Implementation of a COVID-19 Vaccination Program in the Emergency Department

In June 2021, the Centers for Disease Control and Prevention (CDC) advised hospitals, emergency departments (EDs), and urgent care facilities to offer COVID-19 vaccination upon discharge. ¹ EDs serve as the primary health care access point for up to one-fifth of the U.S. population and as a safety net for vulnerable, underserved communities. As such, EDs are recognized as key targets to increase COVID-19 vaccination rates.^1-3

Despite an abundance of COVID-19 vaccination clinics, barriers such as vaccine hesitancy, lack of transportation, transient housing, mental health disorders, and difficulty in making an appointment have impacted vaccination rates in underserved populations. The American College of Emergency Physicians (ACEP) postulated that “rising ED volumes continue to include a disproportionately increasing underserved, uninsured and minority population [who are] less likely to have had adequate preventive and primary care access and are more likely to be under-immunized.” ⁴ A survey conducted by ACEP indicated that a majority of ED medical directors support the idea of ED-based COVID-19 vaccination programs. ⁵ ACEP strongly encourages the vaccination of patients upon ED-discharge and created a COVID-19 Vaccine Toolkit to help institutions develop programs of their own. ⁴

Initially, our health system had decided to wait on decentralizing COVID vaccinations to the ED and inpatient settings until FDA approval, due to the challenges of administrative recordkeeping under Emergency Use Authorization (EUA).

When our region began experiencing the COVID-19 surge associated with the Delta variant, hospital leaders were eager to offer patients vaccines as soon as possible, even while pending FDA approval. The pharmacy department took the initiative to develop a multidisciplinary process offering COVID-19 vaccines to patients in the ED. This process was eventually rolled out to all inpatients. In this article, we outline how a COVID-19 vaccine program in the ED was established and discuss the challenges faced during its implementation.

Practice Setting

Emory Healthcare is an 11-hospital healthcare network in Atlanta, Georgia. Emory University Hospital Midtown (EUHM) is a 550-bed tertiary care facility with a 59-bed ED that cares for approximately 70,000 patients each year. There is an Emergency Medicine pharmacist (EMP) available on the unit for nearly 24 hours/day, except for 2 hours between 8 am and 10 am on Saturday and Sunday. All EMPs are residency trained. Due to its location in Atlanta, GA, EUHM is a disproportionate shared hospital and services a significant proportion of underserved patients.

Standard Operating Procedures and Workflow

To deploy this initiative quickly while keeping it adaptable, a live, editable, shared standard operating procedure was created that allowed all EMPs access to edit the process based upon their experience. Multidisciplinary team members including providers, nursing, pharmacy, and leadership had read-only access to the standard operating procedure, while EMPs had editing privileges. EMPs were also automatically notified of edits made to the procedure. It proved incredibly important to enable the process to remain adaptable as updated information regarding vaccine handling (ie, beyond use dating, dilution instructions), dosing (ie, boosters), and efficacy (ie, literature in pregnant patients) continues to emerge.

Vaccines Offered to Patients

When deciding which vaccines to offer, it was necessary to weigh the benefits of offering all 3 vaccines available in the U.S. (Pfizer, Moderna, and Johnson & Johnson) against the added complexity of having so many options available. These 3 vaccines vary in their beyond-use dating, storage, reconstitution, and dosages. A single-dose vaccine is appealing to many patients; however, the perceptions of the efficacy and safety profiles of the available vaccines vary significantly from person to person. To reach the maximum number of patients, the team decided to offer all 3 vaccines and ensure procedures were in place to mitigate risks. Ultimately, patients are able to choose which vaccine they would like to receive. Flyers stating the availability of COVID vaccines were posted in the waiting room and patient rooms throughout the ED. The single-dose COVID vaccine may be appealing for some patients who have barriers to follow-up, but such patients are not limited to this vaccine.

Patient Eligibility

While the goal was to provide vaccination prior to discharge, we did not want to exclude patients who require hospitalization but are otherwise eligible to receive the vaccine. ED leadership provided guidance for patients who may benefit from deferred vaccination, such as patients who present with acute severe disease. Ultimately, provider discretion is used to determine who is too acutely ill to receive the vaccine. Once our hospital expanded vaccination eligibility to all inpatients, this became less of a concern as admitting providers wrote orders for vaccination prior to discharge. We did not exclude patients who have barriers to follow up, as this program was created in part to address this barrier.

Other exclusion criteria followed CDC recommendations. Patients that received passive antibody therapy (monoclonal antibodies or convalescent plasma) as a treatment for COVID-19 in the last 90 days were excluded. Patients with an allergic reaction to any of the components of the 3 COVID vaccines offered were excluded. Initially, pregnant patients were encouraged to have a discussion with their Obstetrics provider about vaccination against COVID due to inconclusive evidence of placental transmission, but this changed as data emerged highlighting the benefit of vaccinating pregnant patients outweighs the risk of complications. ⁶ Subsequently, all pregnant patients in the ED were encouraged to be vaccinated.

Providers are encouraged to engage in vaccine conversations during the ED visit to increase patient awareness. When a patient declares interest in receiving the vaccine, the provider enters the vaccine order into the electronic medical record (EMR) which triggers the EMP to check the state online immunization registry, dosing schedule, and for any contraindications prior to verifying the vaccine order.

Patient Consent

For each vaccine, either a provider or EMP reviews the vaccine consent form and fact sheet with the patient. While some other vaccines protocols (ie, influenza) are nurse-driven, it was deemed that providers and EMPs were the best equipped to answer questions related to the COVID vaccines, as both groups received education about the process and have access to the SOP, which can be referred to for questions.

Order Processing and Dispensing

The provider enters the vaccine order into the computerized physician order entry (CPOE), selecting for the manufacturer and dose number (eg, “second dose Moderna” or “third dose Pfizer”).

To limit dosing, dispensing, and preparation errors, only EMPs were trained in the initial process. This was solely to restrict the number of pharmacy individuals responsible for the preparation and dispensing of vaccines to minimize the risk of error given complexities of multiple vaccine types.

The EMP removes vaccine vials from the main pharmacy one at a time as patients request doses. Vaccine supplies are kept at the pharmacist workstation, including CDC vaccine cards, needles, syringes, alcohol wipes, Luer tip caps, plastic bags, consent forms and fact sheets, vaccine administration instructions for nurses, and patient education on when and where to obtain follow up doses (if indicated). The EMP draws up each dose from the vial utilizing a 1 mL syringe and affixes the syringe with the patient-specific label noting the BUD, then hand delivers the vaccine dose, completed vaccine card, and nursing and patient education documents to the patient’s nurse. Opened vials are labeled with the date and time removed from refrigeration and assigned a beyond use date (BUD) according to manufacturer specifications and then stored in a dedicated pocket inside an automated dispensing cabinet (ADC) within the ED. The pocket is only accessed by a pharmacist.

Administration and Documentation

While administering immunizations falls within the scope of pharmacy practice for many states, including Georgia, our protocol only allows for nurses to administer the vaccine. This is due to pharmacists not having access to document medication administration in the medication administration record (MAR) and to maintain consistency with standard medication administration practices at the institution. The nurse documents the administration on the MAR, which directly imports vaccine administrations into the state’s immunization registry.

Monitoring

Nursing staff is responsible for post-vaccination monitoring. A reaction monitoring form is linked to the order within the EMR. If the patient has a reaction, it is documented in the patient incident reporting system by the nurse or EMP. A Quality Officer would then report the incident to the Vaccine Adverse Event Reporting System (VAERS).

Follow up

Patients are encouraged to arrange follow up doses at an outpatient clinic or pharmacy on their own and are provided with resources noting the location of various pharmacies in the surrounding area that provide each vaccine. The decision was made to not automatically schedule follow up doses for all patients, as patients may wish to receive their second dose outside of our health system and to avoid ED visit costs.

Challenges and Solutions

The urgency to provide vaccines as quickly as possible made this initiative uniquely time sensitive. Once hospital leadership decided to establish an ED COVID vaccination program, the turn-around time from decision to launch date was just 2 weeks. Typically, projects of this type are more thoroughly planned, vetted, reviewed, and communicated prior to implementation. By creating a live and revisable SOP, the initiative became a unique “refine as you go” process that was still subjected to oversight. This proved to be the ideal way to get immediate feedback and suggestions for improvement from front line team members.

Described below are several challenges faced during the commencement of this initiative, and the solutions implemented to overcome them.

Vaccine Waste

The quick expiry of multiuse COVID-19 vaccines and sporadic ED patient requests resulted in substantial vaccine waste. Considering this drawback, the CDC nevertheless advises providers to not miss an opportunity to vaccinate eligible patients, “even if it means puncturing a multi-dose vial to administer vaccine without having enough people available to receive each dose.” ¹ Along with BUD labeling, a tally system was used to document the number of doses used per opened vial. This labeling helps pharmacy leadership appropriately document usage and wastage when the vial expires. In attempts to reduce vaccine vial waste, we set up a dedicated department phone as the “COVID-19 Vaccine” phone and assigned pharmacy students to manage this phone during weekday and evening shifts. Pharmacists call this phone whenever there is a new COVID-19 vaccine order. The student then calls employee health and other clinics to check for open vials before opening an additional vial. Any vials opened overnight in the ED are sent to the clinic in the morning for utilization, and any opened vials from the clinics are returned to pharmacy for ED use each evening. Once expired, the EMP would document doses administered and wasted for each vial.

Pharmacist Time Commitment

The EMPs took on the responsibility of providing vaccinations against COVID-19 in addition to their other responsibilities, such as the provision of clinical pharmacy services, order verification, day-to-day management of ED operations, and engaging in education, research, and professional development.

Since COVID-19 vaccines cannot be delivered via the pneumatic tube system due to a lack of stability data and the need for tight control of vaccine inventory, EMPs needed to travel back and forth between the central pharmacy and the ED every time a vaccine was requested. Optimizing the process to keep vaccine supplies at the pharmacist workstation and storing opened vials in an ADC in the ED made for easy retrieval and minimized unnecessary trips to the central pharmacy.

Pharmacist Availability

Although an EMP is on service just under 24 hours/day, the EMP would occasionally be unavailable while attending to other responsibilities. There is some overlap between the day shift EMP and evening shift EMP between the hours of 12 pm to 4 pm on weekdays, but otherwise there is only a single pharmacist covering the unit. If an EMP was not available to prepare the vaccine or if a delay in vaccine administration was anticipated, the patient would be provided with a list of nearby pharmacies/clinics where COVID-19 vaccines are offered. While it was important to capitalize on any opportunity to vaccinate patients, delaying discharge for this reason alone was not acceptable.

Delays in Vaccine Administration

Occasionally patients will wait until just prior to discharge to request the vaccine, prolonging time to discharge. Screening patients early during the registration process prevents delays at ED discharge due to COVID-19 vaccination.

Conclusion

A key factor for success was the pharmacy department’s ownership of this initiative. Pharmacy leaders were best suited to lead a multidisciplinary team in this initiative due to pharmacists’ unique role in connecting clinical, operational, supply chain, and administrative aspects of practice. Some of the challenges in developing this program were determining who had the necessary knowledge and available time to consent the patients, who should decide if a patient should get the vaccine or was too acutely ill, and how to avoid vaccine waste and additional ED delays. Pharmacists’ ability to triage these concerns and link them to system COVID-19 vaccination efforts helped ensure the project’s success.

A total of 182 patients received a COVID vaccine in the ED at Emory University Hospital Midtown between June 15, 2021 and February 1, 2021. Of those vaccinated, 42% occurred during day hours (7 am to 4 pm), 32% on evening hours (4 pm to 11 pm), and 25% overnight (11 pm to 7 am). Our vaccination initiative not only provides vaccines to a critical patient population, but also demonstrates the benefits of timely, revisable protocol implementation.

As vaccination efforts against COVID-19 continue to rapidly evolve, it is the health system’s responsibility to evolve with it. Hopefully, other institutions will consider a COVID-19 (or future pandemic) vaccination program upon ED discharge, following CDC best practices ¹ and tailoring to the ED’s established workflow.