Communicating During a Crisis: What a Hospital ......The crisis/emerging infectious disease (EID)...

© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM

Communicating During a Crisis:

What a Hospital Epidemiologist

Needs to Know Yoko Furuya, MD, MS

Medical Director of Infection Prevention & Control

and Hospital Epidemiology

New York-Presbyterian Hospital


Take-Home Messages

You will increasingly be confronted with EIDs

Length of the pre-crisis phase of the CERC lifecycle will vary;

advance planning is key

Integrate a crisis communication plan into your overall

preparedness/operational plan

Transition from pre-crisis to initial phase must happen quickly

Remain sensitive to audience when developing crisis

communications

Use multiple avenues of communication that are transparent

Communications must balance the factual and psychological needs

of stakeholders


You Can Never Overcommunicate:

Be Thorough!

Staff Locations Hospital Leadership Other

All staff EDs Your boss! Health Departments

Medical: - All - Housestaff - Infectious

Diseases - Other

subspecialties? (OB)

Ambulatory ICU

Emergency Management/Incident Command Structure

EMS Medical Examiner

Patients

Nursing

Respiratory Therapy

EVS

Security

Registration staff

Laboratory

Transport

Materials Management

Occupational Health

Risk Likelihood No. Affected Severity Vulnerability

Total

Risk

MDRO

MRSA 7 6 2 3 252

VRE 6 5 3 2 180

CDI 8 7 6 5 1680

CRE 9 2 9 7 1134

Device

CLABSI 6 4 8 3 576

CAUTI 8 7 2 3 336

VAE 5 4 7 4 560

Regulatory

tJC 10 10 2 5 1000

Emergency

Pandemic

flu 1 8 10 10 800

Lab related 1 1 10 10 100

Unknown 3 8 8 8 1536


Why Should Hospital Epidemiologists

Respond?

Scenario #1

Obvious risk for nosocomial transmission

Scenario #2

Even if no concern for nosocomial transmission

Generally, Infection Prevention and Hospital Epidemiology are

seen as hospital experts on creating policies, procedures, and

processes related to infectious diseases

Many of these are or become crises

Effective communication is crucial during a crisis

Immediate action is needed

People process information differently during a crisis


Crisis and Emergency Risk

Communication (CERC) Lifecycle

Pre-Crisis Initial Maintenance Resolution Evaluation


Advance Planning Stage

When you recognize an emerging infectious disease is

coming at a local, national, or international level

Often heralded by a CDC or Health Department alert

Examples: measles outbreak in Disneyland; MERS-CoV;

Zika

Ebola outbreak spreading in West Africa?



What Do You Do?

Predict and address scenarios you might face at your

institution

Predict questions you may get asked and prepare answers

Develop consensus recommendations by experts

Draft initial messages (details can be filled in later)



What Do You do?

Identify resources and mechanisms for communication Recognize which groups you need to connect with as the crisis emerges

Build relationships with key groups/opinion leaders to ensure unified

communication later on

Integrate a crisis communication plan into your overall

preparedness/operational plan Emergency management/incident command structure?

Internal Communications group?

Have an expedited process for approvals and dissemination



Pitfalls

CDC Stacks: 2014 Ebola outbreak in West Africa Graph 1


Not recognizing a

coming crisis early

enough

Like many others, we

did little to prepare for

Ebola until the CDC

HAN in late July 2014

WHO declared

Public Health

Emergency of

International

Concern 4000

14000

12000

10000

8000

6000

2000

0 Mar 14

Total Cases, Guinea

Total Cases, Liberia

Total Cases, Sierra Leone

Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15


Pitfalls

The crisis/emerging infectious disease (EID) hits your local area

(or perceived as a strong possibility)

There may be little to no time between the pre-crisis and initial phase

Or you may not recognize the pre-crisis phase at the time

Examples:

Local measles outbreak is recognized

CDC recommends Zika testing for returning travelers from certain countries

Ebola, July 28, 2014

First CDC Health Advisory warning of increased risk for travel-related Ebola in

the US (first case in Nigeria imported from Liberia; Ebola in 2 US health workers

in Liberian hospital; Recommendation to start screening for travel and symptoms



Initial Phase: Can Have

Different/Escalating Levels of Crisis

“Ebola is diagnosed in Texas, first case found in the US”

- The New York Times, September 24, 2014

“Texan healthcare worker diagnosed with Ebola as

CDC suggests breach of safety protocol”

- The Guardian, October 12, 2014

“NYC officials try to calm public fears after Ebola diagnosis”

- ABC News, October 23, 2014



QUICKLY Create/Modify Messages

Engage key stakeholders in creation of messages

Multiple different levels of communication depending

on audience

Clinical vs non clinical (e.g., environmental services, security,

materials/waste management)

Hospital leadership vs frontline staff

ED vs ambulatory vs ICU



What to Message: Audience Specific

For Staff

5 W’s (who, what, where, when, how)

What is going on

What do they need to do

What the hospital is doing to prepare




For Hospital Leadership

Big picture

What you’re doing to prepare

Risks and vulnerabilities

Potential issues from patients or media




For Patients

What you’re doing to prepare

What they can expect

What can they do




For External Partners

Have a protocol to alert local Health Department Authority

Who?

How?

When?

Phone number to contact?

May need a plan for hospital transfer (EMS), removal of remains

(Medical Examiner)



University of Nebraska Internal Communications

Plan: Ebola Communications Success Story

Types of communication:

Letter to patients signed by president/CEO

Staff Q&A

Memo to staff about the plan

Talking points memo for leadership

Weekly update memo

Relied on advance planning and transparency


Multipronged Communication Plan

Hospital intranet

Email memos

In-person meetings/

huddles

FAQ/Q&As

[The dreaded] town hall

meeting

Social media?

Protocols & Screening

Tools

• Ambulatory Ebola Preparation

and Screening Guidelines

• Emergency Department—

Suspected Ebola Algorithm

2/25/16

• Suspected Ebola Screening

Tool 2/25/16

• Ebola Personal Protective

Equipment (PPE) Training

• Patient Registration Drill

Survey

• Registrations Drill Materials

10/20/14

• Ebola Door Sign

• Ebola Clinical Bulletins to

Date

Ebola Updates For All Staff

& Physicians

• Ebola Update #6 For All Staff

and Physicians 11/11/14 –

11 AM

• Ebola Updates For All Staff

and Physicians To Date

• Ebola Key Personnel

Presentation 10/20/14

Ebola Staff Questions

& Answers

• Ebola Staff Email Questions

and Answers 11/13/14

• Ebola Staff Email Questions

and Answers To Date

• Email Address for Staff

Questions

Human Resources Policies

& Updates

• Interim Policy for Travel to an

Ebola Affected Country

• Ebola-Related Travel

Directive for HCW #2

• HR-Related Ebola Staff Email

Questions and Answers

11/21/14

• Ebola-Related Travel

Directive for HCw #1 Ebola

Door Sign

• Ebola Clinical Bulletins to

Date


Q&A – In Person or by Email

I work in the Cath lab. Should our staff screen

patients for Ebola?

Should surgical masks be placed at the entrances

of ambulatory sites?

What arrangements are being made for staff whose head or

hair cannot be accommodated by the current size of face shield?

There have been references about the Texas nurse who is now

infected with Ebola having committed a “breach in PPE protocol.”

Are there any further details about how this breach occurred?


CDC’s 6 Core Principles of CERC

Be first

Be right

Be credible

Express empathy

Promote action

Be respectful


Be First.

The first message carries the most weight

If you don’t communicate it, then it didn’t happen

(as far as people are concerned)

If you don’t get out first, then someone else will

Hospital epidemiologists are important spokespeople


Be First: WHAT TO DO

Monday, July 28, 2014

First CDC Health Advisory warning of increased risk for travel-related Ebola in the US

(first case in Nigeria imported from Liberia; Ebola in 2 US health workers in Liberian

hospital; Recommendation to start screening for travel and symptoms

CDC released PPE recommendations for US hospitals

Friday, August 1, 2014

We released our first Ebola clinical bulletin with:

Situation update

Clinical signs/symptoms

Personal protective equipment (PPE) recommendations

Laboratory testing recommendations

“Please be aware that this is an evolving situation and we will continue to keep you

updated”

Helpful to have templates ready

No need to reinvent the wheel (use CDC/Health Department memos

as basis)


Be First: PITFALLS

Perfect is the enemy of good

ID/hospital epidemiologists may not be good at this (too detail-oriented,

perfectionist)

The first message doesn’t need to have all the answers

Don’t wait weeks to get something out

Remember to tell staff what the hospital is doing to prepare (not just what they

need to do)

Too many layers of review/approval (large institutions)

May need to create expedited channels for reviews, approvals, and pushing

messages out

Mixed messages from different groups

If don’t align with key opinion leaders from the beginning (e.g., ED leadership,

critical care leadership, etc.)

Consider creation of workgroups


Be Right.

This can be hard in an EID (by definition an evolving

situation)

Say:

What’s known

What’s not known

What’s being done to fill in the gaps

Could be as easy as saying “We’re working closely with

experts in the health department”

*Note: Easier to express uncertainty/shades of gray

verbally than in written memo


Be Credible.

Be honest and truthful

Strive to be honest and transparent, not overly paternalistic

Aim to reassure but acknowledge that we have more to learn

PITFALLS

We tend to oversimplify when trying to calm concerns

and fears

We said that healthcare workers in the US were

very unlikely to get Ebola, based on limited data (!)

Avoid being overly dogmatic if uncertainty exists


Express Empathy. Be Respectful.

WHAT NOT TO DO:

Original Ebola plan: patient would be admitted to medicine service

with ID attendings and medicine housestaff

Monday, October 13, 2014: meeting scheduled with housestaff to

reinforce plan, Q&A

Sunday October 12, 2014: first US transmission to healthcare worker

(nurse in Texas)

Monday meeting:

Last minute decision was made to exclude trainees from caring for

suspect/confirmed Ebola patients

No plan in place for who would admit the patient

I was honest and transparent: The situation has changed. Exclude trainees.

We will work on a plan.

BUT: people were angry and afraid



Don’t dismiss people’s fears

Be cautious using humor in times of crisis

Emphasize what you’re doing and that you’re there to

help and support the people and processes

Humanize the preparedness response



WHAT NOT TO DO: Mistakes

I completely underestimated people’s fears

I wasn’t prepared to answer “What if a patient comes in today?

Tonight?”

THE SOLUTION

Express empathy: “We understand that people are afraid.”

Statement of commitment (even if details/logistics are unclear)

“We (ID/hospital epi) will be here, no matter what. We will take care

of the patient.”


Promote Action.

Create clear protocols for different groups and locations

Remember to think about all relevant parties

Success story: Nebraska Medicine

Developed a series of enduring of webinars on relevant topics:

What to do in the emergency department with a possible Ebola

patient

Considerations for infection control

Transporting patients with Ebola

Testing and transport of laboratory samples

Clinical care of an Ebola patient

Managing Ebola virus contaminated medical waste


Reality Checks!

All the advanced planning in the world can fall apart in light of a

true crisis be flexible

Be prepared for anger, criticism, adversarial interactions during

a crisis

Remember that people are upset and afraid

Don’t get defensive, be humble

Leader as spokesperson

Effective communication can influence behavior and even be life-saving

It’s not only what you say but how you say it

You might be wrong

If so, be honest

Be prepared for many “what if” questions


Additional Resources

CERC: Leader Pre-Event Checklist

The following are keys to successful crisis communication.

Discuss these with your communication director

I know:

Publication information and media response is perceived by us as critical to our operational

success

Spokespersons (by topic) are identified and trained (e.g., empathy, honesty, commitment)

Crisis Communication plan is integrated into overall operational plan

A written procedure and agreement on clearance procedures is in place

These clearance procedures take 15 minutes or less to accomplish

These clearance procedures ensure accurate information is released

These clearance procedures have been tested in drills/exercises

These clearance procedures allow for authority delegation to speed response

Contact information (including after hours) for primary media is handy to all who need it

Adequate manpower and equipment is set aside to keep a 24-hour media operation going for

up to 10 days

Our information telephone number (hotline) for public inquiries is ready with trained

operators


Additional Resources (continued)

Our response partners are identified and know our communication role and expectations

Our stakeholders are identified and know how we will respond directly to them

We have the capability of holding a national press conference if needed

We can monitor media reports and public inquiries for rumors and respond to rumors in

real time

Strategic National Stockpile communication tools are in place

Our emergency response plan notifies the communication director in first wave of calls/pages

As an important stakeholder, we know our elected officials will want to communicate to

constituents about this crisis and we have a plan to ensure a consistent message is delivered

to the public

Our Internet site can post media and public information materials within 45 minutes of final

clearance

We have an accountability plan to public/media about resource allocations during and after

the crisis such as a web page that shows where disaster response funds are going that is

updated routinely

We can conduct a meaningful town hall meeting during crisis recovery

All potential incident command or department leaders are fully trained in Crisis and

Emergency Risk Communication and understand their role as a spokesperson


Additional Resources CERC: Crisis Leader—First Message Build credibility with these 6 emergency message

components:

1. Expression of empathy (e.g., understand

you are hurt, confused, anxious, frightened):

__________________________________

2. Clarifying facts (Fill in only VERIFIED facts,

skip if not certain):

Who ____________________________

What (Action) _____________________

Where___________________________

When ___________________________

Why ____________________________

How ____________________________

3. What we don’t know: ________________

4. Process to get answers: _______________

5. Statement of commitment:_____________

Finally, check you message for the following: Positive action steps

Honest/open tone

Say “we” not “I”

Careful with early promises (can you do it?)

Avoid jargon

Avoid judgmental phrases

Avoid humor

Avoid extreme speculation


Checklist 4-5. Needs Assessment for Crisis

and Emergency Risk Communication

Planning, Research, Training, and Evaluation

Yes No Does your organization have a crisis and emergency risk communication operational plan for public information and media, partner, and stakeholder relations?

Yes No Have you coordinated your planning with the community or state emergency operation center?

Yes No Have you coordinated your planning with other response organizations or competitors?

Yes No Have designated spokespersons received media training and risk communication training?

Yes No Do the spokespersons understand crisis and emergency risk communication principles to build trust and credibility?

If Your Organization Has a Plan, Does It Have the Following Elements:

Yes No Designated responsibilities for public information team?

Yes No Information verification and clearance procedures?

Yes No Agreements on information release authorities (who releases what, when and how)?

Yes No Regional and local media contact list, including after-hours news desks?

Yes No Procedures to coordinate with the public health organization response teams?

Yes No Designated spokespersons for public health issues in an emergency?

Yes No Public health organization emergency response team after-hours contact numbers?

Yes No Contact numbers for emergency information partners such as governor’s public affairs officer, local FBI public information special agent in charge, local or regional department of agriculture or veterinarian public information officers, Red Cross, and other nongovernmental organizations?

Yes No Agreements and procedures to join the Joint Information Center (JIC) of the emergency operations center, if activated?


Checklist 4-5. Needs Assessment for Crisis

and Emergency Risk Communication

If Your Organization Has a Plan, Does It Have the Following Elements:

Yes No Procedures to secure needed resources such as space, equipment, and personnel, to operate the public

information operation during a public health emergency 24 hours per day, 7 days per week, if needed?

Yes No Identified methods of information dissemination to public, stakeholders, and partners such as websites,

Twitter feeds, e-mail li8sts, broadcast fax, door-to-door leaflets, and press releases, during a crisis?

Message and Audiences

The following are types of incidents that could require intence public information media, and partner communication

responses:

Yes No Infectious disease outbreak (e.g., pandemic influenza, cholera, E. coli infection)?

Yes No Bioterrorism (e.g., anthrax, smallpox)

Yes No Chemical emergencies (e.g., nerve agents, oil spill)

Yes No Explosions (*e.g., explosions, terrorist bombing)

Yes No Natural disasters and severe weather (e.g., earthquakes, hurricanes, tornadoes)

Yes No Radiation emergencies (e.g., dirty bomb, nuclear accident)

Yes No Have you identified special populations, such as the elderly, people who speak a first language other than

English, Tribal communities, and border populations? List any specific subpopulations, such as tribal

nations, persons with chronic respiratory illnesses, and unvaccinated seniors, that need to be targeted

with specific messages during a public health emergency related to your organization.

Yes No Have you ever identified your organization’s partners who should receive direct, information and updates

(not solely through the media) from your organization during a public health emergency?

Communicating During a Crisis: What a Hospital ......The crisis/emerging infectious disease (EID)...

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