First Responders see some gnarly stuff, but any trauma patients they see ultimately go to the Emergency Department (ED). ED staff are secondary responders in those situations, but that’s not always the case. Most ED patients are walk-ins, making the ED staff first responders for those cases and the trauma catch-all.
Let’s assess the scene and give recognition to our ED folks.
The ED Scene
Every ED is different based on location, population, and level of care available, so these numbers may not reflect your nearest hospital’s ED, but they should paint a fairly consistent picture as far as what ED staff face on a given day or night.
There’s lots to cover, but let’s look at walk-ins versus transports, acuity, staffing situations, and secondary trauma affecting clinicians and other staff.
Walk-ins vs. Transports
The walk-in rate for the ED can be significantly higher than the transport (ambulance) rate in most areas, up to 80-85% in one study. Though exact percentages vary from hospital to hospital—urban or rural, densely populated or not, sufficient ambulatory accessibility or not—a higher walk-in rate means no initial triage or clinical care until the patient walks into the ED and presents the complaint. This is what makes an ED the trauma catch-all.
With transports, there’s typically a basis of chief complaint, meds, and some initial care administered. With walk-ins, every second could count to identify emergent issues like cardiac, respiratory, or other major issues. Even a few seconds off could alter the course of care. That’s why accurate triage is so crucial.
Acuity
ED staff are trained to handle trauma, but not all hospitals are equipped for high acuity. EDs follow a trauma center rating based on available resources. From surgeons on staff to equipment, the facility gets a rating from Level I Trauma Center (24-hour in-house surgeons, ConEd for the trauma team, availability of specialties and equipment) to Level V (basic ED facilities, 24-hour protocols if center isn’t open, transfer agreements for higher level trauma center).
If a patient is being transported via ambulance, care will be dictated by the severity of the case and the patient will go to the appropriate hospital. However, if the patient chooses to walk-in, staff on site will need to assess and deal with whatever is presented or transfer if needed. It’s the unknown that makes it challenging. That and a surge in acuity taxes both clinical and clerical staff.
The higher acuity, the more care and attention needed, the fewer patients a clinician can handle at once. That’s why triage is so critical and—for lower level trauma centers—protocols for transfer are crucial. Four patients with broken digits or belly aches are not as much work as one patient with high acuity (ei: cardiac arrest, internal bleed, spinal injury, respiratory distress, etc.) Now consider a shift with multiple high acuity patients and you have a severe trauma catch-all situation.
Staffing
Staffing affects both ED operations and morale. With low acuity, a one to four ratio might work, but with high acuity, one to one might be necessary. Unfortunately, schedulers and employers can’t see when acuity or patient population is going to rise, or when staff are going to call out. A well-run ED will be fully staffed with clinicians who enjoy coming to work, but the thing about ideology is… it’s often just an idea.
Even when staffing is low or acuity and numbers are high, a good morale among ED staff can help lessen the burden. Staff are more likely to come in if called to help out. Burnout may be less likely. Since it’s almost a guarantee that those days will happen, it’s important for administration to find ways to boost morale. Prioritizing things like staffing, education, employee support, and an open-door policy for managers to hear complaints helps raise morale. Perhaps the most important treatment for a low morale in a hurting ED is listening to staff. They shouldn’t just feel heard; they should feel seen and be answered.
Secondary Trauma
EDs take on so much trauma, but one of the worst forms is when families are present for the death of loved ones. Clinicians continue to do their jobs, follow protocol, and go through the necessary motions, but those experiences stay ingrained. Try as they might, they come home with them. It’s difficult to leave some things at work, especially deeply emotional moments. We are human and so vulnerable to moments such as these.
Secondary trauma affects ED staff much like first responders. If it’s not addressed, it piles up. It gets packed down and buried under the guise of “I’m fine.” Eventually, it’s going to rear its ugly head.
ED staff need doors opened to deal with secondary trauma. Resources for support, debriefings after particularly difficult cases, and anonymous options for help are all great ways to guide staff to avoid the consequences of unhealed secondary trauma.
The Trauma Catch-All
We recognize and support our local ED staff, especially on Emergency Nurses Appreciation Day (October 9th). They may be the trauma catch-all, but we’re grateful for all they do and handle. Let’s work harder to support them, encouraging stronger morale, interventions for secondary trauma, and continuing growth of our ED brothers and sisters.
[Hey, we support ED folks too. If you need someone to talk to, reach out!]