How should an urgent care operate without influenza (flu) or coronavirus disease 2019 (COVID-19) tests and a functioning electrocardiogram (EKG)?

Operating an Urgent Care Without Flu/COVID Tests and EKG

An urgent care facility without flu/COVID testing and a functioning EKG must implement clinical triage protocols based on symptom severity, utilize point-of-care ultrasound when available, establish clear transfer criteria for cardiac presentations, and maintain appropriate PPE for all patient encounters while assuming all patients may have COVID-19. 1

Clinical Triage Without Diagnostic Testing

Respiratory Illness Management

• Assume all patients with respiratory symptoms may have COVID-19 and implement appropriate PPE protocols (surgical mask, eye protection, and gloves at minimum for all encounters). 1

• Screen all patients at entry using standardized questions about fever, cough, shortness of breath, loss of taste/smell, and recent exposures to identify high-risk features. 1

• Defer non-urgent visits and reschedule elective evaluations to reduce exposure risk and conserve resources during resource-limited situations. 1

• Differentiate based on clinical severity rather than specific diagnosis: Patients with mild upper respiratory symptoms (rhinorrhea, sore throat, mild cough) can receive supportive care regardless of whether it's flu or COVID-19, while those with severe respiratory distress, hypoxemia, or extreme tachypnea require immediate transfer. 2, 3

Cardiac Presentations Without EKG

• Use point-of-care ultrasound (POCUS) as an alternative diagnostic tool to assess for left ventricular systolic function, regional wall motion abnormalities, and right ventricular dysfunction in patients with chest pain or dyspnea. 1

• For suspected STEMI presentations, establish immediate transfer protocols to PCI-capable facilities without delay, as the absence of EKG capability makes urgent care an inappropriate setting for these patients. 1

• Clinical assessment must focus on high-risk features: Patients with ongoing chest pain, diaphoresis, radiation to arm/jaw, or hemodynamic instability require immediate transfer regardless of EKG availability. 1

• Consider that COVID-19 can cause myocarditis with chest pain and troponin elevation, making the distinction from acute coronary syndrome challenging without EKG—maintain a low threshold for transfer in patients with cardiac risk factors. 4, 3

Resource Conservation and Alternative Strategies

Testing Alternatives

• Without rapid flu/COVID testing, clinical management should be syndrome-based: Treat respiratory illness supportively with clear instructions on red flag symptoms (worsening dyspnea, persistent fever >3 days, confusion, chest pain) that warrant re-evaluation or emergency department transfer. 3

• The absence of testing should not delay appropriate antiviral therapy in high-risk patients presenting within 7 days of symptom onset with clinical features consistent with COVID-19 (if remdesivir or other antivirals are available in your setting). 3

• Refer patients to facilities with testing capability for those requiring hospitalization, those at high risk for progression, or when specific diagnosis would change management (e.g., influenza in immunocompromised patients who might benefit from oseltamivir). 3, 5

Equipment Workarounds

• Portable ultrasound devices can substitute for some EKG functions by identifying wall motion abnormalities, pericardial effusion, and severe valvular disease, though they cannot replace EKG for rhythm assessment or STEMI diagnosis. 1

• Establish relationships with nearby facilities that have EKG capability for rapid patient transfer when cardiac evaluation is essential. 1

• Maintain a low threshold for EMS activation for patients with concerning cardiac symptoms, as prehospital EMS can obtain 12-lead EKGs and activate catheterization labs directly if STEMI is identified. 1

Critical Safety Protocols

Universal Precautions

• Implement universal masking and comprehensive PPE use for all patient encounters, as 25-50% of COVID-19 infected patients are asymptomatic, making it impossible to identify all infected individuals through screening alone. 1, 6

• Limit the number of staff members evaluating each patient to reduce exposure risk. 1

• Thoroughly clean and disinfect all equipment and surfaces between patients, with particular attention to high-touch areas. 1

Transfer Criteria

Immediate transfer indications include:

• Severe respiratory distress with hypoxemia (oxygen saturation <90% on room air) 2
• Suspected STEMI or acute coronary syndrome 1
• Hemodynamic instability 1
• Altered mental status 3
• Any condition requiring diagnostic testing not available at your facility 1

Documentation and Communication

• Document clearly why testing was not performed (equipment unavailable) and the clinical reasoning for management decisions. 1

• Provide explicit written discharge instructions including specific symptoms that warrant immediate return or emergency department evaluation. 3

• Communicate limitations to patients upfront about the facility's diagnostic capabilities and when transfer to another facility may be necessary. 1

Common Pitfalls to Avoid

• Do not attempt to manage suspected STEMI without EKG capability—these patients require immediate transfer to facilities with cardiac catheterization. 1

• Do not assume patients without fever or cough are COVID-negative—maintain PPE protocols for all encounters. 1, 6

• Do not delay transfer while attempting to arrange testing elsewhere—patients requiring hospitalization or urgent intervention should be transferred immediately. 1

• Do not dismiss chest pain in patients with recent COVID-19 vaccination or infection as non-cardiac without proper evaluation, as myocarditis and pericarditis are recognized complications. 4