Upon investigation and expert review, it’s clear that the patient’s illness was significantly underappreciated. In addition, the following items can be noted:

1. Insufficient examination of history. The cough was exertional dyspnea. The “worsening at night” likely indicated paroxysmal nocturnal dyspnea due to congestive heart failure. The report of “feels sweaty” was not thoroughly examined and could have differentiated fever from diaphoresis.
2. Insufficient and underappreciated vital signs. Had more vitals been taken in the urgent care facility, they would have likely been considered abnormal given that the emergency department noted a weight gain of 16 pounds in the prior 10 days, respiration rate of 28, pulse of 124 and pulse oximetry reading of 84 percent (room air). The patient was also hypotensive. Even without the benefit of having access to his prior medical record, he did indicate that he was on antihypertensive medication, suggesting this was not his baseline.
3. Insufficient differential diagnosis. Was there a bias towards diagnosing the most common condition, or the diagnosis that applied to the previous patients that day?
4. Concerns regarding supervision and training. The PA’s experience was primarily in an ambulatory setting. He did not have significant experience seeing severely ill patients. Protocols for training and consulting with supervising physicians could have been improved.
5. No appreciation of the importance of the “road test.” The patient had a moderately strenuous occupation and was working the past month, yet he was unable to walk without assistance.
6. The only defense could have been a “causation” defense—arguing that they couldn’t prove that the outcome would have been different had the patient been diagnosed with congestive heart failure in urgent care. Would diagnosing congestive heart failure in urgent care have allowed earlier intervention and optimized treatment of the process? In this case, experts concluded that the 12-hour delay was significant and could have changed the outcome with aggressive treatment.

Expert reviews in medical liability cases will examine “delay in treatment” concerns and whether an earlier diagnosis would have allowed for the appropriate intervention and/or prevention of an adverse outcome.

FACTORS BEHIND INCREASES IN URGENT CARE CLAIMS
We believe the trend is influenced by both an increased relative rate of incidents and claims, and an increased volume of patients who visit urgent care facilities. It’s important for physicians and other medical providers/staff to be aware of the risks unique to urgent care facilities and to examine how the diversity of resources, disparity in patient expectations, and the differences in provider training can affect their facilities.

1. Disparity in Patient Expectations
The expectations of patients who present to urgent care facilities are all different. Claims are filed when the expectations of the patient or their family are widely different from that of the providers and facility. In urgent care, beyond the chief complaint, it’s important to ask the patient (or when applicable their parents, caregivers, or friends of family who are present): 
>“What do you think this is?”
>“What are you most worried about by this?”

The chief concern needs to be addressed at least as thoroughly as the chief complaint. The issue of patient expectations can be a huge factor in the likelihood of a subsequent malpractice action even when the medical care provided is later found to meet the standard of care. We have seen claims arise in the following circumstances:

• When existing patients of the primary care office are seen in extended hours by practitioners whom the patient has previously seen in the primary care setting. This area becomes risky when the current chart or pertinent medical information is unavailable. Prescribing errors can occur. We’ve also seen errors that occur when the extended hours physician fails to address a significant issue that was in progress of work-up. When it was not addressed, the patient perceives the issue to be less important.
• When patients who had not previously visited the facility present for minor, episodic care and expect only this type of care. They identify another physician who is actively serving as their primary care physician. Because of the congruency in expectations, this scenario does not present any unique risks as long as the patient understands that primary, preventive or ongoing care will be provided by the identified primary care physician.
• Patients who have no primary care physician and recurrently visit the facility for episodic, acute care. These patients may view the providers of the facility as their primary care physician. This scenario is the most risky— particularly if the provider fails to diagnose malignancies.
• Patients with acutely urgent or conditions who have chosen to present to the facility for issues of cost, convenience of location, or minimal waiting times.

2. Diversity of Resources
In most jurisdictions, because there is no single definition, licensure, or accreditation required to operate an “urgent care” facility, they possess a diversity of resources. Urgent care facilities vary from a hospital-based facility with resources similar to an emergency department to a freestanding clinic in a strip mall that employs a nonclinical receptionist and a provider—having the ability to do little more than strep screens and urinalysis. Variables can include:

• The experience, training, and turnover rate of the support staff.
• The availability of consultants and laboratory diagnostic services.
• The availability of diagnostic imaging services and access to radiologist consultation.
• Access to and working relationships with existing emergency departments—including any communication problems that exist between the parties.

PROVIDER TRAINING, EXPERTISE, RESOURCES, AND DRILLS
Just as we have described disparities in the resources available, equally important is the disparity of provider training and expertise. Remember, procedural complications typically do not cause claims in urgent care; claims are caused by a failure or delay in diagnosis.

We hope that those staffing urgent care facilities recognize these risks and assign qualified, experienced, and “diagnostically-inclined” physicians to this area. Providers must be well versed in the potential adverse diagnosis that might be lurking behind a seemingly minor complaint. They must be able to take steps via diagnostic work-up, consultation, or close clinical follow-up, document the course, and pick up those significant diagnoses. When PAs and APNs provide care, be sure that protocols are in place to recognize potential diagnostic areas which may require closer physician supervision or consultation.

From a risk perspective, acute and unscheduled ill patients represent a significantly higher risk than regularly scheduled patients. Yet, physicians often have a full schedule, meaning acute and ill patients are seen by the PAs and APNs. This can be especially risky when there is a general attitude that physicians should not be interrupted to consult on acute cases.

Furthermore, cost pressures and insurance issues may cause difficulties. For example, a patient might be worried about a significant medical condition that could represent a medical emergency if not recognized promptly, but chooses to go to an urgent care facility due to perceptions of lower out-of-pocket costs, greater convenience, or a subconscious denial that the problem could be something serious. This latter mindset can be difficult to overcome when the providers in the urgent care setting appropriately diagnose the condition but find it hard to get the patient to seek subsequent admission, consultation or emergency department referral. Asking these patients to sign an “informed refusal” form (a sample template is available at www.callcopic.com/resource-center/guidelines-tools/consent-forms) can assist in the defense of claims when serious adverse outcomes or deaths occur following refusal to complete the work-up or be admitted.

The relative low frequency of emergencies in some centers can represent a challenge when inevitably a patient does present with an emergency. Specific advice to deal with such inevitabilities include drills and training.

Providers in urgent care centers should strongly consider maintaining certification in ACLS, ATLS, PALS, and maintain proficiency in EKG reading. Drills and practice protocols that clearly define the roles and responsibilities of each care team member in an emergency can assist in preparing for the inevitable.

FAILURE TO DIAGNOSE: THE COMMON PRESENTATIONS THAT RESULT IN CLAIMS
The risky presentations that urgent care facilities face closely mirror those of emergency medicine. While emergency department physicians clearly perform more invasive procedures on higher acuity patients, both settings provide a risk of failure to diagnose or delay in diagnosis. Our data for emergency medicine shows high frequency and severity of claims resulting from the failure to timely diagnose the following conditions:

>>Heads 
Atypical presentations of stroke are now the leading delayed diagnosis in urgent care and emergency departments. A timely diagnosis of a posterior circulation event, or a posterior circulation dissection, or a brainstem lesion can be pivotal in the time to intervention and ultimate outcome. Even though the catastrophic outcome may be due to the disease process itself—not to any act of omission on the part of the physician—the allegation of substandard care provided to the patient with a resultant brain injury can be difficult to defend. A detailed and documented neurologic exam including the brainstem and posterior circulation functions is critical to the defense, especially when definitive imaging tests are delayed or unavailable. Specific claims have been made for cerebral aneurysm, cerebral bleed, cerebral thrombosis, subdural hematoma, epidural hematoma, sagittal sinus thrombosis, meningitis, and herpetic encephalitis.

>>Occult Trauma
The mechanism of injury should be actively sought, considered and communicated to radiology to help evaluate potential significant trauma, particularly in the head, spine and great vessels. To avoid missing significant findings, a system should be in place to ensure that the radiologist overread of any imaging study is documented and reviewed in a timely fashion.

>>Severe Infectious Disease 
Our emergency medicine data indicate that the allegation of delay in diagnosis of severe infectious disease such as sepsis, severe pneumonia, ruptured appendicitis, perforated or ischemic bowel, meningitis and encephalitis can lead to catastrophic outcomes and potential claims even when it would have been very difficult to predict the catastrophic outcome. It’s important to pay particular attention to sometimes subtle signs and symptoms such as unexplained tachycardia or relative hypotension, very high or very low white blood cell counts, illness out of proportion to expectation, rapid progression of deterioration, or failure to improve as expected. If referral, admission or consultation is not the chosen action plan in this setting, close monitoring and follow-up can be crucial to providing the provider with a second chance to make this difficult diagnosis in a timely fashion.

>>Hearts 
The failure to diagnosis an impending acute coronary event such as myocardial infarction or acute coronary syndrome can lead to fatal arrhythmia, cardiac arrest or significant loss of cardiac function. A high index of suspicion is necessary because atypical presentations can be common, especially in women and/or the elderly. Seeking early consultation and/or referring to an emergency department, a chest pain track, or admitting a patient may be warranted. Risk factors should be solicited, documented and respected as elevating the potential for the need to consider a cardiac cause. Normal EKGs do not rule out cardiac sources in otherwise high or intermediate risk patients. Gastrointestinal cocktails should never be used as a diagnostic challenge to try to rule out a cardiac source.

>>Abdominal Pain
Abdominal pain is a frequent presenting complaint. It can be difficult to diagnose a surgical abdomen, particularly in the young and the elderly who often present atypically. Document the time of onset and duration; complete vital signs, including level of pain; thoroughly examine the abdomen; address pain out of proportion to the exam; and discuss the differential diagnosis. Also, the diagnosis should not be “gastroenteritis” when the presentation is truly undifferentiated abdominal pain. Provide specific follow-up instructions and schedule a repeat examination within 24 to 48 hours (sooner for the young or elderly and other high-risk patients). Communicate clearly and document this discussion. "Follow-up prn" is not adequate instruction.

>>Malignancy
Failure to diagnose malignancy claims generally arise when the delay is at least six months and usually longer (as such, a single visit generally is not the single causative event in that delay). The exception to this statement is when the physician fails to communicate to the patient or treating physician an incidental abnormality seen on imaging study that was done to rule out a different disease. The bigger risk is when a patient presents repeatedly to an urgent care facility or a patient views the urgent care facility as providing him/her with comprehensive and preventive primary care. The repeated visits, including phone contacts and medication refills, might create patient expectations that prove to be problematic in defending against the need to have adequately worked up a persistent problem that ultimately proved to be a malignancy, such as colorectal cancer.