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Freestanding emergency departments (FEDs) have grown in popularity. They often provide emergent care in areas distant from other EDs. Investigations and research to characterize the operation and dynamics of FEDs are needed.This study characterizes the severity of illness seen at FEDs and compares it with a hospital-based urban tertiary care ED using the emergency severity index (ESI), a quantification of patient acuity.Patient ESI levels were analyzed retrospectively over 1 year for a single hospital system with 1 main urban hospital-based ED and 3 FEDs. Data analysis was completed using analysis of variance with and without time as a factor.The average ESI level at the main ED (3.04) was lower than the FEDs, respectively (3.42, 3.22, and 3.38) (P < .001). Patient ESI levels were significantly different between FEDs (P < .001).The main ED demonstrated lower ESI levels and thus higher acuity than the 3 affiliated FEDs. There were significantly different acuity levels between the main ED and 3 FEDs as well as between individual FEDs.