The Advanced Emergency Nursing Journal launch occurred just after the Institute of Medicine (IOM) released a series of reports entitled "The Future of Emergency Care in the United States Health System" in June 2006. These reports note that not only is Emergency Department (ED) volume increasing across the country, but patients coming to the ED are older and sicker, and require more complex and time-consuming workups and treatments. According to one of the IOM reports, "Hospital-based Emergency Care: At the Breaking Point," nearly 114 million patients visited EDs in the United States in 2003, a 26% increase from the 90.3 million ED visits in 1993. At the same time, the number of EDs decreased by 425 and the number of inpatient beds decreased by 198,000 (Institute of Medicine, 2006). The additive effect of these factors is serious ED overcrowding and resultant quality and safety concerns for patients. Adding to the problem is a shortage of clinicians to care for all of these patients. Following closely on the heels of the IOM report, the Center for Workforce Studies (CFWS) published "The Emergency Care Workforce in the U.S." in August 2006. According to this report, in 2000 there were approximately 95,000 nurses working in U.S. emergency departments. Although that sounds like a lot, it is not enough. The report estimates that the ED is the third most common source of RN openings and accounts for 12% of all open RN positions in U.S. hospitals. In addition, although emergency medicine is a popular specialty for U.S. medical students, the demand for ED physicians is still expected to exceed the supply over the long term (CFWS, 2006). These issues are not a surprise to those of us in the trenches providing emergency care, educating emergency nurses, creating new systems of care, ever-increasing number of legal and regulatory requirements. As advanced practice nurses, we are well positioned to help solve these problems. In the position statement, "Advanced Practice in Emergency Nursing," the Emergency Nurses Association (2003) states

These issues have created a need for innovative and cost effective approaches to the care of emergency patients. Advanced practice registered nurses have a broad depth of knowledge and expertise in their specialty area and manage complex clinical and systems issues [horizontal ellipsis] In addition, an advanced practice emergency nurse is uniquely prepared to develop and apply theory, conduct research, and develop standards of care that enhance patient outcomes.

The implications for the 4,500 advanced practice nurses (primarily NPs and CNSs) working in EDs (CFWS, 2006) is obvious---our work is cut out for us. However, after years of trying to "do more with less," we know that we have to work smarter, not harder. The current situation coupled with an appropriate emphasis on evidence-based practice ensures that constant change will be a way of life in emergency care for the foreseeable future. We hope this issue of the journal provides you with information and ideas to meet these challenges head-on.

"Everything flows, nothing stands still."

K. Sue Hoyt, RN, PhD, FNP, APRN,BC, CEN, FAEN

Emergency Nurse Practitioner, St. Mary Medical Center, Long Beach, CA

Jean A. Proehl, RN, MN, CEN, CCRN, FAEN

Emergency Clinical Nurse Specialist, Dartmouth-Hitchcock Medical Center, Lebanon, NH

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