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Freestanding emergency departments (FSEDs) are an area of practice diversification which has grown rapidly in recent years, though they have existed for over 40 years. There are currently at least 250 FSEDs in the United States in 30 states.1 Emergency department (ED) visits have grown by 32% in the last decade, while the total number of EDs has declined by nearly 5%.2 This average growth per ED of almost 40% has placed enormous pressure on hospitals and healthcare systems to meet the needs of the patients seeking emergency care. Add to this the increasing scrutiny of multiple stakeholders to improve the quality, timeliness, and experience (satisfaction) of care, and the need for alternatives to traditional ED care is readily apparent.

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The emergence of FSEDs has occurred for a number of reasons, including to3

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  • Provide an alternative to acute care EDs for patients with more minor illnesses and injuries
  • Protect emerging markets for hospitals and healthcare systems
  • Provide enhanced access for the increasing demand of emergency services
  • Develop sites and services designed to differentiate hospitals from their competitors
  • Grow market share
  • Meet competitive threats from other hospitals
  • Provide referrals for physicians
  • Increase referrals for hospital services
  • Attain “brand loyalty”

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This chapter outlines the history of FSEDs and the current status of the practice of FSEDs, including the recent rise of physician-owned freestanding emergency centers (FSECs), which are not strictly affiliated with hospitals nor governed by their licensure and certificate of need requirements.

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Historical Perspective

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In 1966, Dr Ernest Rafey and his 2 general practice partners, who practiced at Fairfax Hospital (now Inova Fairfax Hospital), hired moonlighting residents and military physicians4 to keep their Bailey's Crossroads, Virginia office open nights and weekends. Their goal was to better meet the after-hour care needs of their community. Calling the concept Medic-24, the practice prospered in the national capital area by providing convenient and relatively inexpensive acute and nonacute care. Medic-24 was designed to address the full spectrum of general practice care from preemployment and insurance physical examinations to lacerations and extremity fractures.

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Almost a decade later (1975), North Providence Medical Services was incorporated and stated that the service was “the first free standing emergency room in Rhode Island, and possibly the first in the country.”5 Probably not coincidentally, Rhode Island was the first state to regulate FSECs, requiring that any facility with the words “emergency” or “urgent care” in its name must have6

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  • 24/7 operation
  • Minimum staffing levels
  • ACLS capability
  • Medication and medical record policies identical to the hospital-based ED
  • Prearranged and signed transfer agreement with a proximate hospital

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As similar facilities opened throughout the country, other states and the AMA generally followed the Rhode Island example and regulated these kinds of facilities.

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In 1977, Fairfax Hospital and the Fairfax Hospital Association (now the Inova Health System ...

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