Emergency Nurses Week is Oct. 9-15, a time to celebrate the unique and challenging specialty of emergency nursing. Emergency nurses provide care in a variety of settings including hospital emergency departments (EDs), freestanding EDs, rural emergency care, critical care air transport, prisons/correctional facilities, cruise ships, sporting events, concert venues, disaster response and many more. According to the Emergency Nurses Association (ENA), approximately 167,000 emergency nurses work in the United States. In honor of Emergency Nurses Week, my colleague and past ENA president Jean Prohel and I asked emergency nurses through social media channels and an ENA list-serve what they would like critical care nurses to know. To highlight the importance of the AACN Healthy Work Environment Standards of skilled communication and true collaboration, Jean and I would like to share the top five things emergency nurses want to share with you.
1They Just Keep Coming
The ED never closes. The ED is required by a federal law, EMTALA, to see every person who arrives seeking care. This means that regardless of the number of nurses who are working or the number of open beds, the ED cannot turn patients away. Some EDs are allowed to divert patients in ambulances to another hospital for a short period of time, but the ED’s front door never closes, so patients may continue to arrive by private vehicle, on foot or by public transportation. Due to space limitations, emergency nurses often treat patients in the hallway, waiting room, the patient’s car or tents outside. Few states legislate ED staffing ratios, so assignments of six or more patients per nurse are common. When an ED RN is trying to call report on an admitted patient, it is not because they are trying to “dump” the patient, it is so they can take care of other critical patients in the department. One ED nurse said, “They just keep coming.”
2Emergency Nurses Care for All Ages, All Body Systems and All Acuities
The emergency nursing specialty is unique. Providing high-quality patient care to all ages means an ED nurse must possess a knowledge of emergencies involving pediatrics, orthopedics, obstetrics, cardiology, neurology, gastroenterology, oncology, psychology, infectious disease and everything in between. ED nurses often refer to this skill set with the phrase “from womb to tomb.” Every type of emergency and every level of severity is treated in the ED: a septic newborn, hemorrhaging pregnant patient, suicidal teen, 98-year-old stroke patient, a patient who’s being trafficked and a patient with multisystem trauma. Every day, emergency nurses triage patients to determine severity of illness, assess signs and symptoms and, based on their acuity, treat and stabilize a considerable number of patients.
3ED Crowding Is Associated With Increased Mortality
Multiple studies have demonstrated that ED crowding is associated with increased mortality among critically ill inpatients. Emergency nurses have many competing priorities. The patient waiting for a critical care bed may need drips started, lines and a urinary catheter placed and labs drawn, while another patient with a kidney stone needs pain medication as soon as possible, and a patient with a psychiatric complaint needs blood and urine collected and medication administered before the patient escalates. Emergency nurses do not purposefully neglect inpatient orders; they try to complete ED orders on all of their patients. Everything in the ED is timed; for example, door to triage, door to doctor, door to CT, door to vessel open, door to admission. The ED is accountable for making sure each of these metrics is within industry standards. Because the ED doors never close, they try to move admitted patients to their inpatient beds, because there may be 30 or more patients in the waiting room who desperately need an ED bed. The ED never knows what type of patient is coming through the door next. Often the ED charge nurse is tasked with strategically moving patients out of ED rooms to accommodate, for example, a patient in full arrest who just arrived or a 1-year-old near-drowning child who is en route.
4The ED Is a Complaint-Based Care Model
The reason an ED nurse may not know all medications a patient is taking or the history of a rash they have had for two years is that the ED is focused on the patient’s chief complaint or the reason the patient is seeking emergency care. For example, if the chief complaint of the patient is chest pain, the nursing assessment would consist of understanding the onset, intensity, radiation and symptoms associated with the chest pain. The priority for the patient with chest pain is a 12-lead EKG to rule out an acute myocardial infarction. After the chest pain patient is stabilized, it’s on to the next patient and their chief complaint. As one ED RN explains, “We are constantly putting out fires one at a time.”
5The Goal of the ED Is to Resuscitate and Stabilize
Most patients come to the ED without a diagnosis and often with a long list of complaints. During the triage process, an ED nurse listens to the patient and asks themselves, “What is the worst thing this could be?” Although it is not the nurse’s job to diagnose, they have to consider possible diagnoses to implement diagnostic tests and interventions proactively. Is the chest pain a STEMI? Is the facial numbness a stroke or Bell's palsy? Is it a simple fracture or possibly compartment syndrome? Is the patient septic or is this the flu? Often patients arrive at the ED unconscious, without a medical history to rely on and without family members. The ED’s main goal is to diagnose the condition and stabilize the patient before they deteriorate further. ED staff are experienced in resuscitation and stabilization, and then the goal becomes to continue the patient’s care in an inpatient unit.
As one emergency nurse shared, “It’s not ED vs. ICU; it’s ED + ICU = what’s best for the patient.” True collaboration means that a team works together and succeeds together (AACN). The ultimate goal in healthcare is to be one cohesive team with the patient and their needs at the center (Chung, 2021). Understanding the complexities of the working environments of the ED and critical care areas will help build true collaboration. The critical care nurse who comes to the ED to help with a code or consults on critical care patients holding in the ED are examples of true collaboration.
What can you do to build true collaboration between the ED and your unit?
What would you like to share with ED nurses?