Hospital-free ED: A growing trend

In the country's fast-growing suburbs, the freestanding emergency department -- without a hospital physically attached -- is the latest wave in medical facilities.

By — Posted Dec. 26, 2005

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It wasn't a hospital. Nor was it an urgent care center, clinic or medical office building. When the doors opened at Munroe Regional Medical Center's inaugural freestanding emergency department, the community of snowbirds and senior citizens near Ocala, Fla., didn't know what to make of it.

"People didn't know it was out there, and ambulances didn't know they could come out there and get people stabilized. It was difficult," said Joseph Yates, MD, medical director of Munroe's emergency department, who also works at the freestanding facility.

But three years later, the facility has no shortage of patients, demonstrating why the concept of the freestanding ED is growing more popular nationwide. "Now we're at the point where we're adding coverage during the day, and the nights are taking care of themselves," Dr. Yates said.

More than an urgent care center, the freestanding emergency department is open 24 hours a day to serve patients with most types of ailments, injuries and other medical needs. But those requiring hospitalization must be transferred. The facilities tend not to handle major trauma cases and instead are designed as a place for patients, particularly in the suburbs, to get immediate care.

Though the first freestanding emergency department opened in Virginia nearly 30 years ago, the model has been used sparingly, until recently.

Now, with increased pressure on traditional emergency departments, more hospitals are turning to freestanding EDs. For some, it eases problems caused by overcrowding or aging facilities. Others are building in fast-growing suburbs to chase shifting populations. No one has tracked the number of facilities being built, but observers say the interest in them is greater than ever.

The facilities are typically built by hospitals -- not physicians -- but when a freestanding ED arrives in a new community, physicians of all specialties keenly feel the impact.

By offering outpatient services such as imaging, freestanding EDs can provide primary care physicians with the support they need to do their work more quickly and closer to home.

"It should make their jobs easier in the sense that there is more service available in the area for their patients," said Deborah A. Yancer, president of Shady Grove Adventist Hospital in Rockville, Md., which is building a $7.4 million freestanding ED. The facility, which should be open in late spring or early summer, will offer a wide range of services, including an imaging lab. It will be closely watched by state lawmakers, who are trying to develop protocols for regulating freestanding EDs in anticipation of future projects.

When Swedish Medical Center in Seattle opened a freestanding ED in the fast-growing eastern suburb of Issaquah, Wash., last March, it brought an influx of specialists to an area where they had been relatively sparse. That has meant that primary care physicians there now have specialist resources at their fingertips.

"Historically, there have been very few specialists in that community. What it has done is brought a full complement of specialists to the Issaquah community. That makes life easier for the primary care physicians and patients," said Kevin Brown, vice president of Swedish.

For Swedish, the facility could be a precursor to a hospital. The Seattle-based system initially applied for certificate-of-need approval to build a hospital in Issaquah but was turned down. It is appealing that ruling. A competitor has been seeking to build a hospital there as well.

Meanwhile, Swedish decided to build the freestanding ED, which did not require CON approval. The $20 million, 55,000-square-foot facility opened March 1, offering a full emergency department, an imaging center, a clinical lab, a sleep center and office space for physicians.

Nancy Auer, MD, chief medical officer of Swedish and a former president of the American College of Emergency Physicians, said the facility is equipped to handle patients with fractures or complex lacerations, as well as those needing diagnoses, intubations, monitoring and more.

"It's soup to nuts," she said. "We think of our Issaquah complex as almost a freestanding hospital without beds." Other services it's without include a cardiac catheterization lab and operating room. Patients needing those services must be transferred.

Dr. Auer said there is no more risk to those patients than for patients who go to traditional hospitals and are transferred to other facilities for various reasons. At least with the freestanding ED, she said, patients might be stabilized more quickly because they are closer to home.

"Traffic congestion is to me one of the biggest drivers for a freestanding emergency department," Dr. Auer said. "Do you want people stuck in traffic or having to drive long distances when they need to be stabilized? Or would you like them to be stabilized?"

Still deciding what it's all about

Still, not all physicians know what to make of freestanding EDs. Mickey Eisenberg, MD, a former emergency physician who is now director of King County Emergency Medical Services in Seattle, said his agency decided to limit which patients could be directed to the Issaquah facility, because little is known about it.

"The freestanding facility is new in this area, so we wanted really to err on the side of patient safety and gather information about the types of patients that would be eligible. The most important thing to realize is as a freestanding facility, it doesn't have an operating room, an intensive care unit or a cardiac laboratory, so if patients needed those facilities, they would be at a disadvantage," Dr. Eisenberg said. "They clearly are staffed with very experienced people, and they have a good facility with good tools at their disposal, but the bottom line is it's still not a hospital."

The agency was planning to review its rules some time next year, after gathering more information. Meanwhile, the facility expects to grow with the ambulance and walk-in traffic it has been getting. Swedish anticipates 15,000 to 20,000 patient visits in 2006, up from 10,000 in 10 months of operation in 2005, Brown said.

Brown believes that freestanding EDs are a growing model. "We just opened in March, and we've had people coming to look at the center from Michigan and Canada, people from Portland (Ore.) and Boise (Idaho). There are definitely a lot of people interested," he said.

With that growing interest comes the threat that freestanding EDs will proliferate in an uncontrolled way. As more are built, Dr. Auer said, there could be growing confusion about them, because "there's no real good definition of what you have to have."

In Florida, such concerns, combined with questions about how they should be regulated, have led to a temporary moratorium on freestanding EDs while regulators and lawmakers study them. At the same time, the Florida Hospital Assn. has developed a task force to do its own study.

In a report prepared for lawmakers, the Florida Agency for Health Care Administration said freestanding EDs have been part of a trend toward more hospital-based outpatient services.

Though concerns have been raised that uncontrolled expansion of freestanding EDs could threaten safety-net hospitals by creating too much competition, the report concluded that "it is in the public interest" to allow their development because they provide access to care in key areas.

To address concerns about market issues, the facilities should be subject to certificate-of-need review, the report recommended. It said their growth likely also will be checked by liability concerns and staffing issues.

For now, Florida has two freestanding EDs that were opened before the moratorium, including the Emergency Center at TimberRidge, the facility built by Munroe.

Munroe leaders figured a hospital on the site would need at least 60 beds, likely meaning a cost of at least $60 million, said Earline Piscitelli, vice president for corporate development. Instead, the hospital spent $12 million on the freestanding ED, which opened in 2002.

"It's certainly a less expensive way to take health care to fast-growing areas," Piscitelli said. "At the time -- and even today -- hospital beds are not needed in that area, but certainly access to health care providers is needed."

Piscitelli said emergency departments increasingly are serving as the gateway for access to care for patients. "As the supply of physicians continues to decrease, especially in primary care areas, and the number of uninsured increases, there is a lack of access to physicians, so people use the emergency department more," she said.

A different style of practice

Dr. Yates, who spends a few shifts a week at TimberRidge, said if his patients needed an OR, he would prefer to be in the hospital. But if he had to pick between a freestanding ED or nothing, he would choose "having the emergency room closer to the patient."

"It's nice to be able to send somebody to the operating room or send somebody to the ICU and have them ready. But it's more often a blessing to start emergency resuscitation sooner, so the benefit [of the freestanding ED] is greater than the loss," he said.

While some physicians prefer to work at the main hospital, others are attracted to the freestanding facility because it provides a sense of a more tightly knit work environment.

"They're like a family," Dr. Yates said. "Different people like different styles."

Physicians also might prefer the focus on a smaller range of patients, said Joan Miles, assistant vice president for ambulatory services at Inova Health System in Falls Church, Va.

"Turnaround time is usually less. That's all we have to take care of -- we only have the ER patient and the outpatient -- whereas in the hospital the volumes are many more," she said. That also means support services, such as radiology, "support our patients only."

Inova, which serves metropolitan Washington, D.C., has three freestanding EDs in operation, including a facility in Reston, Va., that opened in 1977 and is believed to be the first in the nation.

In the right situation, Miles said, the model works like a charm. "It takes 20 to 30 minutes to get one patient from one facility to another, but patients stay in ERs much longer than 20 minutes to get admitted in some cases. That's the only limitation that I see," she said.

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A question of regulation

The Florida Health Care Administration was asked by the state Legislature to examine if freestanding emergency departments are in the public interest and how they should be regulated. The agency found:

"Under certain circumstances, freestanding emergency departments allow a hospital to provide the most sought-after hospital service to a growing population without forcing it to develop inpatient services that may not be used efficiently."

"Uncontrolled expansion of freestanding emergency departments could change the market shares of the hospitals in a regional market. When one of those hospitals is a safety-net provider, such a change could threaten its financial viability."

"Other factors will likely limit the number of hospitals that attempt to develop freestanding emergency departments. These factors include liability and patient safety concerns, competition for qualified professional staff or adequacy of specialty physician backup."

"As long as the hospital understands that the freestanding emergency department will be regulated identically to the onsite emergency department, there is no reason to have a concern about quality of care."

"The Legislature should add freestanding emergency departments as a project subject to CON review."

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Some freestanding EDs

Swedish Medical Center/Issaquah Campus Emergency Room and Specialty Center

Location: Issaquah, Wash.
Opened: March 2005
Size: 55,000 square feet
Cost: $20 million
Services/features: Full emergency department with 14 treatment beds and three observation rooms; imaging center; clinical lab; clinic space for physicians; sleep lab

Shady Grove Adventist Hospital -- Germantown Emergency Department

Location: Germantown, Md.
Projected opening: Late spring/early summer 2006
Size: 17,000 square feet
Cost: $7.4 million
Services/features: Full emergency department with up to 21 treatment beds; imaging center; next to a physician office building

The Emergency Center at TimberRidge

Location: Marion County, Fla.
Opened: April 2002
Size: 57,594 square feet
Cost: $12 million
Services/features: Full emergency department with 12 exam rooms; laboratory; full-service imaging center

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