When I started my PEM career 10 years ago, I thought every hospital would eventually have a dedicated pediatric ED where PEM physicians could enhance acute care for children. Now a decade later I’m watching medicine steer in a very different direction. Value-based care, accountable care, convenience care, telemedicine, high deductible insurance plans, and changes in pediatric reimbursement are all pushing children out of EDs and inpatient units. Pediatric floors are closing and pediatric inpatient care is regionalizing. Community pediatricians struggle to compete with new disruptive models that are driving routine acute care visits elsewhere. Many alternate models have developed as answers to families searching for on-demand care. Pediatricians have extended visit hours, retail-based clinics have formed in pharmacies, general urgent cares have proliferated, and now telemedicine is providing direct-to-consumer services. These solutions all float in the acute care space between a typical pediatric practice and the ED.
Is it time to be more creative with the scope of pediatric emergency medicine? Is it time for our PEM community to expand clinical practice and leadership outside the walls of hospitals?
Freestanding pediatric urgent care centers (UCCs) are an evolving and increasingly popular concept that may be a solution to providing better acute pediatric care in the community. UCCs are not fast track-urgent care units built out of ED’s to streamline lower acuity patients. Freestanding pediatric UCCs are fundamentally unique relative to “regular” urgent cares because they are staffed by acute-care pediatricians and PEM physicians trained in caring for low-moderate acuity emergencies and routine injuries. The scope of pediatric urgent care can be broad and include wound care, soft tissue infections, respiratory distress, fractures, mild TBI, eye injuries, animal bites, constipation, dehydration, prolonged fevers, retained foreign bodies, or rashes. Quality pediatric UCCs can care for all of these problems in a child-friendly, low-stress, low-cost environment easily accessible to families at convenient hours while accepting all payer types (including Medicaid). Procedural care is unique in these practices, with staff skilled to repair lacerations, give IV fluid rehydration, drain/pack large abscesses, remove foreign bodies, and reduce phalanx fractures or dislocations. Pediatric urgent care may be the ultimate complement to primary care while being a viable alternative to neighborhood EDs. Maybe this is the solution to stratify patients and decompress our EDs from patients who don’t need to be there—allowing the hospital PEM community to focus on the complex or critical patients who actually need our PEM clinical expertise.
The community impact of pediatric urgent care can be tremendous with multiple individual locations reporting more than 35,000 patients annually, open only about half the hours of an ED, with door-to-door times averaging less than 50 minutes. Of the more than 9,000 urgent care facilities nationwide, only about 350 are pediatric-specific so there is opportunity for growth. Some academic centers running multiple locations already have annual patient volumes similar to some PECARN nodes. Colorado Children’s has 5 urgent cares. The busiest sees 33,000 patients annually and is capable of procedural sedation, insulin drips, and intubating an infant in respiratory failure. Children’s Hospital of Atlanta has 6 urgent cares averaging 26,000 annual visits each. PM Pediatrics uses 40+ PEM physicians across 20 locations in NY, NJ, MD, and MA with annual volumes of over 300,000 patients/year and the busiest location seeing more than 41,000 patients/year.
Pediatric UCCs are functioning as intermediary care facilities able to observe patients (e.g., ingestions, asthma, dehydration), provide community triage of serious or surgical disease, and if needed transfer patients to a higher level care. Families tell me that they’d rather come to urgent care with the chance their child needs further testing or hospital admission versus going straight to the ED and risk long wait times, stressful situations, and high deductibles. With transfer rates of 1-2%, pediatric UCCs can handle the majority of diagnoses of a typical pediatric ED and many centers can coordinate direct admissions when necessary.
Pediatric UCCs have the potential to play an important role in the academic mission of PEM. Pediatric UCCs are the ideal locations to initiate the clinical decision rules and risk stratification that have become prominent in the PEM research community, preventing over-testing in the search for SBI, TBI, and appendicitis. There may be no better systems than pediatric urgent care networks to study routine childhood illness such as strep pharyngitis, acute otitis media, and outpatient strategies for pneumonia, pyelonephritis, buckle fractures, and soft tissue infections.
The field of pediatric urgent care is just starting to organize nationally and differentiate from general urgent care medicine, similar to the way PEM germinated from EM 30 years ago. Pediatric urgent care is now a dedicated career path and the PEM community has the ability to influence and develop this field. Ultimately, pediatric urgent care networks can be research beds for academic PEM physicians while decompressing the EDs from patients who’d be better served elsewhere. Several programs have begun offering one-year fellowships designed to train pediatricians in the core components of emergency care, procedural care, radiography, and medical-decision making. For PEM physicians, we have the opportunity to guide this field while simultaneously creating leadership opportunities in community acute care outside the ED.
Please learn more about this field and how your colleagues (PEM attendings, fellows, residents, PAs/NPs) can get involved in your city. This spring marks the 3rd year of the Pediatric Urgent Care Conference (PUCC) in New Orleans, March 29-31, 2017. If you’d like to learn more about this field, the PUCC conference is an excellent opportunity to meet other leaders in this space or just brush up on your procedural or clinical skills. This is also a forum to present research in pediatric acute care. If you’d like to get involved nationally, come to the PUCC conference and consider joining the AAP’s SOEM subcommittee on pediatric urgent care or the Society for Pediatric Urgent Care. If you’d like to get involved clinically, this may be a great complement to a busy and stressful ED shift and may be eye-opening to what you can do outside the hospital walls. If you know residents or community pediatricians interested in this as a career path, check out the different fellowships that PM Pediatrics offers.
Pediatric urgent care is coming into its own but it takes great PEM leadership to guide this field as a unique and prospering entity in today’s medical neighborhood.
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