Urgent care v. ER? Tips on making the right choice

Better safe than sorry? The truth is many situations don’t warrant a trip to the emergency room.

BALTIMORE — 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, said 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 said.

Worse in winter

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 said, 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 said.

“Some situations are no-brainers, but many fall in a gray zone of uncertainty,” Canares said.

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. 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 said.

Broken bones? ER. 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 said. 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 said.

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 is 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.

A mixed blessing

The rapid proliferation of urgent care centers over the last five years has been a mixed blessing, Canares said.

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 may not be 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,” said 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.

No guidelines

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 said.

For example, some urgent care centers have X-rays, other diagnostic equipment or 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 said.

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? See the adjacent list for some tips.

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 said.

Call first

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 said. “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.”