Emergency Care at Eisenhower: Level IV Trauma, Triage and More

Featuring: Eric Leroux
Eisenhower's Emergency Department has been recently named as a Level IV Trauma Center. This episode will help the listener understand what that means and will provide suggestion on when to use the Emergency Dept, when to call for an ambulance and other information about emergency care at Eisenhower Health.


Eric Leroux MD MBA, is Vice President and Chief Quality Officer for Eisenhower Health.

He joined Eisenhower in 2018 as an emergency physician. He served as residency core faculty, director of clinical decision support, and director of research. Prior to Eisenhower he was faculty at Georgetown University, where he was junior faculty of the year. Eric completed his undergraduate studies at Princeton University, where he was cum laude and won the top thesis award for his research on HIV/AIDS. He earned his MD at Stanford University School of Medicine, his MBA at the Stanford Graduate School of Business, and also completed residency at Stanford, where he served as chief resident.

He has worked extensively in global health (Ecuador, Kenya, South Africa, Myanmar, Uganda), published and lectured nationally on topics including resource allocation, health economics, trauma, health technology and clinical care. Eric is committed to appropriate utilization of innovative technologies to improve patient care. He is a former professional soccer player and division 1 ice hockey goalie who now prefers to spend his free time playing tennis with his wife (who usually wins) and their three young children. In the role of Chief Quality Officer, Eric will lead efforts to continually elevate and advance our clinical quality, in pursuit of ideal patient care.


Scott Webb: Time is of the essence when we're having a stroke or heart attack or have suffered some sort of trauma. And joining me today to emphasize the importance of calling 911 when we're suffering from acute symptoms or trauma and how the emergency department's recent designation as a level four trauma center benefits patients is Dr. Eric Leroux. He's the vice president in chief quality officer for Eisenhower. Doctor, thanks so much for your time today. We're gonna talk about Eisenhower's Emergency Department and go through some basic things today. Like why we want folks to call 911, things like that. But as we get rolling here, how many patients does Eisenhower's EDC each year?

Dr. Eric Leroux: Throughout the ED on an annual basis, we see about 80,000 patients, which is approximately 220 a day.

Scott Webb: That's pretty amazing, you know, to think of those numbers, 220 a day. Like that seems like a lot of people, like, how do you do that? How do manage all of that?

Dr. Eric Leroux: Emergency care is quintessential teamwork in that involves the physicians, the nurses, transport staff, radiology personnel, medical technicians, unit assistants, a whole team of people sort of orchestrate this symphony, which is sometimes more of a cacophony, depending on the day. But we really do our best to make it as efficient and safe as possible to help serve those 220 patients or so per day.

One other thing, Scott is we have a fairly high amount of seasonality just because of our geography. So in the winter, volumes can swell to over 300 frequently and then the heat of the summer it'll occasionally dip below 200. But the seasonality we're noticing is sort of stabilizing over the last few years, compared to say a decade or go when volumes would really drop off in the Summer.

Scott Webb: That's really interesting. I love some of your word choices there, right? It's really a symphony hopefully most day. And I know that Eisenhower is a certified chest pain center and advanced primary stroke center. So why is that important to community members and what do those designations really mean?

Dr. Eric Leroux: For each of them, they mean something similar in a way, which is that we as a hospital and a department have held ourselves to a high standard of quality improvement and operational clinical care, to achieve, optimal outcomes, both in terms of doing what's right, but also doing it very quickly in these extremely time sensitive situations. Like a stroke, like a heart attack, like a trauma case, for example. And so there are designating bodies that come and evaluate our personnel, our processes, our procedures, our protocols, to see if they adhere to that ideal standard. And so we're proud to hold those designations by the American College of Cardiology, and other accrediting bodies.

Scott Webb: Yeah. In fact, I know Eisenhower is a level four trauma center. So what does that mean exactly? And what services does a level four center provide?

Dr. Eric Leroux: We will officially be designated as a level four trauma center as of October 1st. So it's important just that I emphasize that because that designation is granted by REMSA, Riverside Emergency Medical Services. And so, we have all the processes, procedures, training, all in place and active, but that designation doesn't take effect officially until October 1st. So if somebody calls an ambulance for a traumatic situation between now and then it wouldn't necessarily be brought to Eisenhower, they'd be brought to the nearest official trauma center. After October 1st, they may very well be brought to Eisenhower.

And so what that designation means is that we've met a certain level of standard for our ability to evaluate, stabilize, and resuscitate patients with traumatic injury. And the reason that's important is because trauma care does require some special skill sets, some special equipment at times, special processes and an operational flow that can respond very quickly so that a patient doesn't need to wait if they have. An injury whose likelihood of being treated well is highly dependent on it being done quickly. And so, within the trauma literature and world of trauma care, we talk about the golden hour of trauma care.

Which is that it really comes down to the fact that in the first 60 minutes, what you do has a disproportionate impact on the ability to save or improve someone's life. And so those first 60 minutes are critically important. And part of that is about getting the patient to the nearest trauma center quickly and safely. And then the other element within those first 60 minutes is what happens when you get to that trauma center. So over the past year or so, we've put in place a number of processes to be able to respond very quickly and efficiently and sort of comprehensively to traumas.

Now within the scope of level four, we will be part of the broader trauma system, which is a really important component of trauma is that it's not just about Eisenhower being a trauma center. It's that we're part of the trauma system broadly. So we're connected to all the regional hospitals that are also part of the trauma system so that patients can be transferred, as needed. If they have a more significant injury we can efficiently transfer a patient to a level two trauma center or a level one trauma center. Either of those reflect higher levels of care, where there may be advanced surgical capabilities or other capabilities that are, or beyond the scope of a level four.

Scott Webb: Yeah. And I know that, the designation is new and sort of coming online soon. But the services aren't, you been providing a lot of these services for a long time. So when we think about that framing at this sort of time is of the essence, let's just cover some basics here, when or why should someone dial 911?

Dr. Eric Leroux: What happens when a patient dials 911 say with, an issue that could reflect a trauma or a stroke or a heart attack, is that the paramedics and the entire prehospital response system performs many. Critical functions. So the obvious is that they can participate in the acute resuscitation of the patient. They can actually help clinically, but there's some behind the scenes logistics that are really important as well. So for instance, in the case of a trauma, the pre-hospital personnel, so the paramedics make a phone call that helps coordinate to which hospital that ambulance should go.

And that ambulance then goes to the nearest hospital that has the appropriate sort of resources and capabilities, for that particular patient. So if it's a trauma, for example, the patient can be taken to a hospital that has been designated as a trauma center so that they get to the right place as quickly as possible so they can be resuscitated properly. So that's an often sort of unseen component of calling 911, is that there's a bunch of coordination that happens behind the scene that has a downstream impact.

Now in terms of the question you asked more directly when to call 911, you know, most people I think have an internal sense and judgment if something might be wrong. And so if you feel that you are having any kind of pain or disability that is acute in nature, meaning it's come on suddenly for some reason, or it seems quite severe then calling 911 for paramedics to assist in your acute management and also getting you to the right place is going to be appropriate. And it's hard to say, much more sort of specifics than that because there's so much nuance to it.

But I think if I can just emphasize that the prehospital personnel are highly trained in a whole variety of clinical circumstances and that they will through their connection across the trauma system or a network of chest pain centers that will get the patient to the right place. So that when the patient arrives, the hospital's also been notified, which expedites the workup in management. S o in the case of trauma being illustrative, the charge nurse, or some of the nursing leadership in the emergency department will receive a phone call in advance of the ambulance arriving.

And then different resources and personnel can begin to be mobilized. So when the patient arrives, there's no element of surprise, even though we're trained to deal with surprises, of course, but the room is ready and everyone's ready the minute the patient comes through the door, things happen more quickly. And that's going to lead to better outcomes for chest, for stroke, for trauma, for any severe medical emergency.

Scott Webb: Yeah, as you and I were chatting before we got started here, you know, it's not just a free ride, to the emergency department. There's more to it. The trained personnel taking care of you, notifying the hospital that you're on the way, making sure whether it's stroke or trauma or whatever teams of folks need to be in place, that they're there waiting for you. And I've heard the word triage before, especially I used to watch MASH when I was a kid. So I'm dating myself a bit, but what is triage exactly? And how does it help to prioritize patients that come into the ED?

Dr. Eric Leroux: Triaging is really about making an assessment of how critical each patient is so that the most critically injured or critically ill patients can be seen quickest because they're at the highest risk of decompensating, we might say clinically or getting worse of the highest rates of mortality. And so if we can intervene more quickly on the patients who are sickest, then we have the greatest chance of helping everybody. And so triage is about making relatively quick assessments about how sick someone is.

It's done differently in different scenarios. So in a mass casualty situation, so a War for example, or a very big mass casualty, like a huge earthquake or something. Then there's a lot of triaging that happens even out in the field by the paramedics to figure out who gets taken first to the hospital. Now there's a different level of triage that happens when patients are in the hospital where we try to figure out which area of the ER, they should go to, which rooms they should go to, and who goes first.

And so, we always try to work as efficiently as possible in the emergency department so that patients don't have to wait. It does happen that sometimes patients do wait And that's because it's not a first come first serve environment, because if or when any of us end up in the situation where we need attention right away, we have to make sure we can provide that.

Scott Webb: Yeah. And also maybe you can help us understand just generally when we're there, what can we all expect between triage testing, waiting for results, waiting for our turn, so to speak. Maybe you can just sort of take us through that experience a little bit.

Dr. Eric Leroux: During the course of a patient visit to the emergency department, one will start out by meeting with a nurse typically, if you arrive by private vehicle, let's do that scenario instead of an ambulance. So you'll meet a triage nurse who speaks briefly with the patient about the reason for their visit, some of their background history. Gets an initial sense of a triage level, if you will, but it's not the end of the triage. The next step is to be seen by a physician in triage. So at Eisenhower, we've put in place a process where a physician sees the patient very soon after arrival.

And during that initial assessment, a brief physical exam can be completed, obtaining some more information about what brings someone in and then some initial tests and sometimes treatments can be ordered at that time. So blood work may be ordered an x-ray, maybe a cat scan depending on the situation. And depending on the acuity level, determined in this triage process, the patient may go straight to a room or may wait for a room to become available. And in the background what's going on while that patient's waiting for the room is the blood tests are being run in the lab.

The patient may be taken for x-ray, may go to CAT scan. The radiologist will look at the images and offer, their interpretations. And so on so that when the patient does get taken to a room, much of that data has returned. And the physician who comes to see the patient again and does a more detailed history and physical exam also has a lot of clinical data from the blood work, from sets of vital signs, radiology studies, and so on to make a more informed decision more quickly.

So it is this multi-step process where many different activities are happening in parallel. Even during times when occasionally a patient is sitting and feels very much like waiting and it is like waiting, but during that time, there's a lot of activity going on in the lab and radiology to try to make it all happen. So that we can do a fairly high amount of medical diagnostic workup in as short, a time as possible. Right. So for, let's say, a typical 70 year old patient who comes in with chest pain or abdominal pain.

Which are very common chief complaints in our emergency department. You know, there may be 10 tests that get ordered, dozens of sets of vital signs, and a few the therapeutic interventions or treatments, and all of that happens in the course of a few hours. So it's a lot of medical care. I think it doesn't always feel like it to patients, but if I could offer like comparison to the outpatient world, how long might it take to get, say, CAT scan, MRI, a bunch of blood work etcetera, done in an outpatient setting? It would take sometimes weeks or months, depending on where one lives and the insurance they have.

So, it's always our goal to find efficiencies and to improve the patient's experience in the emergency department, because nobody schedules a visit by the very nature of the work. Nobody wants to be there. And we know that, so, we really try our best to make it as healing and environment as it can possibly be.

Scott Webb: Yeah, I'm sure there aren't many boring days there for you.

Dr. Eric Leroux: No, there aren't and I remember one of the conversations I had with, Dr. Contaxis who's the medical director of the ED. When we were speaking, before I joined Eisenhower, we were just sort of in the interviewing recruiting process, getting to know each other a little bit. And I was working in, DC at the time with Georgetown. And he said, look, we have incredible patient diversity here. And it's really true, in the course of a day, we just see people from all walks of life and all ages. And what's wonderful about what we try to achieve at Eisenhower is that every single person gets the same, highest level of care that we can provide.

We try to give the absolute. Highest level of quality to every single person doesn't matter about any of the other factors, surrounding their life, their circumstance, their disease process is just, we're trying to do our best for all these people across a very diverse life experience. And that's an exciting place to work.

Scott Webb: It definitely is. I was also reading and just doing a little research for this, about the,, accreditation that you've just received recently, the ED has for geriatric patients. So maybe you can talk a little bit about that for seniors. Why that's so important in the Community?

Dr. Eric Leroux: We're quite proud to have achieved this recognition by the American College of Emergency Physicians. And what it means is that we're accredited as a geriatric emergency department, means that we take some special care and consideration about providing optimal care for older patients, because there are some special considerations. Both from like the medical disease process side of things, pain can manifest differently. There's different physiological changes that happen throughout our life.

And we need to be aware of those clinically when we're caring for people of different ages. And similarly, there's other elements of the care environment that we take into account, to make sure that the experience and the quality for older patients is to the highest standard. And so I believe about 6% of emergency departments in the US have received this accreditation. And so we're proud to be among them. It's particularly important to us because not unlike trauma, where we've been seeing patients with traumatic injuries for years, we see a high percentage of patients older than 60.

Because of where we're located. And we get a lot of snowbird travelers. And so we've been sort of offering some thoughtful protocols and clinical care to this demographic for years. And in recent years, ACEP American College of Emergency Physicians has put a lot of effort behind. Developing special protocols for patients older than 65 because it improves outcomes. And so it's becoming a bit of a national movement and I think it's a great thing that's happening. And so we're excited to be on the forefront of excellence in geriatric care.

And I think we're just going to keep getting better and better in this regard because it's our commitment to do that. And also programs like this and being a chest pain center and being a stroke center, being a trauma center, they all have a very strong component of quality improvement, process improvement built into their programs. So it's never just about doing well on a given day, it's about having in place the systems to get better and better month after month.

Scott Webb: Yeah, just always pushing for excellence. Always trying to get better. As we get close to wrapping up here, I wanted to ask you, whether we're talking about the trauma designation or the geriatric accreditation, all the sort of changes, if you will, what kind of changes has that brought? Whether it's, personnel changes, operational changes, what's been going on behind the scenes, I guess?

Dr. Eric Leroux: There's a really dedicated and innovative group of leaders in the emergency department, who, for as long as I've been at Eisenhower have been optimizing and improving. And so , these are steps along our journey that by themselves, don't require us to change course in any kind of drastic way. Because many of the personnel and processes are just part of this continuous improvement culture that's been developed. In the grand scheme, we're proud to receive the recognitions and the accreditations from these programs because they reflect the commitment and the care that we're trying to deliver.

And we're just gonna keep trying to improve. One of the things that has helped advance the emergency department specifically and Eisenhower more generally, over the last decade or so has been the growth of our graduate medical education program, which is residency training. So, Eisenhower's emergency medicine. Residency started a little over three years ago. Our first class just graduated this past. And we graduated six new emergency physicians who were all excellent and all got great jobs and we're really proud to send them out into the world as emergency physicians.

And so programs like this are supported by their efforts, but also there's this feedback loop where it enhances our recruiting ability to attract top talent who then advance these programs and potentially bring in new programs. And it can develop this culture that just kind of feeds itself, in pursuit of constant excellence.

Scott Webb: Yeah, that's awesome. I think that's just a perfect way to end. It's been so great today to learn more about the new designation, the geriatric accreditation, and just in general, how well Eisenhower is doing in terms of the mission, which is saving lives and doing it in a timely, efficient manner, getting that symphony, , all warmed up on a daily basis, handling whether it's a hundred, 200, 300 patients. So really good stuff. Thanks so much. You stay well.

Dr. Eric Leroux: Oh, thanks a lot, Scott.

Scott Webb: That's Dr. Eric Leroux. He's the vice president and chief quality officer for Eisenhower Health. And for more information, go to Eisenhowerhealth.org/ed. And if you found this podcast helpful, please share it on your social channels and check out the entire podcast library for topics of interest to you. This is Living Well with Eisenhower Health. I'm Scott Webb. Thanks for listening. Stay well. Eisenhower Health, healthcare as it should be.