The emergency department (ED) is a complex organization in which care is provided by healthcare providers with a variety of different types of training, employment relationships, heirarchy of roles, and job descriptions. The staff includes a group that is dedicated entirely to ED patients and a group that works throughout the hospital and responds to the ED when requested.
Emergency Department Organization
Providers
The generic term “provider” is applied to practitioners who are members of the hospital medical staff and exercise independent medical judgment. This category includes physicians (either doctors of medicine [MDs] or doctors of osteopathic medicine [DOs]), physician assistants (PAs), and nurse practitioners (NPs). Providers may be employed either by the hospital, a staffing company, or other medical practice organization that has an arrangement with the hospital for staffing providers. Providers are licensed by the state, credentialed by the hospital medical staff (see Chapter 1 ), and have passed a series of examinations administered by nongovernmental professional societies. Providers generally report to an ED medical director, who is most frequently a physician.
Nurses and Technicians
Nurses are employed by the hospital, licensed by the state, and may also have additional certifications (such as certified emergency nurse) from private professional organizations. They report to an ED nursing manager who often (depending on the size and complexity of the hospital) reports to the chief nursing officer or designee. The ED technicians (EDTs) most often report to the ED nurse manager and are directly supervised by nursing staff while working.
Pharmacists
Many EDs have in-person pharmacy support for all or part of the day. The pharmacist helps both the providers and nursing staff with the selection and administration of medications.
Registrars
The registration team, is responsible for entering patient demographic information into the hospital’s management system and collecting insurance information from the patient. Additionally, they will often have the patient sign a consent to be treated and may document whether a patient has an advance directive.
Unit Clerks
The role of the unit clerk is crucial for smooth, efficient ED operations. Their characteristic duties are as follows:
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Answering the main ED department number for general inquiries
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Directing phone and foot traffic to the proper personnel in the ED
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Directing health provider phone calls from outside facilities to the attending MD
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Helping coordinate logistics for patient transfers
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Scanning paper copies of charts, results, or emergency medical services (EMS) run sheets into patients’ electronic medical records (EMRs)
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Helping coordinate discharge arrangements for special patient categories
The importance of the role cannot be undervalued and one that the EDT may be tasked with on occasion.
Table 2.1 describes characteristic roles of providers, nurses, and EDTs.
| Providers | Nurses | ED Technicians |
|---|---|---|
| Medical evaluation | Patient triage | Venipuncture and IV insertion |
| Ordering labs and x-rays | Nursing assessment | Rooming patients |
| Assignment of a diagnosis | Medication administration | Obtaining an ECG; initiating cardiac monitoring |
| Calling consults | Patient education | Wound care |
| Writing prescriptions and discharge instructions | Managing IV drips | Taking vital signs |
| Performing bedside procedures | Splinting | |
| Coordinating care with the patient’s primary care and specialist physicians |
Hospital Personnel Responding to Emergency Department Consultations
Specialty Consultants
Each hospital develops a relatively unique pattern of specialty physician response to the ED. In larger institutions, there will generally be greater on-site presence of specialists, and there will often be specialty residents (physicians in training) or fellows (subspecialty trainees) who are the first responders to consultations. Smaller community hospitals will have physicians on their medical staff whose availability for bedside ED consultation varies with their other practice demands. Many hospitals have recently hired PAs in a variety of specialty areas who support physician-specialists with postoperative care in hospital patient management, assist in the operating room, and provide in-person ED consults.
Certain specialty consults (most frequently stroke neurology and psychiatry) may be done by off-site physicians via telemedicine. Many initial behavioral health consults will be done by hospital-employed psychiatric social workers who are licensed by the state but are not members of the hospital’s medical staff.
Case Management
As many ED patients have significant, acute social service needs, most EDs have a social worker or case manager assigned to the ED. Some of their duties include coordinating patients’ housing and home care needs, arranging transportation, facilitating acquisition of medications or durable medical equipment, and (depending on their backgrounds), helping with psychiatric screening and assessments.
Specialty Hospital Services
Electrocardiogram Technician
In some EDs, electrocardiograms (ECGs) are performed primarily by the EDT, but in others, a central hospital technician will perform some or all of the ECGs on ED patients.
Respiratory Therapy Technician
Helping with ventilator and advanced airway management is the core of this professional category. They may also assist nursing with other functions such as administration of nebulized medications or suctioning intubated patients.
Physical Therapy
Many ED patients with acute or chronic skeletal injuries can benefit from a physical therapy (PT) visit in the ED. A PT evaluation is most helpful in making disposition decisions on patients with movement or balance challenges and in patients with acute vertiginous dizziness.
Emergency Department Administration
The day-to-day administration of an ED is generally a partnership between the medical and nursing leaders. Each leader has primary responsibility for hiring and scheduling members of their group, defining shift length, and creating a back-up system to help ensure adequate staffing at all times. The leadership team develops a synthesis of views on patient arrival patterns and creates schedule templates for providers and nursing that attempts to best fit the available staffing to the patient arrival patterns.
The reporting structure for the physician medical director will vary significantly with the type of hospital. There is always accountability for credentialing and quality issues to the hospital medical staff committees and ultimately to the hospital medical staff executive committee. Administratively, the ED physician leader could report to an administrator or to another physician such as the hospital medical director or vice president of medical affairs.
The ED nursing director most frequently reports to the hospital’s director (vice president) of nursing or its designee. Depending on the size and complexity of the organization, the ED nursing director may have administrative oversight over ED registration and may report through the hospital’s administrative structure for those functions. Some hospitals will have centralization of functions, such as ED technical charge capture and coding (billing for the hospital) but in others, an ED administrator or ED nurse manager would supervise staff.
The “charge nurse” is a key operational role that is often rotated among a group of experienced nurses. The charge nurse is responsible for managing the operational efficiency of the ED in real time. They help manage the ED patient flow, are usually responsible for calling in additional staff as needed, and coordinate the operations of the ED with those of the rest of the hospital. Table 2.2 describes the types of functions that are required of the ED administrative team.
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