Johns Hopkins pediatricians offer guidelines on choosing between urgent care and ER

It's Friday afternoon and your 20-month-old son is running a fever. He is cranky, refuses to eat, periodically pulls on his ears, and isn't his usual playful self.

Your reaction is:

a. No big deal. You call your pediatrician's office and ask for an appointment the following week.

b. Dreading a fever-induced seizure — it happened to the child of a friend's friend — you rush to the nearest emergency room.

c. Head to an urgent care center, such as Patient First.

If you picked C, you chose wisely. But unfortunately many clinical scenarios are not as clear-cut nor is the choice always obvious to parents and, for that matter, some clinicians, says Johns Hopkins Children's Center emergency physician Therese Canares, M.D.

The result? A backlog of acute pediatric cases many of which don't require emergency treatment, but a trip to the pediatrician's office or an urgent clinic instead, Canares says. The problem gets particularly bad during the winter — cold and flu season — and in the summer, which brings its own set of childhood maladies.

Parents have a natural tendency to fear the worst when it comes to their children and often opt for a "better safe than sorry" course of action, Canares says, but the truth is many situations don't warrant a trip to the emergency room. At the other end of the spectrum are cases that clearly require emergency attention but end up in urgent care instead — a less common scenario, Canares says.

"Urgent care versus the ER versus your doctor's office: Some situations are no-brainers, but many fall in a gray zone of uncertainty. That choice can be particularly tricky when it comes to infants and young children, whose unique physiology dictates different levels of clinical assessment and treatment approaches from older children or adults," Canares says.

For example, fever is always considered an emergency in infants under 2 months of age, but it's less of a concern in toddlers or children, Canares says.

On the other hand, a fair number of children with broken bones are brought to an urgent care clinic when they should go to the ER, Canares says. Urgent care clinics can only deal with the simplest and most minor of fractures, yet many fractures are anything but. A fracture with a displaced bone often requires realignment under sedation, which is not something an urgent-care clinic can do. If you suspect a broken bone and you notice swelling, head to the ER, Canares says.

To ER or Not?

Sparing yourself and your child an unnecessary trip to the ER is not just a matter of convenience. A visit to the ER can expose your already sick kid to the ubiquitous hospital germs and other infections carried by fellow ER visitors. In addition, ER care generally more expensive than care received elsewhere. And because emergency departments are, by definition, designed to care for the sickest patients first, those with less severe illnesses are bound to have longer waits.

The Boom of urgent care: A mixed blessing

The rapid proliferation of urgent care centers over the last five years has been a mixed blessing, Canares says. On one hand, these walk-in clinics offer after-hours and weekend service, filling a much-needed gap in the care of patients who require prompt medical attention but who cannot be seen by their physicians on the same day. At the same time, many physicians and nurses who work at such centers may have minimal training in pediatrics and not comfortable treating infants and young children for anything beyond the simplest of ailments. A recent study published in the Rhode Island Medical Journal and led by Canares revealed that urgent care clinicians are particularly uncomfortable evaluating children for minor brain injuries, suturing a child's facial cuts and caring for acutely ill young infants.

"Because many urgent-care providers are not comfortable treating certain pediatric cases, they preemptively triage them to the emergency department, even when these kids clearly don't need emergency care," says Canares, who has seen her fair share of referrals for basic colds and coughs show up in the ER, none of which warrant emergency treatment. The exception, Canares cautions, are children with underlying chronic conditions, such as asthma, congenital heart disease or sickle cell disease, which render patients with even benign viral illnesses susceptible to dangerous complications.

The lack of universal guidelines that stipulate what services should be offered in urgent care centers and what level of training providers should have, has spawned a mishmash of clinics, some offering fairly sophisticated care, while others providing only the most rudimentary, Canares says. For example, some urgent care centers have X-rays, ECG equipment and the ability to administer intravenous treatments, but many don't. Some have in-house labs to perform on-the-spot urine and blood analyses, while others send the samples out.

"Urgent care is a great concept and critically needed, but we really ought to figure out how to ensure appropriate triage so patients who need emergency treatment don't end up in urgent care and vice versa," Canares says. The new Society for Pediatric Urgent Care, established in 2014, is on a mission to reshape this rapidly expanding niche by developing guidelines on pediatric urgent care.

In the meantime, how is a parent to make the right call?

Canares and fellow emergency pediatricians offer the following guidelines but caution that the first step should always be calling your pediatrician's office or an after-hours answering service to discuss the symptoms with a triage nurse or a physician.

Head straight to the ER if:

•Your child is less than 2 months old and has a fever. Fever is defined as a temperature 100.4 degrees Fahrenheit (38 degrees Celsius) or higher.
•You suspect your child has a broken bone, particularly if there is visible swelling or unevenness and bumps in the injured area — a sign that the broken bone is misaligned.
•Your child hits his head and appears to pass out or lose consciousness for a few seconds
•Your child has had a seizure
•Your child has signs of dehydration, such as very dry lips and mouth, absence of urination for more than 12 hours, lethargy and confusion
•Your child has heavy, fast breathing, is gasping for air or manages to utter only two or three words before taking a breath.
•Gaping cuts on the face, especially in younger children who need sedation or behavioral support while the laceration is being repaired.

Consider urgent care when you can't see your pediatrician within a day or two and if:

•Your child has fever accompanied by cold symptoms and you suspect it may be the flu.
•You suspect your child may have an ear infection; symptoms include drainage from the ear, ear ache and pulling on the ears.
•Your child has a sore throat with or without white patches on the tonsils, a possible sign of strep infection.
•You suspect your child may have pink eye, also known as infectious conjunctivitis, symptoms of which include red, inflamed eyes with or without discharge.
•Your child has had a few episodes of vomiting or diarrhea (without blood in the stool) but has no belly pain or signs of dehydration.
As a rule, if your child is able to walk, talk, interact and play, chances are whatever she or he has is not an emergency, Canares says.
In addition, Canares advises calling the urgent-care clinic ahead of time to ensure they treat infants — many have age limits — and describing your child's symptoms.

"Ask them if based on the age and symptoms, they are comfortable evaluating your child," Canares says. "And do ask to speak with a clinician, rather than the receptionist. The last thing you want is to show up at the clinic with a sick kid only to be told you should make your way to the ER instead."


The opinions expressed here are the views of the writer and do not necessarily reflect the views and opinions of News Medical.
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