The ED Stands Alone

Which raises another question: What constitutes a freestanding ED? There is no singular definition—specifications vary from state to state. In Florida, for example, freestanding EDs don't need to apply for a certificate of need from the state because they are considered an extension of an already licensed hospital. Unlike urgent care centers, Florida's freestanding EDs operate 24 hours a day and are staffed by board-certified emergency physicians and nurses. They are required to meet the same architectural and building code requirements as the state's hospitals.

Florida currently has four freestanding EDs, but that number is expected to grow because Gov. Charlie Crist in June 2007 vetoed a bill that would have extended a statewide moratorium on the facilities. The American Hospital Association, which first included questions about freestanding EDs in its 2006 annual member survey, estimates that there are approximately 179 such EDs in the United States.

But will freestanding EDs begin sprouting up like urgent-care centers and retail-based clinics? Not everyone is convinced that the facilities will provide the return on investment needed to justify their costs. "It's an extremely high-risk project that is appropriate for a very limited amount of situations—those being extremely rapidly growing areas that might have limited access in areas that might be able to support hospitals long term. That might be a good strategy," says Tony Benton, vice president of strategic planning at Mountain States Health Alliance. "Everybody knows that the ER is not a profit center, so to say these are going to pop up everywhere—I wouldn't anticipate that will happen."

Rich Rasmussen, vice president for strategic communications for the Florida Hospital Association, agrees that freestanding EDs have their limitations, but he adds that in some cases the facilities do make financial sense for organizations faced with the alternative of opening an entire new hospital.

"I'm not sure we are going to see a proliferation of freestanding EDs," says Rasmussen, whose organization had opposed the state's freestanding ED moratorium. "But it's a cost-effective alternative. You aren't building a huge new hospital. You're able to put these in an area with a smaller footprint."

Florida's hospitals have experienced a continuing drop in elective surgeries in recent years—while at the same time seeing expanded use of EDs. "We cannot continue to sustain that growth without some additional relief," Rasmussen says. "One way to do that in some of our communities—not all, but some—is the ability to utilize freestanding EDs. They give us that flexibility to manage the growth in our emergency departments." Linda Quick, president of the South Florida Hospital & Healthcare Association, says her organization decided to oppose freestanding EDs in part because of feedback from firefighters and EMTs who "don't like to deliver the same person twice" if a patient needs additional treatment at a hospital. "The rescue people weren't comforted by the fact that the facility was required to have what the hospital ER has, because what the freestanding ED still won't have is a hospital behind it. If it's not serious enough, there is a high probability you don't need to go to the hospital—in which case you probably could have gone to a walk-in clinic."

Beyond that, Quick says freestanding EDs raise more questions than they purportedly solve. "Frankly, we have a hard enough time to get doctors to take ER calls and find the adequate supply of nurses in the hospital-based ERs," she says. "A freestanding ED competing in the same marketplace for that staffing is going to make things all the more difficult. And if they don't have that staffing, then they are not equal to what the license claims they're supposed to be equal to. It's a malpractice suit waiting to happen."