Administration and Leadership, Columns

Freestanding EDs Offer Alternative Patient Destinations

Issue 12 and Volume 40.

Freestanding EDs (FSEDs) have entered the emergency healthcare arena in many states. With the development of these community-based EDs have come questions regarding their appropriate use by EMS providers in regards to routine use, community surge capacity and disaster preparedness.

While initially shunned by hospitals and EMS services due to concerns regarding decreased revenue for hospitals and potential lack of reimbursement for transport, we’re starting to see increasing numbers of providers recognizing FSEDs as approved transport locations.


After returning to the Houston area after working in Pennsylvania, I noticed an “emergency room” neon sign in a local shopping center. Of course, as a “real” ED doctor at the regional trauma center, I had a few choice words and thoughts about the concept. I was quite vocal about this one day with a colleague and said things about “doc in the box” and “fake EDs,” and then he kindly let me know he was also working at that shopping center ED by my house. Oops! He also told me about its CT scanner, X-rays, labs and board-certified emergency medicine physicians, and suggested I drop by to check it out.

I was seduced! The doctors and nurses working there were the same ones working in the big EDs. The equipment was nice, facilities were clean and people were happy. I was so impressed that I started working at one as a side job because it was close to my house. Three years later, I still work in FSEDs.


You may wonder what the allure is. Is it the nice artwork or free coffee? I think it has more to do with the fact that in a very busy world, you don’t need an appointment; there’s rarely any time spent in a waiting room; you see a specialist; get your labs, scans, meds and diagnosis; and still make it home in time to catch the game. It’s a consumer-driven industry that recognizes in a busy world, high quality and efficiency are a powerful combination.

The problem, of course, is the quality question. There are varying requirements across the states with these facilities regarding the staffing, facility requirements and equipment. There may be some FSEDs that exceed the minimum requirements and have physicians who are board certified in emergency medicine or with decades of experience working in EDs. These higher-level FSEDs sometimes also have video laryngoscopy capabilities, a tissue plasminogen activator, LUCAS 2 devices, and other equipment that’s indicative of a high-functioning ED.

Other facilities meet the bare minimum requirements, which in Texas include one year of experience working in an ED setting for physicians. Therefore, an allergist who works occasionally in an ED could be the only physician on duty when a critical patient is rolled in the door.

The solution is to know the details about the FSEDs in your territory and make an informed decision about their role in your system. Some have proposed “leveling” of FSEDs so that state or regional agencies can develop standards to help patients and EMS providers identify high-functioning FSEDs. These levels should not only be indicative of capabilities, but, like the leveling of trauma centers, should be based upon outcomes as well.

A system I recently worked for was evaluating EMS transport to FSEDs after long turnaround times for ambulances at the hospitals and call surges resulted in low numbers of ambulances in service. It doesn’t make sense for us to continue to ignore the importance of FSEDs, particularly as it relates to surge capacity. We may find some FSEDs are utilized regularly to receive ambulance traffic due to patient request or limited resources. Other areas may utilize them only in times of call surge, hospital ED overcrowding or only in disaster planning for untapped surge capacity.


Regardless of how people feel about FSEDs, EMS servicers must make an informed decision about how to utilize these facilities in their routine and surge response planning. We have to appreciate that patients like these facilities because of the personal service they provide.

When the 9-1-1 system ignores these facilities, patients choose to drive themselves to the FSED rather than take the ambulance to the hospital. I’ve taken care of patients with tension pneumothorax, ST elevation myocardial infarctions, strokes and other major traumas who’ve delivered themselves to the FSED either because they were close or because the ambulance refused to take them there.

It’s time to create engaged partnerships so that our patients can benefit from the rapid response of 9-1-1 but also be free to go to a facility of their choice, including FSED

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