In the fall of 2020, Rowan University School of Osteopathic Medicine recognized and embraced the essential need for administering vaccinations in the community the school serves in Southern New Jersey. Thus, “RowanSOM COVID-19 Vaccination Clinic: Operation Save Lives” (henceforth referenced as Operation Save Lives) was created as an innovative approach through which the medical school staff planned and implemented a student-driven vaccination clinic that effectively, efficiently and safely administered critical immunizations to 55,000 individuals, significantly addressing the substantial burden of the SARS-CoV-2 virus on the region.
A Professor of Management at Rowan University’s business school with an affiliate appointment as a Professor of Crisis and Emergency Management suggested that we share our experience with others after he received his vaccine at the Center. He reported that all aspects of our initiative demonstrated effectiveness, efficiency, innovation, quality, customer responsiveness and safety. We came to understand that the process and organizational structure used to create and operate this Vaccination Center may inform other healthcare providers as they prepare for and respond to future healthcare crises.
In response to that understanding, this article relates how medical schools and other healthcare entities can establish and operate vaccination mega sites or pop-up clinics whether during the current COVID-19 pandemic or in response to future epidemics and pandemics.
In the Beginning
The SARS-CoV-2 virus, first identified in late 2019, rapidly spread worldwide, placing substantial burdens on healthcare systems. Pharmaceutical and biotechnology companies raced to develop safe and effective vaccines and treatments to minimize serious illness and loss of life. In the United States, Pfizer-BioNtech was the first to receive emergency use authorization (EUA) and subsequent Federal Drug Administration (FDA) approval of its BNT162b2 (Comirnaty) vaccine for individuals 16 and older, with subsequent EUA for other age cohorts.1 Moderna and Janssen, double and single shots, respectively, received EUA soon thereafter.
“Vaccine distribution became the limiting factor in the national effort to vaccinate the population.”
The EUA for Pfizer and Moderna occurred within a seven-day span in December 2020; subsequent interim guidance on vaccine recommendations by the Advisory Committee on Immunization Practices (ACIP) occurred the week thereafter. It was critical that there were actual vaccination sites available to receive, store and administer the vaccines. Vaccine distribution became the limiting factor in the national effort to vaccinate the population. Rowan School of Osteopathic Medicine (RowanSOM) rose to meet the challenge and implemented Operation Save Lives, staffed by a coalition of RowanSOM medical students, faculty physicians, medical assistants, environmental services specialists and community volunteers.
Operation Save Lives opened on December 24, 2020, and was closed as a large vaccination site on July 2, 2021. In that timeframe, the Center distributed approximately 55,000 doses of all three COVID-19 vaccines, providing a critical service to any individual who lived, worked or was educated in the state of New Jersey. The success of the Center required complex coordination from RowanSOM medical and graduate schools, RowanSOM’s clinical and administrative offices, along with local and state officials and the New Jersey Department of Health (NJDOH). This allowed the Vaccination Center to serve those who came to the physical space as well as those served through an outreach into the underserved communities in the surrounding area, ensuring vaccine equity.
The New Jersey Department of Health announced an open application for the development of COVID-19 Vaccination Centers in November 2020. The state sought small sites, large sites (sites that would administer hundreds of vaccines daily) and those considered mega sites (sites that would administer more than 2,000 doses daily). The leadership team at RowanSOM met to discuss the feasibility of running a vaccination center on campus. In considering the mission of our school and the four pillars of the University (Access, Affordability, Quality and Economic Engine), the team decided this crucial endeavor was our responsibility to the local community and the state of New Jersey. The decision centered on the current quality of healthcare provided at Rowan Medicine and the opportunity for 800 medical students to improve their clinical skill set and play a critical role in ending the pandemic.
Rowan University and RowanSOM leadership began to meet in November and evolved to include core leadership from the medical students, faculty, information resources and technology (IRT), facilities, environmental services, research laboratories and public safety. The large team divided into smaller teams with focus and expertise in their specific areas and then came together to discuss issues and recognize effects other areas may have on their area of expertise. On December 12, 2020, the NJDOH approved our site as a “large” center for COVID-19 vaccine distribution. The team meetings continued weekly and the plans continued to evolve as our team waited in anxious anticipation for the arrival of the vaccine shipment, with a target opening date of December 24, 2020.
From an operational perspective, complex coordination was required in regards to facility set up, vaccine acquisition, vaccine storage, staff training and documentation. The success of this project would be dependent on the structure and design of our larger team. We selected the interdependent team model for many tasks, while other aspects of the project could be accomplished by an individual with coordinated task assignment. Our team also recognized that a six-month project would require multiple leaders to succeed. Communications ramped up at the end of November 2020, as the pending EUA for Pfizer and Moderna became imminent. Coordination with the Graduate School of BioMedical Sciences and Environmental Services became critical to ensure both proper storage of the vaccine and maintenance of a safe, effective workflow for staff and vaccine recipients. Lastly, discussions continued with our Information Resources and Technology Department to implement documentation and billing protocols to properly store patient information, transmit this information to the New Jersey Immunization Information System vaccine repository, and to seek reimbursement from the federal government.
“The schematic had built-in dates that would expand eligibility, and our leadership team recognized early on that vaccine demand would outpace supply.”
Operation Save Lives opened on December 24, 2020, inoculating 150 eligible recipients. Eligibility was set forth by the NJDOH, which followed the Center for Disease Control’s phased approach framework. At that time, this required the individual to “live, work or be educated in the state of New Jersey” and an assessment of that individual’s “risk of acquiring infection, risk of severe morbidity and mortality, risk of negative social impact, risk of transmitting disease to others and social vulnerability.”2 The schematic had built-in dates that would expand eligibility, and our leadership team recognized early on that vaccine demand would outpace supply. It became a central goal to not only secure continuous supply of the vaccine but also to ensure a framework that created zero waste of the current supply.
The needs of the Center would change with expanding eligibility, while day-to-day problems would need to be addressed. As a result, a core leadership team of on-site staff and key off-site stakeholders met daily. Applying research seen in the clinical setting, a multidisciplinary approach, drawing from nearly every department at RowanSOM, became the standard to promote teamwork.3 This model helped facilitate smoother solutions for immediate problems and allowed for flexibility in resolving short-, medium- and long-term needs. Most critically, these meetings provided daily reflections that would allow us to act swiftly on urgent or emergent on-site issues.
The novelty of the Center was medical student buy-in from the beginning. The Center could not function the way it did without medical students carrying a heavy load during its inception and execution. Osteopathic Medical Students (OMS) I-IV received training in both clinical and clerical duties, ranging from administration of the actual vaccine to registration. Maintaining a well-trained volunteer workforce took significant planning to ensure all medical students were properly credentialed.
In order to standardize training and provide a culture of safety and comfort with the task of providing immunizations, several student-produced videos were created and an internal website was published to assist in distribution of information prior to the volunteer’s first shift. All medical students in their preclinical and clinical years were expected to complete blood-borne pathogen training, HIPAA training, electronic health records training and intramuscular (IM) injection training. The IM injection training was a hybrid procedure-based training where the students viewed a video on aseptic technique and vaccine administration combined with a session in our simulation lab to practice on model arms prior to being assigned the role of vaccinator (see Figure 1). Once the student was placed in that role, the on-site physician would supervise each student new to this role prior to providing a final sign-off on mastery of IM injections.
Depending on students’ experience and seniority, they served as Leads for their respective stations, which could, at times, include other multidisciplinary students. A number of students worked directly with RowanEMS to monitor each vaccine recipient post-injection for either 15 or 30 minutes (depending on allergy history). Student interest was incredibly high, with the majority of volunteers being from the first- and second-year classes. Due to rotations schedules, third- and fourth-year students filled in available positions when their schedule permitted. After a number of weeks, time at the Vaccine Center became a mandatory part of the core third-year clerkships. However, due to exam schedules, there were often times when the medical student volunteer base needed to be supplemented.
In order to reduce the possibility of a student volunteering for a role in which they did not meet all of the required credentials, a central database was created where each student would submit their certificates; once they were cleared, they were able to self-schedule for shifts at the Center (see Figure 2). This process was largely managed by medical student Leads who were supervised by a physician-team Lead.
To supplement decreased numbers of medical student volunteers, nursing students from nearby Rowan College of South Jersey (RCSJ), Rutgers University – Blackwood and Rowan College of Burlington County (RCBC) were recruited to assist. Nursing students filled in the clinical roles, such as post-vaccine monitoring, vaccination administration and directional guidance of the flow throughout the building. However, nursing students were not trained on nor utilized in the use of electronic medical records (EMRs) or scheduling. Akin to the medical students on clinical rotation, the Vaccine Center also became a part of the nursing students’ curriculum. Volunteers were also recruited from the New Jersey Medical Reserves Corps (NJMRC). Outside volunteers from the community and local hospitals were also allowed to volunteer, after being vetted by HR and public safety (see Figure 3).
To ensure all volunteers were up to date on changes in operations and public health guidelines, twice-daily meetings were held before the beginning of each volunteer shift. Shifts ran from 8 a.m. to 12 p.m. and from 12 p.m. to 4 p.m. The site physician would brief the volunteers on emergency procedures, Centers for Disease Control and Prevention (CDC) and NJDOH guidelines and updates, explain the responsibilities of each role and provide new updates. These meetings were held 30 minutes prior to the shift start time and questions were promptly answered. New volunteers would get a tour of each section. This ensured that volunteers understood the flow, allowing them to address any issues proximal or distal to their direct site. After this tour, a Lead would be responsible for the training and coordination of the other volunteers that day. As questions arose, the Leads would be on call to handle them. Prior volunteers would report to one of the site administrators for role assignment. Once assigned, volunteers would then relieve the occupants of their respective positions early. This process ensured continuous flow, limited exposure and disease spread within the facility as volunteer shifts occurred.
The establishment of specific roles and departments allowed for the Vaccine Center to be easily managed and regulated. Roles included: vaccinator, registrar, greeter, atrium guide, post-vaccine monitor, site lead, volunteer registrar, vaccine prep person and vaccine runner. While most of these roles required clinical experience, many did not, allowing for a larger pool of volunteers from the non-clinical, general public and non-clinical staff of Rowan.
A queue of people wanting vaccines would appear early outside our Top Doc’s Café waiting for the first appointment, which was scheduled for approximately 9 a.m. (see Figure 4). While waiting, everyone answered screening questions and underwent temperature checks. Any positive responses to these questions would immediately get flagged to the site physician who would decide whether it was safe for the individual to receive the vaccine as scheduled—or should be rescheduled for a later date. After the registration process was completed, people would move into lines to input contact and insurance information into the Rowan EMR system.
Once registered, individuals were ushered into the atrium where information about their allergy history and other critical information would be double checked. Following these checks, applicants were then guided into the multi-purpose room where they would wait for one of eight vaccine stations to open. After being vaccinated, each individual was led to a waiting area to be monitored for 15 or 30 minutes. Following the wait and a final check to access vaccine reaction, each person was escorted out a back exit to the parking lot.
Medical professionals, students and volunteers came together in partnership at Operation Save Lives, showing how interdisciplinary teamwork and altruism can help keep people safe during a global pandemic. As crises arose, physicians utilized their medical expertise and managerial experience; volunteers quickly learned new skills to fill gaps in the workforce; and students assumed leadership positions to help the Center function as a cohesive operation. Daily check-ins became the norm as we sought to provide the vaccinations safely and effectively and to respond quickly to ever-changing directives.
Last Day of Walk-Ins
In an effort to serve the public, walk-ins were permitted at the onset. This information was not made widely available as our Center continued to reflect and refine our internal operations for a smoother experience. Good news, however, travels fast, and droves of eligible area residents came to the clinic. To ensure walk-ins would not supersede those who had appointments, two separate lines at the door were created to separate those with appointments from walk-ins. Vaccine leadership observed these lines continued to grow and people began lining up hours before the opening of the clinic. Based on our limited supply of vaccine and available appointments, it was decided that walk-in appointments would no longer be feasible; therefore, internally we scheduled the last day of walk-ins to be January 15, 2021.
“Lessons learned that day allowed for a cleaner escalation as eligibility expanded, eventually allowing us to vaccinate 1,000 individuals a day.”
On that day, walk-ins started lining up at 5:15 a.m. When the decision was made to close walk-ins at 9:30 a.m., hundreds of eligible recipients had gathered in line, and our intention was to vaccinate all of them. To honor this commitment, an all-hands-on-deck approach became critical. Coordination with public safety became necessary to maintain an orderly, flowing line. Marketing donated RowanSOM totes, umbrellas, water, snacks and other paraphernalia to people waiting in line. Employees with computer training were called in from our Family Medicine, Internal Medicine and Pediatric departments to break bottlenecks in registration. This, combined with a timely delivery of portable laptops, allowed volunteers to register everyone while in line, accelerating line movement. This effort allowed us to vaccinate 606 individuals, more than double any preceding day that week, closing more than two hours after our last scheduled appointment at 4:00 p.m. Lessons learned that day allowed for a cleaner escalation as eligibility expanded, eventually allowing us to vaccinate 1,000 individuals a day.
With success at our physical location, we sought to duplicate the process for special projects. The need to serve specific groups for both initial and follow-up (if applicable) vaccinations became clear as eligibility expanded. This meant promoting uptake in historically hesitant populations, providing modifications for people who were physically impaired, encouraging a younger population to receive the vaccination and going directly to those experiencing homelessness and domestic violence. Adapting our protocols to fit specific needs allowed our team to designate specific days to vaccinate those with special-needs, host a mass pop-up at Rowan University’s main campus and have a mobile outreach to vaccinate those individuals who spend significant time in community shelters or transportation hubs.
One special project focused on promoting vaccine uptake in the Spanish-speaking community. Physicians at Rowan Medicine who interacted with this population identified that two major barriers existed for vaccine uptake: 1) concern regarding immigration status and 2) language barrier. For the first concern, we followed the NJDOH guidance in that “documentation is not required to be vaccinated.” Sites “will not ask for proof of immigration status” and “U.S. Immigration and Customs Enforcement (ICE) and U.S. Customs and Border Protection will not conduct enforcement operations at or near vaccine distribution sites or clinics.” 4
As for the language barrier, Spanish language interpreters became available in case these individuals required language assistance. In the case of the non-Spanish, non-English-speaking, all volunteers were trained to use a language line to facilitate clear communication. But as most of the non-English speakers who came to our Center spoke Spanish, signs, directions and consents were printed in Spanish to aid these individuals during their visit to the Center. Two dedicated days (for dose 1 and dose 2) were set aside on Saturdays tailored towards the Spanish-speaking population. All signage, directions and consent were in Spanish, and all volunteers on those days were bilingual in Spanish and English. This initiative was a unique opportunity to boost vaccination status in a population noted for vaccine hesitancy.5
Through the indefatigable efforts of volunteers and staff, Operation Save Lives was able to deliver more than 55,000 doses of vaccine in a roughly six-month period. The Center saw a large success in reaching general and target populations. Students and staff worked an estimated 20,000 volunteer hours, with a total of more than 500 volunteers contributing time to the Center. Through the coming together of student physicians, physicians and staff, the Center was able to make a sound and lasting impact on the lives of people in our local communities. This unique opportunity allowed all levels of training to help contribute to the ending of a global pandemic.
The success of this effort illustrates how medical schools and other healthcare entities can serve essential healthcare needs of the region, while affording medical students the opportunity to enhance their clinical, interpersonal and procedural skills in real time, whether during the current COVID-19 pandemic or in response to future epidemics and pandemics.