Mass Vaccination Campaign Planning

Outcomes of the San Francisco Department of Public Health

Smallpox Mass Vaccination Exercise June 17, 2003

Ann Stangby RN CEMEmergency Medical Specialist

San Francisco Department of Public Health

Our motivatorsOur motivators

SFDPH estimates on staffing and clinic space were based on CDC estimates and post-event planning documents

Hospitals in San Francisco wanted guidance on setting up their own clinics

To test our assumptions– number of staff needed for one site– skill mix required– space needs– clinic layout– patient flow

Mass vaccination in San FranciscoMass vaccination in San Francisco

Vaccinate ~ 1million residents and visitors in 5 days

Each site would operate 16 hours / day Each site would see 300-350 pts / hr Each site would accommodate ~26,000

people over 5 days– 15-20,000 staff needed – Bilingual capabilities at each site

Defined goals of the exerciseDefined goals of the exercise

Test our ability to provide mass vaccination– 300-350 pts / hour– Bilingual capabilities

Test our ability to recruit volunteer patients

Evaluate the drill and offer information to other jurisdictions interested in similar exercises or real event planning

Background factsBackground facts

66 working days to plan and execute the exercise

CDC Guidance for Post-Event Smallpox Planning was the guiding tool

Steering committee developedSimple scenario with no tricksNo observers allowedMedia access encouraged

RecruitmentRecruitment

Staff– all SF City and County workers are disaster

service workers– Within SFDPH

• email and voice mail messages for volunteers• administrative support• letter to managers from Dr. Katz• cabinet meetings• word of mouth• safety fair

Volunteer patients– neighborhood canvassing– banners / flyers– letters to city employees from Mayor– incentives / give away items– community groups– volunteer center– multi-media outlets

Using the media for good

Exercise EvaluationExercise Evaluation

Time motion studyPatient evaluation formsStaff feedback formsArea hot washesStaff debriefing

V-Day: June 17V-Day: June 17

8:00 am – DPH Staff Sign In 8:25 am – General Briefing, Staff Break Area 9:00 am – Break into designated Areas for Area

trainings from Area Leaders 9:45 am – Area Leaders Reconvene in Clinic

Management Area 10:00 am – Begin Seeing Patients (Doors Open) 11:30 am – Press Conference, Level 2 1:00 pm – VIP Briefing, Level 2 3:45 pm – End of Exercise. Direct all patients to

Paperwork Drop-Off 4:15 pm – Hotwash in individual areas 4:30 pm – All staff gather in Staff Break Area for large

group debriefing 5:00 pm – All staff leave the building

Staff sign in

General briefing

Area TrainingsArea Trainings

Medical Screening

Doors open at 10 amDoors open at 10 am

Vaccination Clinic AreasVaccination Clinic Areas

Triage Fever / Rash Contacts Paperwork

Distribution Education Screening Line Medical Screening Vaccination Line Vaccination Stations

Paperwork Drop-off Mental Health Security Pharmacy Clinic Management First Aid Data Entry Staff rest area*

Patient FlowPatient Flow

Vary with locationVary by staffing, patient needs5 primary stations

– Paperwork distribution– Education– Medical Screening– Vaccination– Paperwork drop-off

Triage

Paperwork Distribution

Educational sessionsEducational sessions

Medical ScreeningMedical Screening

Paperwork drop off areaPaperwork drop off areaGifts, educational information, certificates of appreciationGifts, educational information, certificates of appreciation

Staff toolsStaff tools

Area Leaders for oversightJob Action SheetsMaps / directions / time study

formsStaff education toolsClinic site layoutEmergency instructions

Results/Outcomes

•Time Motion Study

•Patient Perspective

•Staff Perspective

•Vaccination

•Costs

•Lessons Learned and Recommendations

Results – Time Motion Results – Time Motion StudyStudy

1,325 clients completed data entry formsService Type # of Clients % of Total

Clients

Contact 39 2.9%

Contraindications 174 13%

Fever/Rash Exit 17 1.3%

Fever/Rash Mainstreamed 21 1.6%

General 1,033 78%

Incomplete/Inappropriate Flow 40 3%

Rash 1 .08%

Total 1,325 99.88%

Results – Time Motion Results – Time Motion StudyStudy Bottlenecks and Waiting Times

Clinic Stops # of Patients Served

Mean Waiting Time

Triage 1,312 2.73

Contacts 79 29.62

Fever/Rash 53 21.61

Video 1,225 8.89

Screening Line 1,199 14.14

Medical Screening 931 3.36

Contraindications 431 4.00

Vaccination Line 698 1.49

Immunizer/Vaccinator 711 3.70

Wound Dresser 694 0.43

First Aid 3 8.00

Mental Health 16 8.28

Time Motion Study : Staff Time Motion Study : Staff UtilizationUtilizationClinic Stop # of staff Available staff

time (inminutes)

Patient contacttime )inminutes)

% time in patientcontact

Triage 15 3,040 1,176 39

Screening Line 7 1,909 727 38

MedicalScreening

20 5,323 2,480 47

Contrainidicationscreening

13 3,394 1,500 44

Vaccination Line 4 1,048 372 35

Vaccination 26 6,517 850 13

Dressing 26 6,530 535 8

Recommendations from Time Motion Study

Reduce the number of vaccinators Increase and simplify signage Differentiate runners from clinical staff Increase staff training Increase staff available to answer

questions, direct traffic Stagger educational sessions Separate lines for languages, special

needs

Results – Patients

• Approximately 1,400 patients came through the exercise:

•many patient volunteers repeated the procedure

•The median patient age was 42.

•The age range was 1 – 93 yrs., with 65 children < 18.

Language Spoken at home %

Cantonese 29%

Other Chinese (unspecified) 28%

Spanish 24%

Tagalog 8%

American Sign Language 4%

Vietnamese 2%

Russian 2%

Korean 1%

French 1%

Portuguese 1%

Mandarin 1%

12% of patients (n=129) did not speak English at home.

Results – Patients

Question from Patient Evaluation Form

% of All Patients

who Agreed

% of all Monolingual Patients

who Agreed

Medical History and Consent Form was easily understandable

63% 57%

Exercise was well organized and orderly

94% 87%

DPH Staff was confident and knowledgeable

90% 77%

Patient was able to understand all written information given

93% 81%

Results – Patient Evaluation Forms (n=1060)

Question from Patient Evaluation Form

% of All Patients

who Agreed

% of all Monolingual Patients

who Agreed

Patient was given clear direction on movement through exercise

85% 79%

Patient was informed of right to decide for or against vaccination

87% 78%

Video was clear on risks and benefits of vaccination

86% 80%

Patient was given clear instruction on how to take care of vaccination site

76% 70%

Results – Patient Evaluation Forms (n=1060)

• 82% of staff agreed that the on-site training was satisfactory.

• 92% of staff agreed that the job action information they received was easy to understand.

• 96% of staff agreed that the floor plan of the site was easy to understand.

• 94% of staff agreed that the supervision of their work was satisfactory.

• 88% of staff agreed that the supplies provided to them were adequate.

• 82% of staff agreed that the message/communication system at the drill was effective.

Results – Staff Feedback Forms (n=155)

Results – Costs

Medical Supplies $2,632

General supplies, pinnies, traffic flow enhancers

$5,202

Rent, rented equipment, ambulance

$11,119

Materials translation and reproduction

$8,466

Volunteer incentives, watches $4,918

Food, water, beverage for staff $4,782

Total $37,119

Results – Costs

Time Motion Study

$37,119Logistics

Total

$15,000

$10,000PR firm for recruitmentComputer equipment

$33,000$95,119

Staff estimates– Needed more security staff

• Add at least two to each area

– Needed more mental health staff– Possible to decrease number of

vaccinators– Data entry staff may not be used in

actual emergency– Flexibility in assignments needed

Lessons LearnedLessons Learned

Lessons Learned – Staff Lessons Learned – Staff EstimatesEstimates

Using conservative estimates (228 people per site)

– 2 shifts x 40 sites = 18,240 people needed for one day

Lessons Learned – Staff Lessons Learned – Staff TrainingTraining 45 minutes of training was allotted for

the exercise – in reality, doors should not open until all staff are adequately trained.– Have staff watch video.– Staff must know activities that take place at

interdependent areas.– Staff must know proper protocols for

documentation Develop training curriculum in advance

Lessons Learned – SignageLessons Learned – Signage

Clear large signage with creative display is of paramount importance in big open spaces– Use color coded balloons– Use poles– Use paddles to identify available

medical screeners– Place colored tape on floor regardless

of expense

Lessons Learned – MaterialsLessons Learned – Materials

Needed to be more developmentally appropriate– Medical History and Consent Forms– Closed captioning on video– Smallpox educational materials

Lessons Learned – GeneralLessons Learned – General

Have a plan for checking medical licenses in advance to ensure that only licensed staff are giving injections and/or medical advice.

Work out a plan for infectious waste clean-up and disposal in advance

Not necessary to separate patients into “hard” or “easy” categories for screening

Lessons Learned – GeneralLessons Learned – General

Have separate lines for different languages and the disabled

Have information available regarding self care if not vaccinated

There is no such thing as too many bilingual staff

It worked well to have the press and VIP briefings removed from the exercise

Support from top management is extremely important

Conclusion – Next StepsConclusion – Next Steps

Valuable experience overall– High level of camaraderie from

diverse staff– On the spot problem solving– Beneficial to experience issues face to

faceSite layout worked in general

Conclusion – Next StepsConclusion – Next Steps

Work on training curriculaWork on developmentally

appropriate materials and translations

Maintain plans and contacts on paper for 40 different sites– Determine these sites– Develop MOU’s– Develop site plans

Conclusion – Next StepsConclusion – Next Steps

Develop labor pool of interested persons

Develop PSA’s, media announcements now (multilingual)

Keep in touch with interested agencies or organizations

Enhance our flexibilityShare experiences