Clogged phone lines and ethical dilemmas: Texas health providers scramble to roll out vaccine with little state guidance

Jeffrey Warnken, R.Ph., right, and his wife Sandra Warnken R.Ph.,  organize vaccine paperwork at 38th St. Pharmacy in Austin on Jan. 7, 2021.

Jeffrey Warnken, right, and his wife Sandra Warnken, who are both pharmacists, organize vaccine paperwork at 38th Street Pharmacy in Austin on Jan. 7, 2021. The pharmacy ran out of its initial allotment of 200 Moderna vaccine doses this week. “We did not waste one dose,” Jeffery Warnken said. “I didn’t hold any back.”

Credit: Jordan Vonderhaar for The Texas Tribune

Rannon Ching, pharmacist for Tarrytown Pharmacy in Austin, got the call at 8 a.m. on Dec. 23: Five hundred doses of the Moderna vaccine were arriving. Get ready.

“I found out two hours before the FedEx guy came,” he said. Ching frantically called some Austin senior care facilities on his way to work. Could his pharmacists come that afternoon?

By 10:30 a.m. his staff had the vials in hand. By 1 p.m. they vaccinated a doctor’s office. By 3, they’d started on the residents and staff at a nursing home.

“The first day, we immunized over 200 people within the first four hours of having the vaccine,” he said. Staff stayed until 9 p.m. that night entering immunization data for the state — by hand.

By the time Texas told the public five days later that the vaccine could be administered to group 1B, which includes anyone over 65 and those over 16 with certain health conditions, Ching’s pharmacy only had 20 doses left.

But the public didn’t know that. His pharmacy was swarmed — it received 100 phone calls within the first 15 minutes of being open the day after the announcement.

“The state said, ‘You can get your vaccine’ and people thought 3 million doses magically popped up into our freezers overnight,” Ching said.

Texas has largely left the vaccine rollout process in the hands of local providers like Tarrytown Pharmacy, one of more than 1,000 providers approved to vaccinate Texans. And outside of dictating the first two groups allowed to receive it, providers say the state has given little instruction or information on when allotments will arrive, how immunization operations should be organized and what principles ought to be followed in prioritizing within groups 1A and 1B.

As they spearhead vaccination in a state of 29 million people, hospitals, pharmacies and community health centers alike across Texas built new scheduling systems from scratch, struggled to sync their patient information systems with the state’s and answered to an increasingly anxious public wondering when their turn for the shot will come — all while helping fight the COVID-19 pandemic during its highest peak in Texas.

“Every space I have is booked. I have phones going off the hook saying, ‘Where’s mine?’” said Dr. James McCarthy, chief physician executive for the Memorial Hermann Health System in Houston. “The demand is insatiable right now. Everybody wants it today, and we just don’t have enough vaccines. It will take months.”

Empty Moderna COVID-19 vaccine containers stored in the box they were delivered in at 38th St. Pharmacy in Austin on Jan. 7, 2021.

Pharmacist Jeffrey Warnken holds an empty Moderna COVID-19 vaccine container at his pharmacy in Austin.

Credit: Jordan Vonderhaar for The Texas Tribune

The state’s initial allocation of 1.2 million doses had been shipped by Jan. 3, according to state health officials, and another January shipment was expected to bring the state’s total allotment to 1.7 million. That’s still hundreds of thousands of doses short of the roughly 1.9 million necessary to provide just a first dose of vaccine to those Texas health care workers and residents of long-term care facilities eligible in group 1A.

But before many of those first in line had received a dose, the state allowed providers to start administering the vaccine to the second group — about 8 million people older than 65 or at least 16 with certain medical conditions. A Department of State Health Services official said there is some overlap between groups 1A and 1B (doctors and other health care workers over age 65, for example).

Overwhelmed by 1B

The sudden announcement to open vaccinations to the second group — just a week after the first distribution of vaccines for the first group — caught many providers off guard.

“It was in response to all of the chatter and angst to ‘Oh my God, they haven’t given all their vaccines out,’ and it’s been five days,” said McCarthy of Memorial Hermann. “I thought we would get all the health care workers done, and then we would move on. I didn’t think we’d be doing them simultaneously.”

Memorial Hermann got its first allocation of 16,000 doses, enough to vaccinate its front line medical staff, on Dec. 15. “It was all queued, it was all slated to be given,” McCarthy said of the first allotment. “We had no idea when we would get our second allocation.”

All of a sudden, “on Christmas Eve we’re drawing up a plan to do patients” because of the state’s announcement, he said.

Seemingly overnight, many Texas hospitals, health centers and pharmacies’ phone lines were clogged. Websites for providers all over the state crashed. Long lines of the people most vulnerable to the virus began to form at vaccine centers.

In a tweet, Gov. Greg Abbott added to the frustration, seemingly suggesting that an excess supply of vaccine was available and criticizing providers for not moving quickly enough to administer it.

At Memorial Hermann, a link was emailed to 50,000 select, qualified patients to schedule their vaccine at one of seven public clinics. But some recipients started forwarding that link to friends and family, and even posting it on Instagram.

Every space was booked within 36 hours. People who weren’t supposed to register had registered. People who weren’t supposed to show up, showed up. Staff had to turn them away if they didn’t meet the state’s criteria for a vaccine, McCarthy said.

Peggy Duncan, 77, center, with the use of a walker, stands with her daughter Lori McCormick, right, and other Tarrant County residents as they wait to receive a COVID-19 vaccination at the Esports Stadium in Arlington, Texas, on Tuesday, Jan. 05, 2021.

Peggy Duncan, 77, center, stands with her daughter Lori McCormick, right, and other Tarrant County residents as they wait to receive a COVID-19 vaccine at the Esports Stadium in Arlington on Tuesday.

Credit: for the Texas Tribune

“That’s a very difficult thing,” McCarthy said. He said the hospital’s tech team resolved the problem with a link that couldn’t be forwarded.

In the Rio Grande Valley and elsewhere on the border, patients responded to vaccination announcements and found themselves in long lines. One line to get the vaccine at a public drive-thru clinic in Laredo extended for miles last weekend, with Texans at high risk of the virus arriving as early as 3:30 a.m. Sunday, according to the Laredo Morning Times.

Across the state, the vaccine providers quickly realized “first come, first served” was not working. Normal scheduling mechanisms would have to be revised.

In Southeast Texas, CHRISTUS Health piloted some walk-in clinics, but those were quickly overwhelmed.

“It’s not feasible to do a walk-in clinic,” said Dr. Sam Bagchi, chief clinical officer at CHRISTUS Health, a health care system with 34 hospitals in the state, many in Southeast Texas. “We ran out very quickly or experienced long delays.”

The system directed its qualified patients to schedule an appointment, as many other providers have now done. Both CHRISTUS Health and Memorial Hermann executives said that starting with their regular patients was the fastest way to begin distributing vaccines because all of their information was already in the system.

Rows of cars at the Rio Grande Valley Livestock Show Grounds. Area residents lined up early in the morning for the COVID-19 vaccine on Jan. 5, 2020.

Valley residents lined up in the early hours of the morning for the COVID-19 vaccine at the Rio Grande Valley Livestock Show Grounds on Jan. 5, 2020.

Credit: Jason Garza for The Texas Tribune

Smaller providers, too, were bogged down by the huge demand. At Jeffrey Warnken’s 38th Street Pharmacy, a family-owned business in Austin, staff took 500 calls in one hour on the day the state announced group 1B could begin receiving the vaccine.

“Honestly, we couldn’t even fill our prescriptions that day,” due to the enormous call volume, Warnken said. His pharmacy is already out of its allotment; there are thousands on his waiting list. “I’m all in favor of 1B getting it. We just need to get more vaccines.”

Chris Van Deusen, a spokesperson for the state’s health department, said Texas wanted to give providers flexibility to vaccinate priority groups in the best way they can, and that the Expert Vaccine Allocation Panel felt that people in high risk groups should be prioritized as soon as possible.

“We don’t want to have an overly restrictive system that creates barriers to people getting vaccinated,” Van Deusen said.

But limited supplies meant that providers had to make decisions about who should be prioritized within the already prioritized groups.

At Memorial Hermann, the system invited limited pools of people over 65 who are regular patients to schedule — McCarthy said they didn’t want to debate whether or not the patient had a qualifying medical condition.

“It’s not meant to be who is more worthwhile — the fact of the matter is supply and capacity,” he said. “Our intent is to get to everybody … We need a lot of patience to make this work.”

At CHRISTUS Health, a task force mapped out the ethical distribution of vaccines between different groups, particularly emphasizing distribution to communities of color that have historically been marginalized by the U.S. health care system, Bagchi said.

“We had to balance ethical prioritization with the logistics of depleting the inventory as quickly as possible,” Bagchi said.

Some, like CHRISTUS Health, are glad to make those calls: Bagchi said he applauds the state’s move to open vaccination to more people: “Because of the quick move to 1B and broader definition of 1B, I think more people are getting vaccinated faster,” he said.

But at Austin Regional Clinic, Chief Medical Information Officer Dr. Manish Naik said the quick pivot to 1B caught them by surprise.

“(The state) opened up a very large group,” said Naik. “That’s a huge number of people, and there’s a bit of a disconnect versus the amount (of vaccine) we actually have to administer. It’s created a lot of anxiety among patients.”

“We made our best guess”

Before vaccines even arrived, much of the preparation was a guessing game for providers. They didn’t know whether they’d get the Moderna or Pfizer vaccine, which have different thaw times and storage temperatures. They didn’t even know the size of the vaccine boxes and whether they would fit in their freezers.

“We made our best guess,” said Naik of the Austin Regional Clinic, which has 29 locations throughout the Austin metro area. “There was a lot of energy and cost put into preparation before we even got a dose of vaccine.”

Providers stocked up on syringes, Band-Aids and masks, months in advance. IT teams started designing scheduling websites. Still, most of the decisions were being made in the dark. Some decided to invest in ultra-low-temperature freezers to store the Pfizer vaccine. Centro San Vicente, a community health center in El Paso, coordinated with a local university to get access to more freezer space. Others just hoped they’d get the Moderna vaccine.

Once the vaccines arrived, logistical hurdles emerged. Providers had trouble syncing their computer systems with the state’s COVID-19 immunization registry, which the state uses to compile data on vaccinations.

Many had to input the data by hand. It took four Tarrytown Pharmacy staffers six hours to input around 500 patients’ data into the state’s registry, Ching estimated.

“That’s 24 hours they could be vaccinating people — if they had doses,” Ching said. “It creates a huge bottleneck.”

Syringes for the COVID-19 vaccine at Doctors Hospital at Renaissance in Edinburg on Dec. 19, 2020.

A row of syringes for the COVID-19 vaccine at Doctors Hospital at Renaissance in Edinburg on Dec. 19, 2020.

Credit: Jason Garza for The Texas Tribune

In a statement, Van Deusen of DSHS said that the state is continuously working with providers to help them report vaccination data as smoothly as possible.

Less than half of the vaccine doses sent across Texas have been given out, according to state data, although the estimates lag behind real time due to reporting delays. Several providers said their vaccines have already been earmarked for patients. Others have run out and aren’t sure when more will arrive.

H-E-B, for example, wrote in a press release Jan. 3 that it has either already distributed its first allotment of vaccines or has scheduled them to be administered.

Some providers expect a second allotment will arrive soon, but they don’t know when. During the first allotment, many only got a day or a few hours of notice.

“We haven’t gotten a lot of lead time on this,” Naik said. “Within a day we have to scramble to figure out: Where are we going to allot these, and do we have the staff, or do we need to set up a separate site?”

Any vaccine still on shelves could be a result of scheduling patients to receive the vaccine and needing the staff, information and time to get them all done, providers said. Vials must be properly thawed. Vaccinations must be scheduled. Patient consent forms acquired. Reports written for the state. The logistics are unending.

“It’s a very daunting process, so I think the perception of what’s being ‘held on the shelf’ is us trying to organize and prepare,” said Dr. Celina Beltran, chief medical officer at Centro San Vicente, which began administering vaccines to group 1B on Wednesday.

“Giving the patients the vaccine is the easy part,” Beltran said. “We’ve spent a majority of the time on rolling out the process.”

Disclosure: Christus Health and H-E-B have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.

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