The first Freestanding Emergency Departments (FSEDs) were introduced to the American health care system in the 1970s when the need for urgent care was growing, especially in areas where no hospital service was available [1]. A typical FSED is built and owned by a main hospital, open 24 hours a day, and staffed by board-certified emergency physicians (EP) and licensed emergency nurses. It is equipped with an array of diagnostic laboratory and radiologic facilities and backed up by the main hospital’s on-call panel of specialists. FSEDs overall are designed to function just like the Emergency Department (ED) of the main hospital except they do not handle surgery, cardiac procedures, or inpatient services.

Interest in FSEDs has been reinvigorated over the last few years in response to changing trends in hospital outpatient services and market incentives [2-5]. FSEDs are considered asa an alternative to hospitalbased main EDs to provide convenient health care services to growing communities that may not have the critical mass to support a full service hospital ED. They also serve to extend the presence of the hospital from the urban center of a metropolitan area to nearby suburban and rural communities. FSEDs are also advocated as a strategy to decompress the nation’s overcrowded hospital-based EDs. Between 1997 and 2007, the number of annual ED visits rose from 94.9 million to 116.8 million, and on a daily basis, 30% of the nation’s ED are overcrowded [6,7]. In such an environment, FSEDs frequently market themselves as healthcare that is fast, convenient, and accessible, while avoiding the overcrowding issues typically encountered at the urban hospital-based ED [3,4]. Other factors favoring FSEDs include increased competition for healthcare dollars, increased urbanization, long distances between suburban areas and hospital-based EDs, and trends to downsize rural hospitals to FSEDs [3,8]. In a recent American Hospital Association survey of the 16 states that have FSEDs, the number of FSEDs increased by 20% in 2006, from 146 to 179 [9].

Since the growth of FSEDs has its roots in the healthcare customer service movement, FSEDs distinguish themselves by offering quick and friendly service, streamlined registration, short wait times, and comfortable facilities. These are the features that FSEDs rely on to attract local patients with lower acuity medical conditions. Meeting patient expectations and patient satisfaction is therefore critical to the economic success and survival of FSEDs [10-13].

Although attaining patient satisfaction and meeting patient expectations are important to the operation of FSEDs, there is a paucity of data in academic literature that specifically addresses the issues of patient satisfaction and expectations at FSEDs. We conducted one of the first detailed patient expectation surveys at a suburban FSED to characterize what patients expect from an FSED when they present for care.

The protocol was approved by the local institutional review board. This was a cross sectional study conducted over a 10 month period. The 24/7 FSED is located in the suburban area of a midsize city in the Midwest with a census of 14K/yr and a 4.71% admission rate. The metropolitan area (population of approximately 1,000,000) is home to two medical schools and eight full service hospitals. Using convenience sampling, research assistants approached eligible patient subjects, obtained verbal consent, and administered the patient expectation surveys in the waiting room or examination room (Appendix 1). Patients were instructed to fill out the surveys onsite and drop them off in the collection box upon discharge anonymously. Consecutive outpatient adults (≥19 yo) during a given enrollment period were eligible for the study. Patient subjects were excluded if they were <19 yo, hospitalized, had altered mental status, or required a medical or trauma-activation. The 43-question survey explored various areas of patient expectations (Appendix 1). Patient response was recorded using a 5-point Likert scale: 1-Not at all important, 2-Somewhat unimportant, 3-No opinion, 4-Somewhat important, 5-Extremely important. Data are reported as percentages or means [95% CI]. Proportional data and means are compared using χ2 and t-test. Statistical significance is assumed at 95% CI or when p < 0.05.

Of the 299 patient subjects available for enrollment, 62 were excluded, leaving 237 eligible. Of these, 10 declined, 227 surveys were administered, and 162 surveys were returned for a response rate of 68.4%. Demographics of these patient subjects are tabulated in Table 1. 73 out of 162 subjects (45.1% [37.4 - 52.72]) expressed no preference for a particular type of health care provider. Of the remaining 89 subjects who expressed a preference, 83 (93.3% [89.4 - 97.1]) preferred to be seen by a staff physician, 4 (4.5% [0.2 - 8.8]) by a resident physician, 2 (2.25% [-0.8 - 5.33]) by a medical student, and none by a Physician Assistant or Mid-Level Provider (PA/MLP) (Table 2). Expectations for various wait times were consistently short: 13.8 min [9.0 - 15.4] for wait in the waiting room, 23.4 min [22.7 - 25.9] for laboratory testing, 31.3 min [29.7 - 33.0] for special imaging studies, and 64.0 min [59.2 - 65.6] for the total visit (Table 3). Patients at this FSED preferred seeing a competent physician to a caring physician: 94.4% [90.9 - 98.0] of patients rated a competent physician as “extremely important” vs. 82.1% for a caring physician ([76.2 - 88.0], p < 0.001) (Table 4). Other top attributes that received a “5-Extremely important” rating were 1) Receiving a clear explanation of diagnosis (90.1% [85.5 - 94.7]) and of medical care and treatment (78.4% [72.1 – 84.7]); 2) Competent and caring nurses (85.8% [80.4 – 91.2] and 85.2% [79.7 – 90.7]), respectively; 3) Facility cleanliness (84.5% [78.9% - 90.0%]), 4) The ability to play an active role in making health care decisions (74.7% [68.0 - 81.4]); and 5) Courteous and quick registration staff (75.3% [68.7 – 81.8]) (Table 2). The median estimate for the total cost of a visit to a FSED was $350.00 [IQR $200.00-$675.00]. Rated lowest in terms of importance were having medical tests performed (41.4% [22.8 – 48.9]), receiving assurance (32.1% [24.9 – 39.3]), receiving a prescription (30.2% [23.2 – 37.3]) or work excuse (15.4% [9.9 – 21.0]).

Table 1: Demographics.

Table 2: Preference for a specific medical provider.

Table 3: Expectations for various wait times.

Table 4: Percentage of survey respondents reporting specific attributes as “5 - Extremely Important”.

Results of our study suggest that patients seen at an FSED share similar expectations with those seen in the main hospital regular ED [14]. As shown in Table 2, the top five attributes with the rating of “5-Extremely Important” are technical skill of physicians, clear explanation of the diagnosis, medical care and treatment, caring attitude and technical skill of nursing staff, and a clean facility [14,15]. Of interest is the fact that a higher proportion of patients preferred seeing a competent physician compared to seeing a caring physician (94.4% [90.9 - 98.0] vs. 82.1% [76.2 - 88.0], p < 0.001). The data imply that while FSED patients desire both professional medical competency and good bedside manner, they seem to slightly prefer physicians with superior diagnostic and technical skills. Finally, three out of four patients in our survey rated their ability to have a say in their healthcare as “5-Extremely Important.” This is consistent with data in internal medicine and oncology medical literature. Patient autonomy is one of the pillars of modern medicine. Although some patients may choose not to or may not be able to fully participate in the medical decision making process, the majority of patients desire autonomy with consequential improvement in outcome [16,17].

Data on patients’ preferences for the type of health care provider could prove helpful to medical directors of FSEDs. The majority of patient subjects (54.9% [47.3-62.60]) expressed a preference for the type of health care provider (i.e., staff physician, resident physician, mid-level/physician assistant, medical student), and of these, 93.3% [89.4 - 97.1] preferred to be seen by a staff physician.

Meeting patient expectations, and therefore, improving patient satisfaction is an important goal in medical care. Previous academic studies have shown that patient satisfaction can serve as an important measure of the quality of care delivered [18]. Patients who are satisfied with care have been shown to have improved medical outcomes, increased compliance, and decreased litigiosity [18]. Satisfaction scores are used by the Centers for Medicare & Medicaid Services (CMS) and hospitals to determine reimbursement, pay, and performance evaluations of individual physicians [19,20]. Data on patient satisfaction suggest the following top predictors for patient satisfaction: technical competence of physicians and nurses, bedside manner of physicians and nurses, physician’s communication skills, provision of medical information, and perceived wait time in the ED [14,15,21,22].

The results demonstrate that expected wait times for a visit to an FSED are short: 13.8 min [9.0 - 15.4] in the waiting room, 23.4 min [22.7 - 25.9] for laboratory testing, 31.3 min [29.7 - 33.0] for special imaging studies, and 64.0 min [59.2 - 65.6] for the total visit. Patient education may be necessary as these demandingly high expectations for wait times may not be met even with rigorous throughput programs. Patients’ median estimate for the total cost of a visit to an FSED was $350.00 [IQR $200.00-$675.00], well below the average charge of $1,131 for Evaluation and Management Code 99282. These mismatches between patient estimates of throughput metrics, costs, actual wait times, and billable amounts may serve as a source of patient dissatisfaction. Knowledge of these mismatches and preventative communication, coupled with patient education, may help FSEDs manage patient expectations and therefore achieve improved patient satisfaction.

The study has several limitations. It was conducted at a single site FSED in the Midwest using convenience sampling. Data on dropouts was not collected and is unavailable for analysis. The sample size was small. The enrollment periods were not weighted to achieve a more representative daily sampling of the FSED or to balance the effects of the variety of patients and physician practice styles.

FSED patients in this study expect competent, caring, quick, inexpensive medical care at a clean facility, similarly to patients presenting at a main hospital ED. Staff physicians are preferred to other types of healthcare providers. Clear patient-physician communication is important, and physician competency is preferred to affability. Understanding what FSED patients expect may lead to improved patient satisfaction, patient relations, and health care outcomes.

The authors would like to thank Brian Kitamura, Katie Reeve, and Sam Morris for their help in collecting the data.