The emergency department (ED), emergency room (ER), emergency ward (EW), accident & emergency department (A&E) or casualty department is a hospital or primary care department that provides initial treatment to patients with a broad spectrum of illnesses and injuries, some of which may be life-threatening and requiring immediate attention. Emergency departments developed during the 20th century in response to an increased need for rapid assessment and management of critical illnesses. In some countries, emergency departments have become important entry points for those without other means of access to medical care.

Upon arrival in the ED/A&E, people typically undergo a brief triage, or sorting, interview to help determine the nature and severity of their illness. Individuals with serious illnesses are then admitted to the department more rapidly than those with less severe symptoms or injuries. If the anticipated waiting time is particularly long, patients with minor symptoms may be directed to visit a primary care physician or outpatient clinic instead. After initial assessment and treatment, patients are either admitted to the hospital, transferred to a specialty hospital, or discharged. The staff in emergency departments often includes doctors and nurses with specialized training in emergency medicine. The emergency departments of large hospitals operate continuously and accept after-hours cases not seen by smaller hospitals.

Department layout

The resuscitation area is a key area of an emergency department. It usually contains several individual resuscitation bays, usually with one specially equipped for paediatric resuscitation. Each bay is equipped with a defibrillator, airway equipment, oxygen, intravenous lines and fluids, and emergency drugs. Resuscitation areas also have ECG machines, and often limited X-ray facilities to perform chest and pelvis films. Other equipment may include non-invasive ventilation (NIV) and portable ultrasound devices.

The majors, or general medical, area is for stable patients who still need treatment that requires a gurney (trolley). This area is often very busy, filled with many patients with a wide range of medical and surgical problems. Many will require further investigation and possible admission. Patients who are not in need of immediate treatment are sent to the minors area. Such patients may still have been found to have significant problems, including fractures, dislocations, and lacerations requiring suturing.

A pediatric area for the treatment of children has recently become standard, to dedicate separate waiting areas and facilities for children. Some departments employ a play therapist whose job is to put children at ease to reduce the anxiety caused by visiting the emergency department, as well as provide distraction therapy for simple procedures.

The obstetrics area, for women before, during and after pregnancy, is usually a separate part of an emergency department and/or a separate part of a hospital. Women are often primarily seen by obstetricians in an environment where equipment is available for specialized care.

Many hospitals have a separate area evaluation of psychiatric problems. These are often staffed by psychiatrists and psychiatry-trained nurses and psychiatric social workers. There is typically at least one room for people who are actively a risk to themself or others (e.g. suicidal).

Emergency departments may also have a "fast track" service for minor and rapidly treatable conditions, such as minor lacerations. The fast track is usually staffed by a limited team of only a few nurses and physicians, and special consultation rooms are specifically designated for this purpose. This system allows for quicker treatment of patients who may otherwise be forced to wait for more pressing cases to resolve.

Signage

Nomenclature

Commonwealth nations

In Canada, a slang word for the emergency department is "emerge".

United States

During the 1990s, an effort was made to change to the more accurate term emergency department (ED), which is a term increasingly used by members of the specialty internationally. The effort failed and ED never caught on among the U.S. public, perhaps because of the popularity of the TV show ER, and the heavy marketing of the euphemism "ED" for erectile dysfunction by pharmaceutical companies. However, the term does have some circulation among emergency medicine physicians.

A smaller facility that may provide assistance in medical emergencies is known as a clinic. Larger communities often provide a drop-in clinic where people with medical problems that would not be considered serious enough to warrant an emergency department visit can be seen. These clinics often do not operate on a 24 hour basis, and visiting them is sometimes less expensive than going to the ED.

United Kingdom

In other countries without this policy (such as Ireland and Australia), patients may be faced with prolonged waits of hours or even days on trolleys for hospital beds.

Patient experience

Patients arriving independently or by ambulance are typically triaged by a nurse with training in emergency medicine. Patients are seen in order of medical urgency, not in order of arrival. Patients are triaged to the resuscitation area, majors area, or minors area. Emergency/Accident and Emergency departments usually have one entrance with a lobby and a waiting room for patients with less-urgent conditions, and another entrance reserved for ambulances.

Critical conditions handled

Cardiac arrest

Heart attack

If the ECG confirms an ST elevation myocardial infarction or there is onset of left bundle branch block this indicates complete blockage of one of the main cardiac blood vessels. These patients require reperfusion (re-opening) of the occluded vessel. This can be achieved in two ways: thrombolysis (clot-busting medication) or percutaneous transluminal coronary angioplasty (PTCA). Both of these are effective in reducing significantly the mortality of myocardial infarction. Many centers are now moving to the use of PTCA as it is somewhat more effective than thrombolysis if it can be administered early. This may involve transfer to a nearby facility with facilities for angioplasty.

Trauma

The services that are provided in an emergency department can range from simple x-rays and the setting of broken bones to those of a full-scale trauma center. Emergency medical technicians often work as support staff in emergency departments under the supervision of nurses and doctors. A patient's chances of survival are greatly improved if emergency care begins within one hour of an accident (such as a car accident) or onset of acute illness (such as a heart attack). This critical time frame is commonly known as the "golden hour."

Some emergency departments in smaller hospitals are located near a helipad which is used by helicopters to transport a patient to a trauma center. This inter-hospital transfer is often done when a patient requires advanced medical care unavailable at the local facility. In such cases the emergency department can only stabilize the patient for transport.

Some patients arrive at an emergency department for a complaint of mental illness. In many jurisdictions (including many U.S. states), patients who appear to be mentally ill and to present a danger to themselves or others may be brought against their will to an emergency department by law enforcement officers for psychiatric examination. From the emergency department, patients thought to be mentally ill may be transferred to a psychiatric unit (in many cases involuntarily).

Asthma and COPD

Special facilities, training, and equipment

ED/A&E staff must also interact efficiently with pre-hospital care providers such as EMTs, paramedics, and others who are occasionally based in an ED/A&E. The pre-hospital providers may use equipment unfamiliar to the average physician, but ED/A&E physicians must be expert in using (and safely removing) specialized equipment, since devices such as Military Anti-Shock Trousers ("MAST") and traction splints require special procedures. Among other reasons, given that they must be able to handle specialized equipment, physicians can now specialize in emergency medicine, and ED/A&E's employ many such specialists.

ED/A&E staff have much in common with ambulance and fire crews, combat medics, search and rescue teams, and disaster response teams. Often, joint training and practice drills are organized to improve the coordination of this complex response system. Busy ED/A&E's exchange a great deal of equipment with ambulance crews, and both must provide for replacing, returning, or reimbursing for costly items.

Cardiac arrest and major trauma are relatively common in ED/A&E'S, so defibrillators, automatic ventilation and CPR machines, and bleeding control dressings are used heavily. Survival in such cases is greatly enhanced by shortening the wait for key interventions, and in recent years some of this specialized equipment has spread to pre-hospital settings. The best-known example is defibrillators, which spread first to ambulances, then in an automatic version to police cars, and most recently to public spaces such as airports and office buildings.

ED/A&E's usually have their own surgical facilities. They also require very fast laboratory work for blood-typing, measurements of drug levels in overdose, and so on, so they may have separate lab facilities, or first priority when using shared labs.

Non-emergency use

In the United Kingdom, it has become more popular to visit the A&E since it became mandatory for patients to be fully treated and discharged from the department within four hours of arrival. Also, the introduction of the new contract for primary care physicians in that country decreased the accessibility of general practitioner (GP) services. Under this contract GPs can opt out of on-call cover, and patients sometimes present instead to the A&E.

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