Editorials and Opinions – Q1 2023

The field of Urgent Care medicine was born from a revolutionary vision of what healthcare could be and physician innovators who recognized gaps in the healthcare delivery model. Over the past three decades, the growth of Urgent Care has been exponential, driven by the rapidly changing face of the modern consumerist economy. Although Urgent Care has undeniably established itself as an integral component of the healthcare infrastructure, it has seemingly evolved in a separate, albeit parallel, market to traditional healthcare institutions. Urgent Care staffing models, office capabilities, equipment, and medications have had to keep pace to meet the demands of a growing influx of patients as they look for alternatives to the emergency department. What has not kept pace is the ability of Urgent Care to address the needs of increasing numbers of critically ill children presenting in this setting as a result of this shift.

In 2007, the American Academy of Pediatrics (AAP) published guidance on essential and recommended equipment and medications that outpatient pediatric offices should carry in the event of a pediatric emergency and has suggested regular simulation-based practice to maintain skills¹. However, implementation of these recommendations has shown wide variability across settings. In fact, a study from as recently as two years ago reported that almost 50% of practices in a cohort of 42 offices across nine states had no policies or protocols in place for dealing with emergencies².

For years, Urgent Care practitioners have relied on the American Heart Association’s Pediatric Advanced Life Support (PALS) course for guidance in managing pediatric emergencies. PALS has asserted itself as a ubiquitous, reliable reference for clinicians who encounter children in the emergency department and other inpatient settings. However, it has become increasingly apparent that PALS algorithms, equipment, medications, and personnel requirements may not be applicable to the Urgent Care setting. For example, it would be unlikely for an Urgent Care office to have a monitor/defibrillator, wall oxygen or wall suction. Endotracheal tubes and other advanced airway devices are also less commonplace due to medicolegal concerns arising from staffing with newer, inexperienced providers who may lack training in their use. Finally, the staffing make-up of an Urgent Care office may place a physician or an advanced practice provider (APP) with a medical assistant/receptionist, X-ray tech, or possibly a nurse, as the care team that must manage a pediatric emergency. This is in stark contrast to the in-hospital setting in which resources are seemingly inexhaustible and where a critically ill child would be managed by a team of multiple physicians, APPs, and nurses.

It is time clinicians have an Urgent Care-focused resource for managing critically ill children that takes into consideration the unique personnel, medications, and equipment found in this resource-limited setting. Our institution has recently developed and internally implemented RESCUEepc (Resuscitation and Stabilization of Children in the Urgent Care Environment – emergency preparedness course) to address this need. RESCUEepc is a blended-learning activity in which participants must complete pre-course work in the form of online learning modules prior to attending an instructor-led classroom training session. The foundation for the course is a novel, team-based management approach referred to as the “RESCUE Protocol” which utilizes evidence-based, Urgent Care-specific algorithms.  The in-person training comprises a brief review of key points from the online pre-coursework, practice-till-perfect of Urgent Care-specific skills (e.g., operating an oxygen tank, portable suction device, AED, etc.), and simulation-based practice scenarios.  The course concludes with an online post-assessment and megacode scenario. Successful completion of the course requires a minimum passing score of 80% on the online exam and meeting all required competencies delineated in the structured debrief tool for the megacode scenario.

Thus far, RESCUEepc has been piloted in a single region within our organization, totaling nearly 50 provider and nurse participants. The course will be implemented in our remaining regions over the course of this year. Key competencies highlighted in the course are tied to various quality metrics that will be tracked over time.  Ultimately the success of RESCUEepc will depend on whether it has an impact on patient outcomes, which will also be examined. The plan is to eventually make the course available externally to both pediatric and general Urgent Care centers. RESCUEepc has been an ambitious undertaking with the potential to change the way critically ill pediatric patients are managed in the Urgent Care environment. It is an idea whose time has come.

Dr. Shah is the Director of Provider Training at PM Pediatric Care

REFERENCES:

1. Frush K; American Academy of Pediatrics Committee on Pediatric Emergency Medicine. Preparation for emergencies in the offices of pediatricians and pediatric primary care providers. Pediatrics. 2007; 120(1):200–212
2. Abulebda K, Yuknis ML, Whitfill T, et al; Improving Pediatrics Acute Care Through Simulation (ImPACTS). Preparedness for pediatric office emergencies: a multicenter, simulation-based study. Pediatrics. 2021;148(3):e2020038463