At a time when COVID-19 cases are surging while doses of highly effective vaccines are available, a growing number of healthcare organizations are recognizing there is an opportunity for EDs to help vaccinate. The American College of Emergency Physicians has unveiled new resources for EDs interested in establishing vaccination programs.1 Several pioneering programs have surmounted many logistical hurdles.

Some emergency providers may view COVID-19 vaccinations as another task piled on an already-full plate. However, EDs are uniquely positioned to reach many underserved and high-risk populations that have yet to receive protection from COVID-19.

Elissa Schechter-Perkins, MD, MPH, DTMH, director of emergency medicine infectious disease management at Boston University School of Medicine and Boston Medical Center (BMC), says she was thinking about providing COVID-19 vaccinations in the ED from the moment the first solutions were approved in late 2020.

“Many of us in emergency medicine really see the opportunity of using the ED to function as a public health environment because we are often the only contact that individuals have with the healthcare system,” she explains. “We welcome the opportunity to improve our patients’ health — not just from the perspective of the emergency that brought them in, but in a much bigger way. COVID-19 seemed right in line with that view.”

Still, making the vaccines available in the ED at BMC required a multifaceted effort. “I approached our department leadership and our hospital leadership as well as our [Massachusetts] Department of Public Health,” Schechter-Perkins explains. “Back at the time when vaccines were incredibly constrained ... I made the argument that there should be vaccines allocated specifically to EDs across the state in order to capture that [underserved] population.”

In February, Massachusetts decided not to allocate doses to EDs, at least not while vaccine supplies remained constrained. But by mid-April, when shots were more plentiful, BMC decided to go forward with offering the COVID-19 vaccine in the ED. However, the timing proved problematic.

Schechter-Perkins recalls going live with the ED vaccine program on April 13 at 7 a.m. — only for the FDA to announce about 90 minutes later the agency wanted to re-examine the Johnson & Johnson (J&J) vaccine BMC had picked.2

Ten days later, the FDA allowed providers to resume using the J&J vaccine.3 It took some time for BMC to consider the FDA’s findings and determine how to proceed. “We didn’t finally go live again [with the vaccines] until May 13,” Schechter-Perkins shares.

At BMC, administrators added a question about COVID-19 vaccination status to the screen all patients who present to the ED receive. This way, clinicians can see whether each individual has been vaccinated. If not, providers can offer the vaccine to any patient who will be discharged from the ED.

“We as an institution made the decision that admitted patients would not be eligible for consideration for getting the vaccination in the ED because we just didn’t want to confuse the picture,” Schechter-Perkins reports. “If someone developed side effects from the vaccine and spiked a fever in the hospital, it would be too challenging to know whether it was really a reaction to the vaccine or a complication from surgery.”

While vaccine hesitancy is an issue, BMC leaders decided not to spend much effort collecting research about why patients were choosing not to receive the shot. “Our goal was to make the process as easy as possible and just offer the vaccine,” Schechter-Perkins says.

However, she notes BMC created a variety of materials to address vaccine hesitancy in the community. These include guides to help clinicians hone their messaging when discussing the vaccine with patients who are uncertain.

Schechter-Perkins says about 100 patients (as of press time) have received the COVID-19 vaccine while in the BMC ED. While the number seems modest, Massachusetts has recorded one of the highest vaccination rates in the country. Many patients who present to the ED have received the shot. “This is 100 patients who probably wouldn’t otherwise have been vaccinated at all because they had been eligible for the vaccine for a while and had chosen, for whatever reason, not to be vaccinated previously,” Schechter-Perkins explains.

Nonetheless, the ED has bolstered its vaccination efforts. For example, in mid-July, BMC allocated two nurses to work in the ED from 8 a.m. to 5 p.m. every day. “They are there just to talk to patients about vaccines. We are taking this off of the shoulders of the physicians and putting it on the shoulders of these two dedicated nurses who don’t have other ED responsibilities,” Schechter-Perkins says.

Further, these nurses can offer all three available COVID-19 vaccines, not just the J&J solution. “We are still generally defaulting to the J&J vaccine because a lot of our patients are somewhat disconnected from the healthcare system. We are concerned that they might not make it back to a follow-up appointment [to receive a second dose],” Schechter-Perkins says. “However, if someone wants one of the other vaccines, we acknowledge that having one dose of the Moderna or Pfizer vaccine is certainly better than not having any doses.”

If patients in the ED request the Pfizer or Moderna vaccines, the dedicated nurses will administer the first dose and make a follow-up appointment for patients to receive their second dose in the hospital vaccine clinic, located within BMC, not far from the ED.

Schechter-Perkins says securing pharmacy support is “critical” because those in that department store the shots, mix the solutions, and maintain related documentation. Work with other key department heads to identify possible barriers and develop a plan to address them.

Also, ensure all ED providers and nurses are on board with the importance of making COVID-19 vaccinations a priority. “It is so easy to home in on the reason a patient is in the ED ... but taking a broader perspective allows you to think about the person’s health in a different way,” Schechter-Perkins says. “Part of that [involves] understanding how COVID-19 vaccination really ought to be a priority.”

Rhode Island-based Lifespan Health System offers COVID-19 vaccines in all its EDs across the state. This was almost a natural evolution from what many ED personnel were already doing, according to Anthony Napoli, MD, medical director of emergency medicine and chair of the ED at Newport Hospital.

“We actually started to utilize ED staff on off hours or slow hours in the ED because of reports of anaphylaxis in response to the vaccine,” he explains. “We set up the equivalent of high-risk clinics, and ED personnel were being asked to either work with [those clinics] or to be available for those patients because [the vaccinations] were new.”

Lifespan leaders understood their EDs serve as a safety net for an often hard-to-reach population that public health authorities were targeting for the COVID-19 vaccine. “We tend to get patients that have more socioeconomic or demographic risk factors,” Napoli says.

For instance, many patients are elderly, uninsured, or underinsured, and many speak a language other than English. The ED also sees plenty of patients with substance use disorders or other behavioral health concerns.

“Those are your real high-risk populations for not getting a COVID-19 vaccine, and they are exactly the populations of people who come to EDs disproportionately as compared to the general public,” Napoli says. “We have populations that seek care in the ED that, frankly, don’t seek care anywhere else.”

To Napoli, it made sense to offer the COVID-19 vaccine through Lifespan’s EDs. He took a leading role in establishing the program — first, by forming a team that included ED physicians, nursing leaders, and representatives from IT and pharmacy.

This group developed an order for the vaccine in the computer system, fine-tuned the process for thawing and mixing the medication into usable doses, and much more. “You have to time it such that you aren’t wasting the vaccine. You [prepare the doses] at a time when you have the most patients who are eligible in the ED,” Napoli observes.

While providers received education on how to address vaccine hesitancy, they were not given any suggested scripting. “The premise was if [a patient] develops a relationship with someone they trust during the ED encounter, then any discussion about that person’s concerns regarding the vaccine would be something that occurs organically,” Napoli shares. “They have the opportunity to ask questions that they might not otherwise ask, and therefore might not otherwise seek out a vaccine.”

ED providers have overcome the hesitancy some patients have expressed regarding the vaccine. For instance, Napoli says if patients are concerned about potential complications, the provider can explain the risk of experiencing a medical complication is higher if they do not receive the vaccine.

“Being in the ED, you can speak with authority about the things you have seen and the concerns that you don’t want to see in someone else, particularly the person in front of you. That helps a lot,” Napoli says.

The ED-based vaccination program started in mid-April. The initial update was good, although demand for the vaccine has tapered. “In the early April period, we identified a need and we were planning as more vaccine was becoming available throughout the country,” Napoli says. “Then, shortly after we rolled out the process, the amount of vaccine expanded significantly. Our state was quite successful at getting vaccines to populations at risk, particularly elderly populations and populations in targeted ZIP codes where there are people who are at risk.”

Even with all the logistical steps involved, the ED-based vaccination program required no additional resources or staff beyond vaccine supplies. “This is the perfect sort of operation for a hospital-ED because it only involves small, incremental responsibilities for each individual,” Napoli says. “The pharmacy has to make the vaccine, the emergency physician has to discuss it with the patient, and the nurse then has to administer it — but they administer medications all the time.” 

REFERENCES

  1. American College of Emergency Physicians. Setting up vaccination programs in the ED. June 16, 2021.
  2. U.S. Food & Drug Administration. Joint CDC and FDA statement on Johnson & Johnson COVID-19 vaccine. April 13, 2021.
  3. U.S. Food & Drug Administration. FDA and CDC lift recommended pause on Johnson & Johnson (Janssen) COVID-19 vaccine use following thorough safety review.