Jab

Published by The Lancet Respiratory Medicine: https://www.thelancet.com/journals/lanres/home
Shortlisted for the Lancet Wakley Prize 2021

At 6:27am on Tuesday, 8 December 2020, the -80°C freezer in the pharmacy store was opened and the first batch of BNT162b2 mRNA COVID-19 vaccine was moved to the vaccination centre on the 12th floor. The countdown began: five days to inoculate 975 patients before the batch expired.

At 9:23am, I received a message from Professor B.
“Any chance you could help with vaccine roll-out from 10 am for a few hours? Prescriptions needed I think.”

I entered the vaccination centre where a gaggle of nurses, pharmacists, a camera crew and several hospital managers were bustling. I was shown into one of two consultation rooms and a pharmacist talked me through the process.
There were sheaves of paperwork to complete for each patient: the Pfizer-BioNTech vaccine had yet to be granted a Patient Group Directive, which would allow people to receive it without a prescription, like the flu vaccine.
So for the first days of the vaccination campaign, all patients receiving the jab would have to go through a full process of consent and prescription with a doctor.

Unfortunately, arrangements had not been put in place to staff the service with clinicians and only two rooms were available to run through the consent process. A single dose cost £15. As far as I could make out, the hospital had defrosted £14,625 worth of vaccinations without figuring out how to administer them before they expired.

Patients started to arrive and I got moving. The first gentleman was a retired builder. He was delighted to be there.
“I’m chuffed to bits!”
We laboured through the paperwork together, checking risk factors and explaining known side-effects. The builder needed little convincing.
“Just gimme the form, I’m ready!”
I waved him through.

Five minutes later I stuck my head out of the consultation room and saw a huddle of administrators wearing concerned expressions.
“What’s up?”
“He’s not on the list.”
“Who?”
“The guy you just consented. He’s not in the system.”
“I’ll have a word with him.”

I crouched down beside the builder who was sitting in an armchair looking down at his feet.
“Can I ask…how did you find out about your appointment today?”
“What do you mean?”
“Your appointment for your vaccine today.”
“I don’t have one.”
“Right.”
“I saw that bloke on the TV last night and he was talking about the vaccination centre and I thought that was great and so I’ve come along to get one.”
“Ah.”

I explained the situation to the managers.
“He saw it on the news last night and has basically just rocked up.”
“How did he get past security without a letter?”
“I don’t know. He came to the front of the hospital and said he was here for his vaccine. They showed him the way.”
“Well he can’t have it. He’ll have to go home.”
“I don’t think we should do that. He’s here, I’ve spent 20 minutes sorting him out and he’s ready to go. He’s in the right age group too. Plus we’ve got almost a thousand patients to vaccinate this week and we need to get going. Give him his vaccine but ask him not to tell his mates to come without an appointment.”

So it was that one of the first patients in the world to be vaccinated against COVID-19 outside of a clinical trial was an 82-year old chancer.

The day rumbled on. By lunchtime they forecasted that by end of play they’d have administered 68 doses and everyone seemed pleased. I heard the news, blinked several times, and bit down on my tongue. I turned over a consent form and did a few sums. The managers planned to administer the remaining 907 doses between Wednesday and Saturday by running the clinic 8 am-8 pm. This would commit them to delivering 226 immunisations per day. They’d invited staff and patients four at a time, at 15-minute intervals. This would equate to 16 patients per hour which, even if run 12 hours per day without breaks, would only inoculate 192 per day, thus leaving 136 unused doses at the time of expiry. To say nothing of the fact that they only had two available consulting rooms and no doctors in place to staff the service. Hundreds of doses of vaccine risked going to waste.

I explained this in a message to Professor B who responded with an exploding head emoticon. We made several adjustments to the process: we asked patients to pre-fill their demographic information on the forms before coming to meet the doctor and used the staff revalidation email distribution list to ask all doctors in the hospital to volunteer if they could. I started to think of other solutions: vaccinating staff during night shifts, redistributing surplus supply to local GP practices and district hospitals, consenting patients in groups instead of one on one, recording a patient information video that could be shown to waiting patients on medical school iPads to speed up the consent process.

The following morning after a few meetings, I went back to the 12th floor hoping things might be straightening out. The situation was much worse. Staff were in more or less complete disarray, patients had been waiting over an hour past their appointment slot, and barely any doctors were around helping to consent. I buttonholed a Spanish infectious diseases registrar who’d come in on her day off to be vaccinated and asked if she could stay and help, then started to corral groups of patients into an empty consultation room on an adjacent ward to consent them in batches of three at a time. Then I went to find out what had happened with the call for help.

It turned out that the revalidation team had advised doctors able to assist to state their availability by email to a nurse called Tammy. I tracked down Tammy, a nurse sister in day surgery, but she was unaware of this arrangement and was trying to organise things within the vaccination centre itself. She hadn’t checked her email at all and in general seemed to be struggling. I noticed a deer-in-headlights expression grow as I explained what I thought had gone wrong and realised I needed to find whoever was meant to be running the show. I got hold of the operations manager, Zanna, who had also been parachuted in at short notice and who also appeared to be alarmed.

In summary, dozens of clinical staff had responded with offers of help, but when their emails were not replied to, they assumed all was well and had not shown up. Zanna agreed to make one person responsible solely for processing email offers of clinician support and we developed a self-rostering system using a Google form to be sent as a live-editable spreadsheet accessible to all staff with the link. Doctors could schedule their own shifts without additional administrative effort.

On my way back to the consultation room, I stuck my head into the store room where one fridge had stopped working and another was locked with a key that had gone missing. I wasn’t going to be able to do anything about either of those things so I kept walking.

Early in the afternoon, Zanna moved to colonise the private patient area. This allowed a more orderly progression through the vaccination centre: registration, documentation, consultation, inoculation, observation, departure. By the end of the second day, 157 people had been vaccinated, which though a considerable improvement, meant we’d need to get through 250 per day Thursday through Saturday.

Given the expanded space and good uptake with the self-rostering system, it was agreed that we should recruit enough consenting doctors to book in six people every 15 minutes for the last three days. If this worked, we’d have a chance of using all of the batch before it expired. I cancelled my plans and dug in for the rest of the week.

The following day the vaccination centre was barely recognisable. The repurposed private rooms felt calm and orderly. The doctors who volunteered via the self-rostering system showed up and walked patients through the process. I overheard one speaking to a consultant colleague:
“Really lovely, such a nice way to spend an afternoon.”

I met a human rights lawyer, a retired broadcaster, a knight of the realm, a surgical matron, and one 50-something property developer who had accessed a booking link forwarded to her by an elderly friend of her aunt. Opportunists were thought to represent a negligible proportion of the inoculated cohort, but the booking system was clearly not bulletproof. 

The change in the atmosphere was almost palpable. Consultants were calm, motivated and smiling. The fridges all worked. The Chief Executive came in for a wander about and looked quite cheerful. The patients were delighted.
“I’m gobsmacked to have been chosen!”
One gentleman explained it was the first time he’d left his house and garden in 10 months; another didn’t want to leave at all and was reciting passages of Hamlet. By 8pm we’d vaccinated 250 people and were back on track.

On Saturday evening there were 35 doses remaining at the end of the booked appointments. Zanna had by this point handed over to her deputy who didn’t quite share her zeal about the process.
“Well, I suppose it would be nice to get to zero.”
“We have to!” I snapped back and went off to the worst affected clinical areas - the emergency department, intensive care and infectious diseases - to round up staff willing to receive the spare doses at the end of the batch. Many came willingly, handing over bleeps to their colleagues, and we whittled through the remainder. Then at 6.56 pm I consented Betty, the pharmacist. The final dose of the final vial. The last of the last.

Many of our hiccoughs could have been avoided with more careful preparation. The task was purely logistical. Define the object at hand, delineate the process it will comprise, allocate resources sufficient to perform each step. Involve the minimum number of effective staff in roles appropriate to their skillset and ensure clear channels of communication and responsibility.
It sounds so simple; it never is.

Yet for all this, it felt like a triumph. I sent a message to Professor B.
“70 doses given on Tuesday; 250/day by Thursday. Considerable hurdles cleared by NHS managers, IT, administrators, pharmacists, nurses and clinicians. Bit of a plane-built-during-takeoff feel Tuesday-Wednesday, but we got there eventually. Zero vials wasted. Same again from Monday. It can be done.”

Walking home, I overheard a homeless man talking to his friend.
“I quite like going through the bins if I’m honest with ya. You wouldn’t believe the shit I’ve found!”

I see it that way too. You find patterns and people in the world - some tell you their stories and walk with you part of the way. There is humour, and effort, and occasionally something other than failure. You latch on to these - take down notes. Realise that the good life is no more or less than a process of engagement.