Schwab T, Black S, Cannon Q, Forbush L, Daly S. Evaluating Communication of Public Health Policy and Guidelines to Physicians and Clinic Staff During a Pandemic. Harvard Public Health Review. 2021; 27.

Abstract

Background
Communication overload is a substantial trial during a pandemic. One major obstacle is the overwhelming amount of changing public health guidelines and clinic policies. Strategies for effective communication are vital for disease prevention treatment and control during a pandemic.

Objective
The purpose of this quality improvement initiative was to evaluate different communication methods regarding frequently changing guidelines and recommendations between organizational leadership and multidisciplinary clinical teams.

Methods
During the 2020 COVID-19 pandemic, we performed a longitudinal exploratory analysis focusing on different processes for communication. This quality improvement initiative was conducted from March 2020 to April 2020. A total of 52 primary care physicians and 24 staff members (nurses, medical assistants, case managers) in two separate family medicine residency clinics located in Utah were included. A daily, standardized COVID update Short Message Service (SMS) system was implemented in addition to the regular email updates. Data collection included a pre and post-intervention survey distributed to clinicians and staff.

Results
In post-intervention analysis, clinicians and staff respondents reported an increase in communication effectiveness and satisfaction of 66.5% and 71.3%, respectively (P<.001). Additionally, clinicians and staff respondents reported an increase in feeling safe in the workplace of 49.3% (P<.001). During the intervention period, clinicians and staff members reported a 71.4% and 70.0% decrease, respectively, in experiencing an error or adverse event within the 4-week period compared to the pre-intervention period. 

This study was conducted at the Regional Medical Center, a community hospital in Anniston, AL.  We examined the outcomes of healthcare workers that were in contact with two patients that were asymptomatic during their stay, but were subsequently found to be positive upon discharge. The results of this study provide a better understanding of the risks of SARS-CoV-2 spread in asymptomatic patients with a focus on transmission to healthcare workers.

Conclusions
Implementing a regular SMS messaging communication system during a pandemic may improve communication efficacy, satisfaction, and safety while decreasing unintended errors.

Introduction

Pandemics are generally unpredictable, unavoidable, and potentially catastrophic events.1 During a pandemic or public health crisis, continually updated communication is a vital aspect of quality care and workplace safety.2,3 Frontline clinicians, nurses, techs, and staff are important stakeholders in the prevention, diagnostics, treatment, and control of rapidly spreading diseases.4 The World Health Organization recognizes that skillful communication is an essential component to outbreak control.5 The influenza pandemic in 2009 exposed many deficiencies in guidelines for risk and pandemic communication.Hospital systems, clinicians, and clinic staff rely on federal and local health department for updated guidelines, policy and information regarding epidemiological intelligence during a pandemic.3-5, 7

Our research team performed a review of current literature regarding clinical communication of guidelines and policy during a pandemic and found limited published studies or specific recommendations on mobile technology use.4,8-12 There is currently no data available to clinic leadership or health care workers regarding the potential benefit of using mobile Short Message Service (SMS) messaging as an adjunct method to relay guideline and policy information during a pandemic.

The purpose of this quality improvement initiative was to explore the potential value of using mobile SMS message adjuvant methods to communicate frequently changing guidelines and recommendations between organizational leadership and multidisciplinary clinic teams.

Methods

During the 2020 COVID-19 pandemic, we performed a longitudinal exploratory quality improvement initiative focusing on different clinic processes for communication; which was conducted from April 2020 to May 2020. A total of 48 primary care physicians (5 faculty, 43 residents) and 20 staff members (nurses, medical assistants, case managers) in two separate family medicine residency clinics located in Utah, USA were included. A daily COVID update SMS messaging system was implemented in addition to the regular hospital system email updates. The daily SMS updates consisted of a brief summary of updated changes or additions to government, hospital and clinic guidelines and policies. Data collection included a pre and post intervention survey distributed to clinicians and staff. Survey respondents were asked three ordinal questions assessing efficacy, satisfaction, and safety.  Each of the ordinal questions used a sliding scale from 0-10 (0=Inefficient, 10=efficient; 0=not satisfied, 10=completely satisfied; 0=not safe, 10=completely safe) regarding the communication of COVID policies, guidelines and updates at the time of each survey. The fourth question was a binary question (yes or no options) inquiring whether the respondent experienced an error or adverse event due to communication methods used at the time of each survey. Survey data was analyzed. At the time of the quality improvement initiative, there was no validated assessment tool to specifically evaluate communication satisfaction, efficacy and safety. The intermountain Healthcare Institution Review Board (IRB) reviewed the quality improvement initiative and passed judgment for IRB exemption.

Results

Over a 4-week period, of the 58 participants who completed the pre and postintervention survey, forty-four were physicians (75.9%) and 14 were staff members (24.1%). The survey completion rate was 85.3%. In post-intervention analysis, clinicians and staff respondents reported an increase in communication effectiveness and satisfaction of 66.5% (Pre average 4.72, Standard Deviation [SD] 2.35; post average 7.86, SD 1.80) and 71.3% (Pre average 4.60, SD 2.44; post average 7.88, SD 1.84), respectively (P<.001) (Figure1). Additionally, clinicians and staff respondents reported an increase in feeling safe in the workplace of 49.3% (Pre average 5.66, SD 2.49; Post average 8.45, SD 1.26, P<.001) (Figure 1). During the intervention period, clinicians and staff members reported a 71.4% (n=44; Pre-intervention period=7, Intervention period=2) and 70.0% (n=14; Pre-intervention period=10, Intervention period=3) decrease, respectively, in experiencing an error or adverse event within the 4-week period compared to the pre-intervention period (Figure 2). Self-reported pre-intervention events included personal protective equipment (PPE) use errors, patient visitor policy misunderstanding and COVID testing protocol errors. Reported events during the intervention period included PPE use errors only.

 

Figure 1: Physician and staff combined survey data showing the average rating of communication efficiency, communication satisfaction, and safety at work during the 2020 pandemic (Ordinal scale from 0-10).

 

Figure 2: Results from physician and staff survey date showing the incidence of adverse events experienced at pre and post intervention timepoints during the 2020 pandemic.

Discussion

Based on our literature review, we believe this is the first published information specifically evaluating the value of using SMS messages as an adjuvant method to communicate clinic guidelines and recommendations between organizational leadership and multidisciplinary clinic teams during a pandemic. 

This quality improvement initiative demonstrates that despite extensive email communication of clinic guidelines during a pandemic, direct mobile communication via SMS may result in an increase in efficacy and safety while potentially decreasing the chance of errors. Using daily email methods alone to communicate pandemic guidelines may result in communication overload and inefficiency.4-7 

The initiative results are limited by possible selection bias by using two residency clinics which reduces generalizability. Due to the lack of a validated survey method, there is a possibility for inherent measurement bias. An additional limitation includes possible subjectivity to the potential understanding or definition of “error” or “adverse event” in the fourth question of the survey. Many of the limitations could be mitigated in future studies by conducting a prospective, randomized controlled trial using a validated survey method with a large sample size in multiple diverse clinic settings and locations. Some possible alternative explanations of our findings may include subjects becoming more familiar with guideline changes as the pandemic progressed, caregiver burnout, variability in clinician and staff experience level, and improved email communication content during the intervention timeframe. 

The results of our initiative are consistent with existing data that suggests that communication during a pandemic can be overwhelming and may benefit from different effective communication methods.4,8-12 Doing so may vastly decrease the potential of errors and increase communication efficacy and workplace safety. 

Conclusions

Implementing a regular SMS messaging communication system during a pandemic may improve communication efficacy, satisfaction, safety while decreasing unintended errors. Pandemic guideline communication via email updates alone may be inefficient and increase risk of error.  

References

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  3. Reynolds, B., & Quinn, S. C. (2008). Effective communication during an influenza pandemic: the value of using a crisis and emergency risk communication framework. Health Promotion Practice9(4_suppl), 13S-17S. 

  4. Staes, C. J., Wuthrich, A., Gesteland, P., Allison, M. A., Leecaster, M., Shakib, J. H., … & Pavia, A. T. (2011). Public health communication with frontline clinicians during the first wave of the 2009 influenza pandemic. Journal of public health management and practice: JPHMP17(1), 36. 

  5. World Health Organization. (2005). WHO outbreak communication guidelines (No. WHO/CDS/2005.28). World Health Organization. 

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  7. Bandara, T., Musto, R., Kancir, J., & Neudorf, C. (2020, July). Public health physician perspectives on developing and deploying clinical practice guidelines during the 2009 H1N1 pandemic. In Healthcare Management Forum (Vol. 33, No. 4, pp. 178-181). Sage CA: Los Angeles, CA: SAGE Publications.

  8. Eizenberg, P. (2009). The general practice experience of the swine flu epidemic in Victoria—lessons from the front line. Medical journal of Australia191(3), 151-153. 

  9. Ringel, J. S., Trentacost, E., & Lurie, N. (2009). How Well Did Health Departments Communicate About Risk At The Start Of The Swine Flu Epidemic In 2009? In a critical time frame for worried information seekers, state and local health departments’ responses varied greatly. Health affairs28(Suppl1), w743-w750.

  10. Kotsimbos, T., Waterer, G., Jenkins, C., Kelly, P. M., Cheng, A., Hancox, R. J., … & Thompson, P. (2010). Influenza A/H1N1_09: Australia and New Zealand’s winter of discontent. American journal of respiratory and critical care medicine181(4), 300-306. 

  11. Revere, D., Calhoun, R., Baseman, J., & Oberle, M. (2015). Exploring bi-directional and SMS messaging for communications between Public Health Agencies and their stakeholders: a qualitative study. BMC Public Health15(1), 621. 

  12. Li, J., & Ray, P. (2010, July). Applications of E-Health for pandemic management. In The 12th IEEE International Conference on e-Health Networking, Applications and Services (pp. 391-398). IEEE.

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