Freestanding ERs present unique safety concerns
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Freestanding ERs present unique safety concerns
Facilities separate from hospitals save money and provide services in isolated areas, but at what cost?
Staff and patients at hospitals can usually count on a certain level of security when they come seeking emergency care. But what happens when you take the ER out of the hospital?
A new trend in emergency care has led to the advent of "freestanding ERs," which are separate from hospitals but provide most of the same emergency treatment that can be expected at full-service facilities. Many have begun springing up in rural areas of the United States where residents need to be able to find doctors and emergency care, but costs have restricted healthcare systems from building traditional hospitals.
The facilities are being looked at as a convenient way to extend emergency care beyond the doors of full-service, acute care hospitals, especially in rural areas that have access issues. Take for instance, Davis Hospital and Medical Center in Layton, Utah. In 2013, Davis opened a freestanding ER about eight miles away in the town of Weber. Traffic in the area is often slowed down by freight trains passing through railroad crossings, and the trip to the hospital can take a long time, prompting the decision to open the facility.
According to a report in the September 2015 issue of Healthcare Facilities Management magazine, the 16,000-square-foot facility has 14 treatment rooms, a trauma bay, an orthopedic room, a negative pressure room with a separate bathroom for dealing with infectious diseases, and two overflow rooms. It also boasts a full-service laboratory and x-ray capability; soon it will be able to perform MRIs.
Perhaps the most impressive feature of the facility is the relatively quick visits. While many people will wait for hours in a traditional ER before being seen, the average stay in the freestanding ER is one hour and 38 minutes, according to the report.
"Our turnaround times are so short that it's actually becoming quite a popular place," said Leslie A. Christiansen, CEN, Davis Hospital emergency director, IASIS Healthcare, in the magazine's report. He added that in the two years since the facility opened, patient visits have doubled from 300 patients a month to more than 1,000.
But with convenience comes a cost. While freestanding ERs 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 isolated places like strip mall parking lots, which presents security concerns; additionally, the security details at such facilities have been limited to 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."
In other words, if nothing bad has happened, don't change things. That could be a recipe for disaster, however. As violent incidents in America's ERs continue to increase, it's become clear that stricter security protocols are necessary. Full-service hospitals tend to have in-house police departments or at least security personnel that can respond within minutes of an incident, but freestanding ERs tend to have security not much more robust than what you might find at your local urgent care clinic.
"Architects are looking for aesthetics and don't always take security into account," says Beougher. "Security is expensive and inconvenient. We call that a prison, and we don't want our hospitals like that."
Among the Austin-area freestanding facilities that he has seen, Beougher says many have a single access point where triage nurses sit behind an open counter. Some feature outdoor perimeter cameras and card readers at the front door that can lock the facility down if necessary.
"Someone can just hop over and they are into the treatment area," he says. "If you don't lock down that desk, it's your last defense."
According to Beougher, freestanding ERs are a trend driven mostly by the need to save money while still providing quality healthcare, especially in remote places. He is based out of St. David's North Austin Medical Center in Austin, Texas, and his system has built freestanding ERs in places such the mountains of Fort Collins, Colorado, and rural areas in Virginia where the population, although growing, hasn't yet justified the cost of building an entire hospital. In most cases, the plan is to build a bigger hospital around the freestanding facility later.
A freestanding ER can often handle many of the same incoming cases that a traditional hospital can. With this in mind, ambulances can take patients to such facilities, and can make the decision to divert to the bigger hospitals on a case-by-case basis depending on the severity of the situation. However, a freestanding ER can't handle everything a hospital can, and not everyone is aware of its limitations.
"It's a relatively new concept, and people aren't sure what we can take and cannot, and we can get all extremes," says Marion Daughtry, BSN, manager of Pflugerville (Texas) Free-standing ER & Urgent Care.
Daughtry says her facility gets cases involving child abuse, intubations, head trauma, and multiple simultaneous patients. There's only so much they can handle; only four units of blood are kept on hand for transfusions, and there aren't any social services on site to handle patients with severe behavioral health issues. While technically the most severe cases should go to a major hospital, that doesn't always happen.
"A lot of people consider this their place, and they don't know that this isn't the place to come until after it's happened," she says.
Convenience aside, Beougher raises concerns about the security situations in freestanding ERs.
"In many of the security risk assessments I've done, often they don't have any security," he says. "About half is pretty exact, and I'd say a quarter of that only have security after hours."
In one facility in Austin, he describes the setting as a shopping complex that by day is a "bustling center of operations" and at night is a place where the only open establishment is a Chili's restaurant that serves alcohol.
"The staff say they feel pretty abandoned out in these locations," he says. "Part of it is there is a limited amount that even have security officers on campus, and it's rarely round-the-clock coverage. The more remote, the more extended response of law enforcement, and if they hit the duress button, it's waiting for local law enforcement and they aren't on the beaten path."
Beougher adds that the staff of some rural freestanding ERs feel isolated. "They feel like they are an afterthought," he says.
Freestanding ERs are certainly new territory, and the staff who work there don't have the dedicated security forces to protect them like bigger hospitals. While they may not be completely on their own, dealing with potentially violent patients at night can be a daunting task?one that could quickly overwhelm staff members and impede their ability to attend to other patients.
"When we do get a patient who is altered, it becomes difficult to look after these patients and maintain the safety of the staff," says Daughtry. She mentions a situation where a homeless man from out of town showed up in her facility. With no public transportation access, cab services would not give him a ride anywhere without a home address to bring him to.
"He hung around the shopping center when he was released, and he hung around until the police showed up to bring him elsewhere," she says.
Daughtry echoes Beougher's observations about suboptimal facility location. "At night, the shops shut down and it gets dark and the staff are quite isolated," she says?although she notes "we do have a good relationship with the police department and they will come out very quickly. Policemen will 'hover' in the break room if needed."
What do regulators say?
The jury is still out on whether freestanding ERs 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 distinct types of freestanding ER: hospital outpatient departments, also referred to as off-site hospital-based or satellite departments, and independent freestanding emergency centers, which have no affiliation to parent hospitals. While hospitals have operated satellite ERs for years, the concept of independent ERs is still a new thing and is under scrutiny, especially by regulators.
According to ACEP, federal regulations require any off-site or satellite freestanding medical center that accepts Medicare or Medicaid payments for emergency services to follow the same CMS rules and regulations as the parent medical center or hospital. In addition, they must comply with all CMS Conditions of Participation. But what about independent freestanding ERs? ACEP says that state licensing rules and regulations governing facilities that do not seek CMS approval for Medicare/Medicaid reimbursement for the technical component of their services are often inconsistent, unclear, or nonexistent.
That probably explains why not every state has operational freestanding ERs. As of now, many states only allow freestanding ERs that are operated by hospitals, and other states such as California don't allow them at all. According to a July 2015 article in Modern Healthcare, the nation's biggest operator of freestanding ERs is Lewisville, Texas?based Adeptus Health, which owns the First Choice chain of freestanding ERs. As of early 2015, the company opened seven new centers, bringing its total to 63 ERs; many of them are in Texas, which in 2010 became the first state to allow ERs to operate without a hospital affiliation. According to the article, Adeptus also has centers in Arizona and Colorado, though it partners with full-service hospitals in those states, and is looking at opportunities in Ohio and Washington.
Of course, regulations aren't the only potential barrier. "Opening up a new full-service hospital is cost-prohibitive," said Paul Kivela, MD, an emergency medicine doctor in Napa, California, and vice president of ACEP, in Modern Healthcare.
"I don't think it would be a good thing if these freestanding facilities take away the paying patients from the ER," Kivela said. "But I don't think every community can support a full-service hospital."
Despite the drawbacks of freestanding ERs, hospitals are carefully considering their advantages. Many CEOs are looking at them as a way to take the pressure off existing overcrowded facilities, and with more than 400 freestanding centers already sprouting up across the country, they are being touted as a way to reduce waiting times for non-critical cases, as well as another option for routine procedures such as x-rays, CT scans, and ultrasounds; clinical laboratory services; and pharmaceutical issues.
Security oversight necessary
In general, ACEP says it is in favor of freestanding ERs, but like any new private venture, there should be a set of governing regulations and standards. For example, ACEP says in a statement that freestanding ERs should, at the very least:
- Be available to the public 24 hours a day, seven days a week, 365 days a year
- Be staffed by appropriately qualified emergency physicians
- Have adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility
- Be staffed at all times by an RN with a minimum requirement of current certification in advanced cardiac life support and pediatric advanced life support
- Have policy agreements and procedures in place to provide effective and efficient transfer to a higher level of care if needed (i.e., cath labs, surgery, ICU)
In other words, the freestanding ER should not be the only available option in an area, and there must be a way for patients to be sent to a hospital where they can get more specialized care if the facility can't handle it.
What is not being talked about is what level of security these facilities should have, although if they are being held by CMS to the same level as a hospital, then ostensibly they should be held to the same emergency management and planning standards as their parent facilities (assuming one exists).
"I'm sure there are a lot of communications, but they don't get invited in planning and emergency planning," says Beougher. "Are we doing drills? Because the reality is an active shooter can walk in there just as easily."
Daughtry, who says her facility?13 miles from the closest hospital?has a proactive director but notes its perimeter security consists of no more than some outdoor cameras and a few door locks, has some advice on how security can be improved at these facilities:
- Protect staff. As in traditional hospitals, the caretakers have to come first. In rural areas where police patrols are not routine, the need for perimeter security and access limits becomes even greater.
"We had a patient come in who had access to guns and behavioral health issues, and he was a worry to the staff because he was a loose cannon person, and I consider after hours to be the biggest factor," says Daughtry. "These [strip malls] close down at night, and we do have drugs here."
- Make security a nightly thing. Even if security can only cover 10 p.m. to 6 a.m., the wee hours of the night are when facilities are most vulnerable, with less staff and people around, and in some cases only female nurses on duty, Daughtry says.
"Think about it. Someone says they need help outside in the car. You don't know what you're walking into," she says. "It's dark, and bad things happen at night. There's just more people during the day."
- Lobby management for more security. Fight for every bit of security that you can. Even security glass at triage stations, video cameras, and improved door locks can make a potential wrongdoer think twice. Insist on security personnel, even if it's just someone who can do hourly rounds to check up on things.