Resident Eagle is a monthly column profiling the work of top EMS physicians and medical directors from the Metropolitan EMS Medical Directors Global Alliance (the "Eagles"), who represent America’s largest and key international cities. Tentative dates for the Gathering of Eagles 2021: June 14–18, Hollywood, Fla. For more see useagles.org.
As we pass a year since COVID-19 emerged and reshaped American lives, there may finally be an end in sight. Vaccine efforts continue, intimately involving EMS on both ends of the needle. For a current pulse on how things are going, EMS World surveyed some top EMS physicians about their teams’ vaccine acceptance and best practices.
These responses come from Ken Scheppke, MD, EMS medical director for Palm Beach Fire-Rescue and the state of Florida; Michael Kaufmann, MD, FACEP, FAEMS, EMS medical director for the state of Indiana; Jon Jui, MD, EMS medical director for Portland Fire & Rescue and Multnomah County, Ore.; Chris Kahn, MD, MPH, and Joelle Donofrio-Ödmann, DO, FAAP, FACEP, FAEMS, medical director and associate medical director, respectively, for San Diego Fire-Rescue; Fionna Moore, MD, executive medical director for the South East Coast Ambulance Service NHS Foundation Trust, U.K.; and James Augustine, MD, FACEP, national director of prehospital strategy for U.S. Acute Care Solutions.
EMS World: We know healthcare workers had some vaccine hesitancy. What were some of the most important, effective, or helpful messages you gave to your providers that may have helped them regard the vaccine as safe and effective? How would you characterize their hesitation?
Scheppke: The newness of the technology, speed of both development and emergency use authorization, misinformation regarding risks and side effects, as well as the sense that their personal risk was low all seem to be major contributors to vaccine hesitancy among fire/rescue personnel. Trusted medical subject matter experts educating these providers in simple, honest terms on the facts of the mRNA technology; its rapid but scientifically sound development; vaccine study design and results; plus having that subject matter expert receive the vaccine as an example of acceptance of its safety all seem to be extremely helpful in reducing vaccine hesitancy.
Additionally, addressing each of the various points of misinformation and shining the light of scientific data and common sense helped improve the acceptance rate. As more of their colleagues obtained the vaccine and shared their experiences, acceptance grew.
Kaufmann: Indiana, like most other states, saw a relatively high rate of hesitancy to accepting and taking the COVID vaccines. The Indiana Department of Homeland Security sought to better understand this hesitation, and through phone calls, informal assessments, speaking engagements, and e-mails, the vast majority of emergency responders listed two resounding themes: lack of understanding the science behind the vaccines and the short timeline that brought the current vaccines to market.
To address these concerns, IDHS and other state agencies launched an aggressive campaign to increase acceptance. We engaged national experts in both EMS and vaccine science to help provide reliable information. Dr. Ken Scheppke spoke in December 2020 at the Indiana EMS Leadership Conference. Facebook Live sessions with the Indiana Fire Chiefs Association also proved to be a great way to reach a large audience. Likewise, IDHS developed online, on-demand training opportunities that awarded continuing education credits in the form of distributive learning that spoke to the effectiveness and safety of the vaccine.
Anecdotally and through word of mouth, vaccine acceptance has dramatically improved by simply refuting some of the barstool misinformation that quickly spread when the vaccine first became available.
Jui: In Multnomah County there is variation in the acceptance rate of the COVID-19 vaccine by our fire and EMS agencies. For example, the rate with Portland Fire is approximately 85%. This number is truly amazing given that our normal acceptance of the flu vaccine is approximately 50%. Additionally, EMS (AMR) acceptance is going to be in the low 90% range. However, fire providers in the east county have a much lower acceptance rate, approximately 50%–60%.
The reason for this discrepancy is currently not clear. However, there seems to be a correlation that the more you’re exposed to patients who present with COVID-19, the more likely you are to accept a vaccine. Additionally, experience with members who had COVID-19 also seems to affect acceptance. Finally, the actual mechanism of vaccination seems to make a difference. For our fire agencies, when they vaccinate as a station, the acceptance rate is markedly higher. There seems to be some peer pressure being exerted in this situation, and acceptance by leadership also seems to make a difference.
As far as messaging we used a combination of techniques: consistent and stable messaging over 3–4 weeks; a video discussing all aspects of the vaccine, including key questions; development of written FAQs; planning by occupational health personnel and discussion with leadership; and setting a personal example of being vaccinated. I cannot emphasize enough the role of the EMS medical director as a “trusted agent” getting the vaccination.
Moore: We have seen very little reluctance among our staff—quite the reverse. The issue has been more around justifying the prioritization guidance and staff being very keen both to get vaccinated and ensure that their families could also be protected. We have strict rules around who can get vaccinated and in what order, then had a debate over whether call handlers in our EOC were considered frontline or not. We absolutely agreed they were.
Kahn/Donofrio-Ödmann: Our fire department was quick to put up an aggressive fight against COVID, with frequent and consistent messaging over many months. Consequently we headed toward vaccination with a high baseline level of trust, commitment, and communication. We developed a multicity COVID management team that included medical directors, fire, EMS, lifeguards, and law enforcement. With daily briefings we were able to address questions and concerns quickly. To offset the concerns brought on by social media and conspiracy theories, the medical directors put together an informational written briefing, video FAQ, and list of additional educational resources. Likely due to the collaborative efforts, along with the realities of the hard-hit healthcare system from the holiday surge, we had higher-than-expected vaccination rates. We did notice that acceptance rates varied based on role (lifeguards, fire/EMS, or dispatchers) and added education as needed. We would advise other departments to look into their own agencies to see if any particular groups may need additional focused guidance.
EMS World: How are EMS services in your area being used to administer the vaccine? What does training and operationalization look like? If EMS isn’t being used, why not?
Kaufmann: Indiana EMS providers were included in phase 1A vaccination efforts. To that point, they can now register to receive any one of the available COVID-19 vaccines. Likewise, EMS is fully engaged in the delivery of vaccine to Hoosiers across the state. EMS professionals make the perfect partner for this monumental effort: EMS is available 24/7, with the appropriate training on giving IM injections and also the ability to monitor and treat adverse reactions. Likewise, EMS is embedded within every community. To increase the pool of available vaccinators, the Indiana EMS Commission, along with an executive order from Gov. Eric Holcomb, opened the procedure of COVID-19 vaccination administration to basic EMTs.
Scheppke: EMS and fire/rescue have been at the vanguard of Florida’s response. They have been used to evacuate healthy patients from nursing homes with outbreaks; perform widespread weekly testing of long-term care facility staff and residents; educate those facilities on infection-prevention methods; and educate hospitals on safe handoff practices using outdoor air as well as prenotification of patients en route. Most recently EMS and fire/rescue have served as force multipliers for mobile vaccination strike teams for long-term care facilities, churches, over-55 communities, mass-vaccination sites, and individuals who lack mobility or transportation. We have developed a state vaccination screening and consent form as well as vaccination protocol that EMS is using and has been adopted by all our county health departments.
Moore: We already have a high take-up of the flu vaccine (79% this year) and an established way of vaccinating our own staff. We were also given access to a small number of hospital and other sites for staff in high-risk groups. We set up a large tent at our headquarters in Crawley and used clinicians from our Nursing & Quality and Medical Directorates (who could not be deployed on ambulances) to undertake the vaccinations. We developed a patient group direction (based on the national version) for the Oxford AstraZeneca vaccine, and the vaccinators undertook a nationally mandated training package.
Kahn/Donofrio-Ödmann: In our jurisdiction we need both scope-of-practice approval by our local EMS authority (LEMSA) along with public health approval to give the COVID vaccination. This was initially provided to paramedics and recently opened to include EMT-Bs. We had early contact with both our LEMSA and public health along with our city governance teams to ensure we were able to hit the ground running to facilitate vaccinations to our providers and the community per the designated tier levels. We developed a multicity approach to enable consistent training and communication. Initially we hosted a large single venue to vaccinate up to 300 first responders a day. Train-the-trainer events led to further spread of vaccination sites within the various fire/EMS agencies. Additionally, we have been able to assist with both vaccination of the community and optimization of 9-1-1 response at a collaborative COVID vaccination “superstation” hosted at a local stadium.
Augustine: It’s critical that EMS and public safety providers are well respected and trusted members of the community. Their participation in vaccine programs has been essential to building confidence in the community.
EMS is helping the world work through the first mass vaccination program that has the unique difficulty of requiring multiple doses. As more vaccine has come available, the EMS workforce has clearly been a force multiplier. It is also very aggressive in developing and disseminating best practices. EMS has worked to develop best practices in the five arenas that constitute the vaccine environment: drive-in sites, walk-up sites, congregate care sites, rotating community sites (churches on Sunday, fire stations on weekends, senior centers on Wednesdays, etc.), and mobile vaccination vehicles.
EMS can take some of the credit for the mass change in confidence in the vaccine program. As respected EMS leaders and medical directors explain to the community that it is safe, effective, and the way to return to an interactive society, we can exit the pandemic and implement some of the innovative programs developed during the “COVID year” to deliver unscheduled care.