The ER alternative: urgent care clinics coming of age

Barbara Sibbald

CMAJ 2000;162:1037-8

Her experience is a case study of the fast one-stop service now available at a growing number of urgent care centres. The centres, which offer the services of an emergency room but don't accept ambulances, are emerging across Canada as ERs close and their waiting times grow.

Medical staff at these centres treat urgent or acute medical problems such as cuts, sprains, fractures, headaches, bronchitis — basically, the same type of problems that clog ERs. The centres also offer laboratory, x-ray and, often, pharmacy services on site. And not only do they provide faster service, they're also significantly less expensive, mainly because of lower overhead costs. Hospital-based urgent care centres cost about half as much to operate as an emergency department, while privately run centres are even more cost-effective.

Since the first centre opened in Windsor, Ont., in 1989, about 25 new ones have appeared across Canada. Some, like the Riverside UCC in Ottawa, are created when hospitals merge and ERs close. Others, like the UCC in the rapidly growing Ottawa suburb of Orleans, are businesses run by physicians with ER experience.

UCCs definitely take the load off local ERs, says Dr. Jo Hauser, chair of the Orleans UCC and medical director at the Riverside UCC. In addition to offering treatment, physicians at these centres also assess and refer patients directly to specialists or hospitals.

Because of cutbacks and lengthening patient line-ups, the number of urgent care centres seems destined to grow. Hauser and Dr. Robert Robson, president and CEO of the Orleans clinic, think the time is ripe to set standards for accreditation.

Robson says the public should be able to expect a certain level of service at these centres. Hauser would also like to see them differentiated from walk-in clinics, which "are often nothing more than a physician's office with extended hours and no x-ray or lab facilities in the evenings or on weekends."

14 hours a day, 363 days a year

The UCC doctors are looking at the Canadian Association for the Accreditation of Ambulatory Surgical Facilities for inspiration and as a potential model. The first step is to contact other UCC physicians who are interested in forming a national association.

After 27 years in the ER, Robson is an enthusiastic proponent of the UCC model, and the public seems to share his eagerness. In its first year — 1994 — the Orleans centre had 40 000 patient visits; last year it had 70 000. It's a huge convenience for Orleans' 100 000 residents because the nearest hospital is 35 km away and the UCC is open 14 hours a day, from 8 am to 10 pm, 363 days a year. The Orleans centre, which is run by a 5-physician Board of Directors, is currently searching for its first executive director.

At least 2 physicians are always on duty, with others on call. The centre's professional staff, which includes 17 physicians and 11 registered nurses, all work part time. Half the physicians also work in hospital ERs.

Robson says he finds work at the UCC clinically challenging. The Orleans centre is equipped to handle problems ranging from heart attacks to respiratory failure, arrhythmias and serious allergic reactions. He often gets feedback from patients' physicians, who receive treatment documentation.

In a typical day, about 180 patients are seen. During the Christmas holidays, however, the Orleans physicians saw just over 300 patients in 1 day, thereby saving Ottawa's backlogged ERs an even larger headache. About 55% of its patients are under 16, and most have an infection or minor trauma. Each day, between 2 and 10 patients are sent to hospital for further treatment or admission.

Patients rarely wait more than an hour to be seen. "We're unhappy if it's over 45 minutes," says Robson. Once they see the physician, service is quick. X-rays are available in 15 to 20 minutes, while lab work usually takes less than an hour. Both the lab facilities and pharmacy are privately owned businesses that operate the same hours as the centre. There are 10 examination rooms, including ones for fractures, resuscitation, ear, nose and throat, and a "walking wounded" room.

Patients who pay

For patients, the main difference between the Orleans UCC and the hospital-based Riverside UCC is that in Orleans patients must pay for their medications, such as intravenous solutions and intramuscular drugs, while Riverside patients do not pay because that UCC is part of a hospital. The Riverside also has more nursing staff, with 3 registered nurses always on duty, and much more space than the Orleans centre.

Since opening in May 1999, the Riverside UCC has seen a growing number of patients and now averages 85 per day — more than it saw as a 24-hour ER; it is now open from 7 am to 10 pm daily. One physician is always on duty, with a total of 8 on staff.

The biggest administrative difference between the 2 centres is that the Riverside is part of a hospital and has to conform to all hospital policies and procedures. As a result, the Riverside UCC costs more to operate than the Orleans UCC, where overhead averages $13 per patient. It's difficult to separate the Riverside UCC's overhead costs from other hospital expenses, but patients without insurance are charged a facility fee of $50, which includes the cost of any drugs they might need.

Hauser, who has worked in emergency medicine for 34 years, says the Riverside UCC costs much more to operate than its counterpart in Orleans. The big-ticket item is salaries: at Riverside, nurses earn the unionized pay rate, and a full-time nurse manager and a director are employed; drugs add another $25 000 to overall costs. Hauser estimates that overhead at the hospital costs $80 per patient.

Physicians interested in forming an association for urgent care centres can contact Robson (rrobson@compmore.net) or Hauser (jhauser@mac.com).

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