Urgent Care Practice Research Articles

Analysis of ChatGPT in the Triage of Common Spinal Complaints

ChatGPT is a natural language processing chatbot with a significant prevalence in modern media with a clear application in the medical triage workflow. ChatGPT has shown significant capacity for understanding clinical vignettes, radiology reports, and even passing the American Board of Neurological Surgery board examination. There has never been an evaluation of the chatbot in triage and diagnosing spinal vignettes common to primary and urgent care practice. Fifteen clinical scenarios were created to mimic spinal complaints common to primary and urgent care scenarios. GPT-4 was instructed to assess the situation as if it was in a primary care office and determine diagnosis, imaging recommendations, and if emergency room (ER) or operative referral was necessary. Answers were recorded and the results compared to those of attending and resident respondents. GPT-4 provided the most likely diagnosis in each scenario. Additionally, it recommended reasonable clinical management of each scenario which would fall within standard practice guidelines. ChatGPT tended toward over-referral to the ER; however, this was not significant. GPT-4 was noninferior in all categories when compared to respondents. ChatGPT is a powerful tool for primary triage of spinal issues. It can rapidly and accurately evaluate clinical scenarios and provide clear diagnostic reasoning. GPT-4 is not designed for medical use and will provide a disclaimer as such. It did tend toward over-referring patients to the ER. With specific training, it is likely that artificial intelligence and natural language processing chatbots will become widely used in primary triage of spinal issues.

Urgent care practice in anorectal abscess. Still a pending task

Urgent care practice in anorectal abscess. Still a pending task

Cauda Equina Syndrome Clinical Guidelines Review

In the wake of the COVID-19 pandemic, the national health services (NHS) had to adopt certain measures to amicably respond to the pandemic on the domestic front. Among these was the suspension of direct patient and physician interface to the extent possible, and the consultations were minimized to telecommunication. This review article aims to share the critical insights of current urgent care practice at the forefront of the advanced practice agenda that deals with complex issues both systematically and creatively, makes sound judgments in the absence of complete data, and communicates conclusions. Moreover, this review also highlights the originality in the application of knowledge, together with a practical understanding of local and national policy and drivers to support and develop an advanced practice that helps to critically evaluate current research and advanced scholarship in advanced practice.

P021 Development of a Rheumatology Hot Clinic in the Midst of a Pandemic

Background/AimsThe COVID-19 pandemic has had a significant impact on emergency and scheduled care, affecting both inpatient and outpatient services for all specialities, including Rheumatology. During the first pandemic peak, rheumatology outpatient clinics all became virtual (i.e. telephone or video), except for a single emergency clinic per week. However, this face-to-face clinic, quickly became oversaturated resulting in a waiting list extending above 4 weeks for our patients.MethodsIn the lead-up to the second COVID-19 peak during the winter, we developed a novel, urgent, hot Rheumatology Clinic within our Ambulatory Emergency Care (AEC) department. This whole-day weekly clinic was delivered by a Rheumatology registrar, with consultant support. Its purpose was to provide a service for patients who did not require hospitalisation but required urgent face-to-face Rheumatology speciality review that could not wait for an outpatient appointment. Referrals came from General Practice, Urgent Care (i.e. Emergency Care, Acute Medicine and AEC) and from the Rheumatology department. Pathologies reviewed included vasculitides, inflammatory arthritis and inflammatory connective tissue diseases. The clinic facilitated for patients with suspected new diagnoses or flares of established rheumatological diseases. Furthermore, patients could also undergo urgent joint and soft tissue procedures. All referrals were directed to the Rheumatology registrar to triage. Because of the success of the clinic, it continued beyond the second peak with data gathered from its inception.ResultsData was collected between November 2020 and June 2021, covering 23 hot clinics. A total of 118 patients were reviewed during this period. The highest number of referrals occurred during the second peak of the pandemic (38 patients over seven clinics compared to 48 patients over ten clinics post-peak). The majority of referrals were from Rheumatology directly (70%) compared with Urgent Care (14%) and General Practice (12%). Most (60%) were seen within 7-days of referral; a further 27% were seen within 7- 14 days. The main reasons for review delays beyond seven-days were lack of available clinic (46%) or lack of space (29%). The most common disease encountered was a chronic inflammatory arthropathy (48 patients).ConclusionThe service has generated positive feedback from all patients. Furthermore, this clinic has benefited both Rheumatology and AEC. Firstly, it ensured timely face-to-face reviews of patients requiring urgent Rheumatology assessments. Secondly, it eased pressure on the Rheumatology department, particularly the outpatient emergency clinic. Thirdly, it ensured that the Rheumatology registrar continued to have Rheumatology training opportunities, particularly when redeployed during the Winter wave on other days of the week. Fourthly, the AEC department have had easier access to Rheumatology reviews. Finally, it has empowered the registrar to manage their own workload and organise the clinic enhancing management and leadership experience. The success of the clinic has resulted in its ongoing continuation.Disclosure A. Khan: None. C. Murdoch: None. I. Wamuo: None.

Delayed antibiotic prescribing to reduce antibiotic use: an urgent care practice change

BackgroundAntibiotic overuse threatens global health, food security and human development through the development of antibiotic resistance. Antibiotic resistance is associated with worse clinical outcomes and increased healthcare costs. Studies suggest...

Identifying patient characteristics associated with potentially redirectable paramedic transported emergency department visits in Ontario, Canada: a population-based cohort study

ObjectiveParamedic redirection from emergency department (ED) to subacute centres may be more beneficial for some patients, though little is known about which patients are potentially appropriate. We examined whether patient...

Effect of Peer Comparison Feedback, Individual Audit Feedback or Both to Clinicians on Opioid Prescribing in Acute Care Settings: A Cluster Randomized Clinical Trial

Research ObjectivePrescribing opioids, particularly the number of pills, is associated with greater likelihood of patients developing longer‐term opioid dependence. Nudges targeted to clinicians are a low‐cost strategy that could reduce unnecessary opioid prescribing. In particular, clinician‐focused peer comparison feedback has been effective in influencing prescribing for other medications. However, peer comparison feedback has not been well‐tested for opioid prescribing, alone or compared against other feedback approaches such as individual audit feedback.Study DesignWe conducted a pragmatic, four‐arm factorial cluster randomized clinical trial among 48 emergency department (ED) and urgent care (UC) practice sites within Sutter Health System including a 6‐month pre‐intervention period and a 6‐month intervention. 438 clinicians were cluster randomized by practice site. Interventions were delivered to clinicians monthly by email. Peer comparison feedback included the number of pills per opioid prescription and proportion of encounters with an opioid prescription in the prior 3 months, relative to that of their practice site peers. Individual audit feedback included the number of prescriptions with >30 pills in the prior 3 months, indicating potential outlier prescriptions. The primary outcome measure was the change in the number of pills per prescription. Secondary outcomes included changes in the proportion of pills and milligrams of morphine equivalents (MME) per prescription.Population StudiedThe sample included 263 ED and 175 UC clinicians comprised of 294,962 patient encounters, with a mean (SD) age of 49 years (19), 56% female, 9% Black, and 21% Hispanic.Principal FindingsDuring the pre‐intervention period, there was a mean (SD) of 15.1 pills (3.9) and 76.3 MME (23.0) per prescription, and 9.3% of encounters with an opioid prescription. In adjusted analyses compared to usual care during the intervention, there was a significant decrease in pills per prescription among clinicians receiving peer comparison feedback alone (−0.9 pills per prescription; 95% CI ‐1.5 to −0.3, P = 0.002) and receiving both peer comparison and individual audit feedback (−1.4 pills per prescription; 95% CI ‐2 to −0.8, P < 0.001), but not among clinicians receiving individual audit feedback alone (−0.4 pills per prescription; 95% CI ‐1.0 to 0.2, P = 0.24). There was also a significant decrease in MME per prescription for peer comparison feedback alone (−3.4 MME per prescription; 95% CI ‐6.6 to −0.3; P = 0.03) and combined with individual audit feedback (−4.3 MME per prescription; 95% CI ‐7.5 to −1.1; P = 0.009), but not for individual audit feedback alone (−3.1 MME per prescription; 95% CI ‐6.2 to 0.1; P = 0.06). There were no significant changes in the proportion of encounters with an opioid prescription.ConclusionsPeer comparison feedback was effective, alone and together with individual audit feedback, for significantly reducing the number of pills and MME per opioid prescription.Implications for Policy or PracticeThis is one of the largest trials ever conducted testing the impact of nudges on opioid prescribing and provides promise for low‐cost strategies to change clinician prescribing behavior more broadly.Primary Funding SourceThe Donaghue Foundation.

Does Education in Oral Health Competencies in Physician Assistant Education Programs Translate to Delivery of Oral Health Services in Clinical Practice?

The purpose of this study was to determine the extent to which physician assistants (PAs) are educated in oral health competencies and the relationship of education to providing oral health services to patients. The study was conducted in 2016 by administering an Internet-based survey to a nationwide sample of 2014 graduates of programs accredited by the Accreditation Review Commission on Education for the Physician Assistant. The survey response rate was 12.7% (N = 304). More than half of the PAs who received education in oral health in their professional education programs indicated that oral health curricula were either integrated into one or several topical areas in the base curriculum or delivered in stand-alone lectures. The majority of PA respondents rated their educational preparation as good or excellent in helping them provide oral health education to their patients (54.8%), make appropriate referrals to oral health providers (53.7%), and provide preventive oral health services (51.2%), while more than 40% rated their preparation as good or excellent in helping them identify oral diseases, conditions, and intervention strategies. More than one-third (35.7%) of all PA respondents reported that they provided oral health services in their clinical practices. PAs who received instruction in oral health competencies through the PA education curriculum or from other sources were 2.82 times more likely to provide oral health assessment and screening services to their patients (95% confidence interval, 1.19-6.67). The PA respondents' provision of oral health services was also significantly associated with working in primary medicine or urgent care practice specialties but not with the work setting. PAs educated in oral health competencies are more likely to provide such services to patients, especially in primary medicine or urgent care settings.

Comparative effectiveness of direct admission and admission through emergency departments for children: a randomized stepped wedge study protocol

BackgroundApproximately 2 million children are hospitalized each year in the United States, with more than three-quarters of non-elective hospitalizations admitted through emergency departments (EDs). Direct admission, defined as admission to hospital without first receiving care in the hospital’s ED, may offer benefits for patients and healthcare systems in quality, timeliness, and experience of care. While ED utilization patterns are well studied, there is a paucity of research comparing the effectiveness of direct and ED admissions. The overall aim of this project is to compare the effectiveness of a standardized direct admission approach to admission beginning in the ED for hospitalized children.Methods/designWe will conduct a stepped wedge cluster randomized controlled trial at 3 structurally and geographically diverse hospitals. A total of 70 primary and urgent care practice sites in the hospitals’ catchment areas will be randomized to a time point when they will begin participation in the multi-stakeholder informed direct admission program. This crossover will be unidirectional and occur at 4 time points, 6 months apart, over a 24-month implementation period. Our primary outcome will be the timeliness of clinical care provision. Secondary outcomes include (i) parent-reported experience of care, (ii) unanticipated transfer to the intensive care unit within 6 h of hospital admission, and (iii) rapid response calls within 6 h of hospital admission. We anticipate that 190 children and adolescents will be directly admitted, with 1506 admitted through EDs.Analyses will compare the effectiveness of direct admission to admission through the ED and will evaluate the causal effect of implementing a direct admission program using linear regression with random effects for referring practice clusters and time period fixed effects. We will further examine the heterogeneity of treatment effects based on hypotheses specified a priori. In addition, we will conduct a mixed-methods process evaluation to assess reach, effectiveness, adoption, implementation, and maintenance of our direct admission intervention.DiscussionOur study represents the first randomized controlled trial to compare the effectiveness of direct admission to admission through the ED for pediatric patients. Our scientific approach, pairing a stepped wedge design with a multi-level assessment of barriers to and facilitators of implementation, will generate valuable data about how positive findings can be reproduced across other healthcare systems.Trial registrationClinicalTrials.gov NCT04192799. Registered on December 10, 2019).

Urgent care practice in anorectal abscess. Still a pending task.

The aim of the study was to evaluate urgent care practice with regard to anorectal abscesses (AA) in a tertiary-level referral hospital. this was retrospective and unicentric study. Patients who underwent surgery for AA between 2016 and 2017 were included in the study. Demographic variables were analyzed as well as the treatment performed, the need for hospitalization, use of antibiotics, and referral to the coloproctology outpatient department (COD). The recurrence risk factors were also evaluated. A total of 220 evaluations under anesthesia were performed, corresponding to 190 patients, 129 males (mean age 46 ± 14.9 years). The most frequent treatment in the emergency department (ED) was simple drainage (75.8%). Antibiotic therapy was prescribed in 62.9% of the cases. A total of 41.1% of the patients were referred to a specialized COD. The only risk factor associated with recurrence was the presence of an associated anal fistula. Anorectal abscesses are very frequent in the ED. There is great clinical variability regarding the taking of cultures, prescription of antibiotics, and referral criteria to a specialized coloproctology outpatient department, without clear impact of any of them on the recurrence of the abscess.

Framework for development of urgent care services towards strengthening primary healthcare in India - Joint position paper by the Academy of Family Physician of India and the Academic College of Emergency Experts.

Urgent care practice (UCP) is a novel concept for India. Urgent care primarily deals with injuries or illnesses requiring immediate care. Medical emergency and urgency can happen anywhere unannounced. Research has shown that 90% of the morbidities can be resolved within the community by primary care physicians lead teams. Given the changing professional demands, non-specialists tend to refer away far too many cases to specialists, undermining generalist medical care, particularly in Indian settings. The spillover of the patient load from the primary care setting to the tertiary care centers is enormous leading to resource mismatch. Family physicians and other primary care providers are best positioned to develop practices and provide good quality urgent care to society. Family physicians, general practitioners, and medical officers are already functioning as the frontline care providers for any emergency or medical urgency arising within communities. Urgent care is essentially ambulatory care or outpatient care outside of a traditional hospital emergency room. “UCP aims to provide timely support, which is easily accessible with a focus on good clinical outcomes, e.g. survival, recovery, lack of adverse events, and complications. Core interventions of urgent care are centered on the 4Rs - Rescue, Resuscitate, Relate, and Refer. At present, there are no available, established training model for future faculty, residents, and medical students on “UCP“ in India.

32 Implementation of a Novel Rapid Cardiac Evaluation Unit Program, Through a Collaboration Between an Academic Medical Center and a Large Urgent Care Practice, Allows for Timely and Safe Evaluation of Low-Risk Chest Pain Patients in an Outpatient Cardiology Setting

Chest pain (CP) accounts for 5.2% of emergency department cases, with an approximate treatment cost of $3,500pp (ED+CP/OBS stay). Although there are methods employed by institutions to initiate early discharge pathways for low-risk cases with a high suspicion of non-cardiac CP, there remains a significant need for diverting this population to appropriate, non-emergent care. In an effort to reduce ED congestion, the Mount Sinai Hospital partnered with CityMD to implement the Rapid Cardiac Evaluation Unit (RCEU); an ambulatory cardiovascular (CV) unit that is able to safely and effectively, provide urgent cardiac care as well as same-day testing.

Rickettsia parkeri and “Candidatus Rickettsia andeanae” in Amblyomma maculatum (Acari: Ixodidae) collected from the Atlanta metropolitan area, Georgia, United States

Rickettsia parkeri is a recently recognized human pathogen transmitted in the southeastern United States by Amblyomma maculatum, the Gulf Coast tick. Since R. parkeri was conclusively identified as a human pathogen in 2004, over 40 cases of R. parkeri rickettsiosis have been identified in the United States, most of which occur in the southeastern states. During 2012–2014, five of these cases were identified by a single urgent care practice in Coweta County, a Georgia county within the Atlanta metropolitan area. To investigate the occurrence of R. parkeri-infected A. maculatum in the Atlanta metropolitan area, ticks were collected from 6 counties around the city of Atlanta and evaluated for infection with a Rickettsia species. A total of 263 questing adult A. maculatum were collected during 2015 and 2016. Of these, 93 (35%) were PCR-positive for DNA of R. parkeri and an additional 46 (17%) were PCR-positive for DNA of “Candidatus Rickettsia andeanae,” a spotted fever group Rickettsia species of unknown pathogenicity. No co-infections of these two rickettsiae were detected; however four of the six counties sampled showed presence of both rickettsial organisms. The high frequency of R. parkeri in these tick populations indicates a potential risk for those living, working, or recreating in A. maculatum-infested habitats within these six counties in the Atlanta metropolitan area.

Extended training to prepare GPs for future workforce needs: a qualitative investigation of a 1-year fellowship in urgent care.

It has been argued that UK general practice specialist training should be extended to better prepare GPs for the challenges facing 21st-century health care. Evidence is needed to inform how this should occur. To investigate the experience of recently trained GPs undertaking a 1-year full-time fellowship programme designed to provide advanced skills training in urgent care, integrated care, leadership, and academic practice; and its impact on subsequent career development. Semi-structured interviews conducted longitudinally over 2 years augmented by observational data in the West Midlands, England. Participants were interviewed on at least three occasions: twice while undertaking the fellowship, and at least once post-completion. Participants' clinical and academic activities were observed. Data were analysed using a framework approach. Seven GPs participated in the pilot scheme. The fellowship was highly rated and felt to be balanced in terms of the opportunities for skill development, academic advancement, and confidence building. GPs experienced enhanced employability on completing the scheme, and at follow-up were working in a variety of primary care/urgent care interface clinical and leadership roles. Participants believed it was making general practice a more attractive career option for newly qualified doctors. The 1-year fellowship provides a defined framework for training GPs to work in an enhanced manner across organisational interfaces with the skills to support service improvement and integration. It appears to be well suited to preparing GPs for portfolio roles, but its wider applicability and impact on NHS service delivery needs further investigation.

Implementing a urinary tract infection clinical practice guideline in an ambulatory urgent care practice

A clinical practice guideline for uncomplicated urinary tract infections in an ambulatory urgent care practice was implemented. Aims were to increase the number of first-line antibiotics prescribed to treat uncomplicated urinary tract infections, increase the use of second-line antibiotics prescribed when appropriate, and decrease the number of unnecessary urine cultures.

Integrating Family Nursing Into a Mental Health Urgent Care Practice Framework: Ladders for Learning

Integrating family nursing into a busy mental health urgent care setting is a challenge given the high acuity of patients and the demands of delivering service 7 days/week, 14 hours/day. In this article, the authors describe the development of a Mental Health Urgent Care Practice Framework that incorporates four elements: mental health/psychiatric assessment, physical health assessment, family nursing, and integrated behavioral health care. Sample family nursing skills and ladders for mental health urgent care practice are highlighted.The framework and ladders have implications for recruitment and hiring, orientation, peer mentoring, performance appraisals, and continuing education and supervision. A clinical vignette illustrates sample conceptual/ perceptual and executive skills used to apply the framework and ladders in practice. Family nursing is conceptualized as an integral component of nursing care provided to individual and families in this unique setting.

Abscess Incision and Drainage

Incision and drainage is the primary therapy for cutaneous abscess management, as antibiotic treatment alone is inadequate for treating many of these loculated collections of infectious material. Most localized skin abscesses without associated cellulitis can be managed with simple incision and drainage and do not require antibiotic treatment. Cutaneous abscesses have been described in all areas of the body, but are most commonly found in the axillae, buttocks, and extremities. This outpatient procedure is appropriate for many office settings, as well as for urgent care and emergency department practice environments. Diagnosis of a skin abscess is the first step . . . .

Effect of particulate matter air pollution on hospital admissions and medical visits for lung and heart disease in two southeast Idaho cities

Few, if any, published time series studies have evaluated the effects of particulate matter air exposures by combining hospital admissions with medical visit data for smaller populations. We investigated the relationship between daily particulate matter (<10 microm in aerometric diameter or PM10) exposures with admissions and medical visits (emergency room, urgent care, and family practice) for respiratory and cardiovascular disease in Pocatello and Chubbuck, Idaho (population about 60,000), from November 1994 through March 2000. Within generalized linear models, time, weather, influenza, and day-of-week effects were controlled. In single-pollutant models, respiratory disease admissions and visits increased (7.1-15.4% per 50 microg/m3 PM10) for each age group analyzed, with the highest increases in two groups, children and especially the elderly. Statistical analyses suggest that the results probably did not occur by chance. Sensitivity analyses did not provide strong evidence that the respiratory disease effect estimates were sensitive to reasonable changes in the final degrees of freedom choice for time and weather effects. No strong evidence of confounding by NO2 and SO2 was found from results of multi-pollutant models. Ozone and carbon monoxide data were not available to include multi-pollutant models, but evidence suggests that they were not a problem. Unexpectedly, evidence of an association between PM10 with cardiovascular disease was not found, possibly due to the lifestyles of the mostly Mormon study population. Successful time series analyses can be performed on smaller populations if diverse, centralized databases are available. Hospitals that offer urgent or other primary care services may be a rich source of data for researchers. Using data that potentially represented a wide-range of disease severity, the findings provide evidence that evaluating only hospital admissions or emergency room visit effects may underestimate the overall morbidity due to acute particulate matter exposures. Further work is planned to test this conclusion.

Listening & learning. Fostering health care in Bulgaria.

Linda Phillips, RN, MSN, is a nurse practitioner with Community Health Care in north central Wisconsin, doing urgent care and family practice. She served in medical missions for three years in Zambia, Africa, and four years in Eastern Europe. She attends Christ Lutheran Church in Abbotsford, Wisconsin, and volunteers with the Green Bay Mission Support Group.Figure