Objective In response to concerns about patient care and safety, our urban, tertiary care, Level 1 trauma center adult emergency department (ED) created an advanced practice provider‐staffed critical care step‐down unit (CCSU). We conducted a comprehensive evaluation of the CCSU's impact on patient care, safety, and ED operations. Methods We compared ED length of stay, return visits to the ED within 72 hours, billing code assignments (current procedural terminology evaluation and management [CPT E&M] codes), and quality of electronic health record documentation per QNOTE for the 2 years after the CCSU was initiated (CCSU period) versus before its initiation (pre‐CCSU period). Results There were 31,418 critical care ED patient visits in the pre‐CCSU period and 33,396 in the CCSU period. Median ED length of stay did not change overall between the CCSU versus pre‐CCSU period (∆1 [95% confidence interval (CI) = −2.4, 4.4] minutes), but decreased for patients who remained in the critical care suites (∆‐4 [95% CI = −7.8, −0.2] minutes). 72‐hour return ED visits also did not change overall (∆0% [95% CI = −0.1, 0]), but decreased for patients who remained in the critical care suites (∆0.4% [95% CI = −0.05, −0.4]). CPT E&M billing increased for highest‐level visits (99,291: ∆1.3% [95% CI= 0.5, 2.0]). Quality of electronic health record documentation as measured by QNOTE also improved (∆11.5% [95% CI = 4.9, 18.1]). Conclusion This ED's CCSU performance metrics indicate at least moderate improvement in ED length of stay, 72‐hour return visits, critical care patient billing, and electronic health record documentation. EDs elsewhere can consider implementation of this advanced practice provider‐staffed solution to improvement in critical care in ED.

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Study Objectives: The number of freestanding emergency departments (FEDs) is increasing at a rapid pace. Little is known about differences in visit clinical characteristics between FEDs and hospital-based EDs (HBEDs). The objective of this study was to compare clinical demographics, method of arrival, acuity level, patient disposition, and ED length of stay (LOS) for visits to FEDs versus HBEDs.Methods: This was a retrospective review of electronic health information collected for ED visits from 1/1/2016 -12/31/2017 within a health system using data from 5 FEDs and 16 HBEDs. The system serves an urban-suburban mix with a metropolitan area population over 2,058,844. Frequency differences between FEDs and HBEDs for categorical variables were tested using Chi squared. For continuous variables, mean standard deviation (SD) was reported and Student's t-test was used to determine the difference in mean score between FED versus HBED patients. Significance was determined using a ¼0.05 as a cutoff.Results: Sample size of this study was 326,356 patients (10 % FED and 90% HBED patients). Mean age was 43 years, and similar for both facility types (SD): + 24, p¼ 0.2976]. Racial distribution among FEDs to HBEDs: Caucasian (78.2% versus 62.6%), Black (16.2% versus 32.4%), Asian (1.4% versus. 0.9%), and other (4.1% versus 4.1%), which were overall significantly different between facilities (p<0.001). FEDs compared to HBEDs saw more females 55.7% versus 54.9% (p¼0.009). Insurance status at the FEDs compared to HBEDs was: Medicaid 24.6% versus 27.4%, Medicare 14.2% versus 15.4%, private 53.6% versus 49.4%, self pay 6.8% versus 7.1% and Veterans Administration/Tricare 0.8% versus 0.7% respectively (p<0.001). We found mode of arrival at the FEDs versus HBEDs was: ambulance 11.5% versus 25.6%; car 85.1% versus 63.8%; walk-in 2.7% versus 10.3%, and overall these were significant (p<0.001).Average ED LOS was 158 minutes (SD: + 102) for FED patients and 221 minutes (SD: + 236) for HBED patients (p <0.001). Emergency severity index (ESI) level 1 made up 0.1% of patients seen at FEDs compared with 0.4% at HBED. ESI level 2 represented 5.6% of patients seen at FEDs and 11.5% at the HBED. ESI level 3 comprised more than half of patients seen by both FEDs (58.6%) and HBEDs (57.9%). ESI level 4 was 33.8% at the FEDs and 27.9% at the HBEDs. ESI level 5 comprised slightly fewer visits at the FEDs (1.9%) compared to HBEDs (2.2%). The difference between the ESI levels for FEDs compared to HBEDs was p<0.001. Admissions accounted for 15% of dispositions at FEDs, compared to 24% at HBEDs. Discharges accounted for 83% of dispositions at FEDs, compared to 75% at HBEDs (p<0.001). Left without being seen rates were lower at the FEDs (0.01%) compared to HBEDs (1.0%) p<0.001.Conclusions: Average ED LOS for all patients was significantly less for FED patients versus HBED patients. FED acuity levels, insurance status, method of arrival, and patient disposition were significantly different compared to HBEDs.