key: cord-0748907-fooe0t0i authors: Sivashanker, Karthik; Mendu, Mallika L.; Wickner, Paige; Hartley, Tricia; Desai, Sonali; Fiumara, Karen; Resnick, Andrew; Salmasian, Hojjat title: Communication with Patients and Families Regarding Healthcare-Associated Exposure to Coronavirus 2019: A Checklist to Facilitate Disclosure date: 2020-05-08 journal: Jt Comm J Qual Patient Saf DOI: 10.1016/j.jcjq.2020.04.010 sha: 52818b2c16976eddf4bc139a813d618e5e8ab4d1 doc_id: 748907 cord_uid: fooe0t0i nan As the novel coronavirus 2019 (covid-19) pandemic unfolds, health care institutions will need to grapple with the challenge of notifying patients and their family members about possible or known exposures to the virus. This task will become increasingly monumental as the virus rapidly multiplies within communities. It will be critical for health care organizations to use a standardized, robust, and clear communication strategy to notify and guide patients in the ambulatory setting. Each organization will need to identify a disclosure team with the capacity to respond rapidly to clinical questions about symptoms and prognosis; to instruct patients on containment strategies; to provide supportive responses to emotional distress; to help patients and their families connect with resources they need to adhere to recommendations such as wearing masks, self-quarantine, and diagnostic testing; and to systematically track and notify at-risk patients and those proximally associated with them. We have developed a pragmatic covid-19 exposure disclosure checklist (see Table 1 ) to standardize the disclosure process and ensure that all key areas are considered in every conversation. There are five core competencies that are critical to facilitating an effective covid-19 exposure disclosure conversation: clinical, infectious disease, risk management, language, and psychosocial (see Table 2 ). Skill in cultural sensitivity, clear communication, and emotional intelligence is also helpful. These competencies are embedded in the checklist, which is simultaneously a list of reminders, a sequence of steps to facilitate a natural flow of information, a diagnostic tool to assess risk, and a treatment of prescribed next steps based on current best practices. This checklist is intended to facilitate a clear and consistent disclosure process that reduces inconsistencies and, hopefully, improves patient safety and outcomes. 1 Facilitators should be quickly trained in the use of this checklist and can lean on the sample scripted language to respond to patients and families in a sensitive manner. For more complicated situations, domain experts can fill in gaps in knowledge or skills. Given variation in personnel across institutions, it is important to establish which departments (e.g., occupational health, infection control, quality and safety, human resources) will be responsible for communicating with and supporting patients and families that have potentially been exposed. As a first step, a system for tracking exposed patients and family members should be created and staff should be assigned to investigate the details of the actual exposure. These details should then be entered into the tracker to facilitate a smooth disclosure process. Key elements to include regarding the exposed patient or family member are their name, phone number, date of birth, medical record number, demographic information, preferred language, contact information, history of prior covid-19 exposure, and documented or reported covid-19 testing and results. For the source of the exposure, elements to include are the individual's title/role and the date they were identified as positive. Information should be tracked regarding the location and the date of the exposure event and the last day of the incubation period. Finally, all aspects of the outreach process should be tracked and then documented in the electronic health record, from the time of first outreach, to the modality used (e.g., email, phone), to the final outcome. At our institution, to avoid further exposure and facilitate rapid disclosure (i.e., within 24 hours of the exposure), phone calls are the preferred means of communication. Use of interpreters, notification of the patients' primary care doctor, activation of social work, and any other interactions with other services should also be noted. When communicating health care-associated exposures to covid-19, standard disclosure principles and practices apply. [2] [3] [4] [5] [6] The goal of the disclosure process is to encourage open dialogue and a safe space for venting, conflict, and resolution, with appropriate use of mediation and apology. To illustrate how the checklist might be used in the context of a flexible conversation, consider the following hypothetical and generic covid-19 disclosure. After the initial introduction, staff should be ready to answer the most commonly asked questions (e.g., "what's my risk of dying?"), to empathically hold patients' and their families' anxiety (e.g., "we're in this together and we're going to do everything we can to walk you through this process"), to apologize when appropriate (e.g., "I'm so sorry that this happened in the course of receiving care with us"), to give clear instructions on next steps (e.g., "for your safety and others, we recommend that you isolate yourself…I'm going to explain what this means and how to do it"), to ask about psychosocial needs (e.g., "are there any resources you need, or are at risk of losing, that may make it difficult to follow our recommendations?"), to ask about other at-risk individuals in the home (e.g., "are there any older or immunocompromised people in the house"), to assess for overcrowding (e.g., "do you have space in your household to stay 6 feet away from others at all times?"), and to offer resources when indicated (e.g., "a social worker will be reaching out in the next 24 hours to talk about available resources"). Early on in the disclosure process, organizations should consider assigning the role to more senior staff members who can use their experience to examine strategies and navigate the unexpected. There is no checklist that can account for the wide-ranging variation of human reactions to stress. In their responses, patients and their families may be suspicious (e.g., "I think hospitals are deliberately infecting patients"), hostile (e.g., "You can't make me do anything!"), or even flippant (e.g., "This will all blow over soon"). Patients may also raise unique challenges that have no clear answers-such as how they can avoid exposing their young children if they are the sole caregivers and have no support, or how they can self-isolate in a crowded household with no alternatives for housing. It will be important for staff to observe how more experienced facilitators move on and off script in mediating these situations through improvisation, de-escalation, re-direction, and other techniques. Developing and training a team to perform disclosures ensures a more consistent and reliable process than having the providers who have cared for the patient do the outreach. Although the therapeutic relationship of the latter may be of some benefit, it is critical that accurate information is conveyed and that all questions are correctly answered. This is in contrast to patients admitted to the hospital where it makes more sense for the patient's providers to perform the disclosure rather than having an unknown person interrupt the continuum of care. The disclosure team should still consider offering guidance to the inpatient team to encourage a consistent process. This may be especially helpful when the disclosure involves surrogate decision-makers and other complexities. Organizations should prioritize public health, transparency, and equity over concerns for medico-legal risks to the organization. While it is possible that some complaints may emerge from this crisis related to health care organizations exposing patients to covid-19, there is a broad consensus that this is a highly transmissible disease that may be difficult to contain, even with strict adherence to best practices and protocols. Patients and staff will almost certainly get infected in the course of delivering and receiving health care. It is the responsibility of health care institutions to prioritize prevention efforts and to be fully transparent with patients when transmission occurs to maintain the public trust. It is the responsibility of patients and their families to take this pandemic seriously and to protect themselves, their loved ones, and their providers by following the recommendations of their providers and public health officials. Staff should be prepared to use an interpreter based on the patient and their family's language preference with consideration for health literacy (e.g., "I'm calling with an interpreter on the line. Is it okay if we continue or do you prefer another language?"). Written instructions in the preferred language may also be handed to the patient (inpatient) or mailed/emailed (outpatient). Although language preferences are not always reliably recorded in the medical record, checking the medical record before calling the patient may save time. Use of bilingual staff may also be considered, depending on availability of staff and the patient population. U.S. health care institutions should pay special attention to reassuring undocumented and immigrant patients that their information is protected and that their exposure status will not be communicated to immigrations and custom enforcement (ICE) by health care officials. This population of patients may disenroll from health services and other government programs from fear that the government might deny their green card or visa application (i.e., public charge rule). 8 Most individuals in this population do not need to worry about the public charge rule and should be encouraged to seek medical care for covid-19 and to utilize available services when indicated. 8 Appreciating the wide variability among health care institutions and the populations they serve in the United States and abroad, organizations will need to adapt the checklist to their needs. For example, an organization caring for people with disabilities may spend more time asking about possible disruptions in their disability services. A mental health organization may instead focus on whether patients are able to get their prescription psychotropic medications. Yet, for both of these organizations, asking about psychosocial needs and offering resources is critical and cannot be overlooked. The steps outlined in this checklist were developed based on consensus expert opinion and are currently being employed at our institution. We are using an ongoing patient tracking and contact program that will inform the utility of the checklist. Although the checklist has not been formally studied with respect to impact on outcomes, we believe it can serve as a blueprint for other institutions tackling the spread of covid-19. Depending on the infrastructure of your organization, a decision should be made on which department is best suited to facilitate and support exposure disclosures to your patients and/or visitors. Verify that the people selected to be on the disclosure team have undergone prior training. Consider using a "see one, do one" approach by pairing senior staff members to lead and junior staff members to observe and then practice. Provide a transparent, open disclosure to the patient and/or visitor. The general location and date of the exposure may be shared, but specific identifying information regarding the affected provider should be kept confidential. Ensure the disclosure is performed in the patient's primary language, with medical interpreters available, at the appropriate literacy level, as necessary. Offer reassurance that you are here to help them navigate through the best next steps, and to connect them with the resources they need. If unable to reach the patient, stop checklist and document the attempt in the medical record. We recommend at least 3 documented attempts spaced at least 24 hours apart before terminating outreach efforts. Suggested communication: "My name is ____ and I'm calling from ____ . I want to make you aware that an employee who cared for you/your loved one on [Date/Time] has tested positive for covid-19. Because you were in close contact with this person for more than 15 minutes, there is the potential that you were exposed. To assist you with the next steps, we have information, resources, and support tools available to ensure you and your loved ones have the support you need." Review symptomo logy 2 If patients are not experiencing any symptoms or only mild (sore throat, cough, fever, etc.) symptoms, emphasize the importance of isolating themselves for the next 14 days. This includes protecting family members from exposure. Staying physically away (6 to 8 feet) from others as much as possible 1) Utilizing a separate bedroom and bathroom if possible 2) Utilizing separate household items (such as towels, utensils and personal items) whenever possible 3) Limiting contact with pets 4) Avoiding personal household items 5) Cleaning high-touch surfaces daily Checking temperature twice daily and self-monitoring for symptoms Assess the home situation for overcrowding and the presence of elderly, immunocompromised, and other individuals at high risk of harm if exposed. For some patients, it is not possible to practice physical distancing in their living space (e.g., those living in crowded homes). Patients should consider relocating to a temporary residence (e.g., rental, hotel) if they can afford it or if provided by their employer or other source. On the other hand, keep in mind that isolation may present a significant financial and social burden to some patients. Be sure to ask if there are any resources the patients needs to ensure they can safely and effectively quarantine themselves. If yes, direct them to resources outlined in Step 6. Explain that, should the patient become symptomatic, they may need to be tested for the virus. Depending on the health care system communicating the disclosure, instructions around testing may vary. If, during the disclosure, the patient or family member informs you that they have already tested positive for the virus, ensure they understand the isolation guidelines prescribed earlier and that they are referred to a primary care doctor for further management. Most important, make sure the instructions are clear and the patient has the resources they need, such as transportation, for testing to take place, and access to primary care, if necessary. If patient does not have the resources required, direct them to the resources listed in Step 6. Suggested communication: "To be extra careful, there are several steps you can take to help limit the spread of this disease. The most important is isolating yourself as much as possible for the next 14 days. This means staying physically away from others, including your pets, using a separate bedroom and bathroom than others in your household, avoiding personal household items, and cleaning surfaces in your house that you touch routinely daily." "If you develop any of the symptoms we discussed, we recommend that you get tested. Please write down this number _____to order and set up a time for you to get tested. The testing site is located at X." [If tested positive] "I'm sorry to hear you have tested positive. In addition to the guidelines I described earlier on how best to prevent the spread of disease, I also recommend you connect with a primary care doctor, so they can assist you with management. Would you like me to reach out to your primary care doctor on your behalf?" If severe symptoms (skip if If the patient or their family member is experiencing severe symptoms (shortness of breath, fever, etc.), ensure that the patient can be Have prepared a list of local resources that may be able to assist patients with a variety of needs. Should a patient/visitor voice a concern related to any of the items below, be sure to communicate how they are best able to access the resources they need. Consider having the contact information for your institution's Social Work and/or Care Coordination department available for additional assistance. The Checklist Manifesto A system of medical error disclosure. Quality & safety in health care Disclosing adverse events to patients: international norms and trends 7-8. for Disease Control and Prevention. Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (CODID-19) A system of medical error disclosure Suggested communication: "If any other questions or concerns arise, you can always call X for more information and support. We'd also like to contact your primary care provider to update them." * Guidance provided by World Health Organization and Centers for Disease Control and Prevention may evolve over time and should be referenced for updates.