Editorial: The Changing Landscape of Emergency Medicine II: Free-Standing EDs



If an emergency department is considered the “front door” to the hospital, how do we regard a free-standing emergency department (FSED) with no hospital attached to it? Until recently, FSEDs were most commonly located in rural areas lacking hospitals and primary care providers. But fueled by recent hospital closures in the face of steadily increasing demands for emergency care, FSEDs are now appearing in previously well-served urban areas, too. In the past 6 months, three new FSEDs have opened in New York City on the sites of recently closed hospitals. What do FSEDs mean for emergency medicine and emergency physicians, and are they safe alternatives to traditional hospital based EDs?

Newer technologies and treatments, coupled with steadily increasing pressures to reduce inpatient stays, razor-thin hospital operating margins, and the refusal of state and local governments to bail out financially failing hospitals, have created a disconnect between the increasing need for emergency care and the decreasing number of inpatient beds.

On one end of the EM patient care spectrum, urgent care centers and retail pharmacy clinics—collectively referred to as “convenient care” centers—are rapidly proliferating to offer care to those with urgent, episodic, and relatively minor medical and surgical problems (see last month’s editorial, “Urgent Care and the Urgent Need for Care”). With little or no regulatory oversight, convenient care centers staffed by EPs, family practitioners, internists, NPs, and PAs, offer extended hour care—but not 24/7 care—to anyone with adequate health insurance or the ability to pay for the care.

On the other end of the EM patient care spectrum are the FSEDs, now divided into two types: satellite EDs of nearby hospitals, and “FS”-FSEDS with no direct hospital connections. Almost all FSEDs receive 911 ambulances, are staffed at all times by trained and certified EPs and RNs, provide acute care and stabilization consistent with the standards for hospital-based EDs, and are open 24/7 – a hallmark that distinguishes EDs from UCCs. FSEDs code and bill both for facility and provider services in the same way hospital-based EDs do. Although organized emergency medicine has enthusiastically embraced, and recently endorsed FSEDs, its position on UCC’s has been decidedly mixed.

Are FSEDs safe for patients requiring emergency care? The lack of uniform definitions and federal and state regulatory requirements make it difficult to gather and interpret meaningful clinical data on FSEDs and convenient care centers. But a well-equipped FSED, served by state-of-the-art pre- and inter-facility ambulances, and staffed by qualified EPs and RNs, should provide a safe alternative to hospital-based EDs for almost all patients in need of emergency care—especially when no hospital-based ED is available.

Specialty designations of qualifying area hospitals such as “Level I Trauma Center” will minimize but not completely eliminate bad outcomes of cases where even seconds may make the difference between life and death. In the end though, the real question may be is an FSED better than no ED at all?

Ideally, a hospital-based ED should be the epicenter of a network of both satellite convenient care centers and FSEDs, coordinating services, providing management and staffing for all parts of the network, and arranging safe, appropriate intranetwork ambulance transport.

Although many hospitals are less interested in offsite convenient care centers than they are in FSEDs that can supply more inpatients, EM cannot afford to ignore any of the alternatives being offered to hospital-based ED care, and should immediately embrace all of them before other specialties begin helping themselves to slices of a pie that EM has worked hard to bake to perfection for almost half a century.

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