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 last post) 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.