The number of freestanding emergency departments in the United States has increased dramatically in the past decade, responding rapidly and efficiently to the increase in visits to emergency rooms. At nearly the same time, the number of hospital-based emergency rooms has dropped by 27% since 1990, according to a study published last spring in the Journal of the American Medical Association.1 Why are hospitals losing their emergency departments? Are freestanding emergency departments up to the task of replacing them? How can a community ensure that in-and-out healthcare is just what the doctor ordered?


Whither emergency departments?

In 1990, there were 2,446 hospitals with emergency departments in nonrural areas of the United States. That number had dropped to 1,779 by 2009. Researchers found that emergency departments were most likely to have closed if they were in hospitals with low profit margins, served large numbers of the poor and Medicaid patients, were at commercially operated hospitals, or operated in highly competitive markets.

While these emergency departments were closing, visits were soaring, increasing by 30% between 1998 and 2008. Overcrowded emergency departments contribute to longer waiting times, create unsatisfactory patient conditions, and escalate the cost of healthcare, making a crisis situation even more dire.

Many patients would avoid the emergency room altogether if primary care physicians were more immediately accessible. Indeed, the number of primary care health professionals nationwide continues to plummet. According to the Association of American Medical Colleges, the nation will have a shortage of approximately 21,000 primary care physicians in 2015, due to the needs of an aging population and a decline in the number of medical students choosing primary care.2

Freestanding emergency departments (FEDs), less expensive than a hospital to build and maintain, may just bridge the gap between what can be done in a traditional outpatient clinic and an  acute care hospital, and can serve people, particularly in rural areas, where access to emergency care is limited.

According to the American Hospital Association, there were 241 FEDs in 2009, 65% more than there were just five years before, when there were 146 such facilities. Now located in 16 states, FEDs are capable of delivering excellent service, significantly upgrading the quality of healthcare available in their areas.

Where there are large distances between population centers and limited helicopter transportation, the FED may be the only facility that can provide any significant emergency care. They are generally open 24/7 and are staffed by emergency physicians and nurses. The AHA reports that some FEDs clock a door-to-doctor time of 30 minutes or less, compared with hospital emergency department door-to-doctor times of 55.8 minutes, on average. In addition, FEDs report an average door-to-discharge time of 90 minutes or less, compared with the hospital-based emergency room average time of 180 minutes.

FED caregivers can stabilize patients and provide initial treatment to those with a wide range of emergent problems. They often have arrangements with local emergency medical services personnel to deliver patients elsewhere who need services not available at the facility. It is a positive trend and an effective way to meet increased emergency needs without adding expensive hospital square footage.


Case study in New Jersey

The new AtlantiCare Satellite Health Center in Hammonton, New Jersey, is a classic case. When Kessler Memorial Hospital closed its doors in 2009, it left some Central Jersey residents 20 miles away from the closest hospital. To prevent a crisis in the underserved region, the State Department of Health asked AtlantiCare, which has several acute care facilities across the state, if it would establish and maintain an emergency department in Hammonton. The state got much more than it had requested.

Like many FEDs, the AtlantiCare Satellite Health Center is a one-story building that contains an emergency department with fast-track and universal treatment bays. Like some specialized FEDs, it also contains a GYN/SANE room, isolation room, psych holding room, resuscitation room, decontamination area, point-of-care laboratory testing, and a helipad for patient transfers to acute care facilities. Co-located at the facility are an imaging center, physician timeshare, outpatient laboratory, and wound care zone. An existing building on site has been adapted and renovated into a conference center and is linked to the new facility by a trellised walkway. More than an emergency department, it has become a healthcare destination for the community.

Architect EwingCole’s primary goal was to provide a welcoming and reassuring environment for patients in a stressful situation. The building design reflects the genial farming community in which it is located, featuring pitched roofs and cedar plank screens with climbing vegetation.

The interior is an inviting, noninstitutional environment of hard-wearing finishes that imitate natural materials. Commissioned artwork throughout the facility is focused on the local community and its surroundings.

The clinical area of the emergency department takes advantage of the peaked roof exterior, providing an open, bright interior for staff, who typically have infrequent access to sunlight. Patient rooms also have views to the exterior with clerestories strategically placed to provide calming views of nature.

When it opened in August 2011, the facility was able to immediately treat patients suffering from severe lacerations or burns, broken bones, sports injuries, allergic reactions, food poisoning, work-related injuries, and many other medical emergencies. The primary difference between this FED and a hospital-based emergency room is that there are no inpatient rooms or operating rooms. But since it is operated by AtlantiCare, it has access to all the personnel and services that the system can provide.

The project has proved to be a win-win. The community now has an economical, state-of-the-art emergency department that also furthers AtlantiCare’s brand image as an advanced healthcare provider with a commitment to hospitality-inspired patient and family-centered care.


Rapid evolution

Saving lives, time, and funds are the vital aspects of FEDs. More treatment can be done on an ambulatory or outpatient basis these days, conserving both time and money. Many of those who visit the emergency department will get much better during the initial treatment period and avoid an expensive hospital admission. Others don’t require hospitalization, but they need much more than a walk-in clinic can provide. An FED fits well in the middle of that range.

Areas of the country that are experiencing steady growth in population will also have an expanding need for emergency and ambulatory care. It is really just part of the ongoing evolution of healthcare. We do expect to see more care delivered locally in lower cost and more flexible facilities such as this one.

This is a new model for a time in which there are limited public resources. FEDs can be more cost-effective to build, speed time to treatment, relieve overcrowding in nearby emergency departments, and serve as a vital resource nationwide for those with limited access to primary care physicians. FEDs are proving successful because they can meet the community’s emergency needs and maintain a clean bill of health. HCD


Mary Frazier, AIA, LEED AP, is a healthcare architect with EwingCole. For more information, please visit



1. Factors Associated With Closures of Emergency Departments in the United States. JAMA. May 2011.

2.  Fact Sheet: Creating Jobs and Increasing the Number of Primary Providers., US Dept of Health & Human Services, July 2010.