The Emergency Department: Critical Care Nurses’ Other Home?

Critical care only happens in the ICU.

I believed this misconception, and then realized it wasn't true during my emergency nursing career. Patients and their loved ones seemed to think that as soon as someone was declared “critical” and approved for ICU admission that *poof* – a magic wand would wave, and they'd be whisked away.

Sadly, that's not how it works.

Patients requiring critical care arrive in the emergency department (ED) and often stay there for a long time. Often longer than they should, given the national patient boarding crisis. This crisis means critical care must be provided in the ED by – you guessed it – emergency nurses!

What is a critical care nurse?

A critical care nurse cares for patients who are critically ill or injured and, very often, require lifesaving medical interventions. This role is most commonly attributed to nurses working in a designated unit to care for newborns (NICU), children (PICU) or adults (ICU).

However, critical care isn’t about the location. Critical care is the care delivered to a critically ill or injured patient wherever they are. That means critical care nurses can provide care anywhere in the hospital. And, often, the most unstable patients are those who arrive through the ED – a health system’s front or back door.

The Emergency Department: Where the magic starts!

Major car accident? Heart stopped? Stroked out? Fell down? In those cases, critical care will start in the ED.

Most often, the most unstable patients arrive by ambulance. If they’re hemorrhaging or their heart has stopped, lifesaving efforts will have started before they arrive. (Shout-out to the highly skilled prehospital personnel who deliver critical care in the field!) Once in the ED, nurses, medical providers and other support staff take over this patient’s critical care.

Critical care is a continuum.

How healthcare is delivered has changed over time. Once, critical care happened only in the ICU. This often meant a patient did not receive a timely and appropriate intervention until their condition had deteriorated to the point where ICU care became an unsuccessful last-ditch effort and, often, not successful in saving their life. As medical thinking has shifted, critical care has become understood as a continuum of critical care -- one of the ways a patient is cared for throughout their time in the hospital and after discharge.

This change led to enhanced critical care training for nurses and other clinicians in the prehospital, emergency and rapid response settings, as well as providing patients access to critical care consultants 24/7. Further, the importance of post-ICU care, including post-discharge, has been emphasized to minimize the potential negative impacts on a patient’s long-term physical and mental health, starting with their time in the ICU.

A difference in critical care focus: What does an ED nurse do?

There are many assumptions about what ED nurses do and what they are like. Think of the adage that it’s important never to assume. Knowing how ED and ICU critical care nursing differ can help clarify common misconceptions.

ED nurses focus on:

• Triage -- ED nurses triage or sort patients by assigning an acuity score to guide care while the patient is in the ED. Key triage skills include recognition of signs and symptoms of critical illness or injury and deterioration.
• Investigation -- When a patient arrives in the ED, there is usually no testing data, and sometimes little history or information, especially when a patient is unconscious, a poor historian, or arrives alone with no one to fill in the information gaps. ED nurses know how to work with whatever information they have at hand, using their assessment skills to support providers in selecting the most appropriate tests, interventions and treatments. ED nurses are the ultimate clinical detectives.
• Stabilization – Being able to rapidly assess and implement stabilization protocols that often include lifesaving interventions is key to the ED nurse’s toolkit. These interventions include obtaining vascular access, supporting the airway and anticipating the need for rapid sequence intubation (RSI), advanced cardiac life support (ACLS) or pediatric advanced life support (PALS).
• Ideal Scenario – Transfer a patient to the next level of care. In an ideal healthcare world, the ED is not the final destination for care. Critically ill and injured patients are theoretically supposed to be stabilized, receive initial diagnostics and interventions, be evaluated by specialty consultants, then moved to a specialized care destination such as an ICU, PICU, NICU, OR or cardiac catheterization lab. This requires preparing a patient for safe and efficient transport within the hospital facility or to another facility by ground or air. ED nurses are often tapped to facilitate the nursing care, monitoring, medications and advanced airway support of these patients en route when a critical care transport nurse is unavailable.
• Present Reality for Boarding Care -- There is currently a boarding crisis in the United States. This crisis means that critical care patients requiring admission to an ICU cannot be transferred as quickly as necessary and must remain in the ED as “boarders,” cared for by either ICU float nurses or, more commonly, by ED nursing staff. ED nurses manage ongoing critical care in collaboration with the interdisciplinary team as long as the patient remains in the ED, which could be hours, days or until discharge.

Universal Challenges

Just like critical care nurses do in the ICU, ED nurses face barriers to delivering optimal patient care:

• Nurse Staffing Crisis – Like everywhere else in the hospital, the ED has a high rate of turnover and faces staffing shortages.
• Burnout – Healthcare workers also face burnout. And ED nurses are highly susceptible to burnout, a factor that contributes to their intent to leave.
• Workforce Diversity – The majority of nurses surveyed in “The 2020 National Nursing Workforce Survey” described themselves as white/Caucasian, yet a Brookings Institution analysis of 2020 U.S. Census Bureau data showed 40% of the U.S. population identifies as people of color. Diversity across the healthcare workforce is essential to improve the quality of patient care. Emergency nurses are taking part in that work.
• Concern for Safety – Nurses often report experiencing verbal abuse, physical abuse, sexual harassment and discrimination. ED staff, in particular, experience high rates of workplace violence and abuse.
• Technology – As technology becomes an essential part of healthcare, vulnerabilities and gaps increasingly come to light. EDs experience unique impacts when electronic medical record (EMR) systems become inoperative and patient data cannot be accessed.

We have so much in common.

An ICU shift may seem a lot different than one in the ED, yet critical care nurses in both areas have so many skills and experiences in common:

• Supporting Patients and Loved Ones – Critical care patients experience some of the most difficult moments of their lives. Often unexpectedly. Critical care nurses have to be skilled in offering compassionate support to patients and loved ones.
• Managing Stress – Critical care nurses work in fast-paced, high-stress environments. Knowing how to decompress and care for yourself will support a long and fulfilling career.
• Staying Calm in an Emergency – Whether it is a trauma patient arriving at the ED by ambulance or a patient crashing in the ICU, critical care nurses have to be able to stay calm and objective when the “proverbial excrement hits the oscillating cooling device.”
• Work smarter, not harder! – Critical care nurses are natural innovators who are constantly finding creative solutions to improve patient care. Have a patient care problem? Ask a critical care nurse!
• Team Dynamics – Healthcare is the ultimate team sport with critical care being one of the fields where interdisciplinary care teams work together the closest. Critical care nurses in all areas need to be skilled communicators who make effective decisions and foster true collaboration to help save lives.

Same Team

It turns out that ED nurses and ICU nurses are more alike than different. While ED and ICU nurses focus on different parts of the critical care continuum, we are on the same critical care team working together to care for our patients.

So the next time someone asks, “Who is a critical care nurse?” be sure to include ED nurses. Critical care isn’t a place; it’s a continuum that encompasses nurses and staff both inside and outside the ICU.

What else do you think ICU and ED nurses have in common?