Critical Thinking: Imagine that you have been charged with transforming the performance of a team at your workplace

1Al Knawy BA, et al. BMJ Open 2019;9:e017476. doi:10.1136/bmjopen-2017-017476

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Perceptions of postoutbreak management by management and healthcare workers of a Middle East respiratory syndrome outbreak in a tertiary care hospital: a qualitative study

Bandar Abdulmohsen Al Knawy,1 Hanan M F Al-Kadri,2 Mahmoud Elbarbary,3 Yaseen Arabi,1 Hanan H Balkhy,4 Alex Clark5

To cite: Al Knawy BA, Al- Kadri HMF, Elbarbary M, et al. Perceptions of postoutbreak management by management and healthcare workers of a Middle East respiratory syndrome outbreak in a tertiary care hospital: a qualitative study. BMJ Open 2019;9:e017476. doi:10.1136/ bmjopen-2017-017476

► Prepublication history and additional material for this paper are available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2017- 017476).

Received 25 April 2017 Revised 24 October 2018 Accepted 11 March 2019

For numbered affiliations see end of article.

Correspondence to Dr Bandar Abdulmohsen Al Knawy; knawyb@ ngha. med. sa

Research

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

AbstrACt Objectives This study examines perceptions of the operational and organisational management of a major outbreak of Middle East Respiratory Syndrome (MERS) caused by a novel coronavirus (MERS-CoV) in the Kingdom of Saudi Arabia (KSA). Perspectives were sought from key decision-makers and clinical staff about the factors perceived to promote and inhibit effective and rapid control of the outbreak. setting A large teaching tertiary healthcare centre in KSA; the outbreak lasted 6 weeks from June 2015. Participants Data were collected via individual and focus group interviews with 28 key informant participants (9 management decision-makers and 19 frontline healthcare workers). Design We used qualitative methods of process evaluation to examine perceptions of the outbreak and the factors contributing to, or detracting from successful management. Data were analysed using qualitative thematic content analysis. results Five themes and 15 subthemes were found. The themes were related to: (1) the high stress of the outbreak, (2) factors perceived to contribute to outbreak occurrence, (3) factors perceived to contribute to success of outbreak control, (4) factors inhibiting outbreak control and (5) long-term institutional gains in response to the outbreak management. Conclusion Management of the MERS-CoV outbreak at King Abdulaziz Medical City-Riyadh was widely recognised by staff as a serious outbreak of local and national significance. While the outbreak was controlled successfully in 6 weeks, progress in management was inhibited by a lack of institutional readiness to implement infection control (IC) measures and reduce patient flow, low staff morale and high anxiety. Effective management was promoted by greater involvement of all staff in sharing learning and knowledge of the outbreak, developing trust and teamwork and harnessing collective leadership. Future major IC crises could be improved via measures to strengthen these areas, better coordination of media management and proactive staff counselling and support.

ArtiCle summAry This work can guide organisational actions for the control of rare infectious outbreaks in advanced healthcare settings. This research was conducted by independent researchers with participants well-placed to provide insights into the management of the outbreak. The lessons learnt from this work are:

► The outbreak was perceived to be serious and caused by inadequate readiness of the facility to implement infection prevention control guidelines effectively.

► Management of the outbreak was inhib- ited by a lack of institutional readiness to implement IC measures and reduce patient flow, low staff morale and high anxiety.

► Effective management was promoted by greater involvement of all staff in sharing learning and knowledge of the outbreak, developing trust and teamwork and harnessing collective leadership.

► Future major IC crises could be improved via measures to strengthen these areas,

strengths and limitations of this study

► This study examines stakeholder perspectives of the factors contributing to or detracting from successful infection control management of a serious Middle East Respiratory Syndrome caused by a coronavirus (MERS-CoV) outbreak.

► The MERS-CoV outbreak was of international signif- icance due to its high mortality.

► The study was independently conducted and includ- ed perspectives of key stakeholders, managers and frontline health care worker and focused on the per- ceptions of key stakeholder participants.

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2 Al Knawy BA, et al. BMJ Open 2019;9:e017476. doi:10.1136/bmjopen-2017-017476

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better coordination of media management and proac- tive staff counselling and support.

intrODuCtiOn How can decision-makers and health professionals in large healthcare organisations better manage major infection outbreaks? This is important because rapid and widespread pandemics pose a high threat to life, health systems and economies locally, nationally and globally. Middle East Respiratory Syndrome (MERS) is caused by one such coronavirus (MERS-CoV). It leads to severe acute respiratory infection with multiorgan failure and has a 65% mortality rate.1 2 MERS-CoV outbreaks have now occurred in 26 countries across the Middle East, Africa, Europe, Asia and North America.2–4

Successful management of MERS-CoV outbreaks is very challenging because the infection occurs most commonly in healthcare workers (HCWs)2 but knowledge of both the causes of the virus and its treatment is still limited.3–6 Most outbreaks have been attributed to low-adherence to infection control (IC) practices, crowded emergency departments (ED) and slow responsiveness to outbreaks.7 Consequently, to assist organisational preparedness,8 9 more knowledge is needed to guide future management of MERS-CoV infection outbreaks.

This study focuses on a major outbreak of the MERS-CoV which occurred at the King Abdulaziz Medical City-Riyadh (KAMC-R) in June 201510; a large teaching hospital and university centre in the Kingdom of Saudi Arabia.11 The outbreak resulted in 130 cases of infection (53% mortality rate); the outbreak directly or indirectly involved 9000 HCWs and all major departments at the institution (table 1). A comprehensive objective analysis of this outbreak10 identified that one third of infection cases were in HCWs, with about half of these cases (54%) occurring in ED staff (mean age: 37 years; 77% female) with no deaths.10 Infected patients (non-HCWs) had a median age of 66 years; 65% male.10 Symptom onset in the last infected case was 28 August 2015; the end of the outbreak was on 28 June 201510 following two 14-day incu- bation periods without new cases

Despite the severe and widespread risks that MERS-CoV poses, little research on the virus exists to guide its management in crises situations. While health professionals’ perceptions of risk12 and psycho- logical reactions13 to similar respiratory viruses have been explored, to our knowledge, this is the first study of stakeholder perspectives of the factors promoting and inhibiting effective infection management of a widespread MERS-CoV outbreak. Generated from the world’s second largest recorded outbreak of MERS-CoV to date, this study examines key stakeholder perspectives of the factors promoting and inhibiting effective IC. As an intense study of a single ‘complex’ outbreak, this research seeks to provide useful lessons for the manage- ment of future similar outbreaks.

methODs Qualitative study using process evaluation of a single complex case14 15 was used to identify key stakeholder perceptions of the processes, lessons and insights arising from the successful management of the MERS-CoV outbreak.15 Data were collected by authors (HMFA-K) and (AC), through semi-structured individual interviews and focus groups in May 2016.

semi-structured and focused group interviews Twenty-eight ‘key stakeholder’ participants took part in the study. Semi-structured individual key informant qual- itative interviews were undertaken with 9 senior leaders/ decision: each responsible for one or more facets of the major management decisions during the outbreak. Additional data were collected with 19 frontline HCWs (10 nurses and 9 physicians) who were each in direct patient care contact with MERS-CoV patients during the outbreak. Recruitment was undertaken via volun- teer quota sampling of decision-makers and staff from across the hospital. Data were collected in the clinical institution by independent researchers (AC) and (HK), with no direct involvement with the site, with schedules developed from past literature, approaches to learning organisations, and the respective role(s) of participants (online supplementary appendix 1). Interviews were audio-recorded via a digital device with data transcribed immediately after data collection. Each interview/group lasted between 45 and 100 min; transcripts included non-verbal behaviour. Prior to the interviews, institute revenant written documentation such as memorandums and committee meeting minutes was analysed to direct the questions posed during the qualitative data collection (table 1, online supplementary appendix 1).

Data management Qualitative data using process evaluation generates insights from key stakeholders on contributions to, and factors affecting key outcomes or processes, in organi- sations or interventions.14 15 Interview transcripts were analysed manually to determine common themes using recognised principles of qualitative research.16 For each interview, codes, subthemes and themes were then iden- tified and subsequently refined to avoid redundancy and guarantee accuracy via a cyclical analytical process by two of the investigators.16 The analysis moved back and forth between the interviews to ensure the finalised analysis was completed.

Rigour was maintained via a variety of recognised techniques.16 Member checking of the qualitative data enhanced credibility and transferability: the results were presented to 13 participants to ensure the findings were comprehensible and had resonance. Participants concurred with the proposed results. Peer debriefing was used in which a second researcher analysed a random selection of interviews to ensure themes were under- standable. No major changes to the analysis arose from this debriefing.

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3Al Knawy BA, et al. BMJ Open 2019;9:e017476. doi:10.1136/bmjopen-2017-017476

Open access

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4 Al Knawy BA, et al. BMJ Open 2019;9:e017476. doi:10.1136/bmjopen-2017-017476

Open access

Patient and public involvement The research question and design were informed by the high mortality and severe morbidity resulting of MERS-CoV. Neither patients nor public were involved in the study; answering the research question does not require their participation.

results Data analysis identified 5 major themes and 15 suthemes. The major themes were: 1) the high stress of the outbreak, 2) factors perceived to contribute to outbreak occur- rence, 3) factors perceived to contribute to success of outbreak control, 4) factors inhibiting outbreak control and 5) long-term institutional gains in response to the outbreak management (table 2). In the results, themes are presented in bold and subthemes are presented in italic bold typing.

the high stress of the outbreak All participants reported that the MERS-CoV outbreak was seen to constitute an episode of the most pressing and serious clinical significance to the organisation and country. Consistently across interviews, it was described in such terms as a serious and straining situation and a situa- tion that carries national and international significance.

Frontline HCWs and senior decision-makers alike not only perceived this high gravity, but also experienced extremely high and diverse demands personally (a very demanding situation). Throughout the interviews, partici- pants described the outbreak as being a sustained period of severe and sustained ‘tension’, ‘doubts’, ‘challenges’, ‘fear’ and ‘anger’. Frequent visits, communications and collaborations from external regulatory agencies (such as the Saudi Ministry of Health, the US Center for Disease Control and Prevention and the WHO), were perceived to be useful but also compounded these stresses.

The perceived seriousness of the outbreak was reported to motivate staff to expend maximum effort to assist in its management. However, the high levels of stress were exacerbated by a pervading sense that controlling the outbreak involved hard and uncertain progress. In the midst of the outbreak, both how it would progress and the future were seen to be very unclear.

Factors perceived to have contributed to wide occurrence of the outbreak Strong consensus existed among participants that the organisation’s growing reliance on emergency department boarding was the main contributor to the outbreak. While some participants lamented that this build up was ‘permitted’ by senior decision-makers to occur over the long-term, other participants saw other upstream factors as also being influential, notably inadequate implementa- tion of Infection Prevention and Control (IPC) guidelines. Indeed, poor recognition of the importance of IPC principles across the organisation was perceived to be compounded by the high demands placed on the ED

by the large patient population. Other more upstream factors seen to contribute to the outbreak included: high trust patients had for the National Guard Health Affairs, the relative lack of primary care services, problems asso- ciated with patient flow across the city, poor communica- tion and teamwork between the city hospitals, and a lack of pre-emptive national planning to allow hospitals across different sectors to share the burden of the growing city population.

Factors perceived to have contributed to the success of outbreak control Throughout this challenging situation, teamwork and collaborative management were seen to be pivotal. There was a sense of close alignment between both decision-makers and frontline HCWs in management priorities. The approach of senior management to the situation was perceived by participants as being open, without blame or ‘finger-pointing’. Indeed, managers were seen to have focused on empowering HCWs to work collaboratively to address the outbreak, involving staff in outbreak control and stimulating staff resilience and teamwork. In this way, the dominant culture was perceived by staff to be one of collective leadership practice (table 1) with leaders being seen to have practiced high levels of availability, visibility, empowerment of middle management and strong links with frontline staff during the height of the outbreak.

Key factors seen to contribute to this sense of collab- orative culture included: the existence of a clear shared-vision across staff of the high priority outbreak control measures, the high frequency of meetings of decision-makers involved in the outbreak control (twice daily), rapid and efficient decision-making, involvement of all the right units and decision-makers in decisions, and a high level of accountability. Having a centralised Command and Control Centre committee was seen widely to facilitate openness with high accountability, strategic utilisation of team diversities and strong mutual support. The success in controlling the outbreak in a relatively short time fostered a widespread sense of pride among those working in the organisation. Collectively, these measures served to improve mutual trust between front liners and top management.

Factors inhibiting outbreak control Factors perceived to inhibit management of the outbreak were mostly related to initial poor management practices and the negative and compounding effects of media reporting and high stress. The organisation was perceived to be acutely and chronically slow in responding to the outbreak. For example, organisational responses from management to the outbreak was perceived to be rela- tively slow compared with the rapid speed with which the infection spread. Moreover, despite references to high management transparency, some staff cited that poor staff orientation and management ambiguity contributed to staff being isolated and unclear about the decisions and measures being adopted by senior management to

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5Al Knawy BA, et al. BMJ Open 2019;9:e017476. doi:10.1136/bmjopen-2017-017476

Open access

Ta b

le 2

E

xt ra

c ts

f ro

m s

tu d

y d

a ta

t h e m

e s

a n d

s u

b th

e m

e s

S tu

d y

th e

m e

s /s

u b

th e

m e

s Q

u o

te s

In te

rv ie

w n

o

(i n

te rv

ie w

e e

le ve

l)

S tr

e ss

o f

th e o

u tb

re a k

1 .  A

s e ri o

u s

a n d

s tr

a in

in g

si

tu a ti o

n

2 . S

it u a ti o

n t

h a t

c a rr

ie s

n a ti o

n a l a

n d

in te

rn a ti o

n a l

si g

n ifi

c a n c e

‘W e g

o t

a h

it …

th e s

ys te

m f

a ile

d u

s. M

a yb

e w

e o

ve re

st im

a te

d o

u r

c a p

a c it y.

M a yb

e w

e u

n d

e re

st im

a te

d a

n u

n kn

o w

n e

n e m

y… . W

e w

e re

a n

g ry

a b

o u

t w

h a t

h a p

p e n

e d

…

T h e re

w a s

a lo

t o

f e le

m e n ts

t h a t

h a p

p e n e d

a t

th a t

ti m

e .

S o

w e w

e re

… fe

e lin

g is

o la

te d

a s

a n o

rg a n iz

a ti o

n …

To b

e h

o n e st

, it –

it b

ro u

g h

t th

e b

e st

in u

s a n

d t

h e w

o rs

t in

u s.

T

h e b

e st

in u

s in

t e rm

o f

o u r

re si

lie n c e a

n d

o u r

a b

ili ty

t o

c o

p e .

T h e w

o rs

t in

u s

is o

u r

w e a kn

e ss

e s

a n d

o u r

in se

c u ri ti e s

a n

d o

u r

d e a lin

g w

it h

e a c h

o th

e r…

A n d

t h e re

w a s

a lo

t o

f in

te rn

a ti o

n a l p

re ss

u re

o n u

s… th

e re

w a s

a lo

t o

f in

te rn

a ti o

n a l p

re ss

u re

s. Y

o u c

a n u

n d

e rs

ta n d

it d

o e sn

’t a

ff e c t

N a ti o

n a l G

u a rd

. It

a ff

e c ts

e ve

ry th

in g

… .

S o

t h e re

w a s

a lo

t o

f p

re ss

u re

a t

th a t

ti m

e .’

Tr a n

sc ri p

t 1

(d e c is

io n

-m a ke

r)

3 .  A

v e ry

d e m

a n d

in g

si

tu a ti o

n ‘ A

lo t

o f

th e o

rg a n iz

a ti o

n d

o n

o t

re a lly

– k

n e w

w h a t

w a s

g o

in g

o n .

T h a t

w e w

e re

m e e ti n g

a t

n in

e o

’c lo

c k

in t

h e m

o rn

in g

, w

e ’r

e m

e e ti n

g a

t th

re e o

’ c lo

c k

e ve

ry d

a y…

e ve

ry

d a y,

in c lu

d in

g w

e e ke

n d

s. N

o r

e st

a t

a ll.

’ Tr

a n

sc ri p

t 1

(d e c is

io n

-m a ke

r)

4 .  H

a rd

a n d

u n c e rt

a in

p

ro g

re ss

‘ W

e w

e re

w o

rr ie

d f

o r

th e s

ta ff

a n d

w e w

e re

w o

rr ie

d f

o r

th e p

a ti e n ts

. A

n d

d u ri n g

t h a t

ti m

e ,

w e w

e re

a h ,

d o

in g

fi ve

h u n

d re

d u

m …

t e st

s. A

n d

e ve

ry d

a y,

w e c

o m

e in

. A

n d

w e

se e t

h e n

u m

b e rs

. A

n d

s o

, to

d a y

w e t

e st

e d

1 5 p

o si

ti ve

s. T

o m

o rr

o w

, 2 0 .

A n d

w e w

e re

s a yi

n g

, w

h e n d

o w

e h

it a

n in

fle c ti o

n p

o in

t? W

h e n

t h

e se

n u

m b

e rs

g o

e s

d o

w n

? A

n d

it

g o

e s

d o

w n f

o r

a b

it , a n d

it c

o m

e s

u p

. A

n d

e ve

ry t

im e ,

yo u ju

st h

o p

e t

o G

o d

t h a t

th is

is it

… S

o t

h e m

o ra

le w

a s

g o

in g

u p

a n

d d

o w

n .’

Tr a n

sc ri p

t 1

(d e c is

io n

-m a ke

r)

5 .  Te

a m

w o

rk a

n d

c o

lla b

o ra

ti ve

m

a n a g

e m

e n t

re q

u ir e m

e n t

‘ W

e t

o o

k it v

e ry

s e ri o

u sl

y. W

e k

n o

w t

h e m

a g

n it u d

e .

W e k

n o

w t

h e im

p a c t

o f

it .

W e k

n o

w h

o w

t h is

a ff

e c ts

t h e ,

th e p

a ti e n

t c a re

a n

d h

o w

t h

is a

ff e c ts

t h

e r

e p

u ta

ti o

n o

f th

e

o rg

a n iz

a ti o

n , a ff

e c ts

e ve

ry th

in g

. A

n d

… th

e p

u b

lic im

a g

e a

n d

a ll

o f

th is

h a s

to b

e a

d d

re ss

e d

t o

t h e M

in is

te r.

W e s

a id

( m

e a n

s a ll

le a d

e rs

) h

o w

e ve

r, it is

, it is

, it ’s

a m

u st

t h

a t

w e …

.s h o

u ld

d o

it . …

.I n s

p it e o

f a ll

o f

th is

s tr

e ss

a n d

d iffi

c u lt ie

s w

e f

e lt t

h a t

w e n

e e d

t o

b e f

o c u se

d a

n d

a d

d re

ss is

su e s

sc ie

n ti fic

a lly

. A

t th

e s

a m

e t

im e y

o u

k n

o w

w e h

a ve

to

s u p

p o

rt p

e o

p le

w h o

a re

w o

rk in

g a

t th

e f

ro n tl in

e .

W e h

a ve

t o

d o

t h a t,

w e h

a ve

t o

r e a lly

b e t

h e re

a n d

w e k

n o

w t

h a t

th e y

a re

v e ry

s tr

e ss

e d

.’

Tr a n

sc ri p

t 5

(d e c is

io n

-m a ke

r)

F a c to

rs p

e rc

e iv

e d

t o

c o

n tr

ib u te

t o

o u tb

re a k

o c c u rr

e n c e

1 .  G

ro w

in g

r e lia

n c e o

n

E D

b o

a rd

in g

‘ …

.T h e o

rg a n iz

a ti o

n is

w e ll

kn o

w n

in t

h e c

o u n tr

y fo

r m

a n y

su c c e ss

s to

ri e s

a n d

… th

a t

b a si

c a lly

p u t

so m

e p

re ss

u re

o n t

h e o

rg a n

iz a ti o

n o

f p

e o

p le

a sk

in g

t o

b e t

re a te

d

h e re

… . T

h ir d

t h in

g is

… .o

u r

lo c a ti o

n h

e re

a s

th e o

n ly

b ig

h o

sp it a l i

n t

h e E

a st

o f

R iy

a d

h …

B e c a u se

o f

th e la

rg e n

u m

b e r

a n

d b

e c a u

se o

f th

e e

xp e rt

is e in

m a n

a g

in g

t h

e

c a su

a lt ie

s… T

h o

se f

a c to

rs b

a si

c a lly

, I m

e a n r

e su

lt e d

in a

h u g

e n

u m

b e r

o f

… b

o a rd

in g

p a ti e n ts

in t

h e E

D …

… ’

Tr a n

sc ri p

t 7

(d e c is

io n

-m a ke

r)

2 .  In

a d

e q

u a te

im

p le

m e n ta

ti o

n o

f IP

C

g u id

e lin

e s

‘ …

It ’s

n o

t so

m e th

in g

y o

u w

a n t

to s

e e …

A n d

w h e n y

o u k

n o

w ,

it ’s

b e c a u se

s o

m e o

n e d

id n ’t

w a sh

t h e ir h

a n d

s. T

h a t’s

t h

e b

it t

h a t

ki lle

d m

e . S

o m

e th

in g

s im

p le

, it w

a sn

’t t

h a t

w e d

id n ’t

h a ve

a D

a V

in c i (

R o

b o

ti c s

u rg

e ry

) in

t h e O

R .

It ’s

b e c a u se

t h e y

d id

n ’t

w a sh

t h e ir h

a n d

s. ’

Tr a n

sc ri p

t 1

4 (f ro

n tl in

e H

C W

)

F a c to

rs p

e rc

e iv

e d

t o

c o

n tr

ib u te

t o

s u c c e ss

o f

o u tb

re a k

c o

n tr

o l

1 .  C

o lle

c ti ve

le a d

e rs

h ip

p

ra c ti c e

‘ T

h e o

rg a n iz

a ti o

n is

w e ll

st a ff

e d

w it h v

e ry

s m

a rt

, d

e d

ic a te

d in

d iv

id u a ls

– a

c ro

ss a

ll sp

e c tr

u m

s …

A n d

I t

h in

k th

a t

re a lly

w a s

w h

a t

h e lp

e d

o u

t. M

id d

le m

a n

a g

e m

e n

t,

c h a ir m

e n o

f d

e p

a rt

m e n ts

… . th

e y

ro se

t o

t h e e

q u a ti o

n …

. A

n d

I t

h in

k th

e re

w a s

tr e m

e n d

o u s

a m

o u n t

o f

w o

rk t

h a t

w a s

d o

n e b

y so

m e o

f th

e C

h a ir m

e n

. I th

in k…

it w

a s

re a lly

… h

a rd

o n lo

t o

f th

e m

… . W

e ju

st f

e lt ,

w e ’r

e n

o t

b la

m in

g a

n yo

n e ,

w e ju

st n

e e d

e d

o n e c

le a r

g o

a l t

h a t

w e n

e e d

t o

g e t

o u

t o

f it q

u ic

kl y,

q u

ic kl

y, a

s q

u ic

k a s

p o

ss ib

le …

. I

th in

k p

e o

p le

w a n te

d t

o p

ro ve

t h a t

th e y

a re

, th

e y

a re

, th

e y

a re

g o

o d

. I le

a rn

e d

t h a t

b e in

g c

lo se

t o

t h e m

a n a g

e m

e n t

b e in

g a

c c e ss

ib le

t o

m a n

a g

e m

e n

t, t

o t

o f

ro n

tl in

e w

a s…

g o

o d

… W

e h

o p

e fu

lly h

a ve

le d

f ro

m t

h e ,

fo rm

t h e f

ro n t.

’ ‘W

h e n w

e s

ta rt

t o

s e e t

h e C

E O

d o

in g

r o

u n d

in t

h e E

D ,

a lm

o st

e ve

ry d

a y…

.a n d

s o

w e c

a n c

o n ta

c t

h im

. S

o y

o u c

a n t

a lk

w it h

h im

. S

o y

o u

c a n

a d

d re

ss t

h e p

ro b

le m

d ir e c tl y.

S

o h

e is

d o

in g

h is

r o

u n d

s a lm

o st

o n a

d a ily

b a si

s… A

n d

h e m

e e ts

w it h u

s o

r th

e h

e a d

s o

f th

e u

n it s

a n d

a sk

, ‘s

o ,

h o

w c

a n

I h

e lp

y o

u in

t h

is u

n it ?

’ ‘ T

h e re

w a s

le a d

e rs

h ip

… th

e c

o m

m it m

e n t

c a m

e o

u t.

T h a t

is t

h e fi

rs t

ti m

e t

h a t

w e s

a w

e a c h o

th e r

tw ic

e d

a ily

. W

e w

e re

s p

e n

d in

g t

im e t

o g

e th

e r

m o

re t

h a n

w e s

p e n

d w

it h

o

u r

fa m

ili e s.

S o

e ve

ry d

a y,

I w

ill s

e e D

o c to

r __

_ [L

e a d

e r]

, e ve

ry d

a y

I w

ill s

e e D

o c to

r __

__ [ L e a d

e r]

. S

o w

e w

e re

a lw

a ys

t h

e re

… S

o t

h e re

w a s

– th

e re

w a s

a lo

t o

f c o

lle g

ia lit

y th

a t

– th

a t

w a s

re a lly

b u ilt

. A

h , st

o rm

in g

le d

t o

p e rf

o rm

in g

. M

e a n in

g t

h a t:

o ka

y, y

e s,

w e h

a d

d iff

e re

n c e s

o f

o p

in io

n s,

b u

t a t

th e e

n d

o f

th e d

a y,

w e h

a d

t o

c o

m e u

p w

it h

d

e c is

io n s.

… ’

‘ T

h e re

w a s

fla tn

e ss

( to

) th

e d

e c is

io n t

re e –

it d

id n

o t

re a lly

n e e d

a c

o m

m it te

e t

o a

p p

ro ve

it .

It u

se d

t o

b e o

n e m

e e ti n g

, to

t w

o m

e e ti n

g s

– w

e a

g re

e o

n s

o m

e th

in g

a n

d it

g

o e s.

O r

w e d

is a g

re e a

n d

s o

m e b

o d

y m

a ke

s th

e c

a ll.

A n d

s o

, so

t h e d

e c is

io n -m

a ki

n g

p ro

c e ss

w a s

– w

a s

q u ic

k. ’

Tr a n

sc ri p

t 5

(d e c is

io n

-m a ke

r) Tr

a n

sc ri p

t 1

1 (f ro

n tl in

e H

C W

) Tr

a n

sc ri p

t 1

(d e c is

io n

-m a ke

r)

2 .  Im

p ro

ve d

m u tu

a l t

ru st

b

e tw

e e n f

ro n t

lin e rs

a n d

to

p m

a n a g

e m

e n t

‘ T

h e re

s e e m

e d

t o

b e …

p ro

b a b

ly m

o re

t e a m

w o

rk .

A n d

t h e re

s e e m

e d

t o

b e a

lo t

m o

re a

d m

ir a ti o

n f

o r

e a c h o

th e r.

Y e a h , a n

d I t

h in

k –

a n

d t

h a t

– a n

d it

w a s

e xp

re ss

e d

t o

m e

b y

D o

c to

r __

_ [L

e a d

e r]

1 d

a y,

a n d

I r

e m

e m

b e r

th e c

o n ve

rs a ti o

n .

H e s

a id

, ‘y

o u k

n o

w ,

I c a n ’t

b e lie

ve t

h a t

th e se

g u ys

k e p

t tu

rn in

g u

p .’ Y

o u

k n

o w

? [ In

te rv

ie w

e r:

U h

u m

] A

n d

a h , a n d

I –

I t

h in

k w

e g

re w

a b

it o

f m

u tu

a l r

e sp

e c t

fo r

e a c h o

th e r,

o u t

o f

th e w

a y

w e h

a n d

le d

t h a t,

t o

b e h

o n e st

.’

Tr a n

sc ri p

t 1

5 (f ro

n tl in

e H

C W

)

F a c to

rs in

h ib

it in

g o

u tb

re a k

c o

n tr

o l

1 .  L o

g is

ti c b

a rr

ie rs

t o

p

ro m

p tl y

im p

le m

e n t

th e

e sc

a la

ti o

n p

la n

‘W e h

a ve

im p

le m

e n te

d it

( m

e a n s

th e I D

E P

e sc

a la

ti o

n p

la n ) o

n t

im e ,

b u t

fo r

e xa

m p

le t

o c

lo se

t h e E

D it

t o

o k

u s

ti m

e t

o e

va c u

a te

it …

. th

e p

o si

ti ve

c a se

s in

c re

a se

d a

n d

w e

w e re

m o

ve d

f ro

m s

ta g

e t

o s

ta g

e …

.’ Tr

a n

sc ri p

t 1

(d e c is

io n

- m

a ke

r)

C o

n ti n

u e d

o n

S e

p te

m b

e r 1

9 , 2

0 2

1 b

y g u e

st. P ro

te cte

d b

y co p yrig

h t.

h ttp

://b m

jo p e n .b

m j.co

m /

B M

J O p

e n

: first p u

b lish

e d

a s 1

0 .1

1 3

6 /b

m jo

p e

n -2

0 1

7 -0

1 7

4 7

6 o

n 5

M a y 2

0 1 9 . D

o w

n lo

a d e d fro

m

6 Al Knawy BA, et al. BMJ Open 2019;9:e017476. doi:10.1136/bmjopen-2017-017476

Open access

S tu

d y

th e

m e

s /s

u b

th e

m e

s Q

u o

te s

In te

rv ie

w n

o

(i n

te rv

ie w

e e

le ve

l)

2 .  P

o o

r st

a ff

o ri e n ta

ti o

n

a n d

m a n a g

e m

e n t

a m

b ig

u it y

‘I w

a s

ke p

t ve

ry m

u c h in

t h e d

a rk

a s

to w

h a t

w a s

g o

in g

o n …

it w

a sn

’t t

ra n sc

ri b

e d

. W

e w

e re

– w

e w

e re

n o

t –

w e w

e re

o n

ly …

o n

ly f

e d

in fo

rm a ti o

n t

h a t

w e n

e e d

e d

t o

k n

o w

. S

o , ra

th e r

th a n t

e a m

d e b

ri e fin

g e

ve ry

d a y,

w h ic

h I w

o u ld

h a ve

a p

p re

c ia

te d

, th

a t

d id

n ’t

( h a p

p e n )…

S o

p o

o r

c o

m m

u n ic

a ti o

n . A

n d

it –

it –

a lm

o st

a h

ie ra

rc h

y o

f w

h o

n e e d

s to

kn

o w

w h a t.

A n d

y e t,

w e w

e re

in t

h e f

ro n tl in

e .’

Tr a n

sc ri p

t 1

(f ro

n tl in

e H

C W

)

‘W e ll,

t h e re

w a s

lo ts

o f

g re

y… g

re y

a re

a s…

.A h ,

w o

u ld

y o

u p

u t

a m

a sk

a h ,

th ro

u g

h o

u t

th e s

ta y,

in t

h e a

is le

– h

o sp

it a l,

a h

, in

t h

e c

o rr

id o

rs ?

W o

u ld

y o

u n

o t

d o

a s

so m

e

p e o

p le

a h , d

id ? …

s o

m e p

e o

p le

d id

n o

t a h ,

d o

t h a t.

T h e re

w e re

lo ts

o f

m ix

e d

m e ss

a g

e s

c o

m in

g f

ro m

e ve

n I P

C d

e p

a rt

m e n

t. …

… A

h , w

h ic

h c

o n

fu se

d u

s, w

h ic

h …

a h

, a n

d

so t

h e re

w a s

lo ts

o f

va ri a ti o

n s…

so m

e p

e o

p le

w e re

m o

re c

o n se

rv a ti ve

. S

o m

e p

e o

p le

m o

re –

w e re

m o

re li

b e ra

l i n d

o in

g t

h e se

t h

in g

s. ’

Tr a n

sc ri p

t 1

2 (f ro

n tl in

e H

C W

)

‘ A

c le

a r

e xa

m p

le is

d e a lin

g w

it h v

is it o

rs a

n d

d e a lin

g w

it h t

h e m

ili ta

ry p

e o

p le

… w

h o

c o

n tr

o l t

h e v

is it o

rs h

e re

. A

n d

t h e re

w a s

a c

le a r

m is

c o

m m

u n

ic a ti o

n a

n d

…

m is

u n d

e rs

ta n d

in g

. Y o

u c

o m

e t

o t

h e m

a n d

s a y,

‘ W

h y

d id

y o

u le

t th

e m

( vi

si to

rs ) in

? ’

Y o

u k

n o

w ? T

h e y

a re

n o

t re

a lly

g e tt

in g

it . A

h –

I ’m

– I ’m

s u

re . I’ m

s o

rr y

to s

a y

th a t,

b u

t th

a t’s

– t

h a t’s

w a s

o n e o

f th

e b

ig g

e st

c h a lle

n g

e s

I th

in k.

S o

t h e y

w e re

n o

t g

e tt

in g

it a

n d

it –

t h e h

ig h e r

– th

e a

d m

in is

tr a ti o

n …

. ra

n ks

o f

th e m

ili ta

ry , w

a s

n o

t re

a lly

g e tt

in g

it .

A lt h o

u g

h t

h e y

w e re

… p

a rt

o f

th e c

o m

m a n d

c e n te

r.’

Tr a n

sc ri p

t 3

(d e c is

io n

- m

a ke

r)

3 .  N

e g

a ti ve

m e d

ia

c o

m m

e n ta

ry ‘ …

T h e s

o c ia

l m e d

ia p

u t

a h

u g

e a

m o

u n t

o f

p re

ss u re

. A

n d

o f

c o

u rs

e …

so m

e o

f it …

o n r

e a so

n a b

le f

a c ts

a n d

t h e o

th e rs

a re

m yt

h s

b a si

c a lly

. L

o ts

f o

r e xa

m p

le o

f ta

lk ,

o f

p e o

p le

d yi

n g

f ro

m …

. fr

o m

t h e h

e a lt h w

o rk

e rs

. O

f c o

u rs

e I m

e a n t

h a t

c re

a te

d p

re ss

u re

. […

f o

r e xa

m p

le I m

e a n h

a d

o n

e o

f o

u r,

o n

e o

f th

e C

h a ir m

e n

a n

d o

n e o

f th

e

in fe

c ti o

n c

o n tr

o l l

e a d

e rs

w h o

, w

e re

t e st

e d

p o

si ti ve

b u t

th e y

w e re

b a si

c a lly

a sy

m p

to m

a ti c ,

b u t

… w

h a t

h a p

p e n e d

in t

h e m

e d

ia ( re

p o

rt e d

t h

e y)

h a d

d ie

d …

!’

Tr a n

sc ri p

t 5

(d e c is

io n

-m a ke

r)

‘… .W

e c

o u ld

h a ve

d o

n e b

e tt

e r

w it h

t h e m

e d

ia ,

I fe

lt v

e ry

v u ln

e ra

b le

, a c tu

a lly

.… I fe

lt v

e ry

v u ln

e ra

b le

… A

n d

t h a t

w a s

a h

u g

e b

u rd

e n

f o

r m

e …

.B ig

.’ Tr

a n

sc ri p

t 1

0 (d

e c is

io n

-m a ke

rs )

4 .  L a c k

o f

a p

p r o

p ri a te

st

a ff

c o

u n se

lli n g

a n d

m

e n ta

l h e a lt h s

u p

p o

rt

‘ D

r. B

… W

h e n e ve

r yo

u s

e e s

o m

e b

o d

y sn

e e ze

y o

u ’r

e c

u p

p in

g ( h a n d

s o

ve r

fa c e ). I t

w a s

sc a ry

, st

a y

a w

a y.

W a s

ju st

t e lli

n g

( a n

o th

e r

c o

lle a g

u e ) th

a t

m y

b a rb

e r

re fu

se d

t o

g e t

m y

h a ir c

u t.

D r.

C :…

.E ve

n in

s o

c ia

l a h , a sp

e c ts

… th

e m

o sq

u e n

e xt

t o

m y

h o

u se

, I u su

a lly

g o

t o

p ra

y w

h e n I li

ke .

O n e d

a y

h e c

a lle

d m

e ( m

e a n

s th

e I m

a m

) w

h e n

I w

a s

le a vi

n g

a n

d s

a id

‘Y

o u k

n o

w , w

e k

n o

w e

a c h o

th e r,

w e a

re v

e ry

c lo

se n

e ig

h b

o rh

o o

d ,

so h

e s

a id

, yo

u k

n o

w t

h e o

th e r

n e ig

h b

o rs

… …

b e c a u

se o

f C

o ro

n a …

. so

m a yb

e y

o u

h a d

b e tt

e r

st a y

a w

a y’

.

Tr a n

sc ri p

t 2

(d e c is

io n

-m a ke

rs )

L o

n g

-t e rm

in st

it u ti o

n a l g

a in

s in

r e sp

o n se

t o

t h e o

u tb

re a k

m a n a g

e m

e n t

1 . Ta

n g

ib le

im p

ro ve

m e n t

in I C

 p ra

c ti c e s

P 4 : I th

in k

th a t

th e o

rg a n iz

a ti o

n h

a s

c e rt

a in

ly m

a tu

re d

. A

n d

t h e y

h a ve

a d

iff e re

n t

o u tl o

o k

o n …

o n t

h e E

D …

F ro

m t

h e M

E R

S -C

o V

t ra

g e d

y… I th

in k

th a t

th e re

w a s

a h

u g

e

w a ke

-u p

c a ll.

A n d

I t

h in

k it w

a s

a s

te e p

le a rn

in g

c u rv

e t

h ro

u g

h t

h e o

rg a n iz

a ti o

n .

S o

t h e y

u n d

e rs

ta n d

n o

w t

h a t

w h e n E

D s

a ys

… th

e C

h ie

f N

u rs

e o

r th

e C

E O

a re

r e c e p

ti ve

. Tr

a n

sc ri p

t 1

3 (d

e c is

io n

-m a ke

r)

W e –

w e h

a d

a lo

t o

f su

p p

o rt

f ro

m I n fe

c ti o

n C

o n tr

o l d

e p

a rt

m e n t…

lo ts

o f

in fo

rm a ti o

n a

va ila

b le

. U

m ,

th e I n fe

c ti o

n C

o n tr

o l p

ra c ti ti o

n e rs

w e re

o n

t h

e u

n it s

d a y

a n

d n

ig h

t,

su p

p o

rt in

g t

h e s

ta ff

. M

a n a g

e m

e n t

a s

w e ll…

.in t

e rm

s o

f su

p p

lie s,

e q

u ip

m e n t,

a ll

o f

th a t,

w e d

id n ’t

h a ve

a n y

is su

e s.

I t

w a s

su p

p lie

d –

r e a d

ily a

va ila

b le

. Tr

a n

sc ri p

t 1

3 (f ro

n tl in

e H

C W

)

2 .  Im

p e tu

s fo

r c h a n g

e in

p

e rs

o n n e l a

n d

p ro

c e ss

e s

(t ra

n sf

o rm

a ti o

n )

‘ …

th e , th

e b

o a rd

in g

a n d

a h , b

o a rd

in g

p a ti e n ts

w it h in

t h e E

D is

n o

t n e w

, it ’s

f ro

m 2

0 0 5 t

o 2

0 0 6 .

[In te

rv ie

w e r:

Y e s]

b u t

is g

e tt

in g

… e

ve ry

y e a r

w a s

g e tt

in g

w o

rs e …

… . F

ro m

1 7 0 ,…

w e h

a ve

n o

w 5

6 b

e d

s (m

e a n s

a ft

e r

th e E

D t

ra n sf

o rm

a ti o

n ), o

u r

e ffi

c ie

n c y

a n d

w a it in

g t

im e s,

im p

ro ve

d s

ig n ifi

c a n

tl y

b e c a u

se t

h e b

o a rd

in g

p a ti e n

t re

d u

c e d

… S

o w

e

kn o

w , fo

r u s

it w

a s

ve ry

c le

a r

th e is

su e w

a sn

’t w

it h in

t h e d

e p

a rt

m e n t

(E D

d e p

a rt

m e n t)

, it w

a s

w it h in

t h e fl

o w

o f

p a ti e n

ts w

it h

in t

h e o

rg a n

iz a ti o

n .’

Tr a n

sc ri p

t 6

(d e c is

io n

m a ke

r)

‘ B

u t

w e –

ju st

w e c

o m

p le

te ly

r e d

e si

g n e d

– n

o t

o n ly

u m

, it w

a s

c o

m p

le te

s ys

te m

– r

e st

ru c tu

re a

n d

s ys

te m

r e d

e si

g n …

.U m

, p

e o

p le

w e re

p ra

c ti c in

g in

a w

a y

th a t

th e y’

ve

n e ve

r d

o n e b

e fo

re –

n u rs

e s

a n d

d o

c to

rs …

.’ Tr

a n

sc ri p

t 1

4 (f ro

n tl in

e H

C W

)

E D

, e m

e rg

e n c y

d e p

a rt

m e n t;

H C

W , h e a lt h c a re

w o

rk e rs

; IC

, in

fe c ti o

n c

o n tr

o l;

IP C

, in

fe c ti o

n p

re ve

n ti o

n  a

n d

c o

n tr

o l.

Ta b

le 2

C

o n ti n u

e d

o n

S e

p te

m b

e r 1

9 , 2

0 2

1 b

y g u e

st. P ro

te cte

d b

y co p yrig

h t.

h ttp

://b m

jo p e n .b

m j.co

m /

B M

J O p

e n

: first p u

b lish

e d

a s 1

0 .1

1 3

6 /b

m jo

p e

n -2

0 1

7 -0

1 7

4 7

6 o

n 5

M a y 2

0 1 9 . D

o w

n lo

a d e d fro

m

7Al Knawy BA, et al. BMJ Open 2019;9:e017476. doi:10.1136/bmjopen-2017-017476

Open access

promote IC. This perceived poor communication created additional confusion that led to low coordination of IC instructions from bothIC and the nursing teams. Conse- quently, some health professionals, and other administra- tive and military staff, did not even appreciate the severity of the outbreak. Their consequent lack of attention to reducing the number of new patients and visitors entering the institution was seen to further elevate infection risk.

All participants referred to consistent and pervasive negative media commentary on the MERS-CoV outbreak occurring at the KAMC-R. This negative coverage contributed to significantly negative public perceptions of the Ministry, KAMC-R, its senior decision-makers and the frontline HCWs. These negative commentaries were evident across local mass media (television, radio and newspapers) and social media - particularly Twitter. The negative media reporting was cited as negatively impacting staff morale and affecting workers socially, psychologically, and mentally. During this challenging period, this compounded the negative effects of work demands. Reactive and poor media management by the KAMC-R was seen to contribute to the ongoing frequency and negativity of this commentary. Participants suggested that the institution should have a media centre to coor- dinate media coverage in such emergency circumstances (table 2).

Staff capacity to handle this challenging situation was further reduced given the perceived wide prevalence of high anxiety in staff due to the lack of appropriate staff counselling and mental health support. The psychological demands on frontline health professionals escalated due to a range of coalescing factors; most notably the need to manage the outbreak simultaneously with the closure of most of the institution’s units, combined with the nega- tive media commentary. Almost all frontline participants strongly and repeatedly expressed the need for counsel- ling and mental health support of employees.

DisCussiOn Learning from crises helps foster systems improvements.17 However, learning from major events is challenging because each event is comparably rare and occurs in a distinctive context. As these events are also complex,18

qualitative as well as quantitative research10 is useful for generating insights and lessons to inform future outbreak control.18

Useful lessons gleaned from this study of MERS-CoV crisis management (table 3) concur with other research. It is not just the actions of HCWs and decision-makers that contributed to successful management, but also the mutual trust that accrues via the delegation of respon- sibilities, team management, coordination, tasks distri- bution, role clarification and communication.19 20 This reflects the practice of collective leadership—defined as 'a dynamic leadership process in which defined leaders, or set of leaders, selectively utilize skills and expertise within a network, effectively distributing elements of the leader- ship role as the situation or problem at hand requires’.21 This research corroborates other work identifying that a number of different strands of management contribute to success, particularly, the benefits of centralised yet inclusive meetings during which senior decision-makers and frontline HCWs share knowledge and learning22 from different parts of the organisation.23–25 Other key lessons arising from this study arose from the weaknesses around the media management during the outbreak which in turn adversely affected reported staff morale and anxiety.26 Such challenges are not unusual.27 Large health institutions managing major crises should have a dedicated media centre or representative capable of implementing a well-designed and coordinated media crisis plan to aid communication, address questions and proactively act to protect the reputation of the organisa- tion and its staff.

Mental health support to frontline HCWs was a major missing element in managing the MERS-CoV outbreak. Indeed, psychological and personal support and coun- selling for staff during emergency situations is recom- mended.28–30 In Singapore for example, the Ministry of Health funds a ‘comprehensive crisis response manage- ment system’ for health professionals.28 Such initiatives may be more effective in supporting staff than support from other health professionals29 and can be targeted to those in most need via screening.29 30

While the themes presented are not uncommon in organisation studies of infection outbreaks,31 32 these

Table 3 Lessons learnt from the management of the MERS-CoV outbreak

1 Inadequate facility readiness to implement IPC guidelines and poor IC practices may lead to an outbreak situation. Strict implementation and monitoring are mandatory regardless of the volume of work.

2 Patient boarding in ED should follow the internationally accepted figures regardless of the number boarded.

3 Collective leadership is the management method of choice when dealing with a multidimensional leadership crisis.

4 In national level crisis management, media centre and a pre-existing media disaster plan are mandatory to reduce HCW anxiety and improve trust in the institution and its staff.

5 HCW mental healthcare and anxiety relief are important factors to increase resilience and cooperation within the workforce.

6 Despite the immediate consequences of a healthcare crisis, it can represent a strong drive for change and institutional reform.

ED, emergency department; HCW, healthcare worker; IPC, infection prevention and control; MERS-CoV, Middle East Respiratory Syndrome caused by a coronavirus.

o n S

e p

te m

b e

r 1 9 , 2

0 2 1

b y g

u e

st. P ro

te cte

d b

y co p yrig

h t.

h ttp

://b m

jo p e n .b

m j.co

m /

B M

J O p

e n

: first p u

b lish

e d

a s 1

0 .1

1 3

6 /b

m jo

p e

n -2

0 1

7 -0

1 7

4 7

6 o

n 5

M a y 2

0 1 9 . D

o w

n lo

a d e d fro

m

8 Al Knawy BA, et al. BMJ Open 2019;9:e017476. doi:10.1136/bmjopen-2017-017476

Open access

reflected our data and, as studies and systematic reviews indicate concur with other accounts of major outbreaks such as ebola.31–33 As such, our findings reiterate the imperative of addressing these transcending aspects across different types of infection outbreaks.

research limitations and strengths This research documented learning from an unusual, burdensome and serious infection outbreak and used methods recognised to be well suited to explore the complexities of outbreaks.31 32 Similar to other ‘rapid’ qualitative accounts of major outbreaks with high mortality notably ebola,31 this study addresses key interdisciplinary aspects of perceived outbreak causes, infrastructure, IC, facilities and health needs.32 Unlike this previous work, the rigour of this study was increased via comprehensive details of the sample, participants and context.32 As with other studies,32 participants included in the study were very well-placed to provide insights into the outbreak but inevitably then the research was also conducted retro- spectively, was based on subjective data, and involved a select group of participants whose perspectives may differ from the broader population. As with other studies,32 while independent researchers undertook the inter- views, responses may have been influenced by perceived ‘official’ links between the project and the organisation. Staff perspectives may have also been influenced by the time duration since the outbreak was curtailed (around 8 months). We addressed these limitations through different data collection sources, member checking and data triangulation.

COnClusiOn Management of the MERS-CoV outbreak at KAMC-R was widely recognised by staff as a serious outbreak of local and national significance. While the outbreak was controlled successfully in 6 weeks, progress in manage- ment was inhibited by a lack of institutional readiness to implement IC measures and reduce patient flow, low staff morale and high anxiety. Effective management was promoted by greater involvement of all staff in sharing learning and knowledge of the outbreak, developing trust and team work and fostering collective leadership. Future major IC crises could be improved via measures to strengthen these areas, as well as better coordination of media management and proactive staff counselling and support.

Author affiliations 1Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia 2College of Medicine, King Abdulaziz Medical City and King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia 3College of Public Health, King Abdulla International Research Center and King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia 4Department of Pediatrics, King Abdullah International Medical Research Centre and King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia 5Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada

Acknowledgements The authors do acknowledge the King Abdullah International Medical Research Center for funding this manuscript.

Contributors BAAK: Initiated the research idea, contributed to proposal writing, contributed to data collection, validated data analysis, contributed to final manuscript writing, read and approved the final manuscript. HMFA-K: Contributed to research proposal writing, to data collection and analysis, contributed to final manuscript writing, read, proofed and approved the final manuscript. ME: Contributed to research proposal writing, contributed to data collection and contributed to final manuscript writing. YA: Validated data analysis, read and approved the final manuscript. HHB: Validated data analysis, read and approved the final manuscript. AC: Contributed to data collection and analysis, contributed to final manuscript writing, read, proofed and approved the final manuscript.

Funding King Abdullah International Medical Research Centre (RC16\131\R) fundedthe research.

Competing interests None declared.

Patient consent for publication Not required.

ethics approval The King Abdullah International Medical Research Center approved the research and funded the data collection and analysis, RC 16-131/R, 2016. The Institution Review Board (IRB) at the Ministry of National Guard Health Affairs approved the research proposal.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Author note Agree on the data mentioned

Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.

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