Nurse Specialty Spotlight: Emergency Nursing

In an emergency department (ED), no two days – or hours – are the same. From heart attacks and strokes to motor vehicle accidents, fractured bones and more, emergency nurses see it all.

“I like to think of the emergency nurse role as the ‘Swiss Army knife’ of nursing,” says Brian Holbrook, RN, who works as a charge nurse at Cleveland Clinic’s main campus emergency department. “One minute, you’re taking care of a COVID-19 positive patient on a ventilator with numerous IV drips and the next, you’re caring for a human trafficking victim, an athlete who fractured their ankle or a homeless person who needs social work services like shelter to get out of the cold.”

Because of the wide variance in patient condition and population, including symptoms, trauma, injury or illness, as well as age (from pediatric to geriatric) and ethnic background, emergency nursing is considered a ‘big picture’ specialty. And it’s extremely fast-paced with patients coming and going 24/7.

Assess, identify, treat, repeat

Since urgency is key in the emergency environment, emergency nurses must be able to think fast and stay calm and collected under stress and pressure. They quickly need to perform an assessment, identify the major problem, stabilize the patient, minimize pain and treat the patient – then repeat the process for the next patient.

To effectively care for the patients they see, emergency nurses are specially trained to triage patients based on immediate observation and acute assessment skills and are highly experienced with treating symptoms in order of life-threatening priority. At Cleveland Clinic, for example, nurses decide the acuity level of a patient based on the chief complaint, medical history and vital signs. They assign the patient one of six severity/acuity levels based on the department’s ‘Emergency Severity Index’ (ESI). The least acute is a level 5, followed by levels 4, 3 low, 3 high, 2, and then the most acute, which is a level 1 where the patient is at risk of immediate loss of life or limb.

“Successful ED nurses need to be flexible to adapt to anything, assertive, confident and empathetic,” Holbrook says. “They also need to have patience and be critical thinkers with excellent prioritization and time management skills.” He notes that providing care with confidence can have a big impact on a patient’s level of comfort and calmness. Additionally, he says teamwork in an emergency environment is crucial.

A closer look at emergency nursing care

At Cleveland Clinic, the main campus ED comprises 64 beds with 14 additional 23-hour observation beds. Annually, more than 61,000 patients visit the ED, which is divided into ‘pods’ with staggered open and close times based on patient census. In addition to the observation area, which is known as the Clinical Decision Unit, there are three areas that include acute beds with cardiac monitoring capability, a low-acuity Split Flow area (without cardiac monitoring), and a triage area. At maximum bed allocation, roughly 20 registered nurses (RNs) staff the department.

Holbrook first started working in the main campus ED in 1998 as a clinical technician (CT) while attending nursing school. In 2004, he was the first new graduate RN hired at the main campus ED and, today, he is the department’s charge nurse, where he is responsible for leading staffing, patient assignments, throughput, physician communication and more.

“When I started this career I had every intention to go to paramedic school and become a firefighter – then I saw what the ED nurse does every day and how they touch the lives of not only their patients, but also patients’ families and I knew this was my calling,” Holbrook comments.

When Holbrook first arrives for his shift at 7 a.m., he describes his typical, immediate responsibilities as:

• Receiving the department report from the off-going charge nurse.
• Touching base with oncoming staff physicians.
• Reviewing assignments for staffing issues.
• Assessing units to ensure stretchers in every room, plus three additional stretchers in the overflow hallway.
• Checking in with Medical Intensive Care Unit (MICU) and Neuro-Intensive Care Unit (Neuro-ICU) throughput nurses for bed status updates.
• Conferring with Cleveland Clinic’s bed management team for bed status updates throughout the main campus hospital.
• Checking the status of triage and waiting areas.

At 9 a.m., the multi-disciplinary team holds a daily huddle to discuss operational readiness and prepare for any challenges that may impact emergency department flow, such as hospital census or caregiver call-offs. Then, it’s all hands on-deck.

“The flow of patient traffic is endless with ambulance traffic coming in from the back and foot traffic coming in through the front,” Holbrook says. “The charge nurse assigns the squad to a room and determines immediate resource needs. Nurses care for patients and answer phones, taking advice calls and patient reports. HUCs (health unit coordinators) screen calls, make calls for consults and prepare paperwork. CTs obtain electrocardiograms, draw blood work and transport patients.”

Holbrook says his department also has teams of physicians, nurses, paramedics and respiratory therapists they call ‘Acute Care Teams,’ who care for the most critical patients, such as those who are having a stroke, STEMI (ST-Elevation Myocardial Infarction) or neutropenic fever.

A career with a variety of options

In addition to charge nurse, other emergency nursing positions include those such as trauma nurse, code nurse, triage nurse, disaster preparedness/emergency preparedness nurse, flight nurse, critical care transport nurse, pediatric or geriatric ED nurse, burn center nurse and military nurse. Emergency nurses also often have public education roles, including participating in programs that promote wellness and prevent injury.

Additionally, there are many different emergency department settings emergency nurses may work, such as critical access, rural areas, community settings, urban areas, teaching hospitals, stand-alone emergency departments and disaster settings.

To become an emergency nurse, you must first become an RN by obtaining either an Associate degree in Nursing (ADN) or a Bachelor of Science degree in Nursing (BSN). After passing the NCLEX-RN examination, you will be a fully licensed RN and can begin working toward a specialty in emergency nursing.

To garner experience, emergency-related positions, such as working as a float nurse in a hospital ED or assisting paramedic or critical care transport teams are ideal. After 2 years of related emergency experience, RNs can apply to earn specialty certification from the Board of Certification for Emergency Nursing (BCEN), if desired.

If considering a career in emergency nursing, Holbrook says to keep in mind that learning to be an ED nurse is a marathon, not a sprint – and no matter how long you’ve been an emergency nurse you will always be learning. “Be patient, confidence is gained over time,” he says.

Holbrook adds: “The way you touch the lives of your patients and their families makes all the difference when they are their most vulnerable. To have a patient or family thank you for caring for them will make you always remember why you became a nurse.”

Happy Year of the Nurse to all emergency nurses!