Abstract
Urgent care centers frequently encounter patients with problems that are beyond the capability of the center to treat. In this chapter we will discuss some of the commonly encountered emergencies and the medications and supplies that are suggested to be kept on hand to be used in these instances. We will also briefly discuss transfer of patients from the urgent care setting and communication with the receiving facility. The significance of syndromic surveillance and recognition of the presentation of CDC class A biological agents will also be discussed.
Keywords
adult emergencies, disaster preparedness, office emergencies, pediatric emergencies
1
A 4-year-old boy presents to your urgent care center after falling from monkey bars 1 hour prior. He sustained a blunt head injury, but there was no loss of consciousness. While in your waiting area he proceeds to have a generalized tonic-clonic seizure, has multiple episodes of vomiting, turns blue, and stops breathing. You detect no peripheral pulses. How often do serious emergencies occur in urgent care centers?
Although not meant to replace emergency departments (EDs), urgent care centers may need to provide the acute assessment and management of moderately to severely ill or injured infants and children. While studies examining the etiology of pediatric emergencies, including those considered life threatening, that present to urgent care centers have not been published, retrospective studies have found that the rate of emergencies in primary care practices that provide care to children range from less than 1 per office per year to more than 30 per office per year, with the most common reported emergencies being respiratory distress, severe dehydration, seizures, severe trauma, abdominal pain, syncope, and behavioral/psychiatric disorders. A recently published study of urgent care centers in the United States showed that 71% of respondents reported that their center has contacted 911 or community EMS to transport a critically ill or injured child to a definitive care facility.
2
Do emergencies occur more or less frequently in the adult urgent care setting?
Emergencies in the adult population are frequently encountered in outpatient offices and in the urgent care setting. A Canadian study from the Ottawa area recorded more than 3,000 calls for “life-threatening” emergencies to family practice offices over the 3-year period of the study. In addition, an Australian study found that 95% of family practice offices had seen an emergency in the preceding 12 months. Although these studies were conducted in the primary care office settings, they may help to give us an estimate of the frequency of emergencies in the urgent care center setting. The Urgent Care Association of America notes that 4% of patients are either “directed or transferred from an urgent care center to an emergency department.”
3
What types of adult emergencies are seen in the urgent care setting?
Almost any kind of emergency could conceivably present to an urgent care center. The patient who presents with “indigestion” may experience a cardiac arrest as his complaint is really a myocardial infarction. The patient who presents with a headache or weakness may be having a stroke. Allergic reactions may rapidly progress to airway obstruction. One must also consider that patients may be brought into the urgent care center from traumatic events such as motor vehicle collisions that occur in close proximity to the center. A Canadian study found that general illness and cardiovascular, respiratory, neurologic, and endocrine problems were the five most common reasons for adult life-threatening emergencies to occur in the outpatient office setting.
4
What kind of equipment should be readily available in the urgent care setting in the event of a life-threatening emergency?
The urgent care center must be prepared to act in emergency situations involving both adult and pediatric populations. Therefore it is important to have equipment that is appropriate for all age ranges from neonate to adult populations. Box 53.1 lists emergency equipment that should be maintained in the urgent care setting. In some emergency situations airway management is necessary. Often this can be achieved by use of airway adjuncts and effective bag-valve mask ventilation. If the center is staffed by physicians who are certified in endotracheal intubation, having the equipment needed for placing an endotracheal tube is a consideration.
Automatic external defibrillator (AED) or a cardiac monitor with defibrillator
Bag-valve mask ventilators in multiple sizes with masks for infants through adults
Blood pressure cuffs of various sizes
Color-coded resuscitation tape (pediatrics)
Gloves, masks, and eye protection
Glucometer
IV access equipment (IV catheters, butterfly needles)
IV tubing
Nasopharyngeal airway set
Oropharyngeal airway set
Nebulizer sets
Oxygen delivery devices (nasal cannula, simple mask, nonrebreather masks) in appropriate sizes
Oxygen tank(s) for portable use
Portable suction device with catheter
Pulse oximeter, adult and pediatric sizes
Additional Equipment to Consider
Laryngoscope with curved and straight blades of various sizes
Endotracheal tubes, various sizes
Magill forceps
Cervical collars and backboards
5
What emergency medications should an urgent care center stock for use in an office emergency?
Box 53.2 and Table 53.1 list recommended medications that should be readily available in the event of an adult or pediatric emergency. The Joint Commission recommends that, whenever possible, emergency medications are available in unit-dose, age-specific, ready-to-administer forms.
Drugs and Fluids
Acetaminophen
Albuterol (MDI or nebulized)
Aspirin, chewable 81 mg
Ceftriaxone IM or IV
Corticosteroids (IV and po)
Dextrose (25% and 50% for IV use)
Diazepam, IV (Valium)
Diphenhydramine (IV and po) Benadryl
Epinephrine (EpiPen)
Epinephrine (cardiac 1:10,000)
Naloxone
Nitroglycerin (spray or sublingual tablets)
Saline (IV fluid)
Other Medications to Consider
Narcotics, such as morphine
Lidocaine
Glucagon
Atropine
Flumazenil (Romazicon)
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