Hospitals are opening freestanding EDs (FSEDs) at a rapid rate and mostly in states that allow them without meeting “determination of need” requirements, according to an article by Nir Harish, MD, MBA, at the Yale Department of Emergency Medicine; and Jennifer L. Wiler, MD, MBA, and Richard Zane, MD, both from the University of Colorado.

FSEDs may also be known as hospital outpatient department (HOPDs) or independent freestanding emergency centers (IFECs).

In 2016 there were 387 FSEDs operated by 323 hospitals, a 76% increase from 2008 to 2015, the authors reported. Most are found in Texas, Colorado, and Arizona because those states do not require a “determination of need” to be licensed. Other states require providers meet that requirement to protect other healthcare facilities from excessive competition and financial losses. In addition, there were 172 independently owned freestanding EDs, almost all in Texas, operated by 17 for-profit entities.

Unlike the hospital-owned EDs, the independent FSEDs cannot participate in Medicare, Medicaid, or TRICARE because they are not “outpatient departments of an acute care hospital,” which means they are not subject to federal regulations required by those programs. The authors reported that there is growing interest from independent FSEDs to affiliate with hospital systems so they can participate in federal reimbursement programs.

FSEDs first appeared in the 1970s to serve rural areas without a hospital-based ED, but the idea has spread to other areas as technological innovations made them more cost effective, they wrote. Healthcare systems also look to FSEDs as a way to meet increasing demands for immediate care, and as a potential profit center, the authors said. (The full report is available online at:

“The growth of FSEDs has been so fast in some states — more than tenfold within five years in Texas (Colorado is catching up) — that it’s not uncommon to find two FSEDs within sight of each other,” the authors noted.

Capable of treating most illnesses, heart attacks, strokes, and minor trauma, FSEDs are different from urgent care centers or the immediate care clinics often found in retail locations. An FSED provides 24 hour/seven days a week access to an emergency physician, an emergency nurse, laboratory and radiology technicians, and more extensive, complex testing than can be found in the other settings. The ED also will provide radiological services not found in urgent care or immediate care clinics.

More than 95% of FSED patients are walk-ins, compared to hospital EDs that often receive nearly half of their patients by ambulance, the authors reported. Fewer FSED patients are admitted to a hospital, less than 5% rather than the typical 15-35% for hospital-based EDs, the authors said.

“It is a rare FSED that can observe a patient overnight; most transfer patients to a full-service hospital for any emergent subspecialty need, an operation, or hospitalization,” according to the report.

When freestanding EDs surged in 2014, the American College of Emergency Physicians (ACEP) developed standards and expectations for their patient care and management.

ACEP notes that freestanding EDs owned and operated by medical centers or hospital systems must comply with the same rules and regulations of the Centers for Medicare & Medicaid Services (CMS) as the ED of the medical center or hospital, and must comply with all CMS Conditions of Participation (CoPs). For those facilities that do not seek CMS approval for Medicare/Medicaid reimbursement, ACEP cautions that state licensing rules and regulations for the technical component of their services are often “inconsistent, unclear, or nonexistent.”

ACEP established the following seven qualifications that facilities should meet to qualify as a freestanding ED:

  1. It must be available to the public 24 hours a day, seven days a week, 365 days per year.
  2. It must be staffed by appropriately qualified emergency physicians.
  3. The ED should provide adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility.
  4. A registered nurse with a minimum requirement of current certification in advanced cardiac life support and pediatric advanced life support should be present at all times.
  5. There must be policy agreements and procedures in place to provide effective and efficient transfer to a higher level of care if needed.
  6. FSEDs must follow the intent of the EMTALA statute. All individuals arriving at an FSED should be provided an appropriate medical screening examination by qualified medical personnel, including ancillary services, to determine whether the individual needs emergency care. The ED should provide stabilizing treatment within the capability of the facility, or transfer the patient as necessary, regardless of the patient’s ability to pay or method of payment.
  7. FSEDs should operate under the same standards as hospital-based EDs for quality improvement, medical leadership, medical directors, credentialing, and appropriate policies for referrals to primary and specialty physicians for aftercare.