The Henderson County influenza vaccination clinic, sponsored by the health department and two area hospitals, planned to vaccinate 15,000 residents against influenza over 2 days. The traditional flu clinic design was altered to improve efficiency and capacity as a mass vaccination exercise. Planning started 8 months ahead with the collaboration of two hospitals, the health department, and Emergency Management. The health department serving as lead agency managed the details of the clinic. A health department planning team included personnel from management, health education, management support and nursing. They located a site, obtained and prepared supplies, designed a clinic-flow diagram, organized food donations, equipment, public relations, operational tasks, and assigned workers. Recruiting retired nurses, Red Cross volunteers, and nursing students from the community college supplemented agency staffing. A total of 8,300 people were vaccinated. The average time per vaccinee was ten minutes door-to-door, improving efficiency by 50% from previous years.
The Henderson County Department of Public Health traditionally conducts an annual influenza vaccination clinic. The goal of each influenza vaccination clinic is to decrease the chance of a pandemic influenza outbreak and reduce morbidity and mortality in high-risk populations in the community. The health department also administers vaccine in rest homes, schools, and other sites. Each year, the health department vaccinates about 10% of the population, reducing the potential burden of flu illness. In 2002, the health department changed the clinic site and operation to accomplish the following three goals: 1) to conduct a mass vaccination involving other community agencies, businesses and health providers; 2) to distribute influenza vaccination in the community for greater equity and accountability; and 3) to introduce the citizens to the concept and process of a mass vaccination drill. Event planning created trust and respect between agencies and strengthened the public image of the ability to work together in the event of a public health emergency. In the past, vaccination efforts were not coordinated, creating competing and duplicated services, which contributed to flu vaccine shortages.
The role of the Henderson County Department of Public Health was to coordinate all the details of planning the vaccination event, bringing together the hospitals and county government in a neutral environment. The Incident Command System was used for orchestrating the exercise, with the health department's Communicable Disease Nurse serving as Incident Commander. The health department was responsible for fairly dispersing resources that included cost and profit sharing before and after the event. The hospitals were responsible for meeting periodically with the community influenza team, for planning and recruiting staff volunteers, and then participating in the actual event. All three agencies put their logos on the public media announcements to credit each party for the event and to demonstrate cohesiveness. In the community, the two hospitals are competitors, and this is the first event of its kind that brought them together. Emergency Management played an important role in the mass vaccination exercise. The community has a highly skilled Director of Emergency Management who participated in the planning meetings and organized his staff to assist in traffic control and public safety. They also assisted with site preparation, routing traffic flow, waste disposal and general manpower. Local media contributed to the promotion of the clinic through live television and radio broadcasts from the site, as well as newspaper coverage before and after the event.
The cost of the event was $140,555 including almost $117,600 for vaccine stock. Cost line items included supplies (i.e. vaccine, gloves and glove liners, syringes, bandages), sharps disposal, printing, advertising, equipment rental, color-coded event t-shirts, and food for volunteers. Some food and medical equipment such as wheel chairs were donated or loaned. The vaccine supplier donated $500 toward the cost of food for the workers. Revenue totaled $117,550. Medicare payment of $11.61 per vaccine dose was accepted and charged non-Medicare clients $15 per vaccine dose. In general, the fiscal goal of the event is to remain revenue neutral in order to keep the price of the vaccine low for non-Medicare-eligible participants.
Henderson County Department of Public Health has conducted an annual mass influenza vaccination clinic for over twenty years with proven success. The agency flu team is experienced and skilled at conducting the annual clinic, but in 2002 the team proved that it could surpass the previous goals through multi-agency collaborations. During the years of shortage of influenza vaccine, the local health department was the only health agency in the community that received vaccine on time, but local grocery stores and pharmacies were able to purchase vaccine early at an inflated price. This system created financial stress for the hospitals and the doctors’ offices, since they were unable to vaccinate the high-risk employees and patients in October as usual. Many residents and physicians in the community were distressed about the health disparity created by this lack of control over the vaccine supply.As part of the exercise, the Health Director included the regional Public Health Response and Surveillance Team (PHRST6) and a representative from the CDC, Dr. Jacqueline Mason, to document the efficiency of the vaccination clinic model. This level of interest helped with promoting the idea of a community mass vaccination clinic, both for the local media and for an example to the other health departments in North Carolina. The data they collected helped evaluate the patient flow design and efficiency. During the busiest times when patients were lined up from registration out to the parking lot, program staff were able to project the patient wait time, and how many people could have been seen in the set up. Program staff learned 20,000 people could have been vaccinated based on the flow rate from this exercise. This valuable information will be instrumental should the community face a mass vaccination scenario, and is encouraging proof of good planning.
In general, the fiscal goal of the event is to remain revenue neutral in order to keep the price of the vaccine low for non-Medicare-eligible participants.
There are many possible explanations for not reaching the goal of 15,000. The fact that the community did not encounter a vaccination shortage in 2002 may explain a lower turnout. Given that the participation was similar in years past, this may represent the number of people in the community willing to come to a vaccine clinic for their flu shot.
Use of different types of syringes created multiple problems. The program decided in the future to use only pre-filled syringes. The amount of time and dosage saved is significant. Using pre-filled syringes would also avoid the confusion created by requiring different vaccine lot numbers to be recorded on the consent forms.
Traffic control in the parking lot proved to be a problem area. Traffic congestion may lead to the inaccurate perception of long wait times and may have affected turnout. In the future, the health department plans to improve signage to display wait times prominently and to route traffic more efficiently for large crowds. The parking lot was partially filled with staff vehicles and gave the impression of a busy clinic. In the future, staff and volunteers will be asked to park in the rear of the building.
Collaboration between public health and the hospitals was a productive process and improved the cohesiveness of the medical community which proved to the community that public health activities run more efficiently when organizations work together.
The program determined the need for a "floater" nurse to administer vaccine in cars and buses in the parking lot for clients with disabilities. Registering and administering vaccine to those who were unable to enter the building presents some challenges to be addressed for future clinics.
Trash disposal is a significant issue to consider. Mass clinics such as this generate large quantities of waste. Prior arrangements to rent disposal equipment must be considered.
Time: Order vaccine stock by early spring. Set up meetings with hospitals prior to ordering the vaccine. Time this to prevent duplication of vaccine ordering and foster a working relationship with the managers involved. Get buy-in between the Health Director and the hospital administrators, and then have hospital representatives meet with the health department team. Have a follow-up meeting to get commitments for staffing. Let the health department team be responsible for the details of the event, but inform the partner agencies about those details such as what to wear, where to park, and what shifts to cover. Reserve a location or two in advance. The timing of this depends on the community. Look at some options and choose the location based on parking and traffic flow, patient flow, cost, and number/accessibility of bathrooms available to workers and public. Confirm vaccine stock delivery date. Locate a facility that can store a large quantity of vaccine under refrigeration. Confirm the availability of extra staffing to help. Order supplies in sufficient time to allow preparation. Nursing and clinic staff can help prepare by opening items such as syringes and band-aid packages in the weeks before the event. Public health agencies should plan so that public announcements and ads to run in the three weeks before the event. Staff: There were approximately 350 individuals who worked the two-day clinic. These included greeters, registration clerks, traffic managers (inside and outside), nurse vaccinators, nurses to draw up vaccine, supply coordinators, cash collection desk clerks, EMS personnel, and Spanish interpreters. Clinic Operations: To make identification of staff easier for everyone, general staff wore blue t-shirts with the “Fight the Flu” logo and supervisory staff wore identical shirts in red. Greeters met the clients at the door, asked them to remove coats, get out their Medicare cards, and roll up their sleeves. Clients were then routed toward registration lines. The most physically disabled clients were routed to a special area and staff came to them. Healthier clients were routed to the main registration line. Clients who would need to pay with cash went to a separate line. It quickly became apparent that a nurse needed to be stationed outside to vaccinate those who were unable to get out of the car, or to provide services to busloads of people who were transported from local retirement centers. We already knew that registration moved much more quickly if much of the information was already printed on the form so lot numbers, site location, Medicare codes, etc. were preprinted. These forms were loaded into copy machines and the Medicare cards were copied onto them. Clerical personnel then filled in the address and birth date and had the client sign the form. This form then became both the record of injection and the billing form. The client (with form in hand) was then routed to an injection station. The client presented the form and was asked about allergies, previous vaccine reactions, and given an opportunity to ask questions. Injections were then administered, consent forms collected and initialed by the nurses, and then placed in a box for later collection and billing. Volunteers were stationed to keep the exiting traffic moving. Supervisory personnel kept track of the flow and kept the stations supplied with all necessary materials. Nurses were rotated for breaks and rest periods. Since the pace is intense most nurses were scheduled for four-hour shifts and were given breaks as requested, at least one per shift. Food and drinks for the staff were provided in an area that was out of sight of the public. This area was staffed with Red Cross volunteers who kept it clean and stocked. Under the supervision of their instructors, student nurses from the local community college also helped. In addition to the above staff, staff members were assigned to collect trash, keep the area clean, collect and separate.