HSP) act as molecular chaperones that prevent exertion and the physiologic characteristics of the pa- denaturing of other proteins at higher temperatures. Ini- tient. In the average adult, exertion can raise the basal tial heat stress triggers increase HSP expression, which metabolic rate from 100 kcal/hr to more than 1000 protects cells from a second heat exposure.4 Any process kcal/hr, 70% to 100% of which is released as heat.2 or comorbidity that interferes with cardiac output, va-

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MANAGING HEAT ILLNESS IN URGENT CARE

Increased TBW allows increased TABLE 1. cardiac output. Dehydration causes 9,10 Key Risk Factors for Heat Illness or Heat-Related Death a reduction in available cardiac Age Behavior output, and greatly reduces the Ⅲ Elderly (>65 years old) or very young Ⅲ Failure or inability to seek cool benefits of acclimitization.3 (<5 years old) environment Ⅲ Left unattended in car Chronic disease Ⅲ Low fluid intake Epidemiology Ⅲ Cardiac Ⅲ Drugs and alcohol Heat illnesses are a growing con- Ⅲ Mental illness Ⅲ Lack of acclimatization cern. It is estimated that there are Ⅲ Endocrine Ⅲ Nutrition Living conditions 60,000 presentations for heat-re- Ⅲ Infection Ⅲ Lack of access to air conditioning lated illness a year in the U.S., with Ⅲ Urban an average of 688 deaths per year.6,7 Drugs Ⅲ Low income This figure does not include the Ⅲ Sympathomimetics Ⅲ Social isolation Ⅲ Neuroleptics deaths of undocumented migrants Ⅲ Cardiovascular Prolonged outdoor activities crossing the border between the Ⅲ Diuretics Ⅲ Agricultural workers U.S. and Mexico, which between Ⅲ Ⅲ Alcohol Runners 2002 and 2003 was estimated to be Ⅲ Anticholinergics Ⅲ Child/adolescent athletes Ⅲ Laborers 409 persons, just for the border Ⅲ Undocumented border crossers section between Yuma, AZ and El Paso, TX.8 Several populations have in- TABLE 2. creased risk of heat illness (Table Therapeutic and Recreational Drugs That May Contribute to Heat 1). The elderly and the very young, Illness—and Their Mechanisms9,10 patients with comorbidities, patients taking medications or drugs Drug category Relevant mechanism that interfere with heat homeosta- Diuretic (e.g., alcohol [ADH suppression], Deplete intravascular volume sis (Table 2), and persons with lim- furosemide, HCTZ) ited cognitive ability, low socioeco- Cardiovascular (e.g., beta blockers, calcium Decreased cardiac output and vascular nomic status, and mental illness channel blockers) resistance impairs cutaneous vasodilation are at elevated risk. Relatively Anticholinergic (e.g., antihistamines, Inhibit sweating young adults such as athletes, labor- Parkinsonian medications, atropine/ ers, and border crossers are suscep- scopolamine, tricyclic antidepressants, tible during high exertional states, neuroleptics) even in moderate temperatures. Sympathomimetic (e.g., cocaine, Vasoconstriction, increased muscle activity, amphetamines, ephedrine/ increased metabolic rate Diagnosis and Management pseudoephedrine) Key elements of the history in- Neuroleptic (e.g., phenothiazines, Inhibit sweating (anticholinergic); inhibit clude exposure, acclimatization thioxanthenes, butyrophenones) hypothalamus-directed vasodilatation status, comorbidities, drug and alcohol history, and a medication history (Table 3). Knowledge of sodilatation, sweating or sweat evaporation, electrolyte patients’ social resources is crucial for disposition deci- balance, or normal behavioral response can impair tem- sions and preventative counseling. perature homeostasis. The physical examination should focus on vital Acclimatization requires one hour daily of moderate signs, general appearance and mental status, hydration exercise for 10 to 14 days in conditions of heat stress.5 status, skin condition, and the cardiovascular and Acclimatized persons have increased sweat gland num- nervous systems. bers, sweat volume, and salt reabsorption, leading to en- Vital signs, including orthostatics to assess volume sta- hanced ability to dissipate heat by evaporation, reduced tus, help sort patients into those with relatively minor hyponatremia, and increased total body water (TBW). versus major heat illnesses.

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MANAGING HEAT ILLNESS IN URGENT CARE

Skin conditions, including heat rash and sunburn, interfere with TABLE 3. sweating and evaporative heat Key Elements of History losses.11 HPI Chief complaint, length of exposure to heat stress, exertion, hydration Anhidrosis should be assessed in the axilla, as forehead sweating is PMH Comorbidities, especially cardiac and mental health, acclimatization an unreliable marker.5 status, mobility, medications, drugs and alcohol, social support, access to air conditioning Hydration can be assessed from pulse and blood pressure, fontanel, Associated Fainting, weakness, lightheadedness, thirst, nausea, vomiting, diarrhea, oropharynx mucous membranes, symptoms urine output and color, muscle cramps and myalgias, headache, seizure, and ROS behavior change, rash, sunburn, sweating lacrimation, sweating, active vomiting or diarrhea, and urine color and output. Cardiovascular examination TABLE 4. should focus on murmurs, espe- Key Elements of Physical Examination cially in exertion-related syncope, and heart failure signs. In exer- Vital signs Temperature (preferably rectal) tional heat illness, it is important Pulse Respiratory rate to assess for muscle tenderness, Blood pressure and orthostatics considering rhabdomyolysis. Pulse oximetry Altered mental status or an ab- Random fingerstick blood glucose normal neurologic examination – Diabetics – Suspected altered mental status should prompt immediate transfer to a higher level of care, even if the General Mental status, body habitus, ill or not ill, motor activity level patient’s temperature is normal Skin Color and perfusion, pallor, cyanosis (Table 4). Diaphoresis, axillary anhidrosis miliary rash, sunburn Heat Syndromes There are several common entities HEENT Fontanel level, tears, oropharynx hydration seen in urgent care centers related Pulmonary Tachypnea, apnea to heat exposure, ranging from mi- Cardiovascular Tachycardia, bradycardia, dysrhythmias, murmur, heart sounds nor annoyances to higher risk for significant morbidity. These in- Abdomen Ability to tolerate oral fluids, vomiting, diarrhea clude heat rash, heat edema and GU Urine color, output heat syncope, heat cramps, and heat exhaustion (Table 5). Musculoskeletal Muscle tenderness or spasm, edema Neurological Cognitive ability, focal neurological deficits Heat Rash Psychiatric Reality testing, bizarre affect Heat rash, also known as prickly heat, lichen tropicus, and miliaria rubra, occurs when sweat ducts are blocked by dead skin. Tiny vesicles form as sweat accu- Heat Edema mulates under the skin, resulting in pruritis. Chronic Heat edema occurs mostly in older individuals who are vesicles can rupture into the surrounding tissue, causing adjusting to an increased heat strain. Vasodilatation, in skin thickening and scarring. Secondary Staphylococcus combination with relative venous stasis, causes blood and Streptococcus infections can occur. pooling. No dehydration or salt imbalance is usually Treatment includes antihistamines for pruritis, cool present, and diuretics are not warranted. This must be baths, and time in a cool environment. Chronic heat distinguished from more worrisome causes, including rash will need dermatologic follow-up for treatment deep vein thrombosis (DVT), nephrotic syndrome, liver with salicylate gels to avoid scarring.7 failure, and congestive heart failure. Heat edema is a be-

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MANAGING HEAT ILLNESS IN URGENT CARE

TABLE 5. Heat Stress Syndromes7,10,12

Heat rash Heat edema Heat syncope Heat cramps Heat exhaustion Heat stroke Mechanism Macerated skin blocks Pooling of blood with Vasodilatation and lack of Unclear: Prolonged exposure over Heat stress from internal sweat glands, vesicles vasodilatation, venous venous return from Loss of sodium in sweat hours or days to heat and external sources form stasis posture cause transient Dehydration stress, dehydration overwhelms ability of Chronic rash when hypotension Plain water hydration Exacerbated by exertion body to dissipate heat; vesicles rupture deep Spinal reflex14 leads to shock History Lack of rest in cool Elderly, not acclimatized Prolonged standing in Painful spasm in exerted Lack of access to cooling Risk factors environment, heat muscle groups, during or Exertion AMS sweating Responds immediately to hours after exercise Nonspecific: Headache, Similar to heat exhaustion lowered posture, cooling Previous history, not malaise, dizziness, acclimatized, drinking nausea, vomiting, water only, anorexia irritability

Signs Vesicles Pitting or nonpitting Transient hypotension Spasm, fasciculation in Diaphoresis AMS Erythematous edema of lower Responds rapidly to rest, large muscle groups, Tachycardia, tachypnea Core temperature >39.5 C Pruritic extremities, usually not cooling usually flexor Normal or elevated core Hypotension Chronic beyond ankles temperature lichenification scarring Hands may be edematous

Laboratory tests None None None routinely Electrolytes often normal Electrolytes Transfer to higher level of Elderly/comorbid/ Hyponatremia Renal function care for extensive exerting need EKG, labs, Hypokalemia Creatinine kinase laboratory tests imaging appropriate for Creatinine kinase Liver function syncope work-up Coagulation studies

Treatment Antihistamines Elevation Fluids Fluids Fluids ABCs Cool environment Compression stockings Rest Pain control Rest Begin cooling/hydrating, Cool environment Cool environment air conditioning, fan Acclimatization Acclimatization water spray Protect from re-exposure

Concerning Secondary infection CHF Hypertrophic heart Rhabdomyolysis Heat stroke: Neuroleptic malignant differential diagnosis Heat exhaustion DVT ACS Heat exhaustion AMS syndrome Liver disease Dysrhythmias Hypotension Serotonin syndrome Nephrotic syndrome Stroke Core temperture >39.5° C Seizure Rhabdomyolysis Heat stroke Septic shock

Red flags Inhibits sweating Should not extend above Ask about eating Altered mental status ankles disorders Disposition Discharge: Discharge Admit: Discharge Admit: Medical emergency Follow up Any concern for serious Avoid exertion for Risk factors Transfer to a higher level dermatology if chronic cause 1-3days No access to air of care immediately Discharge: Must re-acclimate conditioning Simple heat syncope Not responding Follow-up: to treatment Cardiology for IHC Discharge: Responds to cooling and fluids

nign condition that is self-limiting, and may be treated standing at attention with locked knees are at risk. with elevation and compression stockings. Follow-up Persons usually recover promptly with lowered head, with a primary care provider is recommended in seven elevated lower extremities, and a cooler environment. to 10 days (or sooner if the condition does not improve Differential diagnosis for syncope includes concern- with conservative measures). ing entitities such as idiopathic hypertrophic cardiomy- opathy, dysrhythmias, acute coronary syndrome, and Heat Syncope cerebral vascular accident. Heat syncope occurs when peripheral vasodilatation In a young, non-exerting, otherwise healthy individual and impedance to venous return caused by posture who responds to appropriate therapy, disposition may in- combine to lower the blood pressure enough to inter- clude discharge home. However, advanced age, comor- rupt cerebral blood flow. Classically, military personnel bidities, and a history of exertion at time of syncope re-

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MANAGING HEAT ILLNESS IN URGENT CARE Urgent Care Medicine quire further testing. In young patients with exertional syncope, restriction on activity level pending a referral to a cardiologist for further work-up is appropriate. Ag- gressive search for serious disease must be made in older Medical patients and patients with comorbidities, and admission or transfer to a higher level of care is appropriate. Professional

Heat Cramps Heat cramps are defined as motor unit hyperactivity in Liability major muscle groups, usually thigh or leg, during or several hours after prolonged exertion under heat stress. Insurance The exact mechanism is not clear. It was originally thought that hyponatremia due to excess sweating The Wood Insurance Group, a leading and hydrating with water caused heat cramps. How- national insurance underwriter, offers ever, heat cramps can occur before any rehydration significantly discounted, competitively has taken place, and many patients with heat cramps priced Medical Professional Liability have no electrolyte or serum osmolarity derange- Insurance for Urgent Care Medicine. ments. A spinal reflex caused by overexertion has also We have been serving the Urgent Care 13 been proposed as a mechanism. community for over 20 years, and our The two most useful prophylactic steps to prevent UCM products were designed specif- heat cramps are heat acclimatization and consuming adequate water during exercise. Relative muscle dehy- ically for Urgent Care Clinics. dration appears before the subject experiences thirst, so the advice should be to consume water at regular Our Total Quality Approach includes: intervals during exercise even if the athlete does not Ⅲ Preferred Coverage Features feel thirsty. Ⅲ Per visit rating (type & number) Treatment for heat cramps includes rehydration Ⅲ Prior Acts Coverage with an oral salt solution or IV normal saline, as well Ⅲ as pain control, which may require narcotics. Elec- Defense outside the limit trolytes should be checked and replaced as needed, Ⅲ Unlimited Tail available and creatinine kinase levels measured to rule out Ⅲ Exclusive “Best Practice” rhabdomyolysis. Typically, heat cramps respond rap- Discounts idly to treatment, rarely lasting for more than 15 Ⅲ Exceptional Service Standards minutes during a flare-up. They can produce agoniz- Ⅲ ing spasms during a flare-up, and can recur several Knowledgeable, friendly staff times over the next 24 to 48 hours. During the recov- Ⅲ Easy application process ery period, the patient should avoid exertion since the Ⅲ Risk Mgmt/Educational support spasms can be triggered by a normal muscular con- Ⅲ Fast turnaround on policy changes traction. Unfortunately, they can be triggered during Ⅲ Rapid response claim service sleep, and awaken the patient with severe pain. The painful contractions are usually in the flexor muscles, and hyperextension of the involved muscle may overcome the spasm. When they involve the ham- string flexors, extension of the hip and knee are useful, as is standing up, and slow mild pacing. Icing the involved muscles may provide the patient with pain relief, and mild analgesics are useful when the cramps subside. 4835 East Cactus Road, Suite 440 In the elderly patient who is perhaps already on a di- Scottsdale, Arizona 85254 uretic agent for hypertension, the cramps are worsened (800) 695-0219 • (602) 230-8200 • Fax (602) 230-8207 E-mail: [email protected] Contact: David Wood Ext 270

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MANAGING HEAT ILLNESS

Credentialing, by any potassium imbalance. Many Contracting, of these patients will obtain relief from potassium oral supplementa- Coding, tion even when the serum electrolyte level of potassium is normal. Billing/Collection Heat Exhaustion headaches seem to be getting Heat exhaustion is generally a result of prolonged exertion or pro- bigger each day? longed exposure to a higher heat index than normal. Symptoms are nonspecific, and can include any of the above syndromes, as well as lightheadedness, malaise, fatigue, headache, nausea, vomiting, decreased urine output, and thirst. Dehydration and electrolyte abnor- malities are common but not necessary to the diagnosis, and patients with a history of exertion need to have rhabdomyolysis excluded. Patients with heat exhaustion need to be in a cool, air conditioned environment, and inappropriate ex- tra clothing should be removed. Hy- dration can usually be accom- plished with oral salt solution or normal saline, with electrolyte cor- rection as necessary. Patients should Stop suffering and call respond to cooling and hydration; any patient with persistent symp- Urgent Care Billing and toms or comorbidities should be admitted to the hospital. Collections of America, LLC. Prudent discharge requires that the patient have access to a cool, air con- Our Credentialing, Coding, Billing and ditioned environment for the next 48 to 72 hours, especially for those Collection team members have been with risk factors for heat illness. instrumental in bringing relief to our Elderly patients, patients with clients’ Accounts Receivable pains. limited mobility, and mentally ill or retarded patients need a care- If you are a new start-up or have been taker or family member to check open for years, we can assist you. on them at least twice a day during periods of higher than normal heat or humidity. Close fol- Contact us at 866-660-8089 low-up should be arranged. and start feeling better! Workers and athletes likewise re- www.ucbca.org quire 48 to 72 hours of decreased activity in a cool environment, and must re-acclimate.

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MANAGING HEAT ILLNESS IN URGENT CARE

Heat Stroke urban areas have heat wave response plans that include Heat stroke needs to be considered in patients with heat shelters, such as malls. Fans have not been shown core temperatures above 39.5 ºC, anhidrosis, or any al- to be protective.17 teration in mental status. These patients must be imme- Exertion should, if possible, occur in the early morn- diately transferred to a higher level of care. This is a true ing or late afternoon or evening, avoiding activity dur- life-threatening emergency. ing the heat of the day. Outdoor laborers should be given regular rest and hydration breaks; an air condi- Prevention tioned rest area is protective against heat illness and All patients with heat illness are at higher risk for relapse maximizes exercise tolerance. in the short term and for recurrence in the long term. It is important to avoid re-exposure for two to three Summary days, as heat shock proteins and body water composi- Heat illness has an unknown incidence, but heat stroke tion take time to equilibrate. Athletes and laborers will is the second largest cause of environmental or weather- need to re-acclimatize after a period of rest, and cannot caused mortality—more than hurricanes, tornados, and immediately resume their previous level of exertion. lightning combined, second only to hypothermia.18 It It is appropriate to counsel all patients regarding heat is preventable through public health measures, educa- illnesses during the summer months, regardless of their tion, and early intervention. presenting complaint. Most presentations of heat illness can be quickly and During the course of weather episodes in which the adequately treated by the urgent care provider, and se- daily high temperature might exceed 90º F, or 80º F (32 rious morbidity and mortality can be avoided by attend- ºC or 27ºC, respectively) with high humidity, urgent care ing to risk factors, excluding serious diagnoses, pre- physicians can reduce the burden of heat illness with venting complications, and promptly recognizing severe brief counseling, educational handouts, and posters. disease. Preventative education remains an important Excellent patient information sources are available.14,15 part of the urgent care provider’s role. ■ Patients should be counseled to hydrate liberally, un- References less specifically contraindicated. Inactive individuals 1. Heat Index Chart. www.nws.noaa.gov/om/heat/index.shtml. 2007. need four liters of fluids or more daily during heat 2. Keim SM, Guisto JA, Sullivan JB, Jr. Environmental Thermal Stress. Ann Agric Environ Med. waves, and the exerting adult may need up to 10 liters 2002;9(1):1-15. 3. Sawka MN, Montain SJ. Fluid and Electrolyte Supplementation for Exercise Heat daily. Thirst is an unreliable indication of hydration sta- Stress. Am J Clin Nutr. 2000;72(2 Suppl):564S-572S. tus, as it is mainly stimulated by hypernatremia, and hy- 4. Bouchama A, Knochel JP. Heat Stroke. N Engl J Med. 2002;346(25):1978-1988. 5. Yaqub B, Al Deeb S. Heat Strokes: Aetiopathogenesis, Neurological Characteristics, Treat- dration must often be scheduled. ment and Outcome. J Neurol Sci. 1998;156(2):144-151. Exerting adults should drink 250 mL of fluid every 15 6. Heat-related Deaths–United States, 1999-2003. MMWR Morb Mortal Wkly Rep. 2006;55(29):796-798. to 20 minutes during exercise, and children should 7. Walker JS, Hogan DE. Heat Emergencies. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. drink 150 mL. It is often impossible to hydrate enough Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: McGraw-Hill, Med- ical Pub. Division; 2004:1183-1190. during exercise, and hydration must begin before activ- 8. Sapkota S, Kohl HW, 3rd, Gilchrist J, et al. Unauthorized Border Crossings and Migrant ity and continue afterwards. Deaths: Arizona, New Mexico, and El Paso, Texas, 2002-2003. Am J Public Health. 2006;96(7):1282-1287. Thirst is stimulated by eating; hydration at meals in 9. Tintinalli JE, Kelen GD, Stapczynski JS. Emergency Medicine: A Comprehensive Study Guide. addition to during activities is necessary. Electrolyte so- 6th ed. New York: McGraw-Hill, Medical Pub. Division; 2004. 10. Glazer JL. Management of Heatstroke and Heat Exhaustion. Am Fam Physician. lution is generally unnecessary for people consuming a 2005;71(11):2133-2140. normal diet, and has only been shown to increase ex- 11. Pandolf KB, Griffin TB, Munro EH, et al. Persistence of Impaired Heat Tolerance From Artificially Induced Miliaria Rubra. Am J Physiol. 1980;239(3):R226-232. ercise tolerance during the first three days of acclimiti- 12. Wexler RK. Evaluation and Treatment of Heat-Related Illnesses. Am Fam Physician. zation.3 However, if the taste is more tolerable, especially 2002;65(11):2307-2314. 13. Noakes TD. Fluid and Electrolyte Disturbances in Heat Illness. Int J Sports Med. 1998;19 to children, this may encourage hydration. Patients Suppl 2:S146-S149. not consuming a normal diet, exerting heavily for pro- 14. Naughton MP, Henderson A, Mirabelli MC, et al. Heat-related Mortality During a 1999 Heat Wave in Chicago. Am J Prev Med. 2002;22(4):221-227. longed periods of time, or with gastroenteritis will ben- 15. Bernard SM, McGeehin MA. Municipal Heat Wave Response Plans. Am J Public Health. efit from electrolyte solutions, and there should be no 2004;94(9):1520-1522. 16. Heat-related Illnesses and Deaths–United States, 1994-1995. MMWR Morb Mortal Wkly hesitation to use intravenous fluids. Rep. 1995;44(25):465-468. Air conditioning for as little as three hours per day is 17. Martinez M, Devenport L, Saussy J, et al. Drug-associated Heat Stroke. South Med J. 2002;95(8):799-802. the only intervention known to be protective against 18. Heat Wave—A Major Summer Killer. NOAA National Weather Service, heat stroke during heat waves.16 For this reason, some www.nws.noaa.gov/om/heat/heat_wave.shtml. Accessed August 9, 2007.

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Bouncebacks The Case of a 33-Year-Old Male with Abdominal Pain

Bouncebacks, in which we recount scenarios of actual patients who were evaluated in and discharged from an emergency department or urgent care facility and then “bounced back” for further treatment, appears semimonthly in JUCM. Case presentations on each patient, along with case-by-case risk management commentary by Gre- gory L. Henry, past president of The American College of Emergency Physicians, and discussions by other nationally recognized experts are detailed in the book Bouncebacks! Emergency Department Cases: ED returns (2006, Anadem Publishing, www.anadem.com).

Ryan Longstreth, MD, FACEP and Michael B. Weinstock, MD

ver the next few installments of this Question I: What is the incidence of series, we will be discussing bouncebacks? “bounceback” studies, and Several studies have attempted to an- answering the following ques- swer this question, using 72 hours as a tions, in sequence: bounceback “window” and produc- O What is the incidence of ing strikingly similar results. bouncebacks? Though the data were gathered What is the incidence from emergency departments, of bounceback admis- they may also be applied to sions? the urgent care setting. What is the incidence 1998, Annals of Emergency of deaths in patients Medicine: Gordon, et al pub- recently discharged lished a study of 52,553 ED from the ED? visits during a 12-month What percent of period and found a return bouncebacks occur be- rate of 2.7%. cause of medical errors? 1992, Archives of Emer- How can we use this in- © Barton Stabler / Images.com gency Medicine: Wilkins formation to improve and Beckett’s audit of patient safety? 5,811 ED visits found 102 Our feeling is that if we can unscheduled returns, a rate use these data to identify high- of 1.9%. risk patients, we can assure that our ur- 1991, Archives of Emergency gent care evaluation was appropriate. Medicine: O’Dwyer and Bodiwala If we can identify patients who are more likely to published a study encompassing more than bounce back, we can revisit their evaluation before 8,000 ED visits; they found a bounceback rate they leave the urgent care center. of 2.9%.

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THE CASE OF A 33-YEAR-OLD MALE WITH ABDOMINAL PAIN

Ⅲ 1990, Annals of Emergency Medicine: Pierce, et al normal BM, he developed gradual onset of RLQ and published a study of 17,214 visits and found a lower abdominal pain. He describes it as a bloating, 3% bounceback rate. spasm pain. After BM, pt noted urinary stream cut off So, the incidence of ED bouncebacks is felt to be and was no longer able to urinate. Gradually pain got roughly 3%; this translated into 3.3 million return vis- worse, intermittent RLQ pain radiated into the right its in 2005 (of 115 million ED visits total). groin and testicles. Pain is 8/10 with spasms, mild nausea with pain. No dysuria, hematuria, testicular Which patients are most likely to return? swelling, flank pain, chest pain, or fever/chills. Pt has Pierce found that 18% of bouncebacks were due to no history of kidney stones but grandfather had many physician-related factors, and that 30% required hos- kidney stones. pitalization upon their return. Reasons for the bounceback visits included: PAST MEDICAL HISTORY/TRIAGE: Ⅲ misdiagnosis Medications: Claritin D Ⅲ treatment error Allergies: No known allergies Ⅲ admission indicated at initial visit PMH: None Ⅲ psychiatric illness with admission indications PSH: None Ⅲ radiology call-back Ⅲ no pain medication given EXAM (at 21:15): This month’s JUCM case reinforces several general General: Well-appearing; well-nourished; A&O X 3, in risk management principles, primarily the kind of no apparent distress “misdiagnosis” cited by Pierce, above. Head: Normocephalic; atraumatic. The patient is a 33-year-old man who presents with Eyes: PERRL abdominal pain and is discharged without a definitive Nose: The nose is normal in appearance without rhi- diagnosis. In this case, stronger documentation and norrhea timelier follow-up may have ensured a better out- Resp: Normal chest excursion with respiration; breath come, decreased patient morbidity, and minimized sounds clear and equal bilaterally; no wheezes, the practitioner’s malpractice exposure in a clearly rhonchi, or rales high-risk patient. Card: Regular rhythm, without murmurs, rub or gal- As with previous cases we have presented, this case lop illustrates the utility of our two-step approach: Abd: Non-distended; Tender RLQ but no rebound. 1.Identify high-risk patients (i.e., patients with a Mild right flank/side pain. No rigidity, rebound or high-risk complaint and without a definitive di- guarding agnosis). Skin: Normal for age and race; warm and dry; no ap- 2.Review the patients’ evaluations before they leave parent lesions the urgent care clinic. GU Exam: External genitalia normal, no urethral dis- See how many “red flags” you can spot, and con- charge, testes descended bilaterally. No lesions noted sider if you would have done anything differently. on penis or scrotum. Epididymus normal bilaterally.

A 33-Year-Old Male with Abdominal Pain ORDERS (at 21:25): Dilaudid 1 mg IVP, Toradol 30 mg Initial Visit IVP, Phenergan 12.5 mg IVP, .9NS-500cc bolus then (Note: The following is the actual documentation of the 125cc/hr. providers, including punctuation and spelling errors.) RESULTS (at 22:09): CHIEF COMPLAINT (at 20:50): Abdominal pain Urine dip: WNL except: Bilirubin–1 mg/dL Time Temp Pulse Resp Syst Diast Pain 21:16 98.0 72 18 128 60 10 Noncontrast helical CT of the abdomen/pelvis (at 23:33 76 16 104 64 2 22:29)–Unremarkable helical CT of the abdomen and pelvis. HISTORY OF PRESENT ILLNESS (at 21:06): He is a 33 year old male who states that at 7pm, after having PROGRESS NOTE (at 23:23): Pt felt much better but

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THE CASE OF A 33-YEAR-OLD MALE WITH ABDOMINAL PAIN

still had pain into the lower abd. bilaterally with sit- differential. RLQ tenderness and pain radiating to the ting up. testicles may be due to acute appendicitis, incarcerated DIAGNOSIS: Abdominal pain, unspecified site, sus- hernia or testicular torsion, yet it does not appear the pect bladder spasms. practitioner considered these diagnoses. Perform additional evaluation (H&P and/or further testing) when DISPOSITION (at 23:41): The patient was discharged things just don’t add up. to Home ambulatory. Follow-up with primary care Teaching point: Start with a broad differential di- physician in 2 days. Prescription for Vicodin 5mg. Af- agnosis when evaluating undifferentiated abdominal tercare instructions for abdominal pain and kidney pain, focusing on high-risk/surgical diagnosis and use stone/renal colic. ancillary testing to hone in on your diagnosis. Under- stand the limitations of your tests. Discussion of Documentation and Risk Management Issues at Initial Visit Error 2 Error 1 Error: Failure to perform serial abdominal examina- Error: Failure to maintain a thorough differential di- tions. agnosis. Intervention: There is only one abdominal exam Intervention: The history seems to have led the documented on this chart. Abdominal pain is a high- physician down a ureteral calculus/spasm pathway. risk complaint and serial exams may discover an acute This was appropriate, given the patient’s symptoms. appendicitis or another surgical process that was not Although it is not uncommon to see ureterolithiasis evident on initial assessment. Some clinicians seem to without hematuria, a CT that fails to show a ureteral feel the best use for labs is that the patient spends stone or hydronephrosis combined with a normal more time in the ED/urgent care clinic, which allows urine should suggest another cause for the pain, and his disease to progress to the point where it is easier should prompt the provider to move further down the to make an accurate diagnosis. A more responsible

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THE CASE OF A 33-YEAR-OLD MALE WITH ABDOMINAL PAIN

course of action, if it is not “If appendicitis is and had right lower quadrant possible for the patient to tenderness with a (+) Rovsing’s wait in the urgent care clinic, a consideration, sign and guarding. is to send him to an ED. White blood count was 16K. Teaching point: The reexamine the patient The patient was given workup for abdominal pain is meperidine and cefotetan often a time-intensive process; within eight to and taken to the operating use this to your advantage and room, where he was found be sure to perform and docu- 12 hours.” to have a retrocecal appen- ment serial exams. dicitis, with rupture. He went on to develop a post-operative ileus and went home Error 3 five days later without further complications. Error: Failure to document medical decision making in a potentially high-risk patient. Summary of Case and Risk-Management Principles Intervention: Not all high-risk complaints require Our patient described RLQ pain and difficulty urinat- a “million dollar workup,” but good documentation ing, which ultimately led the practitioner down the is essential. It is not clear from this chart which diag- kidney stone pathway. However, when the imaging noses were considered, as the progress note simply did not demonstrate a urinary obstruction, the work- states “…still had pain into the lower abd. bilaterally up stopped. The patient had unexplained, ongoing ab- with sitting up.” It is wise to involve the patient and dominal pain—clearly a high-risk patient, warranting family in this discussion. early and aggressive follow-up. Teaching point: Document a progress note regard- Unfortunately, it does not appear that appendicitis ing medical decision making when dealing with high- was in the differential because the patient was told to risk patients, such as undifferentiated, ongoing ab- follow up in two days, a time span in which it was dominal pain. likely that the appendix would rupture. If appendicitis is a consideration, the patient should Error 4 be reexamined within eight to 12 hours. Error: Failure to provide appropriate time for follow-up. Practitioners must develop a broad differential diag- Intervention: An unremarkable helical CT scan of nosis for any chief complaint and then use the history, the abdomen makes appendicitis less likely, but does physical exam, and ancillary testing to rule in or out a not exclude the diagnosis. The patient was instructed specific disease. While there was a strong workup here to follow up with his primary care physician in two for renal colic, the workup was aborted when the scan days—a timeframe in which the appendix would be was negative. The practitioner would have been best likely to rupture. In light of the fact that the patient served to go back, obtain additional history, perform a was documented to have ongoing lower pain, and be- repeat exam, discuss the possibility of appendicitis with cause appendicitis was still a distinct possibility, the the patient, and develop a time-appropriate follow-up. patient should have been reexamined within eight to Application of our two-step approach may have 12 hours. In such a case, if the patient can’t get in to improved patient outcome. The practitioner would see his primary care physician, then tell him to return have recognized this to be a high-risk patient due to to the urgent care for a repeat exam or to go to an ED. ongoing abdominal pain without a definitive diagno- Teaching point: If you are concerned about acute sis. He/she would have then obtained additional per- appendicitis, prompt repeat examination within eight tinent history, re-examined the patient, and docu- to 12 hours (not two days) will improve patient safety mented serial abdominal exam. This would have and minimize your malpractice exposure. enabled the practitioner to consider additional diagnoses and then document a thorough progress note 33-Year-Old Male with Abdominal Pain and discuss the time-appropriate follow-up with the Return Visit—Less Than 24 Hours Later patient and his family. ■ The patient returned 21 hours later with ongoing abdominal pain, now with associated vomiting and fever. For suggested readings associated with this article, please log In addition, he was now tachycardic, appeared quite ill, on to www.jucm.com

24 JUCM The Journal of Urgent Care Medicine | September 2007 www.jucm.com ciprodex:Layout 1 5/17/07 12:30 PM Page 1

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©2007 Alcon, Inc. 5/07 CDX07505JA CIPRODEX® Otic is indicated in patients 6 months and older for acute otitis externa due to Staphylococcus aureus and Pseudomonas aeruginosa. CIPRODEX® Otic is contraindicated in patients with a history of hypersensitivity to ciprofl oxacin, to other quinolones, or to any of the components in this medication. Use of this product is contraindicated in viral infections of the external canal including herpes simplex infections. CIPRODEX® Otic should be discontinued at the fi rst appearance of a skin rash or any other sign of hypersensitivity. Serious and occasionally fatal hypersensitivity (anaphylactic) reactions, some following the fi rst dose, have been reported in patients receiving systemic quinolones. Serious acute hypersensitivity reactions may require immediate emergency treatment. If the infection is not improved after one week of treatment, cultures should be obtained to guide further treatment. Most commonly reported adverse reactions in clinical trials in AOE patients: pruritus (1.5%), ear debris (0.6%), superimposed ear infection (0.6%), ear congestion (0.4%), ear pain (0.4%) and erythema (0.4%). ciprodex:Layout 1 5/17/07 12:35 PM Page 2 insights_0907:Layout 1 8/27/07 2:56 PM Page 27

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 presenting information to [email protected].

FIGURE 1 The patient is a 10-month- old child who presents, with the parents upon referral by the pediatrician, with a history of three days of pain, but no history of trauma. The child refuses to stand, presumably due to pain, and resists crawling.

View the x-ray taken (Fig- ure 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: greenstick fracture of the distal tibia.

The x-ray was taken and the fracture identified by the urgent care physician. How- ever, the child was placed in a cast splint after referral to hospital, with advice to follow up with an orthopedist.

While the patient could have been casted in the urgent care clinic, tibial fractures in such young children are considered higher risk for abuse; as a matter of policy such cases are typically referred to the hospital so social services staff can get involved immediately.

Acknowledgment: Case presented by Nahum Kovalski, BSc, MDCM.

28 JUCM The Journal of Urgent Care Medicine | September 2007 www.jucm.com Ad_FullPage_Sized:Layout 1 8/11/07 1:29 PM Page 1 Ad_FullPage_Sized:Layout 1 8/17/07 8:50 PM Page 1

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INSIGHTS IN IMAGES CLINICAL CHALLENGE: CASE 2

FIGURE 1

The patient is a 5-year-old girl who presents Ⅲ significant constipation with vomiting and abdominal tenderness. How- Ⅲ occasional vomiting, which has grown more ever, she first presented a few days earlier for a frequent in the last couple of days. wound check following a laceration. Further examination is unremarkable, though The mother also states that the child was cough- you note “fullness” upon abdominal exam. ing and had intermittent fever for five days. Additional history includes: View the x-ray taken (Figure 1) and consider Ⅲ intermittent abdominal pain for a couple of what your diagnosis and next steps would be. weeks Resolution of the case is described on the next page.

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INSIGHTS IN IMAGES: CLINICAL CHALLENGE 2

THE RESOLUTION

FIGURE 2 FIGURE 2

This case is an interesting example of an unexpect- The clinical picture presented is far from a classi- ed finding—specifically, pneumonia. cal pneumonia case. Nevertheless, given the significant finding of the chest part of the x-ray, the The x-ray was done on the basis of “fullness” on child was treated with antibiotics. the abdominal exam. The abdominal film is normal, but it reveals a consolidation in the RLL This case is notable for several reasons: quadrant of the lung. Ⅲ The significant medical history was not the presenting problem. As noted previously, further examination turned up Ⅲ The WBC was consistent with a viral picture. no abnormal findings; the child’s temperature Ⅲ The x-ray finding was incidental and was slightly elevated at 37.8°C, SAT is 98%, pulse significant. is 113, and there is no respiratory distress. WBC is 8.5 with 40.8% lymphocyte and MONOs of 9.8%. Urinalysis is normal.

Acknowledgment: Case presented by Nahum Kovalski, BSc, MDCM.

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ABSTRACTS IN URGENT CARE On Unexplained Fever in Young Children, Removable Brace vs. Casting, and Contamination in Mid-Stream Urine Collection

■ 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.

Evaluating Fever of Unidentifiable Source in nificant decrease in the number of cases of occult bacteremia Young Children and SBI in febrile children, with occult bacteremia rates of 1.6% Key point: An excellent review of the approach to the febrile child. to 1.8%. Similarly, epidemiologic data reflect a decrease in the Citation: Sur DK, Bukont EL. Am Fam Physician. 2007;75:1805- rates of S. pneumoniae infections since the introduction of a 1811. pneumococcal conjugate vaccine. Even with a thorough history and a complete physical exami- Typically, fever that is clinically significant is defined as a rec- nation, one in five acutely ill, nontoxic-appearing children had tal temperature higher than 100.4°F (38°C). Further evaluation an unidentifiable source of fever. Physicians should be cautious is required for previously healthy, well-appearing children 3 to in their approach because of the potential for unrecognized and 36 months of age with a rectal temperature of 102.2°F (39°C) untreated serious bacterial infections (SBI). or higher. Several studies have shown that axillary and tympanic The review notes that most children will have been evaluated temperatures are unreliable in young children. for a febrile illness by 36 months of age and that most of these Specific recommendations are as follows: children have a self-limited viral illness. Ⅲ Any infant younger than 29 days, and any child who ap- However, studies from the 1980s and 1990s showed that pears toxic, regardless of age, should undergo a complete 7% to 13% of children younger than 36 months without ap- sepsis work-up and be admitted for observation and ad- parent sources of fever had occult bacteremia and SBI. ministration of intravenous antibiotics after completion of These infections may include bacterial gastroenteritis, cel- a sepsis work-up until the source of the fever is found and lulitis, meningitis, osteomyelitis, pneumonia, septic arthri- treated. tis, and urinary tract infections. Ⅲ Work-up should include a complete blood cell (CBC) count Since the introduction of Haemophilus influenzae type B with manual differential; blood cultures; lumbar puncture and Streptococcus pneumoniae vaccines, there has been a sig- for cell counts, glucose, protein, and culture; and urinalysis with culture. Laboratory evaluations for neonatal herpes simplex virus in- Nahum Kovalski is an urgent care practitioner and assistant medical director/CIO at Terem Immediate Med- fection also should be considered in patients with risk factors ical Care in Jerusalem, Israel. for infection—particularly maternal infection at the time of delivery; the use of fetal scalp electrodes; vaginal delivery; cerebrospinal fluid pleocytosis; and skin, eye, or mouth lesions.

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ABSTRACTS IN URGENT CARE

However, there should be a low clinical threshold to test for and pediatric emergency department for low-risk ankle fractures treat neonatal herpes simplex virus infection; if the infant is not were randomly assigned to a removable ankle brace or a be- improving while receiving antibiotic therapy, herpes simplex low-knee walking cast. The primary outcome at four weeks was virus infection should be considered. physical function, measured by using the modified Activities For low-risk infants aged 29 to 90 days who appear nontoxic, Scale for Kids. Additional outcomes included patient prefer- have an unremarkable history, and are under the care of a re- ences and costs. liable adult, there are two management options: The mean activity score at four weeks was 91.3% in the brace Option 1: Perform a laboratory evaluation including a CBC group (n=54)—considerably higher than the mean of 85.3% in count with manual differential, cerebrospinal fluid analysis, the cast group (n=50). and urinalysis with urine culture. If the white blood cell count Further, more children who were treated with a brace had is less than 15,000 cells/mm3 with an absolute neutrophil count returned to baseline activities by four weeks compared with less than 10,000 cells/mm3 and cerebrospinal fluid and urinal- those who were casted (80.8% vs 59.5%). ysis are normal, ceftriaxone (Rocephin), 50 mg/kg intramuscu- The removable ankle brace is more effective than the cast larly, may be given, with a follow-up appointment in 24 hours with respect to recovery of physical function, is associated with for repeat history and examination and review of results. a faster return to baseline activities, is superior with respect to Option 2: Perform a CBC count and urinalysis with urine cul- patient preferences, and is also cost-effective. ■ ture without obtaining blood cultures, doing cerebrospinal fluid studies, or giving antibiotics, provided the infant is carefully ob- To Clean or Not to Clean: Effect on served and followed up with a re-examination within 24 hours. Contamination Rates in Mid-Stream Urine If laboratory testing is positive, appropriate action is needed. Collections in Toilet-Trained Children For well-appearing infants and children aged 3 to 36 months Key point: Cleaning may reduce the riskfor returning for repeat cul- with a fever less than 102.2°F (39°C) without an apparent tures and for receiving unnecessaryantibiotic treatment and inves- source, observation only is adequate without any laboratory test- tigations. ing or antibiotics needed, but a follow-up visit should occur if Citation: Vallancourt S, McGillivray D, Zhang X, et al. Pedi- symptoms worsen or fever continues for longer than 48 hours. atrics. 2004;119:e1288-e1293. Well-appearing infants and children 3 to 36 months of age with fever of 102.2°F (39°C) or higher with no apparent source Urinary tract infection is one of the most common bacterial in- may receive observation only, with close follow-up. A second fections among children. Difficulty in specimen collection and option if there is no apparent source for the fever and if the interpretation of inadequately collected specimens may con- child has received the appropriate vaccinations is to order tribute to misdiagnosis of urinary tract infection. The objective screening laboratory analysis and send the child home with was to assess the effect of perineal/genital cleaning on bacte- close follow-up. rial contamination rates of mid-stream urine collections in Recent developments, including the dramatic decrease in the toilet-trained children. incidence of H. influenzae type B infection, mandate re-evalu- The authors conducted a randomized trial in toilet-trained ation of the recommended protocols for evaluating and treat- children who presented to a tertiary care pediatric emergency ing febrile children ages ≥36 months. ■ department between November 1, 2004 and October 1, 2005. All toilet-trainedchildren who were between the ages of 2 and A Randomized, Controlled Trial of a 18 years and hada mid-stream urine sample requested were el- Removable Brace Versus Casting in Children igible. Those whoseparents consented were cluster-randomized with Low-Risk Ankle Fractures by week to either cleaning or not cleaning the perineum with Key point: The removable ankle brace is more effective thanthe cast soap. The risk for a contaminated urine culture and the risk for for isolated distal fibular ankle fractures. a positive urinalysis were analyzed by intention to treat. Citation: Boutis K, Willan AR, Babyn P, et al. Pediatrics. 2007; In all, 350 children were enrolled. The rate of contamination 119:e1256-e1263. in the cleaning group was 14 (7.8%) of 179 vs.41 (23.9%) of 171 Isolated distal fibular ankle fractures in children are very com- in the non-cleaning group. Children who were randomly as- mon and carry very low risk for future complications. Neverthe- signed to cleaning were less likely to have a positive urinaly- less, standard therapy for these fractures still consists of cast- sis (37 of 179 [20.6%]) than those in the non-cleaning group (63 ing, a practice that does carry risk, inconvenience, and use of of 171 [36.8%]). subspecialty healthcare resources. Urine contamination rates are higher in mid-stream urine This was a non-inferiority, randomized, single-blind trial in that is collected from toilet-trained children when obtained which children who were 5 to 18 years of age and treated in a without perineal/genital cleaning. ■

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HEALTH LAW Employment Contracts Part 2: Troublesome Clauses

■ JOHN SHUFELDT, MD, JD, MBA, FACEP

ongratulations, you have found the perfect job! The chemistry Finally, the contract did not mention responsibility for the tail is right, the pay is adequate, and the working environment is or extended reporting provision. Unfortunately, her religious Csomewhat better than a sweatshop. So what’s missing? persuasion did not allow her to “start drinking heavily” (more Ah yes, the contract—that little document designed to protect sage advice from the Delta Tau Chi house); thus, she was forced both parties in the event of a disagreement. Although that de- to seek legal guidance. scription sounds innocuous, employment contracts are usually written by employers and tend to be slanted to their needs, as Preventive Medicine, Legally Speaking opposed to those of the employee or contractor. Therefore, it is Remember the phrase “an ounce of prevention is worth a pound incumbent upon the physician to thoroughly understand the con- of cure”? Reviewing a contract is one of those times it’s more than tract provisions prior to signing the agreement. just a catchy saying. Take the time and spend the money to have For example, a recent client of mine who was right out of res- your contract reviewed. It is money very well spent. idency signed a contract with a large office-based practice. At the Following are some things to consider: time, she did not want to spend the money to have the contract Ⅲ Assume the contract will be enforced as written. Too often, reviewed by an attorney; nor did she negotiate any clauses physicians assume that the person who negotiates the contract which she found confusing or ambiguous. will be the one who ultimately has to enforce the contract, and Not surprisingly, the job did not turn out to be what was de- that the enforcement will be tempered by what was orally scribed in her initial interview. She was treating 60+ patients per agreed to. The typical phrase that a physician hears is, “Don’t day without a break, the clinic was staffed to bare bones mini- worry about that, we would never hold you to it.” mum, and consequently, results were not being communicated People change jobs, however, and the person with whom to the patients nor entered into the chart. you have a great relationship may be long gone when it All in all, the practice was a disaster and she was afraid that comes time to interpret the contract language. the set-up of the office was a malpractice event waiting to hap- The take home point is this: Assume the contract will be pen. When she approached her employer, his response was ba- strictly enforced as written. sically the same one Flounder received in Animal House: “You Ⅲ A corollary to the preceding point is to never rely on oral prom- screwed up, you trusted us.” ises not reflected in the written contract. She wanted out as soon as possible. To her chagrin, however, For example, you may have been told during your interview the contract did not provide an out clause for the physician ex- that you will only be required to work one weekend per cept in the event of breach of contract by the employer. No ex- month. However, when you get the contract it is silent on this amples of what would constitute such a breach were illustrated. issue, or it states, “The physician’s work responsibilities shall In addition, the contract had a restrictive covenant of one year include weekends in accordance with the rotation schedule es- and 10 miles around each office practice. In effect, this radius tablished by the practice.” locked her out of the metropolitan area where she lived. Since the written contract controls, make sure before you sign that what was promised during the interview is contained in the written contract. John Shufeldt is the founder of the Shufeldt Law Ⅲ Be very wary of covenants not to compete. Most physician em- Firm, as well as the chief executive officer of NextCare, Inc., and sits on the Editorial Board of JUCM. ployment contracts contain a provision that if the physician He may be contacted at [email protected]. leaves the practice, he or she will not compete with the practice for a specific period of time in a specific geographical area.

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HEALTH LAW

Therefore, when a physician tries to set up a new practice or Thus, if you sign a three-year agreement with a 30-day out, join another practice, he or she may be open to suit. you have a 30-day contract. There is no “preferred” duration It is much easier to negotiate this clause prospectively than of an out clause. The only caveat is that it should be bilateral. it is to defend your actions after the fact. Most states do allow In other words, the same terms should apply to both parties. a noncompetition clause, provided that it is reasonable in Your employment contract may include every possible clause scope and time. Consult with an attorney on whether your which benefits you. However, if your employer can terminate you state’s law permits such covenants and what terms are reason- at their discretion, your contract is not worth much. Make sure able and enforceable. you completely understand what events can trigger termination. Ⅲ Malpractice clauses can often be very difficult to understand. If the clause is vague, insist that it be clarified in writing. If the It is critical that you have a clear understanding of the em- prospective employer refuses to negotiate, give serious thought ployer’s obligations before signing a contract. as to whether or not you will sign the contract. Make sure the contract spells out who is responsible for pay- Here are some typical termination provisions: ing for malpractice insurance. The contract should specify Ⅲ Sixty or 90 days’ notice by either party the amount of insurance provided, as well as the tail or ex- Ⅲ Loss of medical license tended reporting provisions. The cost of the tail provision is of- Ⅲ Accusation of impropriety (fraudulent billing, sexual harass- ten 150% to 200% of the last year’s premium; consequently, ment, conviction of a felony, etc.) the cost of this coverage can be quite substantial. Do not sign Ⅲ Material breach of the contract with a failure to cure a contract that is silent on the terms of the tail provision, since Ⅲ Illness or disability the cost of the tail or extended reporting provision is typically In summary, you can protect yourself during contract negoti- absorbed by the employer. That should be spelled out. ations by following three basic principles: Ⅲ I have heard a number of physicians comment that they Ⅲ Research your prospective employer’s history and under- signed a three-year agreement containing annual cost-of-liv- stand their practice environment. ing increases. While this clause is very useful, the length of the Ⅲ Get everything promised in writing. agreement is defined by the out clause. Ⅲ Consult a knowledgeable attorney. Ⅲ

40 JUCM The Journal of Urgent Care Medicine | September 2007 www.jucm.com

Every article that has appeared in JUCM, The Journal of Urgent TAKE-HOME POINTS Care Medicine is available on our Ⅲ xxxxxxxxxxxxxxx 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 coding_0907:Layout 1 8/22/07 5:22 PM Page 41

CODING Q&A Coding for Removal of Impacted Cerumen (69210)

■ DAVID STERN, MD, CPC

What is the correct use of CPT code 69210 (re- and multiple instrumentations requiring physician Q.moval impacted cerumen [separate procedure], skills.” one or both ears)? - Question submitted by Kathy Partenheimer, Medical of Dubois If the physician removes cerumen as part of the In the July 2005 issue of CPT Assistant, the AMA Q.exam but the cerumen is not impacted, what A.clearly indicates that you should report 69210 only code would be appropriate? when the following two criteria are both met: A simplistic answer is that removing the wax is sim- Ⅲ “the patient had cerumen impaction” A.ply included in the emergency and management Ⅲ “the removal required physician work using at least an (E/M) code. The actual situation, however, is not quite so otoscope and instrumentation rather than simple lavage” straightforward. [emphasis added]. Since real-life medical coding is governed by multiple entities—including the AMA, CMS, and multiple private- How does one determine that the cerumen is ac- sector payors—there are many areas of coding where con- Q.tually impacted so that code 69210 may be used flicting interpretations exist. Such ambiguity exists in the ap- for removal of the cerumen? plication of the code 69210. For the purpose of accurate coding, the AMA defines In this example, coders may make at least two inter - A.“impacted cerumen” in the July 2005 CPT Assistant pretations: as follows: Ⅲ If you ask the physician if the wax was “impacted,” he Ⅲ “If any one or more of the following are present, ceru- or she may indicate that, because the cerumen was not men should be considered ‘impacted’ clinically: stuck tightly and filling the entire ear canal, the wax was Ⅲ Visual considerations: Cerumen impairs exam of clin- not “clinically impacted.” ically significant portions of the external auditory canal, But be careful; you may be asking the wrong ques- tympanic membrane, or middle ear condition. tion. Before you give up too easily, ask the physician this Ⅲ Qualitative considerations: Extremely hard, dry, irri- question: “Why did you decide to remove the wax?” tative cerumen causing symptoms such as pain, itching, Chances are that the physician will tell you that the wax hearing loss, etc. was getting in the way of performing an adequate oto- Ⅲ Inflammatory considerations: Associated with foul scopic exam of the ear. If so, then the wax actually does odor, infection, or dermatitis. meet the strict AMA coding definition (listed above) for Ⅲ Quantitative considerations: Obstructive, copious impacted cerumen. cerumen that cannot be removed without magnification Since the removal of this “required physician work using at least an otoscope and instrumentation,” the procedure could be billable with code 69210. David Stern is a partner in Physicians Immediate Care, Ⅲ with nine urgent care centers in Illinois and Oklahoma, In some situations, however, using this code according to and chief executive officer of Practice Velocity the strict AMA definition may still not be appropriate. As (www.practicevelocity.com), a provider of charting, coding CMS cautioned in the Federal Register of June 29, 2006 and billing software for urgent care. He may be contacted (page 37233), “It is our understanding that CPT code at [email protected]. 69210 is to be used when there is a substantial amount

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CODING Q&A

“It [is] not appropriate to will not reimburse for the E/M when combined with modifier -25. Although this idiosyncratic coding requirement is use code 69210 unless the truly frustrating, it may be the only way to get paid. procedure required As always, check with your payor. physician work.” At times, the nurses do an ear wash, and the Q.physician does not perform any portion of the work involved in the cerumen removal. Is it appropriate of cerumen in the external ear canal that is very difficult to bill the 99211 with the 69210? to remove and that impairs the patient’s auditory function. - Question submitted by Kathy Partenheimer, Medical of Dubois We will continue to monitor the use of this code for the Since no physician work was required, you should appropriate circumstances.” A.not use code 69210. Instead, you would only bill To stay within the spirit of this definition, it seems 99211. Because of the liability inherent in an ear wax re- best to avoid using this code for situations that only moval (especially in the urgent care setting where the pa- take a minute of the physician’s time to scoop out the tient is not well known to the physician), I would personally wax. Rather, most coders would recommend that code advise against performing this procedure without a physi- 69210 be reserved for use in situations where the ceru- cian evaluating and documenting the condition of the ear(s) men removal takes significant effort by the physician. both before and after the ear lavage. This is a situation where many individual payors have set dif- In this case, the correct E/M code would be a 99212 (or ferent policies for application of this code, so it is best to check higher if indicated by medical necessity and documented ap- with individual payors for their policy. propriately), but it would not be appropriate to use code 69210 unless the procedure required physician work. As an urgent care center, can we also bill an office Q.visit with a 25 modifier and a 69210 on the same If the patient requires removal of impacted ceru- day of service, especially if the doc examines the patient Q.men from both ears, is it appropriate to add first and then determines that he needs an ear wash? modifier -50 to the code 69210 to indicate that a bilat- - Question submitted by Kathy Partenheimer, Medical of Dubois eral procedure was performed? An E/M code may be eligible for reimbursement in addi- No. Code 69210 is defined as “removal impacted A.tion to code 69210 if all of the following criteria are met: A.cerumen (separate procedure), one or both ears.” 1. The patient’s condition required a significantly, sepa- Use this same code only once to indicate that the proce- rately identifiable E/M service above and beyond the dure was performed, whether it involved removal of im- usual pre-service and post-service care associated with pacted cerumen from one or both ears. the removal of the impacted wax 2. The documentation requirements for use of that E/M What are the appropriate ICD-9 diagnosis codes code have been met Q.to justify billing for 69210? 3. Modifier -25 is attached to the E/M code Medicare accepts many different ICD-9 codes as When you are using 69210 for ear wax impaction, it is ap- A.“supporting medical necessity.” By definition, how- propriate to use an E/M code (with modifier -25) if the pa- ever, 69210 always involves the diagnosis of impacted ceru- tient received a true evaluation and management for a sep- men, so it seems reasonable to always attach the code for arate problem (such as bronchitis or pharyngitis) or for impacted cerumen (380.4) to the code 69210. complicating problems (such as dizziness or otitis media). It Of course, the physician documentation should clearly is generally a good idea to include patient records with demonstrate the presence of impacted cerumen, as defined billings (or at least with appeals) to substantiate the med- above. If you are attempting to code an E/M code in addi- ical necessity for a separate E/M. tion to code 69210, appropriate coding of an additional di- On the other hand, if the patient comes in with a com- agnosis is often helpful to reduce denials. ■ plaint of a “stuffy ear” and the physician determines that the patient has a cerumen impaction, removes the wax and Note: CPT codes, descriptions, and other data only are copyright 2007 American Med- ical Association. All Rights Reserved (or such other date of publication of CPT). CPT is there is no medical necessity for a separate evaluation and a trademark of the American Medical Association (AMA). management, then one would code only the 69210. Disclaimer: JUCM and the author provide this information for educational purposes A few payors require the coder to attach modifier -59 (dis- only. The reader should not make any application of this information without consult- tinct procedural service) to the procedure code (69210) and ing with the particular payors in question and/or obtaining appropriate legal advice.

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OCCUPATIONAL MEDICINE Top Communicators Apply These Principles

■ FRANK H. LEONE, MBA, MPH

ho among your network of colleagues and friends do you Ask questions. Listen more than you speak, but maintain con- consider to be “great communicators?” What characteristics trol of the conversation by leading the subject where you want W do they have in common that make them great? to through artful and effective questioning. Broad, open-ended Consider the following principles underlying one’s ability to questions are invariably more effective; e.g., “In a perfect world, communicate effectively: what type of relationship do you envision between your company Keep it simple. Break every message down to a simple, and our clinic?” easy-to-digest concept. Avoid too much detail or trying to jam Articulate a win-win. Fashion a win-win scenario prior to a too many concepts into a single interchange. Use basic, short meeting or conversation and then focus on articulating the win- words. Assume your subject has a minimal attention span. win early, often, and convincingly. Get to the heart of the mat- Be brief. The more you say, the more likely it is that your es- ter by using the phrase “win-win.” A statement such as, “It sential message is lost or muddled amid a sea of extraneous ver- seems to me that our clinic’s relationship with your company is biage. Know when to stop talking. Leave thoroughness to your likely to be a ‘win-win’…” sets things out in clear terms. attorney friends who get paid by the hour. Probe. Constantly probe in order to obtain more specific and Identify a clear objective. Consider the objective of your insightful information. Classic probes such as, “Tell me more…,” comments before you utter a word, then state your objective in ”Exactly what do you mean by...,” or “Why do feel that way?” pro- just those words (as in, “My goal is…,” etc.). When you state a fea- vide greater clarification and more specifics. ture (e.g., your hours of operation), advise the prospect why it is Repeat key points. Pause often and repeat key points. If an of value to them. Constantly associate a “why” with a “what.” idea or point is twice as important as everything else you are say- Focus on your message. Stay “on message.” Continually re- ing, say it twice. Ensure that the most important thing you have turn to your basic objective. Be wary of diversions, whether they to say is the one thing that the subject remembers. are initiated by you or by the object of your communication. Involve your subject. Involve your subject continuously Master pace. Conduct every communication like a fine sym- throughout your discourse. In addition to asking numerous phony orchestra. Vary pace, volume and emphasis in a well- questions, pepper your comments with frequent “mini-closes” crafted and confident manner. Pause frequently (and usually right (e.g., “Do you agree?”), and make the subject think and act after key points) and don’t be afraid of silent moments. Above throughout the conversation. Keep the message fluid and active all, avoid droning on in a monotone. rather than static and stiff. Maintain eye contact. One’s eyes say as much as the words Summarize. The first and last things you say are likely to be- they are speaking. Concentrate on eye contact and learn to income your most impactful comments. Hence, your opening terpret signals from your subject’s eyes as a guide to alter, main- comment should clearly articulate your objective and your last tain, or cease your communication. statement should provide a summary of key points. Becoming a great communicator is not complex. Indeed, just the opposite is true: the more simple, controlled, and focused the Frank Leone is president and CEO of RYAN Associates and executive director of the National Association of process, the more effective the communication stream. Yet even Occupational Health Professionals. Mr. Leone is the author the most dedicated sales professional frequently assumes a de- of numerous sales and marketing texts and periodicals, featist manner when it comes to being a strong communicator. and has considerable experience training medical profes- With adherence to a relatively short and simple array of princi- sionals on sales and marketing techniques. E-mail him at ■ [email protected]. ples, your communication skills will improve multifold.

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Career Opportunities MICHIGAN – Family or Med/Peds Physician MT. WEST HEALTH CENTER, P.A. is currently URGENT CARE CENTER – Salem Clinic, P.C., a sought for clinical and medical director position seeking physicians to join practices in EL Paso, with an urgent care center. 32 hours/week clini- Texas for Urgent Care Center. Excellent opportunity 40-physician multi-specialty group located in cal, 8 hours/week medical director duties. Cur- to work with a large, established private family/ Salem, Oregon, has an opening for a part-time rently the clinic sees about 25 patients/day but urgent care practice in an autonomous manner or full-time family practice at our Urgent Care with expanded hours the expectation is that with other physicians and physician assistants. Center. Please forward, email or fax your CV to: should increase to 35 a day. ACLS certification We offer a competitive salary and benefits package. Connie Finicle, Salem Clinic, P.C., 2020 Capitol is mandatory within 6 months of hire. Beautiful Please contact Brisa Newberry, MBA. Phone: St., NE, Salem, OR 97301. Fax: 503-375-7429 western Michigan resort community nestled on 915-217-2809; email: [email protected]; fax or email: [email protected]. the shores of Lake Michigan and numerous in- 915-850-0546. land lakes. Salary of $150,000-$170,000 plus Urgent Care Physician Opportunity in Lehigh SOUTHERN CALIFORNIA benefits and malpractice insurance. Contact URGENT CARE Acres, Florida! Lehigh Regional Medical Cen- Todd Dillon at 800-883-7345 or e-mail Experienced Urgent Care Physicians, ter: 5-bed ED and 30,000 annual volume. Crite- [email protected]. ID#28924C14. For Physician Assistants, Nurse Practitioners ria: BC/BP EM, IM or FP. Benefits: 10-hour shifts, needed to increase staffing for premier, 23 year more opportunities, visit www.cejkasearch.com. highly regarded, free standing 11,000-square full- and part-time available and located in the foot Urgent Care facility located near the beautiful Ft. Myers area. Contact Mary Langen- SEATTLE, WASHINGTON – URGENT CARE foothills of Glendale, California. Minimum 2 Live the good life! As a MultiCare Urgent Care years experience. Very strong clinical and stein at [email protected]. interpersonal skills a must. Full benefits package, physician, you will benefit from a flexible, rota- professional liability coverage, competitive tional, and “tailor-made" shift schedule with awe- productivity based compensation plan. some work-life balance. Multi-specialty medical Please contact and forward CV to Bill Wilkie at: Carolinas Healthcare System group seeks B/C FP, IM/Peds or ER physician [email protected] for a full- and part-time positions. All urgent care (818) 241-4331 Ext. 113 BC Physicians needed for our expanding clinics are located within 40 minutes of down- network of existing and new Urgent Care town Seattle. Integrated Inpt/Outpt EMR, excel- facilities throughout the Charlotte, North lent comp/benefits, flexible shifts, and Wheelersburg, Carolina area. All facilities are out-patient system-wide support. Take a look at one of the Ohio only, open 8am-8pm, 7 days/week and have Northwest’s most progressive health systems. Year round temperate climate affords outdoor no-call. Openings are employed positions BC/BP PC or IM physician needed for with attractive compensation and benefits. enthusiasts endless recreational opportunities, 22,000 visit freestanding urgent care. such as biking, hiking, climbing, skiing, and golf- No nights! Mid-level coverage daily. For more information about ing. For more information call (800) 621-0301 or Back-up provided by Southern Ohio Medical opportunities, please contact: email your CV to MultiCare Health System Center's main campus. Sarah Foster, Physician Recruiter Provider Services at blazenewtrails@multicare EPMG offers paid family medical benefits, 800-847-5084 • Fax: 704-355-5033 .org or fax to 866-264-2818. Website: www. multi incentive bonuses, flexible scheduling, [email protected] care.org. Refer to opportunity #513-623. “Multi- paid malpractice, and more. www.carolinashealthcare.org/careers/physicians Care Health System is a drug free workplace” Please contact Kim Senda at 800-466-3764, x338 or www.rja-ads.com/jucm • [email protected] [email protected]

Urgent Care Physicians Needed in North Central Wisconsin

Our newly opened primary care clinic in Stevens Point is adding a walk-in department and we are seeking 3 full-time Urgent Care physicians to join our growing practice! Candidates must be Board Eligible or Board-Certified. Our busy, established walk-in clinics in Wausau and Weston are adding an Urgent Care physician due to growth of their program. North Central Wisconsin offers 4 seasons of recreation including all water sports, biking, hiking, golf, downhill and cross-country skiing. You’ll enjoy all the amenities of a big city without the hassles. Excellent schools, shopping and fine dining right outside your back door. For more information concerning this outstanding opportunity, contact Karen Lindstrum at: (800) 792-8728 Fax your CV to (715) 847-2742 or e-mail Karen at [email protected] www.aspirus.org

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Career Opportunities COLORADO Excellent Internal Medicine Excellent Partnership/Medical Director Family Practice Opportunities opportunity available with a new Urgent URGENT CARE CLINIC Care opening in Colorado Springs. We are seeking an experienced board-certified Southern California’s leading physician-owned multi-specialty medical ER/FP/UC physician. Competitive StatClinix Urgent Care, a growing Urgent group has opportunities for full-time Inter- compensation, productivity, bonuses, paid Care organization in Arizona is seeking vacations, paid CME and malpractice experienced Board-Certified UC/FP/ER nal Medicine/Family Practice physicians for current and upcoming physicians in our Long Beach and insurance. Excellent benefits package. Urgent Care Clinics. Los Angeles regions Candidates must be For more information, please contact Board Certified, have a current California Currently recruiting for Payson and Ashley Wiechman at 719-596-6110. Show Low locations. Excellent opportunity medical license, DEA current, for employment with a BLS/ACLS/PALS, suture experience competitive compensation package. preferred. We are a large, dynamic Contact Information: and well-established group and offer a Urgent Care Plus Mary McGuire at 480-682-4111 balanced professional and personal or fax CV to 602-926-2628 or lifestyle, as well as excellent compensation in Austin, Texas email: [email protected] with Partnership Track and benefits. is seeking board-certified/board- www.statclinix.com eligible Family Medicine Physicians or We have immediate openings for per diem and full-time physicians for a Emergency Medicine Physicians. variety of shifts. Our busy Urgent Care Residents too! Immediate openings Clinic treats patients for anything from a available. Two locations both open common office visit to an emergency room 9:00 - 9:00 ~ 7 days a week. visit. Our patient population includes chil- $75.00 per hour for dren, adults and seniors. We will consider 3rd year/senior residents with let- Family Medicine; ters from residency program chief $85.00 for Emergency Medicine resident or director approving moonlighting. Shift differentials offered for Visit us online and reach an weekends. Bonus pay for high census days. unlimited internet audience of For more information, call: Family Practice Internal Medicine, Valerie Gibbs, and Emergency Medicine Apply on line: Director of Operations http://www.healthcarepartners.com (512) 963-2209 physicians who look to this site /careers/careers.asp Email: [email protected] for employment opportunities. [email protected] www.jucm.com Reference: ACP Headquarters is located in Next available issue is Torrance, CA 90502 November with a closing of October 1st

Full-time or Part-time Positions For Emergency Medicine and Urgent Care Physicians

Immediate Health Associates (IHA) provides emergency services at Mount Carmel St. Ann’s Hospital and operates 6 urgent cares in the Central Ohio market. IHA is an employee owned company, known for innovation and patient satisfaction. IHA provides care to over 150,000 patients annually. IHA offers a competitive salary and benefit package including: Company-sponsored health, life, dental & vision insurance 80 hours of PTO in first year • 401(k) plan with employer match • Paid malpractice insurance • CME reimbursement • Flexible spending • Basic life, AD&D, short-term and long-term disability insurances Resumes are currently being accepted for Emergency Department and Urgent Care positions.

Interested individuals may contact: Arlene Kent, Business Manager Immediate Health Associates 575 Copeland Mill Road Suite 1D Westerville, Ohio 43081 Office: 614.794.0481 ext. 100 / Fax: 614.794.3711 [email protected]

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Career Opportunities

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

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

FLORIDA URGENT CARE MEDICAL DIRECTOR GRAND RAPIDS, MICHIGAN Excellent Ownership/Partnership opportunities available with a well-established Spectrum Health, one of the nation’s top integrated healthcare Urgent Care group in Tampa Bay area. systems and the largest tertiary referral center in West Michigan, is Contact: R. Sandhu, MD looking for a Medical Director of its Urgent Care Network located in the Phone: 813-655-4100 Grand Rapids metropolitan area. This position is responsible for assessing and improving all aspects of Fax: 813-655-1775 patient care, implementing medical staff policies, and ensuring the delivery of safe, cost effective, Email: [email protected] high-quality, and efficient care in the Urgent Care setting. This full-time position, directly employed by Spectrum Health, is a mix of administrative and clinical duties. Each year, the current five locations provide care for more than 130,000 patients and are PHYSICIAN open from 8:00am until 10:00pm, 7 days per week. Qualifications include Board-certification or MEDIQUICK URGENT CARE Board-eligibility in either Emergency Medicine, Family Practice, or Urgent Care. Competitive salary/benefits package, including relocation allowance. MidState Medical Center, a state-of-the-art community hospital serving central Connecti- Grand Rapids is a prosperous and rapidly-growing city, (metropolitan cut, has an opening for the right physician in population of 750,000), 45 minutes from Lake Michigan, and is known our affiliated urgent care facility. MediQuick as the cultural, educational, and economic hub of West Michigan. sees 19,000 patients per year and has a stable, For further information, contact: Bob Vander Ploeg, respected nurse and physician staff and offers Spectrum Health Physician Recruitment, strong hospital and director Phone: (800) 788-8410; Fax: (616) 774-7471 support. Work 2-3, 12 hour shifts/week. or email: [email protected] Candidates should be board-certified or Board-Eligible in Internal or Family Medicine. MidState offers competitive salaries and benefits and is within easy driving distance of Boston, New York City, the mountains, the shoreline and Connecticut’s stimulating arts URGENT CARE - FAMILY PRACTICE and cultural offerings. Seeking experienced, self-motivated, and congenial Board Certified Family Practice Interested applicants may contact physician who desires an urgent care setting. Two NEW freestanding facilities located in Dr. Fred Tilden, high-traffic, highly visible locations. Provide primary care services on an express care Medical Director of Emergency Services, basis including diagnostic radiology and moderate complexity lab services. at 203-694-8278. Cross-trained support staff to handle front office and nursing responsibilities. For more information on MidState Medical Established relationship with medical staff at a local 367-bed regional Center, and to apply on-line, visit our website at tertiary medical center with Level II trauma and med flight services offering the full www.midstatemedical.org spectrum of primary care, occupational medicine, and subspecialty support. Solid hourly compensation with a comprehensive benefits package; including paid malpractice insurance. Flexibility in scheduling to allow you to enjoy a busy practice AND support a quality of life. NO CALL OR INPATIENT RESPONSIBILITIES! Services Excellent quality of Life. Vibrant, family-oriented community offering safe, sophisti- cated living and amenities rare in a city this size. Breathtaking landscapes and wooded rolling hill terrain amongst the many area lakes and streams. Cost of living 14-15% BUSINESS BROKER SERVICES. Own a busy, below the national average-one of the lowest in the United States! Chose from public, clinically excellent urgent care practice? Call for private, or parochial schooling options along with a 4-year university in town and two a free consultation from experienced urgent care Christian colleges. Variety of the four-seasons supporting an abundance of recreational business brokers. Contact Tony Lynch or Steve activities for the entire family. Easy access to larger metro areas within 2 hours or less. Mountain at MT Consulting, 610-527-8400 or [email protected]; www.mtbizbrokers.com For more information, contact: Alyssa Hodkin Phone: 800-638-7021 • Fax: 417-659-6343 Email: [email protected] • www.docopportunity.com

PLACE YOUR AD WHERE IT WILL GET NOTICED for Circulation has now increased to 12,500! Practices Sale

With JUCM Classifieds, your ad will FOR SALE- Lansing, Michigan. Busy and very FOR SALE- Orlando, Florida. Urgent Care/Family reach thousands of Family Practice, Internal well-established urgent care. Excellent location Practice conveniently located near Disney, Sea Medicine and Emergency Medicine and reputation. Consistent volume and proto- World, and Universal Studios. Well-established Physicians, Physician Assistants, and cols. Consistent income. Owner would like to re- in prime international and domestic tourist corri- Nurse Practitioners who look to these pages tire. Financing is negotiable. Please contact dor. Tremendous growth potential and consistent for employment opportunities. [email protected]. high income. Contact Dr. Daryanani at 407-465- JUCM is your gateway to an in-clinic sales FOR SALE- Urgent Care shares for sale. Has 1110 or email [email protected]. force andwe look forward to being a been open for 2 years. Carrollton, Texas. Call resource for you and your urgent care center. 469-222-3630. FOR SALE- Free standing Urgent/Family Practice Next available issue is November, center seeking physician to join practice and as- closing October 1st. Contact: Trish O’Brien sume ownership. Owners are planning to retire 800-237-9851 • FAX: 727-445-9380 The Journal of Urgent Care Medicine after running successful practice for 22 years. In- Email: [email protected] (800) 237-9851 • Fax (727) 445-9380 cludes practice and 3,000–sq. ft. building/land. www.rja-ads.com/jucm Email: [email protected] Troy, New York. Contact 518-421-7302. www.jucm.com JUCM The Journal of Urgent Care Medicine | September 2007 47 developingdata_0907:Layout 1 8/27/07 3:59 PM Page 48

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 UData, we will 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: How much time do various staff members spend with patients? As you will see, time spent with the physician is likely less than that spent with some combination of other clinical personnel and clerical staff. This reinforces the obvious importance of hiring and properly training competent individuals for each position, but also highlights the more subtle opportunity each employee has to affect a patient’s experience—for better for worse—during a typical visit to your urgent care center.

AVERAGE STAFF TIME WITH PATIENTS*

PA/FNP, physician assistant or family nurse practitioner; RN, registered nurse; LPN, licensed practical nurse; Nsg Asst, nursing assistant; Reg/Disch, registration and discharge personnel. *Note: Clearly, not all patients interact with each of these staff members during an “average” visit. Rather, these data represent a comparison of how much time, on average, various personnel spend with the patient populations of responding centers.

Areas covered in the UCAOA industry surveys included urgent care structures and organization, services Next in Developing Data: offered, management of facilities and operations, Are payors reimbursing on problem-based patients and staffing, and financial data. UCAOA members who have ideas for future surveys should coding—and if so, what percentage of e-mail J. Dale Key, UCAOA Survey Committee chair. receivables are they reimbursing?

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