Observations

Shots in the Arm

A Day with a Public Health Nurse at a COVID-19 Vaccination Clinic

As a public health nurse for the health department where I live in Bergen County, N.J., I wasn’t surprised to get a call one night in late December, informing me that our county’s first batch of 1,000 doses of Moderna’s COVID-19 vaccine would be arriving in two days.

New Jersey Gov. Phil Murphy has established the phases and timeline for COVID-19 vaccination. The hope is that 75 percent of New Jersey’s nearly 9 million people will be vaccinated by late spring, an immunization campaign of a scale never before attempted here.

California has an even more daunting task — inoculating 40 million people!

Beyond a Flu Clinic

If you’ve ever participated in a flu clinic, you already have a good idea of the general procedures, but COVID-19 vaccination clinics involve some additional challenges.

Patients must preregister online (via our county website), which allows doses to be prepared according to the expected number of patients so that none are wasted. Unlike a flu shot clinic, we don’t let patients leave until they’ve been observed for reactions. (These COVID-19 vaccines are still subject to FDA emergency use authorization, so we have to watch carefully for any adverse effects.)

Also, the current COVID-19 vaccines each require two doses of the same vaccine type  for full effectiveness, which demands additional patient education and follow-up.

Logistics

Years ago, our county conducted a mock training program in response to a hypothetical accident at a nearby nuclear power plant.

In our scenario, the public health system had to quickly mobilize to provide residents with emergency iodine tablets at designated dispensaries. This endeavor required medical personnel to coordinate with emergency services and volunteers. I studied the Incident Command System in order to be aware of the levels of communication and to memorize important acronyms.

Participating in this mock exercise taught me a valuable lesson regarding what it takes to successfully run logistics for a mass event. A lot of it comes down to small details. For example, if you distribute flashlights you also need to supply batteries, and people who are asked to fill out forms need a pen and a hard surface to write on.

We set up our COVID-19 clinic In a  self-contained field hospital, constructed by the Army Corps of Engineers in a parking lot of our large county hospital. It had been solidly built to hold 50 patients in five pods.

Each pod had an aisle with 10 curtained cubicles, five on each side, each with a bed, chair and bedside table. All were wired for electrical power and equipped with call bells. The hospital included restrooms, some with showers; a number of sinks; a medication room; and a break room with refrigerator and microwave.

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Our county has been provided with the Moderna COVID-19 vaccine, which is stored frozen and then thawed by the hospital pharmacist to prepare it for use. The vaccine arrives in coolers, which are kept locked in the medication room. Once thawed, the Moderna vaccine has a shelf life of 12 hours unopened and six hours after opening, allowing it to be used for the entire day.

Our focus for this first limited batch would be “Group 1A”: workers who have direct contact with potentially infectious material, patients in long-term care, and first responders such as EMS workers, firemen and policemen. When this group has been mostly vaccinated, we will move on to frontline workers and people over the age of 75, and then finally start giving shots to the general public.

Patient Pods

On Day One, we were lucky to have good weather, because even with online preregistration there were long lines. To aid with social distancing, appointments were scheduled for small numbers of people at 15-minute intervals.

We had security at the door to allow patients to enter in groups of 10. Before they moved forward, someone checked their appointments and gave them each a clipboard with consent forms.

After hospital or public health staff had verified the patients’ registrations, each pod of 10 was seated at an appropriate social distance for further instruction by one of our health educators.

The educators explained what patients should expect, stressed the critical importance of their second dose, provided a sheet on managing any post-vaccination discomfort and explained how to register with the CDC’s “v-safe” health-checker app to help track any long-term adverse effects. Patients were then invited to ask questions.

The Rolling Cart

While patients were listening to the educator, the nurse was in the medication room, filling a batch of 10 syringes.

Once instruction was complete and patients had signed their consent forms, each patient was seated in a separate cubicle to wait for the nurse, who travelled from cubicle to cubicle with a rolling table, verified the patient’s consent, asked about any health conditions or allergies, administered the vaccine and then handed the patient a slip noting the time they could leave.

This system allowed each patient to remain seated to be observed for reaction or lightheadedness for 15 to 30 minutes.

During the observation period, the pod manager collected the consent forms so the registrars could create a separate online file for each vaccine recipient. During the observation period, the pod manager collected the consent forms so the registrars could create a separate online file for each vaccine recipient.

The pod manager also gave each patient the vaccination card they will need to bring to get their second dose, explaining how to schedule the next appointment and when it would be due. Patients had been advised to take a photo of both the vaccination card and their consent form, which lists the type of vaccine, lot number and date given.

Hiring Now

By the time the last patient had left after their observation period, the next pod of 10 patients had completed their education and taken their places in the cubicles and the nurse had already filled the next 10 syringes from the medication room cooler.

It Takes a Village

Nurses are used to being in control of the immunization process from beginning to end, but this model relied heavily on support from ancillary services. For example, we had an EMT on hand in each pod in case of any problems, and an Office of Emergency Services worker collected the observation time slips as each patient left, preventing people from going anywhere until they had been observed.

There was also an IT specialist in case of glitches with the registration system, and security guards to deal with the few people who tried to enter without an appointment. A doctor was available to answer questions about health issues or allergies, but most problems seemed to stem from anxiety. No significant reactions occurred. Most people were extremely cooperative, so the process ran smoothly. Thanks to this great support, each nurse could vaccinate a patient in four minutes or less.

The Second Shot

At present, most patients are still receiving their first injection, but the scheduling system will soon allow for each day’s allotment to be divided between people receiving their first doses and people returning for their second shots.

All patients are encouraged to schedule their follow-up appointment at the same facility so that they will already be familiar with the process and get the same kind of vaccine. (Since currently only hospitals and county facilities are providing COVID-19 vaccines, there really aren’t any other options, but that may change.)

Patients automatically receive a text message reminding them to schedule their second appointment. Each day, the facility also puts up posters showing the date for the second dose along with a QR code that patients can scan to make an online appointment.

High Stakes

As a public health nurse, my usual work involves baby immunization clinics for patients whose health insurance doesn’t include well visits and blood pressure checks on seniors who are already well-supervised by private physicians.

By comparison, the COVID-19 vaccination clinic had me working at lightning speed, with much higher stakes. I was hard-pressed to accommodate 80 people in a shift, and we were constantly encouraged to work faster.

Naturally, patients slow down the process. There are always those with tight sleeves that they push up one inch at a time, asking “Is this high enough?” (Curtains around the cubicles offer privacy for anyone needing to remove a shirt entirely.) Larger patients or young men with bulging muscles require a longer needle length. Some people have a difficult time hearing you through the N-95 mask and shield, causing anxiety or requiring instructions to be repeated.

Fits and Starts

Because vaccine doses are arriving in fits and starts, the health department has very little notice for employee scheduling. All public health workers are advised to check our emails and texts for schedule changes and to be ready.

I’m glad we’re making inroads on getting our country vaccinated, but going through this process for almost 300 million Americans — twice each! — will be an extraordinary public health accomplishment.


Christine Contillo, RN, BSN, PHN, is a public health nurse with more than 40 years of experience, ranging from infants to geriatrics. She writes the Book Club column.


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