My response area is densely populated for having such a small geographic footprint. Just fewer than 1 million people reside in my 38-mile long, 15-mile wide county, where we are surrounded by water on three sides and are home to what travel sites have touted as some of the best beaches in the world.
Tourist season yearly brings us about another 91,000 potential patients. Those out of state plates begin arriving promptly in September, and continue to pack in through March. This is our EMS busy season; long days and nights of back to back runs and hospital bed delays and resources stretched thin.
13 hospitals serve the 24 municipalities that make up my area. Some have specialized services, like pediatrics or trauma; one is a VA hospital. There are also urgent care clinics on practically every corner, set up in strip malls between dollar stores and hair salons. And given our heavy geriatric population, primary care physician groups have large practices throughout the county. There are even convenient care centers in some of the pharmacies, staffed by ARNPs, who can write a script for your ear infection and send you off with a referral.
With all of these emergent and urgent care options, it was a curious thing when our first freestanding emergency department popped up, almost out of nowhere. And then another one. Plans are in the works for more of them. If you don’t have a freestanding emergency department, what the American College of Emergency Physicians refers to as ‘FSEDs’ in your district, let me break it down for you. It’s an ER with no hospital attached to it, and chances are one is coming soon to your area.
It’s structurally separate, and not even on the same property near a hospital. They operate like hospital-based emergency departments, fully staffed with an ER physician and nurses, and capable of handling emergent and urgent patient care, including all the diagnostic lab and radiology testing. They even have access to ancillary services. But they can’t admit you. Their goal is to “treat and street” – to manage your injury/illness and discharge you with a referral.
This had our EMS a bit baffled. We could transport patients there, but what would we bring? What could we bring? Medical direction of course immediately issued new protocols, limiting what we could utilize these FSEDs for. Still, in busy season, we felt that they must have a role somehow. Hospital-based ERs frequently were overburdened as our call volume soared. In 2015, my county saw 209,994 calls for service, with 163,425 transports. That’s a lot of ER bed space. And we can all admit that some of those patients who overuse the system didn’t need to be there.
So how do these FSEDs fit in? The ACEP has backed FSEDs, but with very specific guidelines. Freestanding emergency departments must:
- Be available 24/7, and 365 days a year
- Be staffed by appropriately qualified emergency physicians
- Be staffed by adequate medical and nursing personnel qualified in emergency care
- Be staffed at all times by an RN certified in ACLS and PALS
- Have policies, procedures and agreements in place with other facilities to provide quick and efficient transfer of a patient to a higher level of care for admit (cardiac cath lab, neuro, surgery, ICU, etc.)
- They have to follow EMTALA regulations
- Have access to ancillary services
- Have the ability to stabilize a critical patient and transfer out rapidly
FSEDs also have to follow the same standards as hospital-based ERs in areas like quality improvement, medical leadership, medical direction, credentialing, and appropriate policies for referral to primary care and specialty services. FSEDs have popped up in Texas, Colorado, Arizona, and now Florida. Nationally, around 387 FSEDs are in operation. They estimate that around 95% of their patients are walk-ins. But some are critical and emergent and require lifesaving interventions.
So with change comes the debate, of course. Are they helping or hurting the system? Some argue that the booming growth of FSEDs means they are also exploiting the healthcare marketplace. FSEDs can charge the same for services as hospital-based ERs, sometimes for complaints that can be handled by an urgent care center. And some say that they are only a gateway to targeted care, booting patients out with referrals instead of follow-ups.
Let’s face it. FSEDs are proliferating because of an unprecedented demand in the healthcare market for immediate emergency care 24 hours a day, 7 days a week, and profiting because of cheaper, faster, innovations in advanced imaging and testing. Hospital-based ERs are overcrowded and overburdened; but dissenters argue that FSEDs aren’t filling that need but instead, they are creating a new one, and driving up the cost of medical care at the same time.
I wouldn’t say I necessarily agree with that. In our system, any additional ER bed space, be it freestanding or hospital based, is a welcome sight when the patient care load clearly outweighs the resources. Any EMS crew that’s waited over an hour (sometimes two) in the hallway with a patient on their stretcher for a bed and to transfer care knows how overcrowding impacts the system. And even those who argue against FSEDs have to agree that seeing, treating and streeting non-emergent patients can reduce the burden on other hospital-based ERs in their service area.
But does EMS transporting into FSEDs make sense? Are we truly delivering our patients to definitive care, or instead effectively dumping them off just to incur another ambulance transport bill when they have to be admitted? The answer lies in good medical direction, and strong protocols, and thankfully our system has both. Some examples of patients we can’t transport into an FSED:
- Blunt, Penetrating or Multi-system trauma
- Acute STEMI
- Acute CVA
- GI Bleed, or any abdominal pain of unknown etiology
- Intubated patients
- Detox or combative psych patients
- Women in active labor
Now, some of these are a no-brainer. But I will say this: if I had a patient that was crashing and had no airway despite my best efforts, and a FSED was the closest facility, I would divert in. Get that doc to help stabilize and worry about transporting after. So FSEDs may be a help to EMS systems in a few respects, and some agencies will probably still demonize them. I say use your resources, whatever and wherever they are, hospital-based or not.
Disclaimer: The content in this article is the opinion of the writer and does not necessarily reflect the policies or opinions of US Patriot Tactical.
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