Preplanning critical for freestanding ED

Pre-existing staff help with fluctuating demand

If you're planning to open a freestanding ED, you won't have any history on which to base your staffing, equipment, and other basics of operations. Nonetheless, say those who have done it, it is essential that you plan ahead as carefully as possible, and you won't necessarily be entirely in the dark.

"A freestanding ED can treat more complex cases on-site vs. immediately transporting patients to a hospital," explains Becky Vasse, BSN, MAS, director of emergency services for the new Shady Grove Adventist Emergency Center in Germantown, MD, and Shady Grove Adventist Hospital in Rockville, MD. Freestanding ED physicians are board-certified in emergency medicine, and lab and radiology services are more comprehensive than in an urgent care center, she says.

"One of the bigger challenges was to get a real objective sense of what the volume was going to be, says Michael Cetta, MD, medical director of the Shady Grove Adventist Emergency Center in Germantown, MD. The center, which opened in August 2006, saw 22,000 patients in its first year of operation, which was 5,000 more than originally anticipated.

With nurses and hospital beds in short supply, says Cetta, "we wanted to do all we could to optimize staffing and be flexible enough to grow." From a physician standpoint, that meant starting with single coverage, which was one doc 24 hours a day. "As we swung into operation and volume gradually increased, we added a midlevel practitioner [a nurse practitioner or a physician assistant]," he says.

In terms of nurse staffing, they looked at the type of patients they thought they might see, based on what they see at the main facility at Shady Grove Adventist Hospital and what group of those patients they thought would go to Germantown, says Vasse. "We knew based on our location next to a 'SoccerPlex' and Germantown that orthopedics would be our strongest base," Vasse says. "We get about 13% of our patients coming by ambulance." That prediction, she says, was "right on."

Beyond that, says Vasse, she attempted to keep the same ratios that existed at the hospital for the same types of patients. "If you look at the acute area, the average is four patients per nurse, and eight in fast track," she says. "There is a blend [of acute and fast track-type] patients at Germantown, depending on the time of day."

Demand was monitored, and changes were made as needed. For example, she says, "at the five-month mark, we added a nurse from 3 p.m. to 3 a.m."

Cetta says having a hospital within 10 miles of the new facility added flexibility to their staffing.

"Out parent hospital has a very large staff, so we were fortunate enough to have built-in buffers," says Cetta. "We hired three new physicians and a few [physician] extenders, but we started them before we opened; they were all trained at Shady Grove Adventist Hospital, and everyone works at both places now."

Therefore, "it's not unusual for us to pull a physician or an extender from Shady Grove Hospital when needed," he says. That was an element of his planning for the start, Cetta says. "A key element of our design was to have the parent hospital so close that all docs and extenders were prepared to work at either," he says. "If you did not have that flexibility, things would be a lot bumpier."

Cetta also used existing relationships when planning for equipment and ancillary services. "We went into partnership with the [hospital] radiology group, and they did a tremendous job of outfitting the facility," says Cetta, noting that X-ray and CT equipment are available 24/7.

They don't have comprehensive blood banking capability, he says. "We can't run drug levels for dilantin, digoxin, and so forth," Cetta says. However, that limitation is not a hindrance because Shady Grove Hospital provides a courier service, he says. "Within two hours we have whatever we need," he says. As for meds themselves, "they are readily available and at our fingertips; we have 100% of what's in the ED at Shady Grove Hospital," Cetta says.

What's more, says Vasse, since she is not struggling with other departments for lab and radiology services, the turnaround time is faster. For example, "our target goal at the hospital for labs is an hour," she says. "In Germantown, it's more typical [to get results in] a half-hour."

Management is different

There are clear differences between managing a freestanding ED and one inside a hospital, says Cetta. "The scale is different, because it's a smaller facility with a smaller staff," he notes. "Therefore, implementing a process change is much simpler."

With a freestanding facility, adds Vasse, "You must be prepared to take care of anything that walks in the front door." So, for example, transfers for trauma or labor must be arranged very quickly. "It's of paramount importance to have those arrangements and contacts very accessible," she says. "We have arrangements with other [nearby] facilities that say they are willing to take them, and since the physicians at Germantown also work at Shady Grove Hospital, they know all the local contacts."

The staff at the Emergency Center "are prepared to handle any type of injuries/illness/condition that comes through the door," notes Vasse, and in some cases, this can be a patient with a serious condition who must be transferred to an appropriate hospital very quickly. Since the building is too small to accommodate a helicopter landing pad, Germantown even had to make arrangements with nearby Montgomery College (less than a mile away) to land on their property, she says.

Sources

For more information on opening a freestanding ED, contact:

  • Michael Cetta, MD, Medical Director; and Becky Vasse, BSN, MAS, Director of Emergency Services, Shady Grove Adventist Emergency Center, Germantown, MD. Phone: (301) 279-6004.