How to run housebound Covid vaccinations efficiently

One of the key challenges in delivering the Covid-19 vaccination programme is reaching the housebound. GP partner and PCN lead Dr David Coleman advises on how to set up a smooth operation.

The challenge of vaccinating the housebound population is a significant and pressing one for both practices and PCN ‘roving teams’.  As Clinical Director of a large (66,000 patients) PCN with a suburban and semi-rural population, this has been a hot discussion topic over the past few weeks.  In typical Covid-19 fashion, the action has moved quickly and we have had to adapt accordingly. 

The following outlines some of the thinking behind our plans to maximise efficiency and speed of the vaccine rollout to this population.

‘Talent’ > ‘Courage’

‘Talent’ is the NHS codename for the AstraZeneca vaccine; ‘Courageous’ that for Pfizer’s offering.  The transport challenges and cold chain requirements for the Pfizer vaccine render it unsuitable for a tour of your practice area.  It is perfectly suitable for the challenge of vaccinating a care home or sheltered accommodation site with a number of residents, but AstraZeneca is more ideally suited for transporting between a multitude of domestic properties.

Set up a PCN ‘SOP’

Imagine a PCN has over 1,000 housebound patients to vaccinate.  Each patient will need to vaccinated twice, so this equates to 2,000 visits.  It is unlikely that the same roving team will be able to do all of these; the PCN may well adopt a practice level approach, with a number of different clinicians from each practice chipping in. Consistency in approach is therefore key, both for efficiency and for safety/cold chain maintenance.

We have published a PCN level Standard Operating Procedure (SOP).  This document, which draws from the NHSE guidance of moving the AstraZeneca vaccine¹ well as well as the NHS Specialist Pharmacy Service (SPS) SOP², sets the ground rules for how to carry out the housebound vaccination work. 

The following summarises the key points:

• Identify a lead for roving vaccination teams to liaise with; we chose our PCN care co-ordinator.
• Each team to consist of one vaccinator and one administrator (at least).  Both should be familiar with the vaccination process, have completed appropriate e-Learning, and studied the SOP; experience at a hub site is desirable.
• Each team to have a 4G enabled laptop to record the vaccinations contemporaneously (ideally) or at very least Pinnacle access at the end of the session. Be prepared for IT failure.
• A rigorous plan is essential. Organise housebound patients in clusters based on the number of doses per vial. Our practice mapped our housebound patients out by street. Consider vaccinating other household members over the age of 70 to maximise efficiency, but make sure all of these decisions are organised in advance and patients informed. Organisation is key to reducing wastage.
• When contacting patients in advance provide them with an estimated time window for the visit. The patient’s consent should be checked, they should be screened for Covid symptoms and allergies, and critically they should be advised to wear a mask and ideally to ventilate the house, ie, open windows. At the visit, the clinician will repeat the Covid screening and allergy questions.
• Remember the cold chain rules and have explicit guidance in SOP about documentation of temperature. We have procured a set of medical grade portable cool bags.
• Vials can be transported several times as long as the cold chain is maintained; initial advice was that the vaccine ‘should not be transported once the first dose has been removed from the vial’.¹ This has been superseded, with the new guidance in this document.³ Essentially, ‘after the vial has been punctured, the vaccine should be used as soon as practically possible and within 6 hours’. The SPS SOP has specific guidance relating to infection control for punctured vials.
• Unused vaccine cannot be returned to the PCN hub at the end of the day – so plan carefully and only release vaccine that you know will be needed.

Tips for smooth delivery:

• The roads may be a little quieter in lockdown, but traffic can still be heavy around peak times.  Try to factor school traffic and rush hours into your planning.  The optimum time to travel around may well be 10am to 2pm. This will also help with vaccinating in any homes that have poor lighting.
• Aim for local staff with knowledge of area to act as drivers.
• An additional SOP for donning and doffing PPE out in the community is useful; we have a practice document for this.
• It is better to take too much PPE rather than too little.
• Don’t forget to factor in consumables and try to have a slight excess. Unlike unused vaccine, these can be returned to the PCN hubs.
• Make sure the vaccinator is clear and up to date with anaphylaxis policy. Managing an emergency on your own in a patient’s home is far more daunting than doing so in a hub with multiple clinicians. Preparation and familiarity helps.
• Don’t be afraid to learn from mistakes. If something goes wrong, share the experience with PCN colleagues so we can all learn and improve.

References

1. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/12/C01009-COVID-19-Vaccine-Oxford-AstraZeneca-movement-vaccine-7-January-2021.pdf

2. https://www.sps.nhs.uk/wp-content/uploads/2021/01/AVH7-Transporting-AstraZeneca-COVID-19-Vaccine-from-PCN-Designated-Sites-Issue-3.2-15.01.2021.docx

3. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2021/01/position-statement-astra-zeneca-vaccine-movement-11-jan-21.pdf