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What Ambulance Crews Should Know About Freestanding Emergency Centers
Freestanding emergency departments (FSEDs) are becoming increasingly common in the United States. These facilities offer emergency medical care much like any hospital’s emergency department but are not physically located within a full-service acute hospital facility.
While the future status of Medicare coverage for this model is in question, a bill to restore Medicare coverage for independent FSEDs, The Emergency Care Improvement Act (HR 1964), was recently introduced in Congress in June by Rep. Jodey Arrington (R-TX) and colleagues.
But in the meantime, what do EMS crews need to know about FSEDs, and how can this knowledge shape the decisions they make every day on the streets? When is the FSED a good idea for the ambulance crew and its patient?
Cameron Decker, MD, LP, FACEP, FAEMS, medical director of Harris County Emergency Corps (HCEC), an ambulance service in Houston, Texas, says FSEDs can be a valuable resource for patients with minor injuries or illnesses who need quick and convenient care.
“We’ve been transporting to freestanding emergency departments for probably about 10 years now, and we have this ability baked into our clinical guidelines,” Decker says. “We find it works rather well for our system.”
The right patients for FSED care are those with minor, uncomplicated medical symptoms, including flu-like symptoms, sore throat, respiratory infection, minor motor vehicle trauma, or lacerations that don’t require specialist evaluation and management. Patients with time-sensitive medical concerns that require further specialist care or higher acuity trauma patients shouldn’t go to the FSED.
Diving Deeper into the Freestanding Model
Although comprehensive data about FSEDs are hard to come by, an estimated 32 states recognize them, but many don’t allow them to operate independently of an accredited hospital.1 In 2016, there were 566 FSEDs in this country, with the largest number located in Texas.2
There are two categories of FSEDs, those owned by hospitals, also called hospital outpatient departments, and those that are independent. In either case, the licensed FSED operates 24 hours a day and is staffed by emergency-trained physicians, nurses, and technicians.
FSEDs offer many of the same services as hospital emergency departments, such as pharmacy, labs, and imaging equipment. However, the scope or hours of these services may be limited compared to hospital-based counterparts. Additionally, FSEDs do not have proximity to hospital beds or other hospital services that may be needed by seriously ill patients, such as catheter labs and operating suites.
Research suggests that these freestanding centers can often have significantly shorter wait times for patients—and for the ambulance crews waiting for the emergency staff to accept the patient. But one of the biggest concerns about FSEDs voiced by consumer groups is that patients don’t know what they’re in for financially, especially if the visit is out of network or not covered by their insurance.
Not the Same as Urgent Care
Patrick Langan, a paramedic with HCEC, says one of the stumbling blocks to properly using FSEDs is when people are not clear on the difference between the FSED and an urgent care center (UCC). They think they can go to the former for a minor condition and be charged approximately what they would have been charged at a UCC.
“They just don’t see it as an actual emergency department, with the same kinds of copays, Langan says. “Once they understand it is an ER and they can get the treatments they need, same as a hospital ED, then they’re confused: Is it going to be as fast?” The transporting crew’s job is to help patients make informed decisions about their emergency department of choice.
“The biggest selling point for FSEDs is when I say I’ll get you straight into a room and you’ll see an emergency doctor within minutes,” Langan says. The alternative may be perhaps waiting at least 30 to 60 minutes or even much longer in the lobby.
He adds that he doesn’t want to deliver patients the emergency department doesn’t want to serve.
“By law, they have to accept the patient,” he says. “But you may not make a lot of friends. And we don’t want to look dumb in front of their staff.” The answer, according to Langan, is to talk to emergency department physicians at an unhurried moment, especially when a new center opens. “They’ll give us an idea of what they can and can’t handle.”
Can Paramedics Make the Right Choice
EMS needs to have robust policies in place for working with FSEDs.
Decker says. “You should have a good risk/benefit discussion with the patient. Of course, that takes good communication skills and good knowledge of the hospital system as well as the EMS system.” One of the conversations that is more difficult, and constantly changing, concerns costs and which insurance plans are taken or not, he says.
“When we actually drill down and look at the data of who subsequently gets transferred for a secondary admission at another facility, more often than not it is somebody that we identified would not have been an ideal candidate for a freestanding ED, but the patient insisted on this FSED or no emergency care at all,” Decker says. If the crew follows agency guidelines but the patient who demanded the FSED subsequently requires transfer to a full-service hospital, that should not be considered a failure.
Charles Hwang, MD, EMT-T, FAEMS, FACEP, an assistant professor of emergency medicine at the University of Florida Health in Gainesville, was the lead author of a 2019 study in the Journal of Emergency Medicine3 that surveyed two county EMS agencies and two FSEDs in Florida to determine if surveyed paramedics can correctly identify patients that can be cared for fully at an FSED. Three-quarters met that criterion.
Hwang, who is also the medical director of Levy County Department of Public Safety, says FSED services are quite varied, just like with EMS, each with different capabilities, nuances, and other factors. The goal is getting the right patient to the right place and the right provider at the right time, but that requires an understanding of what services the FSED can offer or not offer, not just by the paramedics but also by the EMS medical director.
Most FSEDs will have CT but they may not have ultrasound or MRI. There is a need for collaboration between the EMS medical director and the emergency room doctor, he says. “It’s a matter of reaching out to the ER doctor and asking them what patient presentations they can manage. Have the ER team come to train your staff, fostering teamwork, collaboration, and respect.”
Recognition by Medicare
J. Kevin Herrington, MBA, FACHE, former president of the Texas Association of Freestanding Emergency Centers, is the CEO of a Houston-based health system that operates FSEDs in Southeastern Texas.
“Most of our patients come in as ambulatory patients,” Herrington says. “If you have a gunshot wound, you should go to a surgical hospital. But if a gunshot victim walks into our building, we will stabilize them before transferring out. We have a 3 to 5 percent [hospital] transfer rate. We may keep some patients in observation status in our ED for up to 23 hours, with time to repeat lab tests or give IV antibiotics. Then we have to transfer them. We have our own protocols, developed collaboratively between our medical director and EMS. We try to train our local EMS services. We don’t want to waste their time.”
According to Herrington, while independent freestanding emergency centers are essentially the same as hospital-based centers, the big difference is Medicare does not recognize those centers.
Independent FSEDs, Herrington says, have gone through phases where the hospitals hate them and hospitals like them.
“We’ve been through hurricanes and other natural disasters and then the COVID pandemic,” he says. “We’ve proven that we’re an integral part of health care.”
References
- MedPAC, “Chapter 8: Stand-Alone Emergency Departments,” Report to the Congress: Medicare and the Health Care Delivery System, June 2017. http://www.medpac.gov/docs/default-source/reports/jun17_ch8.pdf.
- Gutierrez C, Lindor RA, Baker O, et al. State Regulation Of Freestanding Emergency Departments Varies Widely, Affecting Location, Growth, And Services Provided. Health Affairs. 2016 Oct.; 35(10): 1857-1866.
- Hwang DW, Fitzpatrick DE, Becker TK, et al. Paramedic determination of appropriate emergency department destination. The American Journal of Emergency Medicine. 2019 March; 37(3): 482-485.
