Number of freestanding EDs up, helping ease overcrowding, serving rural areas

Facilities bring hospitals more patient revenue, boost satisfaction

According to some sources, there only may be about a dozen of them in operation in the United States, but ED managers had better familiarize themselves with the term "freestanding ED." The trend appears to be growing steadily. Within just the past few weeks:

  • WakeMed Health & Hospitals in Raleigh opened North Carolina’s first full-service ED in a facility without inpatient beds.
  • St. Luke’s Episcopal Health System in Houston, which already has two freestanding EDs in operation, is getting ready to add four more.
  • Lee Memorial Health System in Fort Myers, FL, has proposed building what would be just the second freestanding ED in the state.

"The freestanding ED model has proved profitable, and the hospital gets patients it otherwise would not have seen," says Kelly Larkin, MD, FACEP, associate medical director of emergency services for St. Luke’s Episcopal Health System. St. Luke’s Episcopal opened two facilities about five years ago, which places them among the pioneers of the concept. "People will choose to go to the freestanding ED for care over other nearby facilities because they can be seen sooner," she says. If they are admitted to the main hospital, that may be an admit that otherwise would not have happened, Larkin adds.

"The turnaround times and wait times [at the freestanding ED] are so good, we tend to have incredible patient satisfaction rates," she says. "Relative to those in the main hospital’s ED, where the staffing is the same, they are much higher."

Just what is a freestanding ED? "You basically reproduce an emergency department," Larkin adds. As they understand the guidelines from the Centers for Medicare & Medicaid Services (CMS), it has to be identical to any other ED, though not physically attached to the hospital, she explains. "That means it’s open 24 hours a day, has trained nursing, has emergency medicine boarded physicians if your ED has them, has the same lab and radiology, and the same specialty on-call panel you have at the main hospital," Larkin explains.

In short, this is not an urgent care center. Olly Duckett, MD, medical director of WakeMed North, whose facility opened July 11, says, "The biggest difference is we take ambulances and have more capabilities." Also, they have the ability to observe a patient for up to 24 hours.

C.B. Rebsamen, MD, chief medical officer for strategic and ambulatory services at Lee Memorial, says, "Urgent care centers, as they have evolved, are really providers of minor medicine."

Larkin’s facility has had patients come in with strokes, and they can handle that condition, she says. "With an acute stroke or heart attack, we can take the patient to the cath lab," Larkin notes. A truly critical patient would benefit more from being in the main hospital if they required emergency surgery, she says.

"We can stabilize a horrible trauma just as they would in the regular ED, but we would still have to transfer them — although it is only a two-mile ambulance ride," Larkin says.

There are two situations in which it makes good sense to open a freestanding ED, she says: if the main ED is overwhelmed and you need a facility to handle the overflow; or if a region or rural area is underserved but a new hospital cannot be justified economically.

At St. Luke’s, the freestanding facilities were built in response to overcrowding. "There was an urgent care place that took a lot of patients and was going to close down," Larkin notes. "If we left [their patients] just for our ED, we would have had a definite overcrowding issue, so we decided to head it off."

Larkin has overall responsibility for all of the facilities. There is a nurse manager at the main ED, and nurse supervisors at the freestanding facilities.

At WakeMed, the impetus came from rapid area growth, "The area is expanding north at a rapid rate, and it’s a long drive for some patients to existing facilities," Duckett explains. "Right now, there’s not a need for hospital beds, but there is a need for emergency medicine services."

WakeMed already had an outpatient surgery center in operation that had ample room for an ED, and that’s where the facility was created. Managed by Duckett, it is staffed with one physician, and during daytime hours, by four nurses. In the evening, there are three nurses, plus support staff.

Lehman Memorial is planning for the future, says Rebsamen. The health system operates three hospitals, "and because of explosive growth, in some areas, our closest hospital takes a minimum of 30 minutes to get there with no traffic," he adds.

After two freestanding EDs had been built in the state, the legislature passed a moratorium. Because the concept is so new, Rebsamen theorizes, they want to make sure they have proper guidelines in place before more are built. "Our next step is to meet with civic leaders," he says.

ED managers who already have seen their facilities open have praise for the concept. "We’ve been successful with the two we have and are determining where to put the next four," Larkin reports.

Duckett says they probably underestimated the number of patients. "We figured to see 30 a day and ended up seeing 50 a day for the first week and a half," he says.

Some challenges arise out of being located in a larger building, Duckett concedes. "People think it’s a hospital and that they can be admitted. They’re upset when they learn they have to be transferred," he adds. Even though admission occurs with only about 15% of the patients, and they usually go immediately to a hospital bed, some patients still resent having to be moved.

With a freestanding ED, it’s important to note, the term "transfer" must be used carefully. If the patient is being moved to your main ED, it is a direct admit, and the Emergency Medical Treatment and Labor Act (EMTALA) does not come into play. "But if that patient has insurance that says they need to be admitted to a different hospital, we do transfer under EMTALA guidelines," Larkin explains.

There are other challenges presented by inpatient admissions, as well as consulting services, Duckett notes. "We have put in place on-scene mobile units that will transfer anyone to any facility if they need to be admitted, and we are working on getting consultants to come out here for patients who may need to be seen by specialists but do not need to be admitted," he says.

Despite the challenges, Larkin says the concept is viable — and can be sold to management. The main ED had total volume of 26,000, she says.

"Now, between both facilities, we are hitting 60,000," Larkin points out. "It’s a kind of build it and they will come.’" Also, they used to have four or five hour waits in the ED, while the freestanding ED’s length of stay is 90-120 minutes door to door, she says.

"A nurse manager could take this information and go to the hospital and show them the number, and say, We can build a freestanding facility approved by CMS, which could increase our volume and increase our revenue,’" Larkin says.


For more information on freestanding EDs, contact:

  • Olly Duckett, MD, Medical Director, WakeMed North, 10,000 Falls of Neuse Road, Raleigh, NC 27614. Phone: (919) 350-8823. E-mail:
  • Kelly Larkin, MD, FACEP, Associate Medical Director of Emergency Services, St. Luke’s Episcopal Health System, 6720 Bertner Ave., Houston, TX 77030. Phone: (832) 355-6904. E-mail:
  • C.B. Rebsamen, MD, Chief Medical Officer for Strategic and Ambulatory Services, Lee Memorial Health System, Fort Myers, FL. Phone: (239) 985-3511. E-mail: