Survey of Patient Knowledge and Expectations about a Free-Standing Emergency Department

Objectives. A free-standing emergency department (FSED) is defined as a facility that is structurally separate and distinct from a hospital and provides emergency care. Nationally, the number of FSEDs continues to grow, but the general public may have limited knowledge about the costs and services associated with FSEDs. The purpose of this paper is to survey patient knowledge and expectations about FSEDs. Methods. A convenience sample of patients presenting to a FSED was given a 19-item survey to complete. Results. 187 surveys were collected; 126 were included for analysis. 40% of respondents thought they could be seen by a specialist at the FSED, and 55% of patients did not know they had to be transferred for hospitalization if required. Most patients did not know that the cost of services at the FSED would be the same as that at the traditional ED. Convenience and perceived shorter wait times were the primary reasons patients selected the FSED for care. Conclusion. In general, patients do not have adequate knowledge about the costs and services associated with FSEDs. Education through marketing and advertising may be helpful in creating more public awareness about FSEDs.


Introduction
A freestanding emergency department (FSED) is defined as "a facility that is structurally separate and distinct from a hospital and provides emergency care." The idea of a FSED is a new concept that has evolved in this country over the past decade. Currently there are over 500 freestanding emergency departments in the United States.
This idea is relatively new as hospital systems are looking for innovative ways to care more efficiently for an increasing volume of patients [1,2]. Emergency department volume increases coupled with fewer emergency departments in the country have forced other solutions. FSEDs are a way for a hospital system to increase the number of acute patients seen without investing in the capital of an entire hospital [3,4]. FSEDs can be placed in geographically strategic locations to increase community market share of patients seeking acute medical care [5,6]. These FSEDs function similar to a hospital-based ED in that they are equipped to take care of any emergency that may present including heart attacks, strokes, and trauma at any time of the day or night [7].
In 2014 the American College of Emergency Physicians released a policy statement regarding FSEDs. This policy denotes two distinct types of FSEDs: hospital outpatient emergency departments and independent freestanding emergency centers. The policy also recommends certain standards for any FSED, including being open at all times, having appropriately trained emergency physicians and nurses to staff the facility, and policies for patient transport to a higher level of care if warranted [8].
The placement of these independent structures within communities may lead to patient confusion as to the level of medical care and cost associated with their services when compared to urgent or acute walk-in care centers. FSEDs are very different from urgent care centers in many ways. FSEDs are able to provide a higher level of care and are open 24 hours a day, every day of the year [9]. The cost structure is also much different. Patients seen at FSEDs are typically billed at traditional emergency department rates with both a professional fee and a facility fee [10]. It is essential to understand how the public perceives the differences between these facilities. Until the public is aware 2 Advances in Emergency Medicine of these differences, many people may confuse a FSED for an urgent care center.
In August 2013, UFHealth, affiliated with the University of Florida College of Medicine, opened a 10-bed FSED in Gainesville, Florida. This FSED was the first of its kind in Alachua County, Florida (population 253,451, US Census Data 2013). This FSED is located approximately 9 miles from the main UFHealth hospital campus. When it opened, this was the fourth true emergency department in the county (UFHealth also operates a hospital-based Adult ED and a hospital-based Pediatric ED, and a non-UFHealth hospital in Gainesville operates a hospital-based ED). In addition, there were six other urgent care centers in the surrounding area, but none of these are considered FSEDs.
The purpose of our study was to survey patient knowledge about FSEDs and to better understand patient expectations in terms of the level of medical care available, their perception of the cost of services at a FSED, and reasons why patients chose a FSED over urgent care center alternatives. The authors hypothesize that the general public has little knowledge about FSEDs and may use urgent care centers as an incorrect comparison to the capabilities and costs of a true FSED.

Methods
In an effort to characterize general knowledge about FSEDs, patients were given a 19-item survey containing questions related to knowledge, expectations, and costs for FSEDs compared to other types of emergency departments. This survey was peer-evaluated to ensure that questions and content reflected the data that investigators were looking to obtain. The survey population was a convenience sample of patients seen at a hospital-affiliated FSED. Paper surveys were distributed from 5/14/2014 to 8/27/14. The front clerk gave surveys to patients who first arrived and signed in for care while the patient was in the waiting room, prior to initiation of any care. Surveys were collected throughout the patients' FSED stay. A total of 185 surveys were collected. Surveys were discarded if the patient did not fill out >90% of the survey (39) or did not have an ID sticker on it (20). A total of 59 surveys were discarded. Data from 126 surveys was used. Data was stored in the secure REDCap database during data collection.
Demographic data was used to characterize the overall patient population of survey respondents. Survey responses were then classified according to questions responses in univariate analysis. All data analysis was performed using SAS v.9.4, Cary, NC.
This study was IRB approved by the University of Florida.

Results
A total of 126 surveys were analyzed. 85.7% of respondents reported that they were the patient, and 14.3% were not the patient being seen at the visit. The mean respondent age was 39.5 (Std = 16.9), with a minimum of 7.0 and a maximum of 87.0. 71.7% of respondents were female and 28.3% of patients were male. The respondent race breakdown consisted of 63.1% Caucasian, 23.8% African American, and 7.14% Other, which consisted of "Asian," "Hispanic/Latino," and "Other" responses. Table 1 provides a more detailed listing of patient demographics. Among participants, 65% reported that they did not know how the bill from this facility would compare to a bill from an emergency department attached to a hospital, and 87% of participants believed that their wait time at this facility was shorter than that at an emergency department attached to a hospital.
The reasons patients chose care at the FESD are many. The majority, 70%, of participants believed that they could be completely treated at this emergency facility for the problem they came in for, although 21% were unsure. Forty percent of participants believed they would be able to be seen by a surgeon or specialist at this facility if necessary, and 20% believed that they would not need to be transferred out of this location if they required hospitalization, while 35% were unsure if they would need to be transferred. When asked about the decision to come to this facility versus another emergency facility, 54% noted convenient location as a reason, 51% noted expecting a lower wait and visit time, 13% did not believe their condition required a hospital-based emergency department, and 12% expected that the cost of this visit would be less than other choices for emergency care. A full description of survey questions with results can be seen as follows: (1) Do you expect for the services provided today to be billed to either you or your insurance company? My bill today will be more expensive than the other location, 3.25% (4).

Discussion
A substantial number of patients in this survey have misunderstandings about the level of service available to them at a FSED. Over 40% of patients think that a specialist can see them at the FSED, when in fact the patient would require transfer to the main campus ED for specialist evaluation. Over 55% of patients did not know they would require transfer to the main hospital campus for admission if their condition required hospitalization. However, the majority of patients (70%) believe they can be completely treated for the condition they presented with at the FSED. These results suggest that many patients do not understand the limitations of services available at a FSED, including the availability of specialty consultations and hospitalization services, and yet expect to be fully treated. Interestingly, a substantial number of patients (42%) responded that another alternate location for emergency or urgent care was closer to them than this particular FSED. So despite a lack of knowledge of the level of service available, choosing this location for emergency care suggests that there is some other perceived advantage to choosing this FSED over alternatives closer to their location.
The top reasons patient chose care at this FSED were a perceived shorter wait time and total visit time, as well as it being a convenient location. It is not surprising that patients seek out alternatives to traditional EDs in hopes of having shorter length of stays at locations more convenient to their location.
Regarding costs of service, the majority of patients (almost 74%) either did not know or believed their cost of service would be lower than a traditional ED visit. This suggests that patients have a perception that the costs at a FSED are more in line with an urgent care center or doctor's office visit as opposed to a standard ED bill for service.
Future study on this subject could include an analysis of the impact of patient education on their knowledge of FSEDS. Would educational efforts lead patients to other choices for emergency medical care over a FSED? Also, an interesting analysis would be a survey of patients to determine the likelihood of returning to the FSED after they have been there at least once as a patient.

Limitations
The limitations of this study include a relatively small sample size in one specific geographic location. A more robust study would be to expand this survey to multiple sites.
Our study did not exclude people with prior visits to a FSED, and it did not exclude patients who may have never visited any ED in the past. Patients with prior knowledge of a FSED may already have certain understandings of limitations and costs, and patients with no prior ED visits may not have an ability to make a good comparison among the different models.
Despite these limitations, we believe that the results are important and allow for a better understanding of patients' knowledge about FSEDs in general.

Conclusions
This study shows that patients chose a new FSED in Gainesville, Florida, primarily for convenience and a perception that service will be faster. Hospitals and other organizations can emphasize these attributes when marketing a FSED to the public.
In general, patients do not have a full understanding of the level of service and cost associated with this FSED in comparison to alternative urgent or emergency care options. It is important that any effort to open a FSED in a community be coupled with an appropriate marketing campaign designed to educate the public as to these important elements. Additional educational materials about the level of services available and process to be hospitalized or receive specialty consultation could be given to patients upon their arrival to a FSED.