Friday, February 14, 2003

Emergency Preparedness and the Pareto Optimum—How shall we balance the Community’s and Our Well-Being?

This column is being written as we at Maimonides are identifying 100-150 volunteers for smallpox vaccination. You are reading it as you have completed the work of vaccinating your own volunteer cadre. Together, you, we and hospitals across the nation have vaccinated approximately 400,000-500,000 individuals who will make up hospital based smallpox response teams. Since September 11, 2001 emergency preparedness activities—always part of emergency medicine—have occupied an evermore central aspect of our professional lives as we realize that the over-crowding in our ED has serious implications for our ability to deliver surge capacity in the event of a mass casualty event. Then too, regulatory mandates from the Joint Commission and others have required increased attention to planning and training for emergency response to community needs which may be a small, isolated spill of a hazardous material on a nearby roadway or the consequences of international terrorism.

Over two years ago I wrote about the pareto optimum in the context of the “Leading Beyond the Bottom Line (LBBL)" thesis articulated in a series of articles in The Physician Executive a publication of the American College of Physician Executives. In brief, LBBL suggests that for physicians to act evermore as managers is a failed approach that vitiates the physician’s unique role in healthcare. The physician-executive authors of the LBBL approach assert that rather than assure profit, the health care entity must reach a pareto optimum among: financial health, patient care, employee well-being and community commitment.

I cite LBBL now, because like you I’m seeking a principled framework upon which to address the legitimate need for emergency preparedness at this time of economic uncertainty compounded by the apparent variance of appropriate emergency preparedness efforts from traditional public health principles. Invoking patriotism as the rationale puts me in an uncomfortable position apropos Samuel Johnson’s, “Patriotism is the last refuge of the scoundrel.” I’d like to believe that when volunteering for smallpox vaccine and thereby accepting some personal risk to health and well being we’re motivated beyond patriotism perhaps by our individual professional understanding of our community commitment.

Thus as I reach out to generalize around the question of resource allocation, “Are we doing the best we can with the resources we have?” I acknowledge that whether it’s money, time or space allocated to vaccinating hospital staff rather than caring for fragile elderly this winter season, we’re making choices. How can we make the best choices for our patients, our hospital, our community and ourselves? It’s here that the principles of transparency and engagement come to the fore. By clearly understanding everyone’s motivations, goals and rationales and engaging all parties in broad discussion we can make the best choices given the present circumstances.

Last month in this column I discussed developing equity and leaving a legacy through the emergency physicians’ efforts in support of his or her hospital. Participating with hospital leadership in the formulation of the hospital’s strategy for emergency preparedness is such an effort. The hospital must decide whether emergency preparedness will for example be limited to that required by regulation, to creation of a community resource, development of a programmatic effort intended to serve as an example in the region or reach some other level of engagement. Regardless, informing your colleagues and then discussing the various views within the emergency physician group should be your first step. While the decision to volunteer for smallpox vaccination is a personal decision, the degree of group support for the hospital’s emergency preparedness efforts should fit with the practice’s overall relationship with the hospital.

But hospital administration by itself should not be the sole caretaker of community relationships. Yes, patient care in the ED is a fine opportunity for focused educational interventions related to smoking cessation, wearing of seat belts, bicycle helmets, drown-proofing children and the like; but it is insufficient for truly building ties with the broader community. If you are part of your hospital’s and the general medical staff’s community outreach efforts that’s fine, but if not then it is likely you don’t understand what your community expects from the hospital in general and the ED in particular, especially with respect to emergency preparedness. Yes, there are reliable certainties: ready quality care with little waiting, but stating the truism doesn’t address the community concern regarding emergency preparedness in these times. If you let others do the communication for you, you’ll have to rely upon their analysis of community expectations and risk assessment.

When I started at Maimonides Medical Center, I let others meet on my behalf—on the emergency department’s behalf—with the volunteer ambulance organizations and other community groups. Meeting with those groups was always stressful and I was always prone to defensiveness. Learning to listen to individuals, to reach for a common understanding—sometimes by adopting a suggestion, or sometimes by “studying” an idea to death gave each of us credibility with the other. Over time we’ve come to see each other as allied on behalf of our patients and readiness for service to the community. Our volunteers have been most reasonable. When space for two, not four decontamination showers was identified, they supported our effort because two was better than none. Emergency physicians, not just hospital administrators, participated in the discussion.

Thus, I encourage your internal efforts with your administrative and nursing colleagues, but what have you as a hospital and as an emergency physician practice done to learn of your community’s expectations for your response to their needs—to their fears? Those of us who came of age in the 1960’s and 1970’s or in the early days of emergency medicine know the power of organized communities. Reach out to your community, seek partners in planning emergency preparedness—the JCAHO now requires it. Some time spent with lay people in your community will help you reach the pareto optimum for your emergency preparedness efforts and validate your personal and practice’s contributions as both equity building and patriotic.