Integrating the Free-Standing Emergency Room as a Valued Component of the Regional EMS System

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Written by:    Michael S. Wallace, BSHS, CCPM


Incorporating a free-standing emergency room into any community is challenging.   Effects to local hospitals, urgent cares, physician offices and their referral patterns must be considered.  Comparatively, integrating a stand-alone facility, as an essential component of the regional EMS system can be a daunting task, likened to breaching a seemingly impenetrable fortress.

How can this be and why would paramedics and EMT’s be a barrier to success?  How do you deal with it?  Should you deal with it?  Is there an opportunity for win-win collaboration?

Understanding that every situation, business model and population presents a unique set of challenges, the answers to these questions are complex, important and necessary.  The intent of this series is to create a platform for Free-Standing ER and EMS leaders to generate meaningful dialogue, understanding, cooperation and most importantly positive outcomes.


General Overview

Ten years ago Americans were quickly becoming familiar with walk-in clinics and urgent care centers but the idea of a full-fledged emergency room not physically attached to a hospital was virtually non-existent.  Today, the concept is still very new but convenience, cost and quality has the idea rapidly expanding and most likely coming to a community near you.

Welcomed addition or controversial reality, regardless of the circumstances, integrating new services into the EMS system will be influenced by everything from destination guidelines and system needs to reimbursement challenges and customer demand.  Unlike the average walk-in clinic, free-standing emergency rooms are simply some of the first to breach the sacred ground of alternative transport destinations, which can create a perceived challenge with any established EMS system.

The paramedic mind-set, by default, has been trained to recognize the benefit of immediate access to the expanded services provided by the traditional hospital model.  One of the first goals of transparency is to clearly demonstrate the free-standing ER’s capabilities for each type of patient, compared to the potential need for expanded services.  Once this understanding is clear pre-hospital leaders can factor scope of practice, transport time, patient conditions and facility options, to help clinicians strategize the best destination decisions possible in the moment.  Utilized correctly, EMS providers may find the free-standing emergency room to be a great value to their patients and the efficiency of the system.  As healthcare reform evolves and revenue streams tighten, it is reasonable to expect that a variety of creative models, both mobile and fixed, will surface to meet demand.

On the other side of the fence, progressive EMS systems across the country are currently exploring everything from alternative forms of low acuity transport to treat and release mechanisms, and even community paramedics equipped with telemedicine options for follow up care to reduce readmissions, just to name a few.  Leaders on both sides must prepare for change, adaptation and even a blurring of the lines that will hopefully integrate and strengthen the continuum of care.


Relationship Building

Collaborating with EMS is not an option for the free-standing emergency room, it’s a must. Gone are the days of the “ambulance driver.”  As a matter of fact, use that terminology and discover how quickly you will alienate yourself and your organization from one of the most valuable assets you have.  High performance EMS systems not only deliver critical care to the living room, they also have immediate influence on their patients’ destination decisions.  It is essential to involve these professionals as valued team members when you implement a new facility.

Every pre-hospital organization and clinician will vary in expertise, quality and experience; however, understanding that mobile healthcare is quickly becoming the preferred access point to the regional medical establishment is crucial.  Evidence is clearly demonstrating improved outcomes in basic, primary and critical care, when EMS is properly trained and integrated as a vital component.

Engaging these teams and building highly collaborative relationships gives you the opportunity to influence the overall patient experience, maximize outcomes, improve efficiency and establish confidence in your facilities’ services.

  • Engage the entire regional EMS system, public and private
  • Transparently share your true capacity and capabilities
  • Treat each organization as a vital partner in the chain of survival
  • Receive and provide a constant feedback loop of quality assurance
  • Provide consistent opportunities for collaboration and team building

As with any business, success depends on taking the time to build mutually beneficial relationships.


Destination guidelines

Every state EMS system typically has established rules or protocols often referred to as destination guidelines.  Initially these policies were developed to insure that high acuity trauma patients were taken to the most appropriate facility.  Destination determination is now rapidly evolving to include a broad variety of patient types and matching the priority of their current condition to the closest appropriate facility.  As always, a competent adult patient still maintains the right to choose (consent), but the EMS provider is required to insure they are properly informed of the available choices, as a part of their care plan.

Paramedics and EMTs have an obligation to understand the resources and capabilities of every facility within their jurisdiction.   Informed clinicians can confidently advise patients and together make educated decisions in time sensitive situations.  Transparency and collaboration is always paramount.


Steps to Successful Integration

Start by taking steps to build and maintain mutually beneficial relationships with each EMS team capable of transporting to or from your facility.  Share openly with each organization so that there is a clear understanding of what can be expected from each other, no two organizations are the same.  Professional dialogue sets the stage for continuous quality improvement.

  • Build mutually beneficial relationships
  • Share capabilities and protocols
  • Understand state and local destination guidelines
  • Learn each EMS provider’s specific transport policies
  • Establish a strong on-going improvement process with each team

Realize that though each ER and EMS team theoretically is equipped to handle any type of situation, every organization has a sweet spot or optimal “conditions” that naturally maximizes outcomes.  If the perfect conditions could be plotted on a bell-curve, the peak performance point would be influenced by a combination of work-load, resources, staff, training and experience.  The mixture and the curve would vary from organization to organization and would shift over time.  Meaningful collaboration will likely drive the performance of your system towards the upper end of the curve.

Emergency providers understand that there is no such thing as perfect conditions; however, everyone involved must be continuously in tune with the system dynamics to create the best circumstances possible.  Cooperation, transparency, feedback and team building are labor-intensive but absolutely critical ingredients to focusing everyone on what matter most.



Healthcare reform is the new reality and its evolution, good, bad or indifferent, is the challenge or opportunity that we choose to make of it.  There is no question that we are at the forefront of changes that will provide the evidence for future best practices.  Mobile health and fixed facility providers will integrate and win the loyalty of their customers or succumb to poor performance.


“Mike Wallace is the EMS Operations Manager at Williamson Medical Center in Franklin, Tennessee where he was involved with implementing a new Free-Standing ER into the existing EMS system. His experience is greatly valued as many other EMS systems are seeking to utilize Free-Standing ERs in their delivery models. The JFSEM has invited Mr Wallace to develop a series of articles on best practices when implementing a Free-Standing ER into local EMS systems. We look forward to his next articles.”

JFSEM Editorial Staff

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