Health systems turn to stand-alone EDs to handle surges in demand, bids for market share

Some stand-alone facilities offer both emergency and urgent care

With demand for ED beds surging as the nation's demographics, health care needs, and finances continue to change, a number of health systems across the country are opening stand-alone EDs — freestanding centers that are staffed by emergency physicians and deliver emergency care, but are not attached to a main campus or hospital facility. In some cases, these stand-alone EDs are meeting a clear community need for emergency care in underserved areas, while in others, they are helping established health systems expand their market share or decompress hospital-based EDs that are overrun with patients.

Regardless of the primary motivation for establishing a stand-alone ED, the number of such facilities is growing rapidly, according to the American Hospital Association. And consumers clearly like the convenience of these new centers, although pioneers with this concept stress that community education is critical to helping the public understand the difference between "urgent" and "emergency" care.

Establish a footprint

Humility of Mary Health Partners (HMHP), a Youngstown, OH-based health system that includes three hospital campuses, first began operating a stand-alone ED in Andover, OH, when it came along with the purchase of a hospital in the late 1980s, explains Genie Aubel, President, St. Elizabeth Boardman Health Center (SEBHC) in Boardman, OH. "The [stand-alone] ED delivers needed care to a rural area that is about 50 miles from the health system's main campus," says Aubel. "That one we inherited, and it has run well."

However, in 2001, the health system decided to open another stand-alone ED for more strategic reasons, says Aubel. "We wanted to build a new hospital [in Boardman, OH], about 10 or 15 miles south of our main tertiary center hospital, but we wanted to get in the area first before other [providers] — to get ourselves a footprint before building a hospital, so we put a [stand-alone] ED there," she says.

The effort began modestly with a modular unit that featured nine emergency care beds, but Aubel explains that it drew people to the area and got them used to coming to the property for emergency care.

Three years after the opening of the modular unit, a permanent ED was constructed on the property. "At this point, we already had a good volume of patients coming in," says Aubel. "People were used to our service line, and the facility was already break-even."

The permanent ED functioned as a stand-alone facility until the new hospital was constructed and opened on the site four years ago. "We were down in this market for six or seven years with an off-campus-based ED that was not attached to a hospital until 2007," says Aubel. "It was a phased-in strategy that helped us step into this market."

Consider demographics

While the stand-alone ED in Boardman was just a stepping stone to a new hospital, the health system had plans for another stand-alone ED, which it opened in Austintown, OH, in November of 2004. "That ED continues to be separate [from a hospital], and in our minds, it will always be separate," explains Aubel, although she says the strategy in opening the Austintown facility was also to increase market share.

Further, deciding where to locate the stand-alone EDs had everything to do with demographic studies that assessed where populations were moving and what facilities people were using for care. "Boardman, which is where we built the hospital, is the fastest growing area [in our region]. Austintown, which is where our non-hospital ED is located, is where the second largest growing population is," says Aubel.

"It was a strategy to increase the feeders into our facilities, as opposed to patients going to other hospitals," she says. "And it was also a strategy to decompress some of our hospital-based EDs. Nationally, hospital-based EDs are overcrowded, so [the Austintown ED] gave people another option that was about 10 miles away, and that was extremely well-received."

When the Austintown facility first opened, it had nine beds, and administrators calculated that it needed to treat 30 patients per day to break even. The facility met that goal within six months, says Aubel, noting that the facility has since been expanded to 15 beds. "Now we're seeing 85 patients per day, and we have had days where we see more than 100 patients."

Get EMS providers on board

There is a lot more involved with making a stand-alone ED successful than just finding a strategic location, stresses Aubel. You also have to work with the EMS squads in the area to make sure they understand the capabilities of the stand-alone ED, and when patients have needs that can more appropriately be addressed at the hospital-based ED.

"The relationship with EMS is really key. We hosted breakfasts and luncheons to sit them down and let them know what we were doing and to get their input," says Aubel. "We have meetings with them throughout the year, we celebrate their EMS week, and we really try to be hand-in-glove with them."

For example, EMS providers understand that trauma cases, heart attacks, and any case that is likely to require hospital admission should go to a hospital-based ED, but the stand-alone ED also has the flexibility and resources to accept any patient, explains Janet Divelbiss, RN, BSN, CEN, the director of emergency nursing services for both SEBHC and the St. Elizabeth Emergency and Diagnostic Center in Austintown.

"Patient preference is number one in the state of Ohio, so if the patient says he wants to go to Austintown, the EMS provider will take him there," explains Divelbiss. Similarly, if the hospital is on diversion, or a patient headed for the main campus has an airway issue or some other problem that requires immediate attention, the Austintown facility will assist. "We have an ED physician, but no specialty services at Austintown," says Divelbiss. "So the ED physician will talk to [clinicians at the main campus], and then we'll send the patient straight to the main ED to be cared for there."

The health system has what Divelbiss refers to as a mobile ICU to transport patients to the main campus, and she indicates that this is one of the main reasons for the stand-alone ED's success. "We can get an MI [myocardial infarction] in and out of our facility in 25 minutes, and straight to the cath lab at the main hospital," she says. "We also have priority for beds when our patients are waiting for beds at the main hospital."

What this means, in practice, is if there are two critical patients, one at the Austintown facility and one on the main campus, the patient from the Austintown ED will receive priority for a bed because the patient in the hospital-based ED already has access to a blood bank, anesthesia, surgeons, and all the other specialty services that are available on the main campus, says Aubel. (Also, see Management Tip: Prioritize team cohesiveness over flexible staffing, below.)

Educate the community

Getting the EMS squads in the area up to speed on the Austintown ED's capabilities was a relatively simple matter because of their expertise and familiarity with emergency procedures. A much more difficult task was educating the community about how they should most appropriately use the stand-alone ED facility, and what the difference is between emergency care and urgent care, explains Aubel. "Our system does operate urgent care facilities in another country," she says. "To try and reeducate the community on what is appropriate for urgent care or, in this case, what is appropriate for a non-campus-based ED is very difficult no matter how you try and do it."

The health system sent representatives to speak with community groups, sent out news releases, used direct mail, and spoke to local media in their attempts to educate the community in advance of the opening of the Austintown ED, and some of these activities are ongoing. However, they still get patients who think they are coming to an urgent care facility, and are unpleasantly surprised by their co-pays, which are at the same ED-based rate that the hospital-based ED uses.

"We use the same triage system that all the hospitals in our system use, but we do get a lot more of the lower acuity patients at Austintown," explains Divelbiss, estimating that roughly 60% of the patients that come to the Austintown ED are [Emergency Severity Index graded] 3s, 4s, and 5s, whereas 40% of the patients who go to the hospital-based EDs fall into these categories.

This failure to understand the different reimbursement rates between ED care and urgent care can lead to some patient dissatisfaction, but for the most part, patients seem to prefer the stand-alone ED, says Aubel. "There is no question that we have pulled patients out of the main hospital-based ED, and that we have pulled patients from our competition, which was the strategy," she says.

Further, the Austintown facility sees 150 patients per month who have never before registered at an HMHP facility, the average door-to-doc time is under 30 minutes, and patient satisfaction for 2010 was at 90%, says Divelbiss.

"We would seriously consider opening other [stand-alone EDs]," adds Aubel. "We don't have current plans put to paper, but we would seriously consider it because this has been successful for us."

Try ED plus urgent care

A newer entry to the stand-alone ED field is Two Twelve Medical Center in Chaska, MN. The center, which opened on February 1 of this year, is owned and operated by Ridgeview Medical Center, which is about 10 miles away in Waconia, MN. The hospital has an attached ED too, but it represents too far a drive for many in the rapidly growing region to the south of Ridgeview, say hospital administrators.

"We believe there are enough [hospital] beds around this area, but there wasn't enough access to emergent or urgent care, so we looked at this model in other areas, and felt like it would be a good fit for the community," explains Mike Phelps, MBA, Chief Administrative Officer, Ridgeview Medical Center.

Like the stand-alone ED facilities operated by Humility of Mary Health Partners in Ohio, Two Twelve Medical Center is open 24/7, but unlike those facilities, Two-Twelve offers both urgent and emergency care. All patients who are walking into the facility check in at the front desk and will then be triaged, explains Ben Nielsen, MHA, the executive director of the new facility. "The triage nurse will do the appropriate assessment, and at that point, he or she will make a decision on what path the patient will go through — whether it is urgent care or emergency care," he says. "If a [designated urgent care] patient gets to the back and sees the physician, and the needs are more critical, then we could flip the urgent care patient to an emergency care patient."

Patients siphoned toward the urgent care pathway will be reimbursed at a lower rate than patients who require emergency care, explains Phelps. "It is something unique. We haven't seen any other combined urgent care-freestanding ED facilities, but we had the desire to compete with some of the [walk-in] clinics and other retail-oriented urgent care centers around," he says. "We wanted to have a model that not only competed, but also has better traction because it is not just open 8 to 10 hours a day like most urgent care facilities. It is open 24 hours a day."

Work with other hospitals

Another advantage to the approach is that the health system not only owns the stand-alone Two Twelve facility, it also owns the ambulance service. "We serve 700 square miles with ambulance service," says Phelps. "That has allowed us the comfort of having a relationship where we could know that we can transport a patient at any given time."

Further, administrators have worked with other local community hospitals throughout the large service area to eliminate any obstacles or negative incentives that might prevent patients from using the Two Twelve facility for care. "We work with those hospitals to find ways to directly admit to their floors so that patients don't have to go back through the EDs at the hospitals they are transferred to, generating more bills," says Phelps.

In addition, since the health system owns the ambulance service, administrators decided not to bill any of these hospitals for the transfer of patients to those facilities. "We don't want that to be a barrier to patients coming here, so we just do that service for free."

Two Twelve administrators are tracking metrics, but say the facility has not been open long enough to report meaningful data as of yet. However, they say patients are providing positive feedback on their experiences with the facility, and Ridgeview's hospital-based ED has seen volumes eased by about 10%.

Phelps acknowledges that turning many ED visits into lower-cost urgent care visits represents a financial hit to the health system, but he believes that lowering the cost of care will ultimately pay off for everyone involved. "We see it as a big benefit to commercial payers, to patients, to Medicare, and I think it could be a model for the future."


  • Genie Aubel, President, St. Elizabeth Boardman Health Center, Boardman, OH. E-mail:
  • Janet Divelbiss, RN, BSN, CEN, Director of Emergency Nursing Services, St. Elizabeth Boardman Health Center in Boardman, OH and St. Elizabeth Emergency and Diagnostic Center in Austintown, OH. E-mail:
  • Ben Nielsen, MHA, Executive Director, Two Twelve Medical Center, Chaska, MN. E-mail:
  • Mike Phelps, MBA, Chief Administrative Officer, Ridgeview Medical Center, Waconia, MN. Phone: 942-442-2191.

Management Tip

Prioritize team cohesiveness over flexible staffing

For hospitals that operate more than one ED, it can be tempting to share clinicians and staff between the various facilities, but Genie Aubel, president, St. Elizabeth Boardman Health Center in Boardman, OH, suggests that greater benefits may come by enabling people to work within their own core groups. "You want to keep one team working together because the team knows how it operates," she says. "You want the concept of a team."