Implementation of a COVID-19 Closed/Open POD Partnership: A Creative Professional Practice Exemplar for Occupational and Environmental Health Nurses

Abstract

Background:

For more than 15 years, the U.S. Centers for Disease Control and Prevention has recommended that all community agencies and workplace environments create structured communication and collaborative plans for emergency or disaster events (2008). This recommendation is aligned with the U.S. Department of Homeland Security’s (2022) National Infrastructure Protection Plan. The Coronavirus Disease 2019 (COVID-19) pandemic ultimately demonstrated the importance of having organized plans and processes in place for the effective and rapid dispensing of medical countermeasures (MCMs) to the general populace. Occupational and environmental health nurses (OHNs) can utilize examples of successful MCM dispensing programs and adjust details to fit individual organizational needs.

Methods:

This report examines a closed point of dispensing (Closed POD) mass vaccination program as a guide for designing successful workplace partnerships.

Findings:

Closed PODs are public or private sites that have set up a memorandum of understanding (MOU) with local health authorities to dispense MCMs to their populations during a public health emergency. The desired outcome of a closed POD agreement is the facilitation of employee health and safety, as well as enabling workplace continuity of operations.

Conclusions/Applications to Practice:

OHNs will play a pivotal role in any future disaster or emergency event. Because OHNs understand the critical need for anticipatory planning, they are in a prime position to drive the creation and implementation of a closed POD partnership between their workplace and their local health department.

Background

The increasing number of worldwide disasters and pandemics create an amplified need for preparation and coordination among healthcare facilities and caregivers. Emergency preparedness activities in the United States have included plans for responding to bioterrorism or infectious disease outbreaks. These plans provide processes for dispensing medical countermeasures (MCMs) such as medications, vaccines, or antitoxins. The U.S. Centers for Disease Control and Prevention (CDC, 2008) recommended that communities be able to provide MCMs to their entire population within 48 hours. To accomplish this, public health departments planned massive, open points of dispensing (Open PODs) for large community groups. In contrast, closed points of dispensing (Closed PODs) are private sites set up to dispense MCMs to their population during a public health emergency through collaboration with local health authorities and a previously drafted memorandum of understanding (MOU; CDC, 2020). The purpose of this report is to provide an overview of the development and implementation of a Closed POD mass vaccination program utilizing an MOU between a local health department and a nearby university and to present a professional practice exemplar that can be adapted and utilized as a guide for occupational and environmental health nurses (OHNs) desiring to create a Closed POD strategy for their workplace. Closed POD agreements not only facilitate employee health and safety using quick and effective access to MCMs but also support workplace continuity of operations via fewer interruptions (CDC, 2020; National Association of City and County Health Officials [NACCHO], 2014).

Both Open and Closed PODs utilize nurses, and as the largest healthcare provider group, nurses are critical to the process of disaster planning. Comprehensive emergency preparedness must include nurses across all healthcare institutions and in all practice areas. This includes OHNs in various workplace settings. The Future of Nursing 2020–2030 Report urges nurses in all practice roles to create structured processes that will facilitate coordination and collaboration in the event of public emergencies or disasters. The Report further recommends that professional nurses work in partnership with local, state, national, and federal agencies to plan and respond to natural disasters and public health emergencies (The National Academies of Sciences, Engineering, and Medicine [National Academies], 2021). The Coronavirus Disease 2019 (COVID-19) pandemic worsened an already concerning nursing shortage, including in occupational and public health areas. As healthcare resources dwindled, most nurses in clinical sites took on additional responsibilities and workloads. Thus, with little available outside help, the pandemic severely tested the ability of public health nurses to complete their regular, ongoing responsibilities along with the addition of contact tracing and oversight of mass vaccination efforts. Because much of the response to preventing and containing infectious diseases falls on the shoulders of public health nurses and administrators, plans must be in place to ensure that public health departments nationwide are adequately staffed with nurses and other healthcare professionals to respond effectively to future pandemics and other disaster events (Pittman & Park, 2021).

As far back as 2013, the federal government identified critical infrastructure sectors that were and are essential for the national security and public health safety of the United States as an integral part of disaster planning. These sectors include emergency and energy services, chemical and commercial facilities, communications, dams, industrial defense, financial services, food and agriculture, government facilities, healthcare, and public health, information technology, nuclear reactors, transportation systems, and water/wastewater systems (Cybersecurity & Infrastructure Security Agency [CISA], 2023). If disrupted, the loss of these business sectors could be catastrophic for the American public. Guidance on the essential critical infrastructure workforce was revisited in 2020 during the early stages of the pandemic to ensure that strategies were in place to protect essential workers via safety practices and equipment, as well as outline the allocation of scarce resources (COVID-19 vaccine and personal protective equipment) for these workers (CISA, 2020).

Rebmann et al. (2015) conducted a national study assessing whether U.S. jurisdictions were prepared to dispense MCMs in the event of a public health emergency. The authors found that although many jurisdictions have confidence in their plans to distribute MCMs to the entire population in 48 hours, more than half of the respondents did not have “adequate staff and/or volunteers to operate their Open PODs” (p. 7). Furthermore, this study found that a strong predictor of a “higher (level) of POD preparedness was having more of the jurisdiction covered by Closed PODs” (p. 7) created through community partnerships. The overarching theme of this national study underscores the supreme importance of creative planning that would ensure the supplementation of staff and volunteer capabilities of local and national public health entities for future emergency events. This recommendation supports the type of collaboration endorsed by the Future of Nursing report.

Accordingly, in response to the need to protect critical infrastructure, the NACCHO created a Closed POD Partnerships Program designed to assist businesses and community organizations in partnering with local health departments as Closed PODs, which will assist in dispensing MCMs to employees, their family members, and their clients. Closed POD program partners are provided with training resources (including training plans), as well as technical and planning assistance. During an emergency event, such as a bioterrorism attack or pandemic, program partners will be able to prioritize their employees, which not only reduces time to treatment for those involved but also reduces workplace interruptions and facilitates the continuity of business operations (CDC, 2020). Thus, OHNs desiring to create a Closed POD plan for their workplace have access to tools and resources that will facilitate collaboration and the formation of an MOU with local health departments. The following exemplar illustrates how a Closed POD plan can be effectively created and implemented.

Methods

Project Plan and Implementation

Two years before COVID-19, a state university set out to forge a Closed POD MOU with their local health department should an event occur that would necessitate rapid dispensing of MCMs. Negotiations ensued, and a detailed plan was designed and approved by both parties. At the time the MOU was signed, neither party had any idea the Closed POD plan would eventually be converted to a combined Open/Closed POD and operationalized as a collaborative partnership to respond to a worldwide pandemic 6 months later.

During the COVID-19 pandemic, public health authorities across the United States implemented large-scale, Open PODs as mass vaccination sites. Each state managed POD planning differently. In Utah, POD planning was assigned to the emergency managers of the local health departments. Before the COVID-19 pandemic, the Weber-Morgan Health Department emergency managers developed an Open POD plan for their two counties. The health department activated its POD plan during the 2009 H1N1 pandemic. Post-H1N1, a system of Closed PODs was then developed to reduce the burden of covering the entire county population. Closed PODs, functioning as an adjunct to the health department, were set up with large community entities that could distribute MCMs to their employees.

In April 2017, the emergency manager at the health department approached the nursing faculty at Weber State University (WSU) to facilitate a partnership. The alliance aimed to implement an MOU, making the university a Closed POD. By establishing a Closed POD agreement, it would be possible to provide MCMs to the university faculty, staff, and students and assist the public health department in vaccinating the general population. The Closed POD plan would also facilitate the continuity of operations across the university should a public health emergency arise. In June 2019, the university and the health department finalized the MOU, and the university began developing plans to initiate a Closed POD if needed.

The Annie Taylor Dee School of Nursing at the university consists of four nursing program levels: Associate of Science in Nursing, Bachelor of Science in Nursing, Master of Science in Nursing, and Doctor of Nursing Practice. The nursing program has approximately 1,000 students and 50+ faculty members at any given time. Other departments at the university, such as public safety and facilities management, were available to support the logistics of the endeavor, including determining a venue for the Closed POD. The nursing faculty working on the plan and the university emergency managers understood this would be a massive undertaking. The university has over 29,000 students and approximately 2,500 faculty and staff. The original plan was based on an anthrax attack and the dispensing of oral medications to heads of households. Therefore, the target group for the Closed POD would be over 31,000 individuals. The plan was to recruit faculty and students from the nursing program to dispense MCMs if the health department opened the Closed POD. The team developed a method to enroll volunteers through the county’s Medical Reserve Corps (MRC) to provide a way to verify licensure and provide liability protection. The state provided National Guard units to fill vacancies when additional healthcare and non-healthcare volunteers were needed.

In early 2020, it was clear that the world was facing a new pandemic. The University Safety Officer convened a WSU COVID-19 Task Force consisting of department heads, support staff, and the nursing faculty member coordinating the Closed POD planning. Efforts to solidify plans for the Closed POD continued in conjunction with the health department. In the fall of 2020, when the likelihood of a vaccine was evident, the nursing program administration organized a task force focused on testing, contact tracing, and vaccination efforts. From previous experience with the H1N1 mass vaccination effort, there was some knowledge about the university venue including an effective set-up plan.

Collaborations for an Open/Closed POD Strategy

As preparations for mass vaccinations were initialized, the health department lost its original venue and needed a new location for an Open POD. The university was willing to adapt its Closed POD plan to allow for health department Open POD activities, which was easily accomplished because of the Closed POD MOU already in place. The health department, in conjunction with the university faculty and staff, set up the mass vaccination clinic. The university was able to maintain its Closed POD activities by setting aside specific dates/times for the vaccination of students and employees.

The events center on the university campus was utilized as a POD in the 2009 pandemic and proved efficient in providing mass vaccinations. The building is a large circular event venue with a main hallway encircling a basketball court. There are multiple entrances to the building, a large parking lot, and indoor protection from weather elements. The events center provided an excellent structure to enhance crowd control and efficiently dispense MCMs. The Closed POD set-up required that the university secure medical supplies, including syringes, Band-Aids, cotton balls, and sharps containers. It was also crucial that the Closed POD had access to a −20°C freezer (for the Moderna vaccine) and a −80°C freezer (for the Pfizer vaccine). Both freezers were purchased using University Cares Act funds and staged at the events center. The COVID-19 vaccine was stored in these freezers by the health department. As mentioned, the site was ultimately utilized as a combined Open/Closed POD. The health department used the university set-up and storage areas identified in the original Closed POD plan. In addition, although the health department staff had their stockpile of supplies, they utilized syringes and other Closed POD materials when theirs were in short supply. These supplemental supplies were a part of the university’s Closed POD stock. The university environmental team disposed of the sharps containers, and the event staff took care of cleaning, garbage, and set-up. Campus police provided traffic control and security for the POD. The health department used Sales Force software for scheduling patients. Due to the lengths of the hallways at the events center, the staff staged wheelchairs in the intake area. The volunteer staff and the National Guard escorted those requiring a wheelchair through the POD.

Other departments on campus were instrumental in setting up the venue for the clinic, including facilities management, human resources, finance, environmental health and safety, public safety, campus police, and the events center staff. The university’s Director of Public Safety coordinated the effort. The mass vaccination venue had four main areas, or stations, connected by long hallways. The public entered the building and progressed to the following stations:

• Station 1 was the screening area, where individuals were greeted by screeners who ensured they were eligible for the vaccine.

• Station 2 was the registration area, where clients were given vaccination registration paperwork. Once this was completed, they were instructed to take their paperwork to the dispensing area.

• Station 3 was the dispensing area where vaccinations were administered.

• Station 4 included a post-vaccination waiting area for safety and monitoring, a first aid station for emergency events, and an education table for post-vaccination questions and answers.

Line monitors were located at each station to ensure the lines remained safe and organized.

Volunteers and Staffing

When the call went out to the faculty of the school of nursing for volunteers, approximately 41 faculty members and 206 students volunteered to dispense vaccines. The coordinator of the health department MRC and the MRC nurse/physician team lead recruited additional medical and nonmedical volunteers across campus. All volunteers were placed in the MRC by the MRC coordinator. The MRC requires a background check and credentialing to ensure the public’s safety. In addition, the volunteers took courses required for membership in the MRC and just-in-time training on vaccines and vaccination procedures. The nursing program maintained a database of all university medical volunteers, and all volunteers wore station-specific, color-coded vests and photo IDs during POD operations.

Once volunteers had completed their training, they were issued a health department MRC photo badge indicating their name and role (e.g., RN, LPN, EMT, Student). Photo ID badges were required to enter the volunteer area of the POD. Nonmedical volunteers from the university faculty and staff operated the greeting area, registration area, and line control. Calendar schedules were developed and shared with the volunteers. Initially, the coordinators scheduled volunteers for 8-hour shifts but later changed those to 4-hour shifts to better meet scheduling needs. The health department provided the first dose of the vaccine to volunteers and critical university staff. Based on state guidance, the health department opened the POD on January 5, 2020.

The COVID-19 vaccine was dispensed to first responders and healthcare providers initially. The clinic had access to both Pfizer and Moderna vaccines, which were stored in freezers located in a locked room in the events center. In the dispensing area (Station 3), a large table was set up away from the public area. Registered nurses from the health department and the university prepared and logged the vaccine per the manufacturer’s requirements. Lot numbers were communicated to those at the dispensing tables located in the public area. There were eight tables. Each table had a vaccine “drawer” who was responsible for preparing the syringe doses and two “vaccinators” who administered the vaccines. In general, tables were explicitly designated as either Pfizer or Moderna tables (which would be necessary for second doses of the vaccine), although vaccinators did have access to either vaccine when needed. Vaccinators reviewed the registration information, completed the vaccination record, administered the vaccine, and then gave the record to the client getting the vaccine. Clients were then instructed to move to the next station (Station 4), where they were asked to remain for 15 minutes to be monitored for adverse events.

The first demographic to be vaccinated was healthcare personnel and long-term care facility residents and staff, followed by persons aged 65 years or older and frontline essential workers. Next were those of the age range 16–64 years with medical conditions that increase the risk of severe COVID-19 and other essential workers identified by the government—followed by the rest of the population aged 16 years or older. (Note: On May 12, 2021, the CDC adopted the Advisory Committee on Immunization Practices recommendation to expand the use of the Pfizer vaccine for those aged 12 years or older).

A list of faculty and staff who desired COVID-19 vaccination was compiled by the university human resources department and sorted by age. Each day, when the mass vaccination clinic was closing, rather than waste vaccine, excess doses of both Moderna and Pfizer vaccines were offered to the faculty and staff, as well as the students in the residence halls, based on a list developed by the university human resources department. If called, they were required to come to the clinic within 15 minutes of notification. In June 2021, 2 days were dedicated to the remainder of the university faculty, staff, and students to ensure maximum vaccination coverage campus-wide. All faculty and staff wishing to be vaccinated were vaccinated by the end of June 2021.

Results

As mentioned previously, Closed PODs are public or private sites that have set up an MOU with local health authorities to dispense MCMs to their populations during a public health emergency. Both businesses and nonprofit organizations are eligible to be Closed POD partners. In a large-scale incident, such as bioterrorism, 100% of the community may need to receive MCMs within a 36- to 48-hour window. Open PODs will be the main venue for mass distribution, but Closed PODs will be instrumental in helping to distribute MCMs to their employees/families/members/clients. This means that Closed POD partners can provide rapid response in getting medications to their population quickly while demonstrating a commitment to employee health and facilitating continuous workplace operations (CDC, 2020; NACCHO, 2014). Closed PODs have the capability of diverting hundreds to thousands of individuals from the limited number of open PODs in any given county. For example, there were approximately 100,000 vaccines given at the university events center during the 6 months the health department/university POD was open. Roughly 31,000 of those recipients were university faculty/staff/students. In addition, all POD staff and volunteers were vaccinated (per their consent) before the POD opening to facilitate the safety of the workers overseeing POD operations.

Ultimately, the health department/university venue was utilized as both an Open and Closed POD. Over 50% of the dispensers (vaccinators) were from the nursing program, both faculty and students, as per the original Closed POD plan. University volunteers and employees were prioritized in such a manner that employee “time to treatment” was decreased. Moreover, the total amount of university faculty, staff, and student volunteer time equaled hundreds of hours, which greatly enhanced the effectiveness of the health department response. This type of cooperation required comprehensive preplanning and communication between the health department and the university. This exemplar of a health department/university POD partnership demonstrates that an inclusive MOU and other associated agreements must be in place before a pandemic or emergency response is needed.

Conclusions/Applications to Practice

The agreement between the university and the health department made vaccination of many in the county possible. POD operations were so successful that volunteers witnessed individuals and families from other counties driving long distances to obtain vaccination. As discussed, this partnership was created before the pandemic. Due to the complexity and detail of the MOU, it was nearly impossible to forge this type of agreement during the pandemic, although many entities across Utah tried.

Although public health departments are ready to respond to pandemic conditions or bioterror attacks, administering medications to thousands or millions of individuals in a short window of time may be impossible. Therefore, having closed POD partnerships already in place will be a critical decision to successfully protecting community members. Local public health departments are ready to assist workplaces and occupational health settings in developing closed POD plans and agreements. They can provide templates and other resources to assist in developing plans and strategies for receiving, storing, handling, administering, and tracking MCMs and associated medical supplies during any emergency. It is possible to become a Closed POD partner without medical personnel on site, although oversight by an OHN in concert with key leadership will be highly beneficial. There is no direct cost to becoming a closed POD site; however, organizations will need to prepare supplies and designate specific personnel for planning and training.

As shown in the POD exemplar provided, POD partners will be responsible for developing their Closed POD plan (with assistance), identifying the location for POD processes, designating staff for POD operations and defining the dispensing population, providing primary and secondary points of contact, as well as maintaining operation supplies. Most states/counties offer POD planning kits, templates, and models. The first step is to contact local public health emergency managers to inquire about the process. Because OHNs understand the critical need for preventive planning, they are in a prime position to facilitate the implementation of a Closed POD partnership for their workplace.

Applications to Professional Practice

Although the local public health departments will have primary responsibility for maintaining points of distribution of medical countermeasures, such as vaccines, medication, and antitoxins, during pandemics or bioterror attacks, occupational health nurses can contribute by ensuring that their employees have rapid access to countermeasures. Health departments can recruit secondary distribution sites through a memorandum of understanding (MOU). The development of this closed point of dispensing (POD) model would provide an onsite distribution center that would receive countermeasures directly from the Strategic National Stockpile. As a result, the employees covered under a Closed POD would receive their countermeasures onsite and would not have to access overburdened public PODs, and business continuity would be enhanced. Becoming a Closed POD is a formal and detailed process. To be successful, organizations must be proactive and have the MOU in place prior to a public health emergency.