Chapter Summary: UCA live: Good to Great

Urgent care providers often find themselves caught between acting like an emergency room provider and a primary care provider all at once.  When patients' complaints are categorized as somewhere in the middle, it’s on us to make sure they have the best possible outcome.  So what can we do to take these visits from good to great? Hosts Sarah, Vicky, and Matt give us tips to throw in our toolkit to elevate the patient experience.

• Maximizing UC resources in pediatric patients:
• Obtaining a urine sample in non-potty trained kids:
• Bladder stimulation technique 
• Requires 3 people.
• One person holds the child under their armpits. The second person cleans the perineal area and catches the urine. The third (provider) person taps the suprapubic area for 30 seconds and then rubs the lower back for 30 seconds → alternate between the two.
• According to one study, the average time to urinate was 52 seconds. Urine was obtained in 55% of kids.
• Quick-wee method
• Requires 2 people.
• Lay the infant on the bed. The first person cleans the skin and catches the urine. The second person takes gauze soaked in cold water and rubs it over the suprapubic area.
• Abscesses: 
• Use a topical anesthetic! → have a good idea of how long it takes to work.
• Eg. lidocaine, epinephrine, tetracaine (LET) cream takes ~30 min to take effect.
• Cover the abscess with the topical anesthetic and put a transparent dressing over it. Remove the dressing when the time is up →this can start drainage of the abscess in ~25% of cases.
• If it doesn’t spontaneously drain, the area should be numb and is ready for drainage.
  
  
• Hypertensive urgencies
• There is no universally accepted definition of what “markedly elevated blood pressure” is:   
• The American College of Emergency Physicians (ACEP) states: systolic pressure of > 160 mmHg and diastolic pressure of > 110 mmHg. This is in line with the JNC-7 stage 2 hypertension classification.
• Literature states > 180 mmHg systolic and > 110 mmHg diastolic.
• To treat in the UC or send to ED?
• Obtain a detailed history and physical exam to determine if end target organ dysfunction is present.
• Does the patient have a previous history of hypertension and haven’t taken their medication? 
• Are other medications causing the pressure to be elevated?
• Look for red flags of target organ injuries (brain, heart, kidneys). 
• Three studies show that elevated blood pressure can be managed in the UC:
• This study from 2015 looked at ~1,000 asymptomatic patients with markedly elevated blood pressure. 
• 42% were treated in the ED with clonidine.
• There was no difference in return to ED or mortality in patients that were treated and those that were not.
• Another study from 2016 looked at ~60,000 asymptomatic patients with elevated blood pressure.
• No increase in major adverse cardiac events.
• This study from 2021 looked at patients that had at least one recording of markedly elevated blood pressure that were asymptomatic. 
• No increased risk of short-term poor cardiovascular outcome at 2 years.
• These pertain to non-pregnant individuals and those that are not prone to rapidly evolving target-organ injury (eg. CHF, CKD).
• Treatment in the UC:
• Allow the patient to rest! This study showed that 30% of patients after 30 minutes of rest had a 10-20 mmHg decrease in blood pressure.
• What comes on gradually, should be decreased gradually!
• Discuss nonpharmacologic methods of lowering blood pressure: weight loss, decreasing sodium intake, exercise.
• Rapid lowering of blood pressure in patients with severe asymptomatic hypertension can lead to major complications, especially in elderly patients. 
• Restart blood pressure medication in select patients. 
• Consider starting a long-term medication in line with the American College of Cardiology (ACC) guidelines.
• Set up follow up with a primary care provider in 1-2 days!
  
  
• Partial fingertip amputations:
• Many hospitals and emergency departments do not have hand specialists to care for hand emergencies. 
• This study included ~16,000 patients, and only 18% of patients had reimplantation.
• Classification: 
• There are 4 Allen “zones” of injury, depending on the amount of the
  fingertip lost. 

• Zone 1: Distal to nail bed
• Zone 2: Distal to distal phalanx
• Zone 3: Distal to lunula
• Zone 4: Distal to DIP joint
  
  

• Management
• Determine if there is an indication for replantation.
• Rarely possible for zone I-III amputations, especially if a crush injury.
•  A viable replantation requires one vein and one artery in the
  anastomosis. 
• Surgical outcomes are poor with only a 50-60% success rate. 
• Consider referral to a hand surgeon for possible replantation:
• Amputations of the thumb or index finger.
• Any Allen Zone IV injury with a clean cut amputation.
• Clean cut amputations at any level by a saw or sharp object. 
  
  
• Repair options
• Surgical closure with flap or graft: There is a growing body of evidence that closing these wounds via a surgical flap or revision is not necessary.
• Dressing: The fingertip heals well with a simple occlusive or
  semi-occlusive dressing over the stump.
• A systematic review of 1400 patients with fingertip amputations treated with a dressing found that the outcomes were just as good as with surgical treatment. The mean time to healing was 4 weeks, 2 point discrimination after healing was equal to other methods, and there was no increased rate of infection.
• Dressing details: apply a non-stick dressing (such as a Vaseline or antibiotic infused gauze) covered by a dry wrap or Coban and a protective splint.
• Adverse side effects
• 6% of patients may have decreased two point sensation.
• Cold intolerance.
  
  
• Antibiotics?
• Evidence is limited, with no clear studies on this specific injury managed outpatient. One study of patients treated in the OR found no reduction in the infection risk with prophylactic antibiotics.
• Infection appears to be an uncommon complication. In a study of 1400
  patients managed without surgery, there were only 13 cases of superficial infections and no osteomyelitis.
• Most hand surgeons will recommend an antibiotic (ie. first generation
  cephalosporin) for prophylaxis.
  
  

References:

1. Krauss EM, et al. Secondary healing of fingertip amputations: a review. Hand (N Y). 2014;9(3):282-288. PMID: 25191157.
2. Germann G, et al. Fingertip and Thumb Tip Wounds: Changing Algorithms for Sensation, Aesthetics, and Function. J Hand Surg Am. 2017;42(4):274-284. PMID: 28372640
3. Boudard J, et al. Fingertip amputations treated with occlusive dressings. Hand Surg Rehabil. 2019 Sep;38(4):257-261. PMID: 31185316
4. Morris L. PURLs: An easy approach to obtaining clean-catch urine from infants. J Fam Pract. 2018;67(3):166-169. PMID: 29509820
5. Herreros Fernández ML, et al. A new technique for fast and safe collection of urine in newborns. Arch Dis Child. 2013;98(1):27-29. PMID: 23172785
6. Tran A, et al. Evaluation of the Bladder Stimulation Technique to Collect Midstream Urine in Infants in a Pediatric Emergency Department. PLoS One. 2016;11(3):e0152598. Published 2016 Mar 31. PMID: 27031953
7. Asymptomatic Elevated Blood Pressure. American College of Emergency Physicians. [Link]
8. Grassi D, et al. Hypertensive urgencies in the emergency department: evaluating blood pressure response to rest and to antihypertensive drugs with different profiles. J Clin Hypertens (Greenwich). 2008;10(9):662-667.  PMID: 18844760
9. McNaughton CD, et al. Appropriate Management of Asymptomatic Hypertension. JAMA Intern Med. 2016;176(11):1723-1724. PMID: 27820641

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