It was social media blowing up with Sea Shanties that got me into this. What is a Sea Shanty, anyway? My wife thought it was a tiny house on the edge of an ocean. Hmm.
Turns out, Nathan Evans from TikTok sings a New Zealand Whaling song “The Wellerman” with a beautiful Scottish lilt. It is the perfect antidote for Work From Home Loneliness. 10.4 million views later, lots of folks agree. The New York Times covers the story.
My favorite quote from the story: “It’s not the beauty … it’s the energy”, “You’re not supposed to sing pretty.” I think they’re talking about me!
I am so tired of working from home, of not seeing anyone, that I fantasize about working together, singing in cadence on a crew of a ship.
CMIO’s take? Fighting Covid is a little like a high-seas adventure. Hope you like my version.
Outdoor vaccine guy says: come along, I’ll show you what I learned.
The UCHealth team held its first Mass Vaccination trial at Coors Field on Sunday 1/24. This was the first Mass Vaccine effort in Colorado, and was coordinated with the City and County of Denver, CDPHE (Colorado Department of Public Health and Environment), Denver Police, Verizon, Denver Health, Stadium Medical and the Governor’s Office. Weeks in the planning, dozens of clinicians, staff and coordinators swarmed the location assembling, arranging, tweaking.
2 hours: 1000 vaccines?
For this event, we planned to give 1000 vaccines in 2 hours to stress-test our design plan and to see if we could maintain or exceed this pace for future events. This was an invite-only event with 500 patients selected from UCHealth existing patients and 500 from newly-signed-up for vaccine from the UCHealth website for the general public aged 70+ per State current guidelines.
Between 6 and 7am, we assembled, got last-minute instructions for our many roles: runners, flaggers, registrars, traffic control, vaccinators, timers, process engineers, clinical observers, flow coordinators, etc etc. Here, I’m standing under a heat lamp, warming my hands for the day to come. The big white tent is registration-confirmation. Sorry, no drop-ins.
Team Number ONE!
With Dr. Jenny Bajaj, CMO of UCHealth Medical Group and Andrew Mariotti, medical student and process timer. We, of course, snagged Vaccine Tent #1. For work like this, snow pants recommended.
The UCHealth team set up a small batch of cars to arrive between 8 and 9am, to work out the kinks at every vaccine station; each station received 2-4 cars to test our supplies and workflow, and see if the runners, pharmacists, flaggers, observers had any questions about their jobs.
We then huddled between 9-10am to debrief questions from the team, then BOOM. Our full-speed test was from 10-12am with 1000 cars to come through in that time.
From the fourth floor of the Coors lot parking garage, the command center station. The RTD commuter trains run along the left, Blake Street on the right, the big white registration tent, where we catch and release any folks without appointment. The Mass Vaccine event (like EVERY Covid vaccine clinic) is highly calibrated down to our last vaccine. If we accepted drop-ins or family members, we would run out for our scheduled patients.
In the right row of tents, the first (most distant from us) tent is for registrations taking longer than usual, so that no registration line gets held up. Vaccine Tent 1 is thus the second (tiny) tent on the right. See me waving? No? No.
Our observation area (not shown) is actually behind the photographer, on the other side of the parking garage, with flaggers guiding the way.
Work station setup.
We re-arranged our area to be increasingly efficient. Working in teams of 2 allowed us to iteratively reduce our cycle time for each vaccination. Orange bucket 1: our vaccine supply (closely guarded by pharmacy and defrosted just-in-time). Orange bucket 2: pre-opened bandaids. Nothing is harder than cold, gloved hands opening bandaid packets when in a rush. Supply of gloves, alcohol swabs, gauze if needed. Raise the Yellow laminated card to indicate to runners if we needed supplies. Red card: help needed. Pink ribbon: attach to drivers side mirror for those warranting extended observation (eg previous history of anaphylaxis).
*One person waves down the car, checks “Please put it in Park!” (about 1/3 don’t unless asked!) asks the screening questions, confirms which arm, which passenger. *Simultaneously, second person (vaccinator) doffs/dons gloves, opens alcohol swab, snags a pre-peeled bandaid, grabs a syringe *Pivot! first person files the screening paper with identity and signatures for later data entry and grabs the vaccine card *Simultaneously, vaccinator: Swab, Pre-attach 1/2 bandaid, Vaccinate in one motion, auto-retract needle (more on this below), Swipe bandaid across, Done! *Pivot! first person explains the card, answers any questions, reinforces importance of second appointment, directs driver to proceed to next flagger to wait for the standard 15 minute observation time. *Simultaneously, vaccinator disposes the syringe, clears trash, dons/doffs gloves and preps the next setup.
With this setup, Dr. Bajaj and I started with about a 90 second cycle time, and with iterative adjustments, pushed our best time down to 59 seconds, with our average running 1:15 to 1:20, if no questions (or profuse thankfulness) from the patients.
On debriefing this, we had several thoughts: the time it takes to chat and manage paper is about the same amount of time to swap gloves, manage supplies, setup. Seems like the 2-person team is, at present, an optimal setup.
In the coming weeks, it may be possible to incorporate a clinician-mobile-app adjunct to our Electronic Health Record that would allow on-the-fly documentation that would take the place of paper questionnaires and signatures when in the field.
Paper is fast, but…
From an informatics perspective, the paper process was a win from a through-put perspective, but an opportunity to streamline data-flow. We had runners taking our paper to the Documentation Tent to be keyed into the EHR in near-real-time.
Contrast that with our in-hospital based vaccine clinic (see my lastpost) where vaccination and documentation occur in real-time, the EHR and the State Vaccine Registry being updated almost immediately, and with a cycle-time (with one vaccinator/documentor) at about 3 minutes.
as my sister is fond of saying. At the end of our time, Vaccine Station 1 reported 67 vaccines given in 90 minutes. That is EIGHTY (80) seconds per shot. Taking into account the times when our station did not have a car, we think we could have completed 10-20% more shots. We are NOT Throwin’ Away OUR SHOT.
Here’s our high-level debrief. Team leaders from each of our major roles reported in: paramedics, police, City and County and State leaders, the Rockies (THANK YOU FOR OUR USE OF YOUR MASSIVE PARKING LOT AND TRAFFIC EXPERTISE). Very smooth. We think we could increase the pace beyond 1000 per 2 hours. We are targeting 5000 vaccines per day for 2 days next weekend. We’ll see!
Total throughput time per car?
Measured another way, we found that cars moved from Arrival at the Registration Tent to Leaving the 15-min Observation Area: 21-27 minutes. TOTAL.
Zero anaphylaxis events. No paramedic transports. There were very infrequent side effects observed in the observation lots. Everyone drove away successfully.
Local news coverage of our event
Sky9 aerial footage (about half way down the linked article). Tent 1 and my white coat is visible at 20 minutes. Woo!
Oh, and here’s a gif of the auto-retracting needle. So cool. How did they even fit a spring into the barrel of this tiny thing?
When done correctly, depressing the plunger completely means that the needle retracts from the patient, completely into the barrel of the syringe, eliminating the chance of unintentional needle-stick. Innovation FTW!
CMIO’s take? Mass Vaccination: another chance to innovate, another chance to take a chunk out of the Covid pandemic. Send us more vaccine. We can handle it.
Join CT on the front line of vaccine clinic at UCHealth!
Hi y’all! I volunteered for a vaccine shift. Me and a couple dozen of my best friends. Here’s the scene: this clinic day was dedicated to second-vaccine doses for nearly 1000 healthcare colleagues, 12 vaccinator stations, and a constant stream of patients down the hallway. Our location can handle 2-3x this number, if we had vaccine supply to do so (and on last Friday, our location and 9 other UCHealth vaccine locations dispensed over 5000 vaccine doses across UCHealth).
Having been a grateful recipient of both my shots, I’m ready to wade in and do my part as well.
Ever wonder what it is like to be a vaccinator at a high-volume vaccine clinic?
On the Vaccine Front Line
First, you receive an email to take your training on EHR documentation requirements ahead of time, and a super quick anatomy refresher on deltoid muscle and intramuscular injections. Easily done, about 10 minutes. Then you report for duty at one of the twice daily 7-hour shifts. You get a quick in-person briefing, some quick hand-holding (ok sounds weird in pandemic times), and off we go!
Here’s my station. Because, as my daughter says, I’m totally into ‘hume-optimizing’ (determining the optimal way for humans to do things – sometimes to the great annoyance of family members or colleagues: sorry y’all) I thought hard and asked lots of questions of my more experienced medical assistants and nurses sitting nearby. Here’s what I learned:
Card colors: Green card: hold in air when ready for another patient; Yellow card: running out of any supplies; Red card: medical question (just embarrassing to hold this one up if you’re a physician)
Computer: login, find the immunization clinic, filter out discharged patients, sort by time of arrival, click to remove word-wrap to show more patients per screen.
The data entry fields pull forward 80% of relevant data to each new patient, as well as the vaccine name, lot#, and details, and I’m down to just confirming patient identity, confirming injection site (6- R deltoid, 7-L deltoid: even the physical mapping makes it easy: when patient facing you, the 6 key is on the same side as the patient’s R arm!), asking the 3 screening Q.
Then the shot itself! Vaccine syringe (obvious) but don’t stick yourself or the patient unintentionally. (HOT TIP) And when you insert the needle, do it with a quick pop so that breaking the skin and finishing the motion are in the same moment and the patient’s sensory nerves don’t get a chance to register more than one ‘oh’ of surprise. Specifically, don’t be slow.
(HOT TIP from a PA colleague in Interventional Radiology) hold the syringe between your thumb and 3rd and 4th digits, with your index positioned over the plunger. Really? That’s the way? (Sooooo much faster than my jab, then switch hands, try not to be awkward, plunge, untangle my hands and pull back) and the jab+plunge was now less than a second. Level up! (Gamer talk). After my “technique improvement” lots of patients were surprised: “Hey! Didn’t feel that at all!”
(Irrelevant aside) I notice that this new syringe grasp is reminiscent of the way you are to hold a Chinese Calligraphy brush, like you are cupping an egg and then grasping the brush. Ah, such elegance.
(HOT TIP From a brilliant nurse colleague) After the alcohol swab of the deltoid, pre-attach half of the bandaid and let it hang down. That way, you know where to put the shot and you don’t lose track (if no spot of blood) of where it went as you look away to dispose of the syringe. Then flip the bandaid fully on, VOILA! Totally changed my life.
Click the needle protector closed with one finger, toss in Sharps container.
Mumble sweet nothings to your anxious client while doing the next steps. Answer any questions.
Type ‘n’ in the time field to get the time Now. Click Accept to complete the vaccine charting. Their patient portal account is automatically updated, and the State Vaccine Registry is updated (I believe either real-time or at midnight every night)! Add 15 minutes to write onto a sticky note to attach to their vaccine card for them to know when they can leave if feeling okay.
Reach for a tiny sticker to put on the vaccine card with vaccine name, lot#, date, location.
Smile with your eyes, gesture to the seating area.
(HOT TIP from another RN colleague): Wipe down: with gloves on, pull an antiseptic wipe for the desk, chair, relevant surfaces. Whip off gloves, rip and prep an alcohol swab and bandaid —easier with gloves off. New pair of gloves, position a new syringe on desk, check if running low on supplies, raise the green card.
NEXT! Cycle time when all was humming, as little as 3 minutes. Less time than it took to read this.
Of course, GEEZ some patients had the temerity to ask questions. Or we would briefly run low on vaccine as the pharmacy team whipped up another batch in the next room, or someone had to run for sticky notes or wipes or gloves etc. Or maybe I NEEDED A POTTY BREAK, OK? Other times, we would have lulls in the action. Then it was up to our green-card-waving skills as to which of a half dozen vaccinators the lone patient would walk to.
Here’s a counterintuitive tip for non-medical workers.
You might think that having your vaccine done by a person in green scrubs or a white coat (in my case, both) would be ideal: they’re the doctors or providers. In our organization, nurses wear dark blue scrubs, medical assistants wear dark purple (violet?). Almost uniformly, the docs volunteering haven’t given vaccinations since … medical school. In my case, 30+ years ago. My recommendation: go with blue or violet scrubs for technical proficiency and years of practice. Of course, if you want a long medical conversation, by all means stop by my booth!
Here’s my tally. Actually 55 by end of day. I figured out that I could keep my needle caps on the desk until I had a break to make my hash marks and throw out the caps. The system worked. I know many of my RN and MA partners were quicker than me or had better patient-attracting green-card-waving skills or took shorter breaks. Not bad for my first half-day shift.
This was unlike my daily work.
As a physician in an internal medicine clinic I would worry about how to reduce the blood sugar of an overweight, depressed and anxious diabetes patient with high blood pressure, severe arthritis, needing wheelchair repairs, a dozen prescription refills and several prior-authorization meds, and now with several new worrisome symptoms and family pressures. As CMIO I would worry about how to balance the anger of providers spending long hours writing notes and orders versus allowing a sloppy, error-prone verbal-order paper-like system. And how to allocate time and effort between reducing physician burnout and improving predictive algorithms when those projects were sometimes in conflict.
Working in a vaccine clinic by contrast was like playing a fun, fast-paced, team-based video game (not that I would know): clear goals, mutual reinforcement, visible progress, strong team camaraderie, repetitive (and improving) physical skills, opportunities for rapid learning, immediate positive feedback and customer appreciation, excitement over doing a public good. We were IN THE ZONE.
Honestly, on good days, both regular clinic and informatics work is like this too.
What’s not to like?
Oh, here’s one of our physician leaders, Dr. Andy Meacham, even with everything he knows about how docs are the worst vaccinators, willing to be my victim. Thank you for your service, Dr. Meacham.
Honestly, it humbles me to part of such an amazing organization that assembled the people, the process, the tools so that I could drop in as part of a well-oiled machine, only a couple weeks into this brand new process. I’ve noted quite a few physician leader colleagues also taking part. So cool.
UCHealth, like all health systems across the state of Colorado, are following the guidance of the Colorado Department of Public Health and Environment (CDPHE). As the guidelines change (sometimes daily!) we follow the guidelines. Our supply of COVID-19 Vaccine is closely tracked, and each next shipment depends on our adherence to guidelines.
We are now opening up vaccination signups to segments of the general public beyond health care workers. See the CDPHE guidelines here: https://covid19.colorado.gov/for-coloradans/vaccine/vaccine-for-coloradans. Based on the state’s plan, UCHealth is focusing efforts on vaccinations for people 70 years old and older. You do not need to be a UCHealth patient in order to get vaccinated.
Here is how it works
Keep in mind that most health systems in Colorado are working on vaccine distribution. Please first check with your primary care provider or primary health system. For those over 70 with interest in getting their vaccine from UCHealth,
We will use My Health Connection, the patient portal for UCHealth’s electronic health record, to communicate with people. If you have an active My Health Connection account, you will automatically receive updates regarding the vaccine. If you do not have an active My Health Connection account, please create one to receive these updates. To learn more and create an account, go to www.uchealth.org/covidvaccine.
Over 80% of patients at UCHealth have a MHC account, and we’ll be using our Electronic Health Record (EHR) to determine our patients who meet the criteria for vaccine (currently, using date-of-birth to calculate age 70+).
You DON’T have to be an existing UCHealth patient or be seeing a UCHealth provider to create an MHC account and to indicate your interest in the COVID-19 Vaccine.
You WILL need to have an email address and be able to access the patient portal yourself. You may have a proxy (trusted designee) sign up for you; keep in mind that this proxy would also potentially have access to your UCHealth electronic health records as well.
At this time, we do not have enough vaccine doses to offer it to everyone. As UCHealth receives shipments of the vaccine, we are providing it as quickly as possible, according to the state’s plan. As we receive additional quantities of vaccine, we will send vaccination invitations through our randomized selection process to give everyone the same chance of receiving a vaccine.
When vaccine becomes available to your phase of distribution, you will receive an invitation from My Health Connection with instructions about how to schedule your vaccine appointments. Please be patient until you see the message titled “Urgent: Schedule your COVID-19 vaccine”. When you receive this message, you will be able to schedule both vaccine doses. You will have 48 hours to get your appointments scheduled. If you miss the 48-hour time frame, you will receive a new opportunity to schedule in a future distribution phase.
An appointment is required to receive the COVID-19 vaccine; walk-ins cannot be accommodated.
This process has worked well for our first 37,000 COVID-19 vaccinations, and we plan on scaling up further, as vaccine availability improves.
Some may criticize us for using an electronic patient portal and perhaps leaving out those without access to the internet. (I have even heard the term “digitalism.” However, looking that up, it seems to mean “being poisoned by digitalis from the foxglove plant.” Hmm. But we digress.)
At the same time, we’re putting plans in place to ensure that those without access to a computer or smartphone also have access to the vaccine. Through phone hotlines, clinics that target low-income areas of the state, and outreach to underserved communities, we aim to provide the vaccine fairly to everyone. Some of these efforts have already begun.
Our main point from using our patient portal was that, using our existing infrastructure where we already have nearly 1 million patients, we could move quickly, filter our patients by age, and create and send invitations thousands at a time. This contrasts with those who might have to postal-mail invitations or make phone calls and set up (and staff-up!) a phone bank, that could take days and weeks.
We launched the invitation and scheduling process over one weekend (thank you and sorry to our IT and project leaders who built this) and offered vaccines the next weekday after receipt of our first batch. I’m so grateful to work with such amazing colleagues and their amazing teams, and grateful that we have an existing information technology infrastructure that allows this. The EHR is our superpower.
Because there are no cameramen allowed to capture video of live soccer matches, an AI cameraman tracks the action by following the round ball around the soccer pitch. Well, a referee’s bald head is very attractive to the AI cameraman; this ruins the day of many soccer fans. So sorry.
This is priceless and also reassuring that we are not yet all out of a job.