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By Emily Musing and Michael Caesar
One year ago this week, on Nov. 19, 2020, a briefing note was circulated within UHN. It read: "Pfizer and Moderna vaccines will be available in Jan-Mar 2021." A few paragraphs later, it added: "product monograph for either vaccine is not available at this time."
As executive members responsible for the rollout of UHN's Vaccine Strategy, we had been watching the vaccine approval process very closely. This note represented an exciting and hopeful time for us. It was the beginning of a journey that neither of us could have predicted at the time – an exciting beginning that was not without challenges.
The missing monographs meant that we didn't have confirmed details on vaccine storage, stability, handling, distribution protocols and, most importantly, recipient contraindications (the situations in which the vaccines should not be given because it might harm the person.) These were a huge gap in our ability to plan. Internally, we also needed to build new processes around vaccine consent, legal considerations for medical directives, and a protocol for prioritization amongst our staff and community. We also had to design the entire clinic process from scheduling and administration to departure.
This briefing note was a foreshadow of what was to come, a notice to take action without all the pieces of the puzzle in place. This was going to be a massive undertaking. It was going to be like nothing we had ever done in our careers. We had a few months to prepare a system to deliver thousands of doses a day to our patients, staff, long-term care partners and our community. On top of this, we kept asking ourselves: how do you deliver mass vaccinations to thousands of people while maintaining public safety guidelines? At this point, all we had was our shared experience and best practices.
If this were not enough, just as the briefing note hit our desks, the Ministry of Health notified us that UHN was to be one of the first two vaccine sites in Ontario. This privilege was not lost on us. All eyes were on UHN. We immediately felt a weight of responsibility to rally experts in the organization, figure out all the pieces of the puzzle and be ready to receive the vaccine. Very quickly.
It didn't take long for us to realize that this work would become all-consuming. Our day jobs were put on hold while we both focused on the design and implementation of this unprecedented undertaking. Before the end of November, we convened a small executive team that began meeting regularly. It represented expertise from Facilities Management, clinical practice, process design, Pharmacy, Data & Analytics, Security, supply chain and Public Affairs.
It was a team made up of committed leaders from across UHN reaching into their decades of experience and offering it to this historical event in uncharted territory. Sitting in the meetings, you could tell they were proud to be there, proud to share their ideas and fully committed to doing their best – for UHN and for Ontario. It took only a few days for us to bond through the pressures of dealing with a constant bombardment of changing information and new puzzle pieces spawned from media reports, public speculation or official Ministry communication. Little did we know, just as we settled into a cadence, our trajectory was about to be turned on its head.
By the start of December, our plans were in motion. We had ordered -80°C freezers, confirmed our syringe supply, designed our receiving and distribution process, identified space options, planned our staffing needs, simulated our clinic work flow, mapped our vaccine documentation process, and engaged dozens of experts across the organization. We were well on track for the anticipated arrival of the vaccine. That would be in the spring. Or, so we thought.
On the afternoon of Dec. 3, we received word that our vaccine supply was no longer on track for the spring but would be arriving in 11 days! We were told we needed to be ready to start vaccinations the morning it was delivered – Dec. 14 – weeks earlier than anticipated. International logistics were already in motion. The first Canadian-bound coronavirus vaccine vials were about to board a plane in Belgium and land in our freezers. With this turn of events, it felt like we were just told to sprint the last half of a marathon.
Hundreds of tasks were in motion and we had to sift through them and focus on those critical to us opening the doors on Dec. 14. Speed was key. We quickly shifted gears and problem solved the answers we needed in real-time. We got into a rhythm of bringing solutions to the table, quickly evaluating them in a rapid-fire manner and then moving on. It felt like we did this hundreds of times a day.
It came down to four questions: 1) did we have the space ready and was it big enough to maintain public safety guidelines?; 2) was the Pharmacy staff ready to receive and prepare the vaccine?; 3) had the vaccine clinic processes been thoroughly tested from the point of a vaccine recipient's scheduled arrival to their departure?; and 4) did we have enough staff to administer the vaccine? These four areas became the singular priorities for our team. They were four critical pieces of the puzzle among a dozen others. We had to focus. It became a day, night and weekend effort, with phone calls, texts, and video calls among the team at all hours of the day. The finish line was in sight.
The first vials arrived at 8:00 am on Dec. 14. It was an emotional day for us all. We had spent the past two weeks preparing the gymnasium at the Michener Institute of Education at UHN. We arrived an hour before those first vials with some team members to make sure everything was ready. It looked set – signage, vaccination stations, supplies, and technology all in order.
In a small, dark room beside the gymnasium, it was quiet. There, in contrast to the energy from the teams next door preparing the stations, there was a tension along with the anticipation. The Pharmacy team, which had tested the vaccine draw process and simulated the flow days prior, now did it for real. You could feel the excitement and nervousness in the air as the purple cap of the first vial was removed; the first time the vaccine was diluted; the first vaccine draw was made; the first syringes were stacked for administration. Standing there, we were witness to the beginning of a process that would occur hundreds of thousands of times over the next several months.
We watched as the media swarmed the first vial and then the five long-term care workers chosen to be the initial recipients. It was historic and there was eagerness to capture this story of hope and excitement. As the first syringe was pulled from the stack, the protective cover removed and the needle delicately inserted into the arm of recipient No. 1, Anita Quidangen, we held our breath. We could not help but think of the unfathomable number of people who were waiting to be vaccinated in the days, weeks and months to come. The scale of delivery was unimaginable. There we were, standing in Canada's first vaccine clinic as Kevin Smith, our CEO, declared we were witness to "the shot heard around the world." Right then, it struck us. We were just stepping up to the starting line.
From that first day, "Get needles in arms" became the singular directive focusing our work. We continued to build up the vaccine clinic: 400 … 1,000 … 3,000 … 5,000 doses per week. Every day, we were asking ourselves: how can we do more? We looked at the numbers, planning our weeks ahead, and pushed the team to empty the fridges.
Over the next few weeks, more pieces of the puzzle began to fall into place. We drafted consent documents and medical directive agreements and implemented a transparent prioritization process. We were also pleased to see our partner hospitals open their doors, joining in, celebrating their first shot and ramping up doses. Many hospitals across Ontario came knocking on our door for advice and insight as more vaccine clinics were opening. Our long days now involved balancing our internal clinic operations as well as ensuring we could pass on as much learning as we possibly could to others across the province.
The spirit of collaboration was high across organizational boundaries, community organizations, and the health system. Little did we know we were about to embark on the roller coaster ride of vaccine supply. In truth, it was more like a weekly lottery: crossing our fingers, hoping to get the vaccine we needed. Some weeks we did, some we didn't. This made it incredibly difficult to face our community, the people we had built this service for, the people who desperately wanted new hope for themselves and the people they cared for. We were the voice of one of the most unwelcome statements since the pandemic started: "we have no vaccine this week." These words were met with high emotion from all around us. This was one of the toughest times of both our careers. As uncomfortable as it was, we shouldered the message, did everything we could to advocate for more vaccine and made sure every last drop was used.
One of the by-products of the unpredictable vaccine supply was that we were faced with periodic downtime. For us, this downtime served two purposes: first we were able to provide well-deserved breaks to those who were working non-stop for months since the vaccine work began, and secondly, we were able to re-tool our process and get better at getting needles in arms. These improvement cycles helped us to manage the endless directional shifts and missing pieces we experienced in the early days. These shifts included changes in priority populations, scheduling out and pulling back the second dose interval – multiple times – partially migrating scheduling to the provincial system and managing multiple vaccine brands in the same clinics. We were able to build robust processes that not only managed every twist and turn that was thrown at us, but also to respond proactively to shifts in policy and implement them almost overnight.
We could tell this was working as we not only felt an overwhelming amount of appreciation and support from our colleagues at UHN, but we also started to see positive social media. It was incredibly inspiring to be part of a team that, once with months of runway and then suddenly with only 11 days, embraced the challenge, and recalibrated to its goal "get needles in arms." It was controlled chaos at times but our strong bond served us well.
One year later, UHN's mass vaccination clinics have resumed, at least temporarily. Third doses are now being administered to staff from UHN and four other partner hospitals in downtown Toronto. That is expected to last for much of the rest of November. Toronto Public Health and community providers have continued with the mission to the broader population of the city. Our small executive team no longer meets daily and we can honestly say it feels like we are missing part of our family. We have returned to our regular jobs but a day doesn't go by that reminds us of the months we spent designing, implementing and running UHN's, Ontario's and Canada's first vaccine clinic.
UHN has administered more than half a million vaccines through our community efforts and vaccine clinics and the numbers continue to grow. This is a result of countless individuals across our system putting their energy, creativity and passion against this historic event. These leaders, at all levels, had to deal with ambiguity, logistical challenges, and endless shifts in priority and focus. While we had challenges, the leaders we interacted with were always driven to bring clarity, wrestle with the connection between policy and reality, and ensure that we always pulled towards our higher objective: "get needles in arms."
We observed silos being broken down both within our immediate community and across the health system. Our success was based on our strong partnerships with academia, primary care, acute care, First Nations, facility management, staffing and technology organizations and, of course, the Ministry of Health as well as Toronto Public Health. Without the nimbleness of these partners, we would never have been able to accomplish so many things vital to our success: rapidly opening and closing vaccine clinics, almost overnight, due to the changing vaccine supply; building a scheduling system that enabled secure vaccine booking through email or text; sending out invitations to thousands of priority community recipients within a few hours; staffing a vaccine clinic with just a few hours' notice on a statutory holiday; shifting more than 50,000 second doses to months earlier the very day a change in dose interval policy was announced by the provincial government.
With a common purpose, bridging across all of us, we partnered in ways we have never before. Of course, that exposed opportunities for us all to continue to work on. What lies ahead is a test of our strength to maintain the connections built during the pandemic, across the community, providers, patients and families and those in need.
While we may be in the vaccine business for some time to come, and may never fully return to normal, rolling out the vaccine is one experience that we will both forever remember as uniting the most incredibly collaborative spirit across the health system. We must keep that spirit with us as we journey out of this pandemic and settle back into the new normal. A new normal that has no boundaries, a laser focus on those in need, and a resilience to wrestle with the complexities of our modern healthcare system.
Emily Musing, Chief Patient Safety Officer and VP, Clinical, UHN, gained her first insights into healthcare as a candy striper volunteer at the Mississauga Hospital.
Michael Caesar, Chief Data & Analytics Officer, UHN, and Adjunct Faculty, University of Toronto, gained his first insights into healthcare during his teenage years as a volunteer at the Wellesley Hospital in Toronto.