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© 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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
Crisis and Emergency Risk
Communication (CERC) Lifecycle
Pre-Crisis Initial Maintenance Resolution Evaluation
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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?
Pre-Crisis Initial Maintenance Resolution Evaluation
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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)
Pre-Crisis Initial Maintenance Resolution Evaluation
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
Pre-Crisis Initial Maintenance Resolution Evaluation
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
Pitfalls
CDC Stacks: 2014 Ebola outbreak in West Africa Graph 1
Pre-Crisis Initial Maintenance Resolution Evaluation
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
Pre-Crisis Initial Maintenance Resolution Evaluation
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
Pre-Crisis Initial Maintenance Resolution Evaluation
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
Pre-Crisis Initial Maintenance Resolution Evaluation
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
Pre-Crisis Initial Maintenance Resolution Evaluation
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
What to Message: Audience Specific
For Hospital Leadership
Big picture
What you’re doing to prepare
Risks and vulnerabilities
Potential issues from patients or media
Pre-Crisis Initial Maintenance Resolution Evaluation
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
What to Message: Audience Specific
For Patients
What you’re doing to prepare
What they can expect
What can they do
Pre-Crisis Initial Maintenance Resolution Evaluation
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
What to Message: Audience Specific
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)
Pre-Crisis Initial Maintenance Resolution Evaluation
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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?
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
CDC’s 6 Core Principles of CERC
Be first
Be right
Be credible
Express empathy
Promote action
Be respectful
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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)
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
Express Empathy. Be Respectful.
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
Express Empathy. Be Respectful.
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.”
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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?
© SHEA 2016 SHEA/CDC OUTBREAK RESPONSE TRAINING PROGRAM
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?