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Planning a freestanding ER? ASHE suggests focusing on life safety issues


February 1, 2019

As health systems constantly seek ways to increase revenues while keeping costs down and dealing with ever-increasing pressures from accreditation agencies, it’s no wonder that they continue to look for alternative locations.

One of the biggest trends to emerge in healthcare facility construction is the “freestanding ER,” a facility that is separate from a hospital but generally provides the same emergency treatment expected at most full-service hospitals. Many of these facilities have begun springing up in parts of the country where costs have discouraged health systems from building entire hospitals, but where residents still need to be able to find doctors and emergency care. These areas include the mountains of Fort Collins, Colorado, and rural areas in Virginia where the population has grown but hasn’t yet justified the expense of a hospital.

As of 2016, there were more than 500 freestanding ERs across the country, according to the Medicare Payment Advisory Commission. That translates to about one freestanding ER for every 10 hospitals today. These facilities are designed as either stand-alone outposts with no plans for expansion or as remote emergency departments (ED) intended for future growth. Most are the latter.

A freestanding ER can handle many of the same incoming cases as a traditional hospital, while being more conveniently located. Incoming ambulances bring in patients and can decide to divert to a bigger hospital if a case is particularly severe.

But while freestanding ERs offer many advantages on paper, the jury is still out on whether they will become the wave of the future, especially as the regulatory and healthcare environment changes.
According to a 2014 statement from the American College of Emergency Physicians (ACEP), there are two types of freestanding ERs: hospital outpatient departments (HOPD), also referred to as off-site hospital-based or satellite EDs, and independent freestanding emergency centers (IFEC), which have no affiliation to parent hospitals. While hospitals have operated satellite ERs for years, the concept of independent ERs is still new and under scrutiny, especially by regulators.

Per ACEP, federal regulations require any freestanding medical center that accepts Medicare or Medicaid payments for emergency services to follow the same CMS rules and regulations as its parent medical center or hospital. In addition, the medical center must comply with all CMS Conditions of Participation. But what about independent freestanding ERs? ACEP says that state licensing rules and regulations are often inconsistent, unclear, or nonexistent when it comes to governing facilities that do not seek CMS approval for Medicare/Medicaid reimbursement for the technical component of their services. That probably explains why not every state has operational freestanding ERs. Many states only allow freestanding ERs that are operated by hospitals, and other states such as California don’t allow them at all.

As of late 2017, the biggest operator of freestanding ERs in the U.S. is Lewisville, Texas–based Adeptus Health, which owns the First Choice ER chain. In early 2015, the company opened seven new ERs, bringing its total to 63 centers. Many of these centers are in Texas, which in 2010 became the first state to allow ERs to operate without a hospital affiliation. Adeptus—which in March 2017 was late to file its annual report, leading to questions about the system’s financial health—also has centers in Arizona and Colorado. It partners with full-service hospitals in those states and is looking at opportunities in Ohio and Washington.

Despite the potential drawbacks of freestanding ERs, hospitals are carefully considering the advantages. Many CEOs are looking at freestanding ERs to help take the pressure off existing emergency facilities. They are being touted as a way to reduce waiting times for non-critical cases, as well as routine procedures such as X-rays, CT scans, ultrasounds, and clinical laboratory services.

Life safety considerations

Much has been written about the security implications of freestanding ERs, especially those that are operating in rural areas without a lot of police presence or that are open at all hours of the day.
While the facilities have succeeded in bringing 24-hour emergency care to areas of the country where a hospital may be hours away, they are often located in places like isolated strip mall parking lots, presenting security concerns. Sometimes their only security presence is skeleton crews and occasional check-ins by local police.

“Often they don’t have any security, because they are new and small and aren’t generating revenue yet,” says Richard D. Beougher II, CPP, CHPA, regional director of operations of healthcare security for HSS, Inc., based in Austin, Texas. “They haven’t seen productivity to warrant the cost or seen the concern.”
Security concerns are inevitable, including making sure staff members are protected, perimeter safety is visible, and appropriate measures are taken to ensure proper patient transfer to more capable hospitals.

However, you as the professional will likely be brought into the conversation from an engineering and life safety compliance perspective should your system decide to add freestanding remote facilities.

In the October 4, 2018 issue of Health Facilities Management (HFM), the American Society for Health Care Engineering (ASHE) laid out a virtual checklist of the considerations that need to be explored before opening a freestanding hospital facility, especially if it will go into a big-box space that was once a department store or a mall.

“[B]ig-box spaces offer two features that could account for a large part of the total project budget for a new building: existing buildings and ample parking,” wrote James Ferris, chief operating officer at TLC Engineering for Architecture Orlando, in HFM. “They are typically in great locations, accessible to patients and near their communities.” However, these spaces typically do not have sufficient infrastructure for a healthcare occupancy, so they must be carefully scrutinized and renovated if necessary.

There are many engineering obstacles that need to be taken into account to ensure life safety compliance, Ferris wrote. Take some notes from what he recommends.

Space separation. By now, you should be well educated on egresses and occupancy types, and on what the 2012 Life Safety Code® requires for your type of facility. Take over a mall or existing building, though, and you may have to deal with several types of construction.

“Where is the demising wall between the two occupancy types and how does this affect the exiting strategy of the remote ED and any adjacent existing space?” Ferris wrote. The location of the wall, the routing, and where the opening ends up are critical to the exiting, the infrastructure, and the security of the new ER.

Structural issues. Any architect you work with will likely scrutinize any building you move into, but at the very least, a freestanding ER will need an X-ray machine and other heavy equipment, along with utilities and generators—and the building may not be able to support that amount of weight.

Mechanical system. Mechanically, any conversion often will include demolishing the existing system and rebuilding a new system, wrote Ferris.

“Most building types utilize return-air plenums, which are not accepted in hospital environments,” he noted. “Existing ductwork is sized to allow for fewer air changes than will be required for a remote ED. And, in an ED, exhaust plays a critical role in the isolation areas, as well as in the waiting rooms. Often, a new air-handling unit will be required to handle the capacity of the space, which, in turn, requires that the structure accommodate the larger air-handling unit.”

Plumbing and medical gas. Non-healthcare spaces don’t typically have gas tank farms for medical gases, but as a freestanding ER, you’ll need them. You’ll have to consider where gases will be stored, as well as plan for a medical vacuum pump and medical air compressor to get them around the facility.

Electrical system. This is where facility professionals might see the most rework coupled with the most temptation to keep existing infrastructure, said Ferris. “Often, utility companies have service to a common location, with submetering already defined, which is unlikely to meet the requirements for new service,” he wrote.

He noted the following questions about power and backup redundancy systems that need to be addressed:

  • Can a fault or event on other tenants affect the operation of the ER?
  • Do the other tenants selectively coordinate with the ER space’s service?
  • Is the service entrance located inside the I-2 (institutional) area, as it should be, or outside of it? Is the service big enough?
  • Who has control and access to the service distribution?
  • Is there anything on the existing system that would affect sensitive electronics typically found within the ER, like X-ray equipment?

Fire alarms. The freestanding ER needs to be designed as a survivable system that will continue to function for at least two hours if the adjacent areas have a fire event, per NFPA 72, National Fire Alarm and Signaling Code. The notification of tenants for evacuation often will be handled differently for the ER than for other tenants and should be designed as such, Ferris wrote, even though it will probably be located in a facility that shares fire suppression and alarm systems with other tenants.

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