Freestanding ER's

[EM Junkie]

So the company for whom I have been moonlighting for for several months (LTAC "Code Blue" coverage) mainly staffs hospital emergency departments. They have just opened a "free standing ED" and have begin courting me to work there after residency.

I would like to hear some opinions from those out there in the "real world" about working in a freestanding ED and their viability in the future - both legally and financially. My current crowd of mentors are all academic faculty at my residency program, and all of them are pretty steadfast against these freestanding facilities taking away all of the insured patients that pay their salaries.

Any and all advice appreciated!
-EM Junkie

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[Hercules]

There was a good article on this in one of those newspaper looking publications that show up in the mailbox. I can't remember who it was made by though. Sorry.

 

[Castro Viejo]

I would like to hear some opinions from those out there in the "real world" about working in a freestanding ED and their viability in the future - both legally and financially. My current crowd of mentors are all academic faculty at my residency program, and all of them are pretty steadfast against these freestanding facilities taking away all of the insured patients that pay their salaries.

Freestanding? As in not attached to a hospital? Then how do you call a consult?

 

[docB]

The "freestanding ED" concept has been around for a while. In short the idea is that a hospital creates a stand alone ED somewhere away from its main campus. In theory it would be a full service ED and would have the same staff contingent as a hospital based ED including an EP. Patients who don't require admission would be seen and discharged, that's 70% in most EDs around the country. Those patients that have to be admitted would be discussed with the admitting doc by the EP in the stand alone ED and then transferred/direct admitted to an inpatient bed, bypassing the ED in the home hospital.

This is an idea is a way for inner city hospitals that have lots of infrastructure but exist in areas with poor payor mixes to try to reach out into suburban communities with better payor mixes. You can imagine the ads "Now you can access the reputation and excellence of Old Respected Downtown Med Center near your McMansion without braving the junkies and hookers to get downtown. Come to our new stand alone ED and bring your wallets."

Consultants would actually fall all over themselves to take call at one of these because of the payor mix. However the vast majority of ED patients who require a consult are going to be admitted an so would be transferred to the main hospital and seen there. I know that lots of you guys in academic setting who get tortured routinely by your EDs can't imagine a place where the consults aren't all BS but in the community I'd rather move patients than call consults and the consults = $.

 

[f_w]

I work as a radiologist at a rural hospital. Another even more rural county next to us lost their hospital in the 50s. Given that you pretty much can't build new hospitals these days from scratch, they are toying with the idea of a free-standing urgent-care/ED. This would be co-located with a long-term care facility existing already. It would be the local receiving center for ambulances and open to walk-ins. Patients who can be discharged would be discharged, admits to our rural hospital would come here directly from the ED, patients who need higher level services (e.g. PCI, major trauma) would be airlifted out.

 

[f_w]

You can imagine the ads "Now you can access the reputation and excellence of Old Respected Downtown Med Center near your McMansion without braving the junkies and hookers to get downtown. Come to our new stand alone ED and bring your wallets."

ROFLMAO

It is so unfortunate that basic human decency and political correctness don't allow you to advertise it this way.

 

[GeneralVeers]

This idea scares me. Quite certainly a stand-alone ED would not have the quality doctors' lounge with free cappuccino and donuts that I require.

 

[docB]

This idea scares me. Quite certainly a stand-alone ED would not have the quality doctors' lounge with free cappuccino and donuts that I require.

I keep telling you guys it's all about payor mix. The stand alone out in Beverly Hills or Grosse Pointe or Long Island or whatever ritzy enclave you choose will probably have a Starbucks, Krispy Kreme and a "full service" massage parlor in the lounge.

 

[GeneralVeers]

I keep telling you guys it's all about payor mix. The stand alone out in Beverly Hills or Grosse Pointe or Long Island or whatever ritzy enclave you choose will probably have a Starbucks, Krispy Kreme and a "full service" massage parlor in the lounge.

Starbucks? You've got me sold now.

 

[bartleby]

Unless they do the "full rubdown", I ain't interested.

and a "full service" massage parlor in the lounge.

 

[deleted6669]

I have worked at 2 such facilities.....you spend A LOT of your time arranging transfers and trying to convince consultants to come to the stand alone e.d. to see a pt...the same docs are on -call for both big name hospital as stand alone so they don't want to leave big name; "send the pt here and I will see them"- great, except "here" is on divert and has no hospital beds....."well, hold them there for 6 hrs and I will have my colleague see them at shift change"....great....colleague arrives 7-8 hrs later(after rounding at big) and says either:
a: this is bs, they should have been in the o.r., cath lab, icu, etc hrs ago
b: this is bs, why didn't you have dr specialist A( who you talked to 6 hrs ago) see them....
lose, lose situation....the worst part is hunting for available beds at every hospital in town to try to arrange admits and woe be it on your soul if you have to transfer and admit a PSYCH pt....suddenly no beds for miles.....
facility #2 that I worked at had it set up a bit better...guaranteed availability of transfers to big...they never went on divert to stand alone ever

 

[Hawk22]

I keep telling you guys it's all about payor mix.

BINGO! We have had several of these built here in NC and I talked with one hospital executive who said that they picked specific sites based on reimbursement and positive payer mixes (i.e. lots of people with insurance). He said that it is so hard to build new hospitals that this is a way to provide more care without going through the whole certificate of need process, etc. If the free standing ED does well, it helps build the case that more medical facilities are needed, especially in fast-growing areas. Basically, they are building these free-standing ED's with the intention of building a hospital behind them in the future. From what I have seen, it seems to work pretty well.

Doughnuts and good coffee are a nice bonus too.... 🙂

 

[southerndoc]

Yale has a freestanding ED that sees a large number of patients. We're expanding it to 24 hour coverage as soon as new faculty are hired. The "satellite ED" as we call it is staffed by ED attendings and PA's only (no residents rotate there), has on-site labs, on-site diagnostic imaging (including CT and U/S), etc. It looks very nice -- very modern and up to date.

Any patient in the satellite ED that needs admission or a consult is transferred to the main ED. We have a contract with AMR to transfer all patients between our ED's. If I'm not mistaken, I think they keep an ambulance on-site to do transfers (it also responds to 911 calls as well, but another truck moves to the satellite ED and replaces it while it is transporting someone else).

 

[gutonc]

I work as a radiologist at a rural hospital. Another even more rural county next to us lost their hospital in the 50s. Given that you pretty much can't build new hospitals these days from scratch, they are toying with the idea of a free-standing urgent-care/ED. This would be co-located with a long-term care facility existing already. It would be the local receiving center for ambulances and open to walk-ins. Patients who can be discharged would be discharged, admits to our rural hospital would come here directly from the ED, patients who need higher level services (e.g. PCI, major trauma) would be airlifted out.

When I was 13 I broke my arm while on vacation out in the desert. I ended up at a place like this...ED attached to a SNF. Nearest hospital 100 miles away. FM doc on call at home, place staffed RTC by 1 nurse who called in the doc when someone showed up. I think it might have made his week.

 

[deleted6669]

When I was 13 I broke my arm while on vacation out in the desert. I ended up at a place like this...ED attached to a SNF. Nearest hospital 100 miles away. FM doc on call at home, place staffed RTC by 1 nurse who called in the doc when someone showed up. I think it might have made his week.

the e.d on catalina island is like that. 2 fp docs take call from home and alternate weeks. e.d. census is 7/week....and often they have fp residents taking 1st call(not kidding....)

 

[emtcsmith]

Are there any stand alone "trauma/emergency centers"? I'm figuring it as a ED with trauma services, cath lab, stroke team, critical care/shock trauma, burn center, or any theory on if that type of facility would work.

 

[gutonc]

Are there any stand alone "trauma/emergency centers"? I'm figuring it as a ED with trauma services, cath lab, stroke team, critical care/shock trauma, burn center, or any theory on if that type of facility would work.

I can't really imagine how that would work. In all of those cases (STEMI, stroke, ICU player, MVC victim), you'd need to admit them after stabilization and acute care. So would you have 5 different free-standing EDs for all these things? One w/ a cath lab and a tele floor, one w/ an ICU, one w/ an OR, SICU and gen surg/ortho floor and one w/ a Neuro ICU and Neuro/NSGY floor? Sounds like you just built 5 small hospitals for the price of 2 or 3 large hospitals when what you really need is just one large hospital. Plus, can you imagine how confused the EMS folks would be? And what if somebody had an MVC w/ a compound tib/fib and pelvic fracture and blunt abd trauma but the reason they wrecked was b/c they had a STEMI and passed out from the pain?

Finally, w/o IM who's going to manage all those insulin drips and consults for post-op DVTs?! (I'm only half joking here.)

 

[GeneralVeers]

Are there any stand alone "trauma/emergency centers"? I'm figuring it as a ED with trauma services, cath lab, stroke team, critical care/shock trauma, burn center, or any theory on if that type of facility would work.

Yes, Shock/Trauma in Baltimore.

 

[deleted109597]

We have a starbucks in our waiting room. No joke. It's open until 2am.

 

[gutonc]

Yes, Shock/Trauma in Baltimore.

IIRC, that is located @ UMD, not really a freestanding (no adjacent hospital w/ other services) ED. Sure, it's a specialized ED but so are a lot of Peds EDs.

 

[f_w]

We have a starbucks in our waiting room. No joke. It's open until 2am.

So much for NPO.

Childrens hospital in philly used to have a MickeyDs in the lobby. With walk-up window to the (secured) side of the hospital. The same residents who would counsel their patients parents on good nutrition during the day would stand there on-call and stuff their faces with dollar menu items

 

[docB]

So much for NPO.

Childrens hospital in philly used to have a MickeyDs in the lobby. With walk-up window to the (secured) side of the hospital. The same residents who would counsel their patients parents on good nutrition during the day would stand there on-call and stuff their faces with dollar menu items

I used to volunteer at CHOP. The best times were when the kids with 10/10 abdominal pain walked in half done with their happy meals.

 

[f_w]

I used to volunteer at CHOP. The best times were when the kids with 10/10 abdominal pain walked in half done with their happy meals.

When I saw this first I thought it was part of some sort of cruel experiment.

 

[docB]

When I saw this first I thought it was part of some sort of cruel experiment.

And it really was, wasn't it😉.

 

[emtcsmith]

I'm not familar with out the shock trauma service works in Maryland, anyone care to give the cliff notes explination on it?

 

[f_w]

I'm not familar with out the shock trauma service works in Maryland, anyone care to give the cliff notes explination on it?

Financially and organizationally, it is an ED/OR/critical care complex separate from the UMaryland hospital. Physically, it is docked to the hospital and many of the consulting and ancillary services are shared back and forth.

 

[docB]

With shock trauma we're talking about an entirely different animal than what we started out talking about. Shock trauma has segrated their trauma function from the rest of the hospital on the same campus because they think it will create various advantages in caring for a specific population. We were initially talking about off site, stand alone EDs which are set up off campus for totally different reasons.