Study objective Communication is commonly understood by health professional researchers to consist of relatively isolated exchanges of information. The social and organizational context is given limited credit. This article examines the significance of the environmental complexity of the emergency department (ED) in influencing communication strategies and makes the case for adopting a richer understanding of organizational communication. Methods This study draws on approximately 12 months (1,600 hours) of ethnographic observations, yielding approximately 4,500 interactions across 260 clinicians and staff in the EDs of 2 metropolitan public teaching hospitals in Sydney, Australia. Results The study identifies 5 communication competencies of increasing complexity that emergency clinicians need to accomplish. Furthermore, it identifies several factors—hierarchy, formally imposed organizational boundaries and roles, power, and education—that contribute to the collective function of ensuring smooth patient transfer through and out of the ED. These factors are expressed by and shape external communication with clinicians from other hospital departments. Conclusion This study shows that handoff of patients from the ED to other hospital departments is a complex communication process that involves more than a series of “checklistable” information exchanges. Clinicians must learn to use both negotiation and persuasion to achieve objectives.