Practical lessons learned from administering COVID vaccine in a small office setting

Andy Pasternak, MD, MS

My office is a small, four-provider family medicine clinic in Reno, Nev. We are very active in administering vaccines to patients, including travel medicine vaccines. Because of my role with Immunize Nevada, our state vaccine non-profit, and the Nevada State Medical Association, we partnered with the Washoe County Health Department to be a vaccine distribution point for the 200+ health care workers in our area. We did this not only to help other health care workers but also to give ourselves a "practice run" before vaccinating patients. We also wanted to be on the front lines of making vaccine history in our community.

When we got our shipment of Moderna vaccine from McKesson, we opened it up like kids opening their Christmas presents. Due to our parking lot constraints, we opted for a "drive-in" clinic, instead of a "drive-through" clinic. On our first day, we vaccinated 97 health care workers over five hours (almost one shot every three minutes) and went through nine vials. As one of the people running from car to car, I was pretty tired at the end of the day.

We quickly learned that, although the COVID vaccine will be our most potent tool to stop the pandemic, administering it takes considerably more work and effort than doing flu shots. The major hurdles are managing the frozen 10-dose vials (or 11 depending on the needles you use) and monitoring patients for 15 minutes post-vaccine (which is why we had them stay in their cars).

While you may have heard COVID vaccine experiences from large hospital systems and health departments, these are our lessons learned as a small practice.

1. Staff appropriately. My office had about 6-8 people working for the first session. We had one person handling check-in/consent, 2-3 people administering the vaccine, and 1-2 people in an outdoor tent to help with paperwork, drawing up vaccine, and prepping. My wife, an anesthesiologist, was vital in that role! We also had 1-2 people inside the practice entering data. My rookie mistake was not scheduling time off for lunch.

2. Start talking to your EHR vendor immediately to ensure the COVID vaccine codes are functional. I thought this would be like any other vaccine, but there were some unexpected difficulties. We didn't bill for these COVID vaccines for health care workers, but we did need to enter them into our EHR, which interfaces with our state immunization registry. Physicians and other providers need to report COVID vaccines to their state registry within 24 hours of being administered.

3. Give the Moderna vaccine enough time to defrost. Waiting was our most significant rate-limiting step. It takes at least 60 minutes for the vaccine to defrost. It is then stable at room temperature for up to six hours.

4. Don't be surprised if the vaccine counts are wonky. We had 20 vials, which should be 200 doses. Initially, we could get 11 doses out of every vial. With Pfizer, there are reports of getting six doses out of a five-dose vial. For us, the syringes made a difference. McKesson sent us two different sets of syringes. With one set, we could get 11 doses out of a vial; with the other set, we couldn't. We're going to have to chat with our state about the accounting on that.

5. Be aware of different syringe types. McKesson sent us syringes where the needle retracts into the syringe when you push the plunger down. These were new to us and sort of startled us. These were the syringes that were less efficient for dosing.

6. Invest in a tent and heaters. Having a tent outside worked great, but heaters are also needed in Northern Nevada in the winter. The downside to heaters is that they can lead to condensation in the tent and a small rainstorm at times.

7. Think through how you'll manage your regular schedule of patients. At an office my size, it's going to be challenging to vaccinate 100 people in a single day and still have a full schedule of patients. We are looking at a model where we have one physician/provider and 2-3 staff working on COVID vaccination and then augmenting with a set of volunteers from the Battle Born Medical Corp (our state's COVID response volunteer force).

8. Keep a waiting list for extra vaccine. It will be critical for offices to have a list of 5-10 reserve people wanting to get vaccinated for the end of the day. Depending on no-shows and how many doses you get from a vial, you may have extra vaccine. We spent a good hour calling offices to find 3-4 people to vaccinate, so we didn't throw away doses. It would have been better to have a waiting list of patients expecting our phone call toward the end of the way.

9. Consider your vaccine supply and demand. As I think about vaccinating our patients, our approach is going to depend on the volume of vaccine we can get. Our practice has roughly 1,300 patients over the age of 75 and about 3,000 patients age 65 and older. There is no crystal ball on vaccine availability, but for a practice our size, if we get 200 doses a week supplied to us, I'll organize vaccine flow very differently than if we get 1,000 doses a week.

10. Pay attention to vaccine expiration dates. The expiration date isn't on the Moderna vials. You have to go to their website and type in the lot number.

11. Plan carefully for the second dose. While we were initially excited that we got extra doses out of many of the vials, I recently woke up in a panic in the middle of the night thinking about the fact that we have to do it all again in four weeks. While it's great to maximize vaccine, you also need to replicate everything for the second dose. Otherwise, you won't have enough vaccine to get everyone their second shot.

12. Expect to be working twice as hard in 3-4 weeks. If your office vaccinates 200 people, you'll have everyone return in 3-4 weeks. As more tiers open up, you will also have a new group coming in for their first vaccine. While we want to get vaccine to people as soon as possible, in 3-4 weeks, you may be vaccinating twice as many people. Be prepared to allocate twice as much time or twice as many people.

13. Get paid for the vaccine administration. We didn't bill for these first vaccines but will start billing for an administration fee once we start vaccinating our patients. Given the vaccines' logistical issues and how much we get paid for vaccine administration, I'll be happy if we break even financially. (See "COVID-19 vaccines coding guide.")

Family medicine offices will be critical in vaccinating our communities and putting an end to this historic pandemic, and we understand the complexities of vaccine administration as much as anyone. Depending on your vaccine allocation, it may be useful to partner with other local offices to do this as a mass exercise. If you get smaller amounts, your model for vaccinating patients may be more flexible.

The bottom line is get your team ready now.

— Andy Pasternak, MD, MS, is a family physician in Reno, Nev.