ER or Urgent Care? Or Neither?

You catch your finger on a sharp edge while working around the house. It’s bleeding a little, and the cut is deeper than you expected. You decide you want to be seen by a clinician, so where do you go?

There often isn’t one correct answer. Primary care, walk-in clinics, telehealth, urgent care, and emergency departments overlap considerably, but they are built to do different things.

Primary Care

Primary care is the bedrock of the healthcare system and of medicine in general. These are the clinicians who know you best. They have access to your records and medications and treat chronic medical conditions, diagnose new medical conditions, order labs and imaging studies and handle referrals to specialists. Primary care includes pediatrics, internal medicine, and family medicine, and some primary care offices have x-ray available and perform minor procedures in the office. There is significant benefit to the continuity of care you receive when going back to your primary care physician.

Many primary care offices have after-hours or extended hours reserved for same-day appointments. Of course, if you strongly prefer to see your own PCP, you may need to wait. Sometimes the wait is a day or two, or sometimes a few weeks. And often enough, a few days or weeks is just fine, though it may not feel like it in the age of “instantaneous everything.”

If you call in the daytime, the person you speak with is often located in the same area as the clinicians. After hours, you may be speaking with an answering service. Many practices can connect you with an on-call nurse or clinician who can help determine what should happen next.

Sometimes that pathway leads you to:

Walk-in Care

Walk-in care often functions as a branch of primary care. The term is used to describe a sort of “urgent care” that takes place in a primary care office. It can refer to those reserved hours mentioned above, or to a separate area with separate clinicians. The name of the game is same day access for relatively straightforward problems, and “walk-in” describes how you get in, not necessarily what the clinic can do.

Very often the walk-in clinician is not your PCP. And if the clinician feels further workup is necessary, they may order it, refer a patient back to their PCP, or refer the patient to the emergency department. Walk-in care does not typically substitute for continuity of care, and does not establish an ongoing clinician-patient relationship.

The walk-in clinic for your primary care office may have the same resources as your primary care office, fewer resources, or more. Some can examine you and prescribe medications. Others may be able to administer IV fluids, perform x-rays, ECGs, or labwork.

The advantage here is access.

Telehealth

I’d like to start with a clarification. Telehealth is a broad term that can refer to virtual visits with your PCP and specialists, or standalone telehealth companies. Here, we’re looking at the latter, and that’s important. A standalone telehealth company may not have access to your full medical record. Some of them are solely for single episode visits, while others, such as chronic condition providers or mental health providers, may attempt to provide continuity of care. Many can prescribe medications. However, continuity of care in telemedicine can be harder when you see a different clinician visit to visit. Your health insurance company or workplace may offer its own telehealth nurse line or clinician line as well. Laws governing telehealth differ by state.

The main drawback to telehealth is that if the question cannot be answered adequately without a physical examination, vital signs, testing, imaging, or a procedure, the virtual clinician may need to send the patient elsewhere. The standard of care doesn’t disappear because the encounter is virtual.

The main advantage here is convenience and remote assessment.

Urgent care

Sometimes urgent care refers to a “fast track” area of an emergency department but here we’re referring to outpatient urgent care centers that are separate from an emergency department, and trying to explain the variability between them is nearly impossible.

Urgent care practices are for episodic visits, typically for new problems. Staffing models and capabilities vary enormously, so a patient can be referred back to their PCP or referred to the emergency department if the patient might require more workup.

Note that many use standard language when sending patients to the ER that says something along the lines of, “You could be experiencing a medical emergency…” A referral to the ER is for an evaluation and does not necessarily mean a patient will have any labwork, imaging studies, or procedures performed after the emergency clinician evaluates them.

The main advantage is same day assessment.

Emergency room

Then we come to the emergency room, or emergency department. These are typically hospital-based and designed around what the emergency room is actually for: evaluating and stabilizing problems that may be serious, time-sensitive, diagnostically uncertain, or require hospital-level testing and/or treatment.

This does not mean that an ED has access to all tests, procedures, and treatments, however. Just because a procedure is performed within a hospital doesn’t mean an ER can order, admit for, or perform it. The same goes for medications and prescriptions. An ED may address chronic medications when necessary for the immediate problem, but ongoing medication management is usually better handled by the clinician who follows the patient over time.

Of note, some states also have freestanding emergency departments. Because they don’t have inpatient beds, patients who require hospitalization must be transferred to a hospital.

The advantage of an emergency department is that it has the broadest immediate access to hospital-level testing, treatment, and stabilization.

Summary

So, how do you choose? Sometimes the answer is obvious, and sometimes it isn’t. You may call your PCP’s office and be referred to a walk-in clinic, urgent care, or emergency department. Or you may go to the emergency department and be referred back to your PCP for evaluation. These categories aren’t rigid. The same symptoms may be appropriate for different settings depending on the circumstances. The important distinction is less “which diagnosis goes where” and more “what kind of care can this setting actually provide?”