Rising to the challenge: a COVID-19 vaccination service for the housebound population

In January 2021, NHS England and NHS Improvement issued a standard operating procedure in order to support the safe deployment of the newly available COVID-19 vaccination programme in England. Community nursing services were tasked with developing a home immunisation service for housebound people (NHS England, 2021). This paper outlines how one organisation planned and set up a home-based vaccination service that was delivered by a community nursing team to people in their own homes. National guidelines dictated the eligibility criteria for the COVID-19 vaccinations (NHS England and NHS Improvement, 2021), and the inclusion criteria and national guidelines have been applied throughout the home immunisation programme. Patients already on district nursing caseloads were readily identifiable, and local GPs were able to identify some, but not all, of their patients. The hardest group to identify were patients who did not regularly engage with primary care services and adults with learning disabilities.

The first actions were to set up a task and finish group that would be responsible for delivering the vaccine programme. A home immunisation delivery group was established and reported into an umbrella group responsible for the Primary Care Winter/COVID resilience plan, as this group was responsible for the local response to the COVID-19 pandemic.

The group met remotely for 60–90 minutes meeting using Microsoft Teams three times a week for approximately 4–6 weeks. Shorter meetings were then held twice a week until the end of the project. The team comprised the following members:

• Project lead (programme manager from the clinical commissioning group (CCG))
• Lead primary care quality manager
• Medicines optimisation lead with the CCG (pharmacy background)
• Lead GP
• District nurse (DN) practice educator
• IT advisor
• Cluster matron for district nursing.

Project manager

A project manager was appointed from the CCG with a background of primary care transformation. This role was primarily to coordinate and project manage throughout the roll-out of the home vaccination programme. The project manager set up regular meetings and kept a detailed action log and had in place a reporting system to the COVID resilience group for the area.

Lead primary care quality manager

The lead primary care quality manger acted as a link between the primary care networks of GPs, the CCG and the home immunisation group. An important part of this coordinating role was in modelling the supply of vaccines. At the outset of the project, patients requiring a home vaccination were not readily identifiable by any of the health systems available. The quality manager role was crucial in order to support the identification of any likely individuals requiring a home vaccine. Patients were primarily identified by interrogating GP databases using clinical coding systems. This individual also took responsibility for weekly reporting of the home vaccination programme. Further, this role included troubleshooting and problem solving, so that information required from primary care about patients that might be eligible for home vaccination was readily available for the DNs administering the vaccines. The manager advised on supply and demand of the vaccines for the duration of the delivery stage of the programme. This was an essential step in securing regular and ongoing supplies of the vaccines. The quality manager initially set up a communications strategy within primary care and ensured that information was shared with all stakeholders about the progress of the programme. Five primary care hubs were established throughout the locality, and each of the hubs was attached to local GP. The quality manager established links between the hub leaders and the adult vaccination service to secure the daily supplies of the vaccines for housebound patients for the duration of the programme.

Head of medicines optimisation

The head of medicines optimisation in the area offered additional support to develop locally appropriate patient-specific directions (PSDs) for nurses to give the vaccine. This role was vital in ironing out issues of governance and safe practice for delivering the vaccine to housebound patients.

The community adult vaccination service worked alongside GPs in order to develop the delivery of vaccinations to housebound patients. The GP was responsible for identifying patients and screening patient suitability for the vaccine. Every patient was contacted by telephone and screened by questions predetermined in the national protocol (NHS England and NHS Improvement, 2021). The national PSD had to be adapted in order to support the roll-out of the programme by the community adult vaccination service. For example, the national PSD is only valid for 24 hours, which proved to be impractical and unworkable in practice. It was impossible that a PSD could be completed by the GP and returned to the administrative hub, it was allocated for making an appointment with the patient and the vaccine to then be administered within a 24-hour timeframe. The head of medicines optimisation took this dilemma to the medicines management committee to seek approval to extend the expiry of the PSD from 24 hours to 7 days. This was subsequently extended, and PSDs now remain valid for 3 weeks.

The cold chain

The pharmacist at each of the five hubs took the lead in ensuring that the cold chain was monitored and properly managed, so that the vaccines were stored safely within each of the hubs. Every hub pharmacist ensured that the temperature of the vaccine fridges was within the recommended range and that the cool bags used by community nursing teams to transport vaccines to the patients homes were also monitored and kept at the correct temperature while the vaccines were in transit. The nurses took over this responsibility when they took delivery of the vaccine at the hub, and they continued to monitor the vaccine temperature in the cool bags. The temperature was monitored and documented every 2 hours until the vaccine vial was used up. All open vials of vaccines had to be used within 6 hours.

Lead GP

The lead GP communicated with every general practice in the area about the community adult vaccination service and provided ongoing support with helping colleagues to understand the processes and mobilised colleagues to engage with the processes required for the successful delivery of the programme. This was very important in encouraging GPs and their teams to identify and screen suitable patients and to respond to requests for information, as well as providing valid PSDs for their patient population.

District nurse practice educator

In December 2020, the head of community nursing at the CCG in question recognised that a vaccination programme for housebound patients was imminent. The existing community nursing workforce identified a pool of 25 community nurses to undertake the COVID-19 vaccination programme outlined in the national protocol and using the newly updated guidelines in the Green Book (Joint Committee on Immunisation and Vaccination (JCVI), 2021; NHS England and NHS Improvement, 2021). Some members of the vaccination team were unregistered and working as healthcare assistants in the community. However, everyone in the team had worked previously as vaccinators and had received additional vaccination training. No volunteers were used, as it was deemed not possible to supervise an unregistered and untrained workforce for this programme. The COVID-19 protocol suggests that two members of staff are deployed to check and administer the vaccine, but the logistics of recruiting and training volunteers was unachievable. Further, many patients were worried about receiving two visitors into their homes during the pandemic, as there were concerns about cross-infection, and most patients had been shielding and were not receiving any visitors in the home. A further requirement was that every team member was up to date with basic life support and anaphylaxis training. The practice educator arranged supervised practice placements, provided practice supervision and signed off competencies for every member of the newly formed community adult vaccination service. No extra infection control measures were required, as community nurses had been visiting patients throughout the pandemic and were already using the COVID-19 infection control procedures.

IT advisor

The IT advisor supported the development of IT services locally to capture COVID-19 vaccinations on patients' electronic records. This involved the development of a suitable template for the electronic clinical record, which is used by DNs and GPs. This is a shared record and updated in real time, so any addition of clinical information, including the administration of a vaccine, can be seen across primary care. During each home visit, the vaccinator completed a paper record documenting details of clinical screening, consent and details of the vaccine that had to be administered. These forms were returned to the hub for inclusion in the national reporting system. The vaccinator then updated the patient's electronic clinical system with details of the immunisation.

Cluster matron for district nursing

The main role of the cluster matron was to advise the steering group on the operational challenges and realities of the programme deliverables. This included advising the group on the operational risks, realistic timeframes, training and mobilisation of the workforce, procurement of equipment and developing and implementing workable processes for delivery.

The project

First steps

The project manager and cluster matron worked together on developing process documents that were adapted for local use from the national protocol (NHS England and NHS Improvement, 2021) (Table 1).

The team was ready to commence immunisation approximately 4 weeks after the first steering group meeting.

Initiation of the project was considered urgent and time critical. The pandemic was at a peak, people were dying from COVID-19 and infection rates were rising. The local hospital was near full capacity, and there was a sense of urgency regarding the protection of the most vulnerable people within the local community.

The adult community vaccination service was ‘virtual’, as all the community nurses were working within community nursing teams and had been redeployed into the home vaccination service rota. It was decided that the most pragmatic approach was for the cluster matron to develop a roster and that two competent nurses from each cluster would be available every day, including Saturday and Sunday. Although financial support to employ agency and bank nurses to backfill for the substantive workforce was available, in practice, it was difficult to find source agency staff at this time, as they were already employed elsewhere. An important factor was the nurses' local knowledge of visiting patients at home, local geography, access to properties and the expiration of the vaccine. Two additional full-time administrators were appointed to work across the week, including weekends. Additional administrative support was used to manage demand, as nearly 2000 patients were referred to the service within just the first week.

NHS Procurement was used to procure cool bags that were fit for purpose. These supplies were authorised by the Primary Care Winter/COVID resilience group, and the order arrived within days. All the other equipment was either supplied by the vaccine hub or was readily available as usual stock items.

Delivering the vaccine

Identifying a list of eligible patients who were housebound was a major undertaking in order to get the project off the ground. At the onset, the process for identifying patients and the formulation of a valid PSD was time consuming and inefficient. There were multiple steps in the process are outlined in Table 1, which summarises these steps, and this process became the working template for everyone working as part of the service.

Over time, the processes were reviewed, and the biggest impact on the efficiency of the process was realised by extending the timeframe for the validity of the PSD. This meant that the visits could be planned more efficiently, and it significantly reduced the workload on the adult community vaccination service and GPs as the PSD no longer required constant updating because it had expired.

First dose

The community adult vaccination service received 1945 patient referrals from 29 GP practices between 26 January 2021 and 19 March 2021. All patients were subsequently contacted via telephone to book vaccination appointments.

From the 1945 patients referred, 503 patients did not receive the vaccine from the service for various reasons, including:

• They had already had it
• They preferred not to have it
• They had COVID-19 infection
• They failed to meet screening criteria
• They were in hospital
• They were uncontactable via telephone
• They had died.

All of these patients were referred back to their GPs for further support and counselling on the benefits of receiving the COVID-19 vaccination, if applicable.

The community adult vaccination service completed administration of the first doses of the COVID-19 vaccinations on 22 March 2021.

Second dose

For the second vaccination, the community adult vaccination service received 1415 patient referrals from 22 GP practices. As before, patients were subsequently contacted via telephone to book vaccination appointments. The reasons for the reduction in referrals by 530 fewer patients for the second dose than the first dose, included the following:

• One GP network deployed their own paramedic for vaccinating people at home
• More local vaccination hubs were open at the time of the second dose, which some patients were able to attend
• They preferred not to have it
• They had COVID-19 infection
• They failed to meet screening criteria
• They were in hospital
• They were uncontactable via telephone
• They had died.

Further, some patients with a LD who had received a first dose of vaccine with the community adult vaccination service were offered their second vaccine with the specialist learning disability team. Where appropriate, patients were referred back to their GPs for further support and counselling on the benefits of receiving the second COVID-19 vaccination.

The community adult vaccination service completed administration of the second doses of the COVID-19 vaccinations on 3 June 2021.

Role of the cluster matron in the community adult vaccination service

The cluster matron role developed into a mainly coordinating function for the service. The matron acted as the clinical lead and was responsible for the overall governance for service delivery. They ensured that the off-duties were developed, that the workforce was made available as required and that the home vaccination programme was delivered safely and in line with the COVID-19 protocol. Every day, it was important to sense check and monitor what the service was delivering.

All the clinical issues that were raised on a daily basis with the administration team required clinical advice and intervention by the cluster matron. Patients with complex health needs would often make a clinical query that could not be answered by other members of the team. For example, patients taking certain drugs or those with complex health conditions required further clinical discussion with the cluster matron. Issues of consent and best interests were referred to the cluster matron for advice, and, in some cases, complex legal and ethical issues were raised, and clarification regarding consent delayed the administration of the vaccine on a few occasions.

Dealing with vaccine hesitancy

All of the community adult vaccination team received the usual training but, added to this, every team member had to be committed to the vaccine and able to confidently answer any questions that a patient may ask. Thus, the team members were particularly adept at addressing individual fears and concerns. They were all excellent advocates for the vaccination programme. A number of clinical queries were received on a daily basis, and effective communication was essential in dispelling myths and helping patients with shared decision making about the risks and benefits of being vaccinated. A significant number of family members raised concerns about the vaccine, and these were passed onto the cluster matron, who spent time counselling the person and addressing every issue.

On occasion during the home visit, a patient changed their mind about having the vaccine, and so the cluster matron would speak to the vaccinator and the patient to clarify the reasons for declining. Further information would be provided that helped the patient with decision making. This conversation often resulted in patients agreeing to be vaccinated, but, if the patient still declined, a further discussion and appointment were offered at a later date.

Challenges

Each vial of the AstraZeneca vaccine contained 11 single doses. Once the vial had been punctured, the vaccine had to be used within a critical 6-hour time window. To ensure zero wastage of the vaccine, home visits were planned with a focus on geographical proximity. This presented a huge logistical challenge, necessitating the employment of two full-time administrative staff, with the support of two to four additional part-time administrators when required.

Funding was available to employ 10 full-time agency band 5 nursing staff for vaccine administration. However, the demands on agency providers at the time meant that securing any extra staff was difficult, especially considering the time demands of the service. Therefore, many staff members worked additional shifts, and part-time staff increased their hours. On reflection, this provided the service with essential knowledge and expertise on the local area, which was fundamental to limiting wastage of vaccines.

A total of 25 patients with learning difficulties were included in the referrals received be the community adult vaccination service. Administration was attempted by the clinicians within the service, but it became apparent that a significant amount of additional time would be required with each patient due to their complex needs, and this would result in vaccine wastage. A decision was made to work with specialist providers and coordinate with the local learning disability team, which agreed that they were better equipped to meet the needs of these clients. This group of patients was referred to the specialist LD team for vaccination, with support from the community adult vaccination service as required.

Key learnings

There were processes in place for other immunisations, but these proved to be too slow and unwieldy and were not fit for purpose to roll-out the home vaccination programme in a timely fashion. Going forward, the organisation will use new processes for future home vaccination programmes.

It would be easier if the supply of vaccines were procured and stored in the adult community vaccination hub, but this has not been sanctioned, so all the vaccines have to be collected and returned to the other vaccination hubs.

Documentation regarding consent and recording immunisation details could be further streamlined and reduced. A shared record would reduce duplication and effort. The two reporting systems means the clinician has to complete two almost identical documents for the same patient receiving a single immunisation. The central record requires the completion of the Pinnacle COVID-19 consent form and repeats the screening questions and details of vaccine administration. The patient electronic record also requires the same details and a further local consent form. All of these different administrative tasks are time consuming, and it would be better if all the information could be recorded in one place and shared across the different systems.

The possibility of using volunteers in future home immunisation programmes should be further explored. A dedicated team, led by a senior community nurse, should also be considered. By building on the existing team, the expertise developed can be maintained, and lessons learned can be built on, so that any future immunisation programmes will be mobilised more efficiently and rapidly.

An important consideration was the use of proper vaccination bags and monitoring the cold chain. Stabilisation of the ambient temperature within the cool bags was problematic, and, eventually, additional nomad bags were purchased and were much more efficient. In the future, procurement of the most efficient cool bags would reduce the risks of inadvertent breaches of the cold chain during transportation.

Conclusion

The COVID-19 pandemic has forced healthcare services to re-assess the way they deliver care, and community nursing services are no exception. The author's organisation was quick to recognise the imminent need for a home vaccination service for housebound individuals, and learnings from the implementation of this programme will inform future delivery of vaccines and other public health services.

KEY POINTS

• Setting up a home vaccination programme for housebound patients can prove challenging, especially in times when community nursing services are already overstretched
• The team involved in such a programme needs to include clinicians, as well as administrative staff, to manage the logistics
• It is important to appropriately identify patients eligible to receive home vaccination, and certain groups of people can be difficult to identify, such as those with learning disabilities
• Home vaccination services and the stakeholders involved must be quick to adapt to evolving needs for successful implementation of such services

KEY POINTS

• What are the various considerations for rapid setting up of a home vaccination programme for housebound people?
• How can you ensure the safety of patients and healthcare workers administering vaccines in the home setting?
• What would you do if a patient with an appointment to receive a vaccine at home refused to receive the vaccine?