Freestanding EDs: The New Hospital Front Door

logoBy Robby Aull, AIA, ACHA, LEED AP, Principal – Senior Vice President – Director of Healthcare (SWSC) | March 4, 2016 | Healthcare Design March 2016 Issue

One of the newest programs and building types being developed within the healthcare industry is the freestanding emergency department (FSED). These projects are growing in popularity as hospitals and healthcare systems strategize ways to provide improved, responsive care in the most cost-effective physical environment possible.

An FSED is not an urgent care center, which is normally based upon primary care models and often utilized for after-hours, non-emergent care. Rather, an FSED is an extension of a hospital and provides emergent care on a 24/7 basis, and many states require that they be owned and managed by a hospital or healthcare system. As an extension of a hospital, the FSED is expected to provide care with direct, on-site access to all services needed for emergent care that are normally found within a hospital, such as lab, imaging, and pharmacy.

However, access to surgery and inpatient beds aren’t provided at these remote locations. Instead, patients remain within the department for less than 24 hours, at which point they’re either discharged or transferred to a hospital.

There are several drivers behind the growth of FSEDs, including hospitals’ and health systems’ desire to gain market share. In this age of retail-oriented healthcare, convenient access to the appropriate service for the health consumer is an important consideration. FSEDs can be located in currently underserved areas away from existing hospitals, allowing a system to either pull new market share or to consolidate existing customers within the service area. An FSED can also be located in current competitive markets, potentially gaining additional market share through the offering of a new choice of service to consumers.

In addition, when emergent care services are needed, time from event to the first point of care can be critical to a successful outcome (i.e., heart attack, stroke, or other critical care needs). Having dispersed facilities can substantially shorten this timeframe.

Overall, these freestanding facilities are more convenient and easier to access than emergency services at an existing hospital campus, allowing providers to adequately serve patients who need emergent care while giving the public a sense of confidence that that care is close by and available when needed. Those who require additional inpatient services, such as specialty diagnostics, overnight observation and nursing care, and procedures/surgery are then transferred to the main hospital—positioning FSEDs to serve as an extended front door and driving hospital volume.

Building considerations

In order to increase access, FSEDs are generally located away from existing emergency services. Plus, when constructed on an open site, these departments can be significantly less costly than when built at a main hospital. This remote construction eliminates the disruption that expansion often creates within existing emergency departments and on constrained, difficult sites. In addition, the regulatory and code requirements for these facilities may allow for staffing models that are less costly, too.

Because it’s a new building type, the codes and regulations pertaining to these facilities aren’t universal and may vary by location. As a starting point, the International Building Code (IBC) categorizes FSEDs as business occupancy, providing that the patients are at the facility less than 24 hours. This classification allows for a relatively simple and cost-effective construction type without the normal requirements of hospital construction. However, the IBC requirements are augmented by the National Fire Protection Association (NFPA) 101 Life Safety Code, which classifies an FSED as an ambulatory healthcare occupancy. The key added requirements within this code are the inclusion of a defined separation between the FSED and other clinical functions within the same building (such as office space), and also the requirement for a minimum of two smoke compartments.

The Facility Guidelines Institute’s 2014 Guidelines for Design and Construction of Hospitals and Outpatient Facilities include the FSED within its Hospital Part 2 section, generally based upon the typical, hospital-based emergency department requirements.

The design regulations become more restrictive when a code that regulates the engineering building systems, NFPA 99, is considered. Although not specific to FSEDs, NFPA 99 categorizes building infrastructure based upon the system’s risk to the safety and well-being of patients in the event of failure. After assessing risk to the FSED patient populations, most hospitals choose to spend additional funds on the various building systems—i.e., back-up power and increased ventilation systems—and construct FSEDs to allow for the continuation of operations in the face of natural or manmade disasters. While the specific code requirements must be considered based upon local requirements, in general, an FSED built to business occupancy and the standards above is less expensive than typical hospital construction.

A new model

The operational models of FSEDs are evolving to better meet the needs of this specialized patient type, too. Patients who are administered care at an emergency room have a wide range of care requirements, from relatively simple sicknesses to life-threatening illness or trauma. Quick understanding of the level of care needed, ease of diagnostic access, and routing of patients to appropriate care environments is of utmost importance.

Algorithm based triage, physician led medical evaluations, vertical treatment methodologies, bed-side registration, and collaborative care are some of the new methods being employed to assure appropriate and efficient medical care is being provided.

To that end, design is evolving, too. Many facilities now include greeter desks that have space for an initial, nurse-led triage (combined with Web-based check-in); a rapid medical evaluation area that allows ambulatory patients to remain upright during their initial work-up; staff-supervised lounges where patients and family can await diagnostic results; private consultation rooms utilized for quick discharge, education, payment, and follow-up scheduling; and bedside computers for real-time imaging review, patient education, and electronic medical records.

The designs are built around the goal of creating positive experiences for patients, family, and staff. The layout must be inviting, stress relieving, uplifting, and functional. Hospitality-based environments with comfortable seating, natural light, and views to the outside provide patients and family support and relief during an often stressful encounter. Staff spaces, on the other hand, are designed to provide collaboration areas, quiet work zones, and dedicated respite regions away from the hectic emergency care environment, all helping with initial staff recruitment and long-term retention.

An important piece

The FSED is an important new tool for healthcare systems seeking to add market share while providing care environments that are convenient, consumer oriented, and cost effective. In order to develop a successful project, it’s important that designers understand location and construction implications, various regulatory and code requirements, and emerging operational models, all while working to fully develop the unique design opportunities of FSEDs.

Robby Aull, AIA, ACHA, LEED AP, is principal of Stevens & Wilkinson (Columbia, S.C.) and writing on behalf of AIA-AAH. He can be reached raull@stevens-wilkinson.com.

**This article originally appeared in the print and online versions of Healthcare Design’s March 2016 Issue.