Published May 28, 2021 (Updated: July 7, 2021)
In March 2021, Ariadne Labs launched the Global Mass Vaccination Site Collaborative to facilitate a rapid information exchange to broaden the impact of and safely deliver more COVID-19 vaccinations globally. Fifty members representing more than 12 mass vaccination sites from across the country began meeting regularly, sharing information, and comparing notes on the effort to get shots into as many arms as rapidly as possible.
The meetings became lively forums on topics ranging from the logistics of directing hundreds of cars in stadium parking lots to efforts to reach vulnerable people right in their communities. Participants spoke frankly about their successes and their challenges, about what they learned, and what they would focus on next time.
“Next time” is the operative phrase. While some countries are making headway against the COVID-19 virus, others are struggling. Even if mass vaccination sites may soon close in the United States, the effort to inoculate the world is still ongoing. “We can’t afford to assume that this is a once-in-a-lifetime pandemic,” said Eric Goralnick, MD, MS, Associate Faculty, Ariadne Labs and Principal Investigator of the collaborative. “We want to share our insights, learnings, and practices with the hope that they will be useful now and in the future.”
Initial Global Mass Vaccination Site Collaborative members include (in alphabetical order):
- Atrium Health, which has held mass vaccination events at Bank of America Stadium and Charlotte Motor Speedway, as well as establishing innovative roving vaccination sites for underserved and rural communities, to ensure equitable access.
- Bellin Health, which operates the Lambeau Field Community COVID-19 Vaccination Site in partnership with Brown County Public Health and the Green Bay Packers.
- The Canada International Scientific Exchange Program (CISEPO).
- CIC Health, which operates mass vaccination sites in Massachusetts at Gillette Stadium, the Reggie Lewis Center, and Hynes Convention Center (the latter currently in partnership with FEMA). Mass General Brigham provides medical direction for all CIC Health vaccination sites.
- CORE (Community Organized Relief Effort), which operates sites at Dodger Stadium in Los Angeles alongside its partners at the City of Los Angeles, LAFD, and medical partners Carbon Health, Curative, and USC School of Pharmacy. CORE also staffs the Mercedes Benz Stadium in Atlanta, in partnership with AFCEMA of Fulton County.
- The State of New Hampshire, which operates the New Hampshire Motor Speedway Mass Vaccination Site in partnership with Regional Public Health Networks, and local police, fire and EMS, and hospitals across the state.
- UCHealth, which operated the mass vaccination site at Coors Field in partnership with the Colorado Rockies, Denver Police Department, Colorado Department of Public Health and Environment, City and County of Denver, and Verizon — and continues to offer vaccines to up to 40,000 people a week at its 11 locations across Colorado.
- UC San Diego Health, which operated the Petco Park site and maintains a site on its campus.
- Metro Public Health Department, which operates mass vaccination clinics in Nashville, TN, in partnership with Meharry Medical College, the Music City Center, FEMA, U.S. Forestry Service, Nissan Stadium, and the Tennessee Titans.
This blog has been launched as a way to record and share the learning and insights gained from this collaboration. Below are narrative summaries and key takeaway points from each collaboration meeting.
Table of Contents
Canada’s Fragmented Response to COVID-19
June 11, 2021
The COVID-19 pandemic highlighted disparities in health care worldwide; even Canada’s often-praised social health care system was forced to confront inequities in COVID-19 treatment and vaccine distribution. This was the gist of a frank and compelling presentation by Shawna Novak, MD, Executive Director, and Keltie Hamilton, Public Health Specialist, of the Canadian International Scientific Exchange Program (CISEPO) on June 11, 2021, for the Mass Vaccination Site Collaborative. CISEPO is a Canadian registered charitable organization that works toward achieving universal healthcare and creating conditions for peace through health.
In their talk on “Empathy, Responsiveness, and Cooperation as Tools for Vaccine Equity,” Novak and Hamilton described how a variated and disjoined COVID-19 response across Canada “laid bare some of the implicit bias in the system.” The pandemic “shook us out of a sense of complacency,” Novak said.
Data tells the story, the presenters said. Black people constitute 9 percent of the Canadian population but 16 percent of the COVID cases. COVID-19 positivity rates in some BIPOC communities is as high as 17 percent while the average in Canada is 4 percent. An estimated 60 percent of workplace outbreaks were due to unsafe conditions in food processing centers and warehouses.
Issues hampering the vaccine rollout included:
- A fragmented vaccine effort, with community-based organization bearing the brunt of reaching out to hot-spot areas.
- Essential/frontline workers faced unsafe conditions and burnout due to high demand.
- Pushback on using age as the determining factor for vaccine priority.
- A major lack of vaccine supplies that severely affected distribution plans.
- Burnout and stress among health professionals trying to administer vaccines.
- Over reliance on volunteers, who were not compensated.
- Difficulty in getting professional staff to operate in different locations due to licensing rules in Canada that do not transfer from province to province.
Currently, the Canadian government has announced that all Canadians should be able to get vaccines by September 2021. CISEPO is working with a partnership based mobile clinic model that can be deployed on a mass scale to reach vulnerable populations with an equity based approach. Vaccine conversation guides are being adopted for the Canadian system and translated into French. From the beginning of the pandemic, CISEPO has worked to engage students who want to help and volunteer and has been supported in this by partners in Toronto like Covid-19 Volunteer Resources led by Dr. Tara Moriarty and team at the University of Toronto.
Margaret Ben-Or of Ariadne Labs commented on how she was struck by similarities between Canada and the United States in issues of equity and access, despite differences in the countries’ medical/public health systems.
- Vaccine reluctance does not respond to “shaming” and there are often other root factors preventing those interested in being vaccinated from obtaining vaccination such as: work schedules that don’t align with clinic hours, lack of sick pay or time off for vaccination, difficulty in getting to mass vaccination sites, poor access to childcare, or linguistic barriers. Instead, teams should work with community members and trusted local leaders (faith based, community interest groups, residents committees) to understand the variable barriers to vaccination.
- Lead with compassion by designing vaccination centres that are trauma informed and anti-oppression through practical measures like providing “hearts” at registration to indicate the need for private tents or areas for youth with anxiety, seniors with mobility issues, or immigrants and newcomers with cultural needs for privacy or additional vaccination support.
- Try to partner with like minded groups like Vaccines Hunters Canada; use social media and stage events such as Doses After Dark and Jabapalooza to get to where the people are and bridge the need/availability gap.
- Advocate for pan-Canadian licensing so professionals can practice in different provinces.
- Focus on integrating principles of Just Recovery for All, which prioritizes people’s health, wellbeing, and equity.
Shifts in Vaccination Focus: International and Children
June 4, 2021
Even as mass vaccination sites are winding down, members of the Global Mass Vaccination Site Collaborative see new challenges looming. One is how to engage colleagues globally who are considering mass vaccination sites as part of their vaccination strategy, and another is the issue of vaccinations for children under 12 years old.
“We know that the risk of infection for this age group is low, but we are still not sure about long-term immunity and whether children can be vectors for COVID-19 infection,” noted Eric Goralnick, MD, MS, Associate Faculty, Ariadne Labs and Principal Investigator of the collaborative, during the June 4 meeting.
Jonathan Ballard, MD, MPH, MPhil, FACPM, of the New Hampshire Department of Health and Human Services, shared his concerns about the ability and willingness of private providers nationally to offer vaccinations in their practices given the constraints with storage and handling, documentation, and multi-dose vials. He expressed uncertainty about whether pharmacies will administer vaccines to children as young as two years of age when vaccines are traditionally administered in pediatric offices for this population. His main worry is if there will be enough vaccine providers for younger children, and there may be a need to restart publicly administered vaccinations again in the fall such as children-friendly vaccine sites.
Other discussion points centered on possibly using schools as vaccination sites, the difficulty of getting consent forms filled out — either online or on paper — and what may happen with booster shots.
Amy Young, MD, of the Dell Medical School at the University of Texas at Austin commented that there have been some post-vaccine positive cases, mostly with the Alpha variant, which was first identified in the United Kingdom. The consensus of the group was that much is yet to be learned about variants. “That’s the big, black box,” Dr. Goralnick said.
Also discussed was vaccination efforts in India and Brazil and how to incorporate vaccination into primary health care.
- Be cautious about shutting down mass vaccination sites if there is a chance they will need to be re-opened in the fall. Considering building plans on how to quickly and efficiently re-open sites if needed.
- International efforts should consider how to relieve fatigued and stressed health-care workers as well as getting shots in arms.
- Consent forms for getting children vaccinated will be a challenge. Plan ahead as much as possible.
Assessing Risk on a Plane — As You Fly It
May 21, 2021
The question was put to the Zoom audience of team members who run mass vaccination sites: Did you proactively do a risk assessment ahead of time to ensure safety and reliability?
Pause. Then Becky Fox, MSN, RN-BC, of Atrium Health, said, “No. We had six days to get ready, and one of those days was a holiday.”
Others nodded. Said Captain Dirk A. Warren, M.D., the Surgeon General of Joint Task Force Civil Support, “We were building the plane in flight.”
But this was exactly the point of Karen Fiumara, Executive Director of Patient Safety at Brigham and Women’s Hospital, who did a presentation on risk management for the collaborative on May 21. Health managers have to focus on both system reliability and human reliability, she said. Distraction, experience, and implicit bias are all part of that human performance. “We consider a system effective if the system manages a risk,” she said. However, “resiliency does not mean unbreakable.”
In a lively back-and-forth exchange, members of the group spoke honestly about the challenges of setting up a system “in flight” and the inevitable incidents that occurred along the way. These included unprepped syringes and unforeseen environmental problems, such as an elderly person who failed to negotiate an escalator.
“If you think you did have a perfect scenario, you probably don’t realize your errors,” said Eric Goralnick, MD, MS, Associate Faculty, Ariadne Labs and Principal Investigator of the collaborative.
Others were positive. Said Will Roy, Federal Coordinating officer with FEMA region 1, in the Zoom chat: “From my personal experience in visiting VAX sites the feedback from the guests has been nothing but positive — ‘flowed like a well-oiled machine’ was the majority of the comments.”
“We scaled up as we learned along the way,” said Randy Van Straten of Bellin Health. “We also learned to partner better with community assets.”
Fiumara stressed that the “cultural experiment” of the pandemic could be used to improve safety in health systems. Her points included:
- Examine errors. Is it the person or the system? Most of the time it’s the system.
- There are two reasons why humans follow rules. One: You’re afraid you are going to get caught if you do not follow rules. (You drive differently when a police car is behind you.) Two: You appreciate the risk of not following the rules.
- You cannot punish somebody into better task performance.
- Avoid attributing vaccine hesitancy to specific groups. Rather, emphasize that there is a “well-earned distrust of the medical community.” Roy noted that you can really only say there is hesitation when you have the supply and the opportunity for vaccination, which was not the case. “We shot ourselves in the foot right out of the gate,” he said.
- Humans are only vigilant to a certain level for a certain period of time. People have to be acutely attuned to risk to remain aware of it.
Fear? Football? Free drinks? Freebies? What Motivates People to Get Vaccinated
May 14, 2021
What encourages people to get vaccinated? In the case of Green Bay, Wisconsin, it may have been the chance to look over Lambeau Field — the home of the Green Bay Packers — from the elite seats. During the May 14 collaborative meeting that focused on creative ways to get shots in arms, Randy Van Straten and Andrea Werner of Bellin Health presented on the mass vaccination efforts by Green Bay Public Health, the Green Bay Packers organization, and Bellin Health. The Lambeau Field site opened March 16 and about 38,700 people have been vaccinated there, an average of 1,200 people per day.
A vaccination site was first staged in Lambeau’s atrium, then moved to the eight terrace suites that overlook the playing field. Van Straten said the numbers of those seeking vaccinations has spiked, helped by the live media feeds from the suites. “The terrace suites are not an area (the average fan) can get into, and by opening this up we are seeing an upswing,” he said.
There may also be an impact from the effective marketing and outreach strategy the health partners have conducted with the 9Rooftops Marketing Agency. Werner described a campaign utilizing local and community influencers rather than actors. Called “Unity.Community.Immunity,” the campaign aims to reach the Latino, Black, Somali, and Hmong communities of Green Bay. “I don’t like the word ‘hesitancy,’” Werner said. Instead the partners have chosen to focus on the structures that hold people back from getting vaccinated. A media campaign with videos featuring the slogan “I Hate COVID” also seems to be having an impact.
Van Straten stressed how the collaborative’s May 7 meeting on “guest experience” was applied to the Green Bay efforts. “You took it from Friday and implemented on Monday,” noted Eric Goralnick, Medical Director of Emergency Preparedness, Brigham and Women’s Hospital, and Ariadne Labs associate faculty who is helping to lead the collaborative.
Van Straten and Werner spoke of challenges. Their team has staged about a dozen mobile sites with 600–700 vaccinations each; however, when Van Straten reached out to meat-packing plants for onsite vaccination, of 1,800 surveyed, only 9 responded positively. The team planned to administer a total of 1,200 shots in a Navy shipyard, but only did 300 vaccines in a two-day period. The group acknowledged that a sense of urgency might have decreased.
The group discussed different creative efforts to encourage vaccination, citing a New York Times article and a MIT study. In North Carolina, breweries offered a free beer if you get a shot. The effort has been effective but there has been backlash from a similar effort in Wisconsin by those who say it encourages drinking.
Could coupons for shots work as well? Could vaccines be ordered like pizza delivery? “How can we figure out how to meet people where they are,” said Van Straten.
- Incentives for vaccinations can take many forms, from offering shots in an alluring place (like Lambeau Field’s top-level suites) to handing out a free beer from a site in a brew pub.
- Media campaigns can be most effective when they employ local influencers, rather than actors.
- A hub and spoke model for vaccine distribution, in which a central location then supplies mobile or satellite clinics, can be effective.
- People may be losing a sense of urgency about vaccination but vaccination efforts should not be deterred, rather teams should settle in for a long haul.
Be Our Guest: Turning Vaccination into an Experience
May 7, 2021
What to call the people getting vaccinations at a public site? The word is “guest,” according to CIC Health Matt West, director of operations, and Rodrigo Martinez, chief marketing and experience officer. They presented on May 7 on how they ran three mass vaccination sites and about 19 pop-up sites in Massachusetts. “From the beginning we’ve called them ‘guests,’ not ‘patients.’ They are not sick, they are our guests. That gets the staff to act more as a host,” Martinez said.
The use of the word “guests” underscored the key point of the presentation: “Overall, the experience of the vaccine is as important as the vaccine itself.”
CIC Health runs four mass sites — Gillette Stadium in Foxboro, Fenway Park in Boston (now closed), the Reggie Lewis Track and Athletic Center in Roxbury, and Hynes Convention Center in Boston. The Hynes is also the hub site for outreach to five cities: Boston, Chelsea, Revere, Fall River, and New Bedford. West shared considerations for this “hub and spoke” model, such as:
- Setting up pop-up sites on Revere Beach, a popular location for the area.
- Working with cities to set up special vaccine buses that would move from bus stop to bus stop to administer doses.
- Use pop-up sites like churches, high school stadiums, and community centers during some days of the week for first doses, while maintaining a fixed site for second doses.
“We are trying to be as creative as we can be,” West said.
Martinez emphasized the use of human-centered design when creating the overall guest experience, beginning when guests visit the CIC Health website and ending on social media. The first sign that people should see at a site is a “Welcome” sign that recognizes the importance of the moment, he said. After their vaccination, guests may be given space for taking selfies to post their story. For example, sites can allow someone to record responses like “I dedicate my vaccination to my grandmother,” collect the various responses, and spread them through social media. “We create a stage for them to tell their story,” he said.
- Vaccination is not merely a procedure. The experience of the vaccine is as important as the vaccine itself.
- A communication strategy should be set at the beginning of the operation and refined throughout.
- Vaccination sites should utilize design principles and consider human factors, such as how you welcome people, set expectations, and provide information.
- Strive to amplify the effect of vaccination by creating social media platforms.
- Aim to turn every guest into an advocate for vaccination.
- Highlight and create assets out of milestones; share and allow guests to share these assets.
The Rules of Engagement for U.S. Military in Emergencies or Medical Crises
April 30, 2021
How do U.S. military personnel — soldiers, sailors, and others — end up in a community to help out with situations like mass vaccinations? The April 30 virtual meeting answered this question by focusing on the deliberate process and operating principles used by the military to determine when and how to deploy personnel in state or local emergencies. Presenting were Major General Jeffrey P. “Jeff” Van, Commander, Joint Task Force Civil Support, Joint Base Langley-Eustis, Virginia and Captain Dirk A. Warren, M.D., the Surgeon General of Joint Task Force Civil Support. Dr. Warren outlined the overview of how the Department of Defense provides Defense Support to Civil Authorities:
- The President or the Secretary of Defense must authorize the support.
- It mitigates the effects of a disaster or catastrophe (manmade, natural, or terrorist).
- It provides temporary essential services at home or abroad.
- Department of Defense always operates in support of the Lead Federal Agency.
The chain of command may appear complicated; however, the goal is to ensure coordination between the Department of Defense and local, state and federal authorities.
When asked about the timeframe of response, Dr. Warren said it is usually about a week but can be expedited, particularly with commanders who have immediate response authority and can take immediate action if they believe they can save lives or mitigate property loss after a disaster has been declared. Commander Van noted that “we can move within hours” if a need is anticipated.
- The U.S. Military is prepared and ready to lend aid. The Department of Defense follows set protocols to ensure that military personnel always coordinate with civilian authorities.
Coping With an Ever-Changing Vaccine Landscape
April 23, 2021
The ever-evolving status of COVID-19 vaccines — including the sudden pause on use of the Johnson & Johnson vaccine — preoccupied attendees of the April 23, 2021, collaborative meeting. Eric Goralnick, MD, MS, Associate Faculty, Ariadne Labs and Principal Investigator of the collaborative lead a round robin discussion in which members shared current challenges.
Discussion was centered on inventory, second-dose appointments, and on how to transition from mass sites to smaller or mobile sites. In Massachusetts, 75 percent of residents are projected to be vaccinated which may lead to closing of large vaccination sites. Collaboration members were also seeing slowdowns in smaller mobile sites as well as mass vaccination sites. Could this be due to hesitation or mass saturation? There were no clear answers.
Becky Fox, MSN, RN-BC, of Atrium Health acknowledged no-show rates have increased in certain efforts from 2% to 8%, which led teams to look for other creative initiatives to bring vaccines to the patients. It was an exercise she compared to “a bit of throwing vaccine-spaghetti against the wall” to see what sticks. The team is shifting to smaller, mobile units but wants to continue to have a mass site presence, so that if and when the need arises (e.g., mandatory requirements and/or school requirements), Atrium Health could expand quickly. Examples include small church groups, behavioral health outpatient treatment centers, restaurants, and small businesses where the number of vaccines ranged from 5–40 total doses per event.
Fox raised another issue: required vaccinations for health-care workers.” If we (health systems and clinical experts) agree vaccines are important, how do we push OUR health care systems to say, ‘This is mandatory for all of our employees?” The issue of requiring college students to get vaccinated was raised with reference to this article and this one. Other organizations shared that they too are considering mandates but would prefer to implement once full FDA approval for the vaccines is received.
Collaborators discussed how to juggle vaccines that must be kept frozen with no-shows. Maintaining inventory remains a crucial issue — everyone is determined that every shot be used. Instead of giving fully thawed Pfizer vaccines, Adrian Backus of CORE described using mobile freezers and thaw as needed. At the time Pfizer had recently released guidance allowing for 14 days of storage in a freezer.” (This has since been updated. See here.) “When you get to the end of 14 days in the freezer, you have an additional 5 days, so you have 19 days,” Will Ford of UC San Diego Health, noted. “You can dilute and draw to give yourself another 6 hours according to Pfizer.” Another issue was whether to offer two different vaccines — like Moderna and Johnson & Johnson — at the same place and offer the choice to people.
Fox described a “great” event in Charlotte in which a vaccination clinic was held at a brewery and those getting shots got a free pint (provided by the brewery). Staffed with about 5 to 6 people, the event drew a diverse group of 107 people aged 18 to 35. No appointments were needed, and it was held in the evening, as many patients have described the challenge of getting to a vaccination site during daytime hours due to their work schedules. There were zero reactions or complaints of anxiety or nervousness — “that was the coolest part, as the observation was in a beautiful outdoor space, where patients could enjoy their beverage if they wished, while they waited.” Social media was used to promote the event, giving it a “cool factor.” They plan to go back to the brewery in three weeks for second doses. This was a good example of “going to the people,” said Margaret Ben-Or, Ariadne Labs’ project manager for the collaborative.
- Stay flexible.Vaccination efforts may morph from mass sites to smaller sites, but a hybrid model might work at the current time.
- Be clear about guidelines for thawing vaccines as teams may have more doses than they first realize.
- Be creative. Go to where people are — even if it is a bar.
Dream Helps Solve Potential Nightmare
April 16, 2021
Data collection and logistics was the focus of the virtual April 16 meeting. Dan Resnick-Ault, MD, administration and operations fellow for the Department of Emergency Medicine, University of Colorado School of Medicine, presented on the challenge of creating a mass vaccination site at Coors Field in Denver. He began his talk by noting that military data indicates that if you could create a good “throughput” or traffic flow with less queuing, you can run a site for fewer hours, decrease staffing costs, and increase the vaccination rate. Thus, his team’s goal was creating an effective traffic flow.
The vaccination site at Coors Field opened February 2021 and was soon able to administer 5,000 doses during a 6-hour window with 200 staff. Two traffic lanes were set up to feed into six queuing lanes that led to the registration tents. Bail-out or snafu spaces were set up to pull aside those cars with problems with registration so as not to block the flow. Cars successfully registered were then sent to 16 vaccination tents and finally directed to observation parking lots. A command post was set up on top of a nearby four-story parking lot. Data collected indicated that 830 cars were processed in an hour.
Resnick-Ault described some of the issues encountered. For example, lanes leading cars to the observation lots narrowed to two lanes and caused a backup so severe “we actually had to pause vaccination at one point,” said Resnick-Ault. Michael Skaggs, a first-year medical student, had a dream about a better way to do this workflow. Before medical school, Skaggs ran a whitewater rafting company in which he had to juggle through-put and timing for a fleet of rafts. Translating that operational skill to the vaccination site, he envisioned having vehicles distributed in a serpentine manner to the observation parking lots and then discharged out to the side. “This means the ingress lane to the traffic is never paused.”
The Colorado team found that the first weekend, people spent about 22.48 minutes total on the site. One of the slow-down points was in registering patients. The team eliminated a separate registration step by registering people at the point of vaccine delivery. With the addition of a mobile app for registration, the team was able to reduce the median time from registration to vaccination from 4.27 to 2.18 minutes, thus decreasing overall time.
Other challenges involved frigid temperatures that made it difficult for staff to operate outside. This was solved with the use of a “mega tent” wide enough for eight lanes. Additional snafu spaces were added to ensure traffic continued to flow smoothly.
The group discussed the issue of holding people for observation in case of a severe allergic reaction. Liquid Benadryl was kept on hand and given to those who said they didn’t feel well. Resnick-Ault recalled a lesson from the Cardinals mass vaccination site in Arizona from which his team learned and incorporated into their setup. In Arizona, a row of ambulances was first stationed near the observation lots; they were later moved out of the direct line of sight, Resnick-Ault said. “When people could see a row of ambulances, they had lots of reactions. When [the ambulances] were moved behind, all their problems went away.” In Denver, people were not pressured to leave lots; no severe reactions requiring hospitalization were observed.
While the Coors site was closed due to a lack of vaccine supplies, Resnick-Ault anticipated that the lessons learned could be applied if re-opened. “We think we can do 15,000 a day without breaking a sweat,” he said.
- The use of a “bail-out” or snafu space for drivers with registration issues to pull into is crucial to keep the general traffic flowing.
- When the team began to use Epic Rover, a mobile app that allows clinicians to record documentation and conduct barcode validation at the point of care, they were able to substantially reduce the time from registration to vaccination.
- The creation and implementation of a real-time data collection tool allowed for visualization of throughput and actionable data for day-of and post-hoc clinic improvements.
- The reduction or elimination of post-vaccine observation time for a second dose might be considered, although this was not a point of universal agreement.
Charlotte Motor Speedway and Bank of America Stadium: >36,000 vaccines in less than 10 days
April 9, 2021
How many 75-year-olds get a chance to drive on the Charlotte Motor Speedway? That was one of the draws for a mass vaccination site set up by Atrium Health, a health system serving patients at 42 hospitals and more than 1,500 care locations in the South, when the system pivoted to provide COVID-19 vaccinations in winter of 2021.
The goal was 1 million vaccinations by July 1, explained Becky Fox, MSN, RN-BC, of Atrium Health, during a presentation on April 9, 2021, to the collaborative. Fox’s presentation covered the team’s efforts to get a mass vaccination process set up, from the planning to the adjustments along the way. One of the initial drive-through sites was the Speedway because, as the staff joked, “No one knows how to move cars faster than a speedway.”
With less than a week to prepare, Atrium launched its vaccination efforts in partnership with Bank of America, Honeywell, and Charlotte Motor Speedway. They provided not one but two large mass vaccination events, including the first in North Carolina. The team used innovative creations that allowed patients to be processed in less than 45 mins, with a 22–25 min average. For example, a screening app sent via text message to patients prior to their appointment identified the patient and screened them for 15 or 30 minute wait times. Multi-field barcodes sped up the medication documentation and required state registry documentation processes. The medication process requires 9 different fields to be documented, which is cumbersome when processing 500–1000 patients per hour, Fox shared. Instead, the 60-second process was brought down to two seconds. “A reporter called us the world’s largest pit crew,” Fox said.
Some challenges emerged from the patient population and sites. “A lot of patients came in with what I called the ‘vaccine fog,’” Fox said. “These were patients who were emotionally overwhelmed by the pandemic, the vaccination efforts and had trouble focusing, so we had to really ensure our communications, our signs, and our processes were smooth, as we were committed to also delivering an outstanding experience.” With a different format of both a walk-in and drive-through site at the Bank of America Stadium, less than five days after the first event, this posed additional difficulties. Because parking was some distance from the vaccination site, staffers provided personal concierge service to those who needed it via wheelchairs; one staffer racked up 37,000 steps in a day taking patients from their car, through the experience, and then returning the 0.2 miles back to the parking garage.
Burnout and trauma for staffers — who had already been dealing with COVID-19 for months — was a prime concern. The “Fill Your Tank” Program was developed for the mass vaccination events, asking front-line staff to work in the vaccination lines, where hundreds of times a day, they heard, felt and saw gratitude from patients and the community. “We wanted to make it a great experience for the team AND the patient,” Fox explained, “and we heard over and over again from staff, how this was some of the most meaningful work they felt they had ever done, and truly the best of Atrium Health and humanity shining through.”
The mass vaccination events and lessons learned were spread to other events held in the community at surrounding counties and included other sites such as colleges, universities, and at the airport in partnership with American Airlines.
The team was confronted with the question of: How do we get vaccinations to people at home without transportation? The decision was made to send small groups of nursing staff to pods of housing locations. No-shows were a problem. During spring break, 4,500 people signed up but only 4,000 showed up.
- Utilize healthcare staff, especially nurses, to lead the efforts.
- Think like Disney and “prime the line” so that people get through quickly with the goal of making it a pleasant experience.
- Keep track of data and use it to make real-time adjustments. For example, if you find you are running no-show rates of 2–3 percent, schedule more appointments using social media to alert people.
- Manage private-public partnerships for effective results.
- Set up processes and policies so doses can be taken off-site to manage the left-overs, i.e., establish a chain of custody.
- People feel more comfortable going somewhere in the community rather than being shuttled to another location.
CORE tackles vaccinations from mass sites to mobile units
April 2, 2021
The switch at Dodger Stadium in Los Angeles from a testing site to a vaccination center was a truly daunting effort. Marlina Crespo, the COVID-19 area manager for the Community Organized Relief Effort (CORE) vaccination effort in Los Angeles, acknowledged this during the April 2, 2021, meeting of the Collaborative. “The amount of equipment and human resources required was definitely not something that we were expecting. We underestimated the scale,” she said.
Nevertheless, more than a million vaccines have been administered in the City of Los Angeles, and nearly 480,000 vaccines were administered at Dodger Stadium — about 12,000 to 15,000 a day — by a staff of about 480 between 8 a.m. and 8 p.m. Crespo, with CORE Co-founder and CEO Ann Lee, explained how their team approached the massive vaccination effort.
Their challenges included:
- Ensuring sufficient supplies across such a large, spread-out venue.
- Having all staffers HIPAA certified.
- Oversight in such a large, spread-out venue.
- Traffic impact in the neighborhood.
- Ensuring enough vaccines were on hand but not overdrawing and risking the vaccines expiring.
- Maintaining communications among the many partners, which included the mayor’s office, the local fire department, medical software companies, local universities, and community organizations.
The team was able to come up with innovative operational solutions, including having a vaccine cart that went from car to car; color-coded vests to distinguish functions among staff; a tracking system created by medical students to track which vaccines should be used first; and yellow magnets placed on cars to indicate observation time needed. Initially, it took as long as 4 hours for a person to receive a vaccination; currently, time can range from 2 hours to less than 30 minutes depending on the crush of the crowd. “Everything needs to work together to be functional,” Crespo said.
CORE also runs mobile units giving 4,000 doses a day; a drive-up and park unit giving 5,000 daily; a walk-in unit at 3,000 a day; and a mobile unit that reaches out to people experiencing homelessness. CORE also works with Access LA, which provides transportation for people without other options.
Lee noted the most efficient and cost-effective model is the walk-in clinic; running mass sites, such as that at Dodger Stadium, can be extremely costly, although insurance reimbursement seemed to be covering most of the costs.
Lee also spoke highly of the effectiveness of mobile clinics, which were sent to an area for a week or so. People did not need appointments, and the word that a unit was there spread quickly in a neighborhood. Mobile clinics have administered over 73,000 doses, 90% of them to people of color. The team also hoped to send a vaccination unit to a garment factory to reach undocumented workers.
“Having so many different options is important,” Lee said. She expects an emphasis on the mass vaccination sites in next months and then a focus on walk-up sites and mobile units later in the vaccination campaign.
- Be prepared for unexpected difficulties.
- Mobile units are helpful for reaching those without access to computers or wifi or with limited computer skills.
- Walk-in clinics may prove to be the most cost-effective option.
Kickoff Meeting Delves into Logistics of Nashville Event that Vaccinated 10,000 in a day
March 26, 2021
As the vaccination efforts were gaining steam around the world, the collaborative held its kickoff meeting to begin the weekly effort to share information, best practices, and stories from the vaccination frontlines.
The March 26 meeting featured a presentation by Rachel Franklin, MBA, AEMT, of the Metro Public Health Department in Nashville, Tenn., who described the mass vaccination effort at Nissan Stadium in Nashville. In one day on March 20, over 10,000 people were vaccinated — an impressive effort that also provided key insights into how to stage such large events.
Organizers drew on previous plans, infrastructure, and funds for other kinds of medical emergencies, underscoring the message of always being prepared. Tennessee got 100,000 doses of the Johnson & Johnson vaccine and asked local health organizations to administer quickly. “We had 18 days to do this,” Franklin explained.
While organizers had a ready site at the football stadium, nothing had ever been done at such a large scale, Franklin said. She described the logistics — creating 20 lanes of traffic, putting together vaccine kits on site, creating the registration process, and using green cards indicating a person was good to go for a vaccine. The team had to be efficient. “It’s hard for nurses not to be conversational but we had to keep it moving,” Franklin said. When a central location used for putting together vaccine kits could not keep up with flow, the team pivoted to create a way to put together kits at each lane. They used pre-printed stickers so that reduced time on writing.
The team also set aside a number of appointments specifically for BIPOC and refugee populations and utilized radio channels on mobile devices for Spanish translations. “Traffic control was a very important part,” said Franklin. Luckily, 20 National Guard volunteers were on hand for traffic control.
Franklin was asked this question: “Given the potential for high winds and/or storms forcing a cancellation and rescheduling of thousands of appointments, is it worth it to pursue outdoor drive through vaccination in markets with less reliable weather patterns? Are they able to achieve that many more doses per day than mass vaccination facilities functioning indoors or is the justification based on greater customer service?”
Franklin said that while they set up a make-up date for severe weather, they decided that even if it was a rainy, cold, “crappy” day, the event would remain open for appointments. “We had plenty of ponchos, and we could get umbrellas quickly,” she said.
Sara White from UCHealth, who represented a mass vaccination site at Coors Field in Denver, shared that her team ended up moving the majority of patients inside when temperatures reached -10 degrees Fahrenheit, as many participants were 70 or older with mobility issues. Many needed help getting into the clinic.
- Have emergency plans in place to ensure that if something happens, health officials can move quickly.
- Keep an eye on traffic flow in mass sites and pivot as needed to avoid bottlenecks.
- Be prepared to deal with weather — either to reschedule or power through.