After transitioning from the “big box” ED to a freestanding emergency center (FEC), I was amazed by how our performance metrics, and my outlook, improved

Who’s your favorite Bond? Personally, until Daniel Craig put on the tuxedo, nobody ‘did it better’ than Sean Connery. Not even Sir Roger Moore. But during Mr. Craig’s performance in the reboot of Casino Royale, I did a double-take and palpitated. Admittedly, fickle me, I have a new favorite. Those of you who still think the original, black and white Barry Nelson, is the best – I’m going to invite you to consider something new.

Members of our specialty may be guilty of presupposing that the best place to receive quality care for true medical emergencies is within the hallowed halls of the “Big Box” hospital emergency departments. This is undoubtedly the prevailing view of emergency physicians practicing in hospital-based settings. But the ACA’s vision and support of the distributed care network (moving care out of the hospital into multiple venues that are more cost effective and convenient for patients) is challenging this conventional wisdom.

Part of that de-centralizing challenge comes in the form of freestanding emergency clinics (FECs). As an emergency physician practicing in Texas I’ve gotten to be on both sides of this fence. I’ve worked at high-volume hospital based facilities and I’m now a partner/owner in FEC’s. That gives me an obvious bias toward their existence and proliferation, but I hope the numbers can speak for themselves.

You see, while I’m not a professional researcher – and I certainly didn’t hire a team of analysts – I was able to use simple math to arrive at some startling results regarding the comparative metrics at our FECs.

I obtained data from 11 Free-Standing Emergency Centers (FEC’s) throughout the state of Texas, who cooperated in sharing metrics and laboratory “turnaround” time data for the 12 month period from May 2014 through April 2015. The results from this admittedly small data set are compelling. In these cases, acute care facilities outside of the hospital were, on average, able to deliver much faster care for “emergent” conditions than their in-hospital counterparts. This included chest pain and abdominal pain patients. Using a combination of tracking system data from the shared information technology system used at many sites, and digital records from the others, and by querying more than 25,000 unique patient visits, I found some impressive performance variation when comparing hospital-based data to the FECs.

For example, compare these sub-cycle time metrics (comparison data derived in part from CDC – National Center for Health Statistics, Ambulatory Medical Care Surveys), and additional sources referenced in the chart to the left.

Even more compelling is the comparative data on acute STEMI patients. These cases are routinely transferred to interventional-capable hospitals from a variety of acute-care facilities, including hospital outpatient departments (HOPDs), acute care hospitals, surgical centers, and even physicians’ offices for their definitive care. The FEC data shows that patients diagnosed with acute MI also receive high quality, efficient healthcare for this truly emergent condition. Though the total numbers were small, the STEMI data shows that metrics were more consistently met when the patient was initially stabilized and treated at these out-of-the-hospital venues.  Current averages on FEC “door-to-balloon” at the receiving cath lab are approximately 67 minutes overall, and as low as 38 minutes at one of the 11 facilities studied.

Admittedly, FECs do not routinely receive the kinds of high-level injury cases delivered by EMS to the trauma-level hospitals. However, my review found that the FECs recorded a few gunshot wounds, patients with traumatic brain injury, and blunt abdominal trauma with organ injury requiring critical care and stabilization. More frequently encountered were multiple-fracture cases, a significant population of walk-in assault, and a multitude of garden-variety acute trauma requiring stabilization and treatment or transfer. To date, there is not enough data to support whether these conditions might also benefit from out-of-hospital stabilization and transfer.

Certainly, we all have our own views regarding hospital efficiency. Some of us may work in departments where the metrics are better than the ones shown here. My own experience, and that of the vast majority of my colleagues, both veteran and green, is that the hospital data shown here (queried from third party references – see below) is actually rather flattering.

Some of you will insist that Mr. Nelson did Casino Royale better than anyone. I challenge you to consider my nomination for Mr. Craig – or at least someone in full-technicolor. The point is this: In our current healthcare climate where everything we do must come under scrutiny, we must challenge the dogma that dictates where we provide care. There may be alternative venues for delivering high-quality acute care, even for true emergencies. “Bonds” will come and go and so will we. However, the weapon of choice never changes – the Walther PPK has been used for over 60 years. Similarly, our shared educational and training backgrounds made us flexible multi-taskers – able to handle anything, anywhere.

The trend toward alternative venues such as FEC’s isn’t diminishing. So whether you prefer one care venue over another – you may still want yours stirred rather than shaken – let’s not be consumed by debate, but rather work together to enhance the acute care services provided in them. The fabric of the safety net has a good chance of unraveling.

REFERENCES
1. Center for Disease Control and Prevention, National Center for Health Statistics, website: http://www.cdc.gov/nchs/data_access/ftp_data.htm
2. Laboratory Turnaround Time, Richard C. Hawkins http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2282400/
3. U.S. Emergency Department Performance on Wait Time and Length of Visit, Leora I Hawkins, MD, MHS, Jeremy Green, and Elizabeth H. Bradley PhD. http://www.ncbi.nlm.nih.gov/pubmed/19796844
4. Multidisciplinary Protocol for Rapid Head Computed Tomography Turnaround Time in Acute Stroke Patients, E.M. Bershad, et al. http://www.ncbi.nlm.nih.gov/pubmed/25920753