On March 27, 2020, Premier Kenney and Chief Medical Officer of Health Dr. Hinshaw announced new restrictions for businesses due to the COVID-19 pandemic, providing a list of essential workplaces that can continue to operate and directing closure of non-essential workplaces. Essential workplaces include hospitals, continuing care (long-term care, licensed supportive living, and home care), and home services for seniors, the disabled and the vulnerable.
Non-essential workplaces that have been directed to close include those that provide close contact personal services, except when providing emergency and urgent services.
“Albertans are prohibited from accessing close contact personal services, including personal services facilities, cosmetic enhancement services, wellness studios and clinics, non-emergency and non-critical health services. Non-emergency and non-critical health services provided by regulated health professionals or registered professionals include any non-emergency or non-urgent physiotherapy.”
The wording of the Public Health Order, and clarification provided by representatives from Alberta Health make the following clear:
- The only in-person physiotherapy services that may be provided at this time are those categorized as urgent or emergency.
- The task of defining what constitutes urgent or emergency care rests with the regulatory body.
As we previously stated, Physiotherapy Alberta does not have the authority to direct that physiotherapy clinics must close. That authority rests with the Chief Medical Officer of Health and the Government of Alberta. We also advised members that if the Chief Medical Officer of Health directed that clinics close, we would advise them of that change.
As of March 27th, the Chief Medical Officer of Health has directed that clinics and other settings where close contact physiotherapy services are provided must close, except for the provision of urgent or emergency care. It is no longer a recommendation it is now an order. Failure to comply with this order, by providing non-urgent or non-emergent care could result in a fine under the Public Health Act.
Physiotherapy Alberta recognizes that physiotherapists provide valued and important health services in a wide range of settings. It can be difficult for clinicians and patients to know when services constitute urgent or emergency physiotherapy. It is also essential that these decisions are consistent across the province. To that end, we are now providing direction regarding what constitutes urgent or emergency care by physiotherapists, categorized by health-care setting.
Acute care physiotherapy services are categorized as urgent services and must continue.
This includes services to individuals with respiratory, neurologic, or musculoskeletal system impairments requiring physiotherapy intervention to optimize health and function and facilitate discharge from the acute care environment. Existing facility protocols for prioritization of services should be reviewed.
Additional considerations for the delivery of in-person services in this sector should include:
- Prioritization of non-COVID-19 patients with functional impairments, with the intent of facilitating rapid discharge out of acute care and into community settings.
- Prioritization of COVID-19 patients on medical wards to address respiratory care needs, with particular focus on patients with co-morbid conditions who may experience a more severe illness trajectory or who may benefit from active respiratory interventions (e.g., patients with co-occurring COPD or similar respiratory illness).
- Prioritization of COVID-19 patients in ICU to address respiratory care needs or provide interventions to prevent or minimize post-ICU weakness and functional decline.
- Non-COVID-19 patients who are categorized as ALC and pending transfer to a continuing care or supportive living facility may be categorized as urgent, if ongoing physiotherapy intervention is required in order to maintain a patient’s functional status and eligibility for transfer to the designated community setting that they are awaiting. Physiotherapists are advised to use their clinical judgment when determining the need for ongoing intervention to support these discharge plans.
When providing services in this sector, physiotherapists are directed to follow facility protocols for patient screening, point-of-care risk assessment, frequent hand hygiene and use of PPE to limit the spread of COVID-19. Questions regarding appropriate use of PPE should be directed to facility-based staff with Infection Prevention and Control expertise.
Decisions regarding caseload assignment and patient care sequencing are best made at the facility level, with due consideration of human resources and other resource availability. However, Physiotherapy Alberta encourages managers and clinicians to consider the following actions:
- Reduce the potential for physiotherapists to spread COVID-19 by assigning patients with suspected or confirmed COVID-19 to a limited number of staff members.
- Sequencing patient care to minimize the risk of becoming a vector for transmission by providing services to patients who do not have/are not suspected of having COVID-19 prior to patients diagnosed with or suspected to have COVID-19.
Subacute and Rehabilitation Facilities
Physiotherapy services provided in this setting are categorized as urgent and must continue.
Patients with functional impairments for whom physiotherapy is required to facilitate discharge home or to community care settings are correctly categorized as having urgent needs requiring ongoing in-person physiotherapy intervention. This includes patients with:
- Recent diagnosis of neurological conditions such as stroke, brain injury, and/or spinal cord injury
- Deterioration of pre-existing neurologic conditions (e.g., Parkinson’s disease, MS) requiring admission for functional retraining and rehabilitation
- Recent amputation
- Post-surgical patients including multiple orthopedic trauma, total joint replacement and similar
- Generalized weakness and functional decline
The goal of physiotherapy services in both acute and subacute/rehabilitation settings is to facilitate transfer out of facility and into home or community care environments to create capacity in the health-care system for managing COVID-19 patients and to limit co-location and transmission risk among non-COVID-19 patients.
Recommendations regarding point-of-care risk assessment, hand hygiene, PPE use, human resource management and patient sequencing are the same as those identified for acute care settings.
Home Health Care Settings
Whether delivered by Alberta Health Services or private providers, physiotherapy services provided in this setting are categorized as urgent in the following situations:
- When physiotherapy care is initiated as part of urgent discharge from acute care, subacute or rehabilitation settings (e.g., early supported stroke discharge, following orthopedic surgery).
- When physiotherapy interventions are required to maintain an individual in their current living environment and prevent hospital admission due to health or functional decline, or injury (e.g., services to elderly, medically fragile or frail patients, patients with elevated risk of falls, those with chronic health conditions or multiple co-morbidities).
- To address post-operative care needs of patients with recent orthopedic trauma, total joint replacement or limb amputation when those services cannot be provided using an alternate means of delivery (e.g., telerehabilitation).
- Services are provided in the home because the patient is unable to leave their home due to mobility or functional impairments.
Services delivered in the home environment because it is the patient or family’s preference to receive care at home should be categorized according to the criteria for private practice/ambulatory care services. Current restrictions on gatherings and provision of personal services do not constitute a physical inability to leave the home and are not an acceptable reason to provide home-based services on an urgent basis.
Clinicians who provide home health-care services are directed to follow employer protocols for patient screening, point-of-care risk assessment, hand hygiene and use of PPE. Questions regarding appropriate use of PPE should be directed to those with Infection Prevention and Control expertise.
Private providers of home health-care services must develop protocols for screening of patients and the home environment for appropriateness of in-person services, conduct point-of-care risk assessment, and employ hand hygiene and PPE according to the recommendations of Public Health Officials.
In the presence of suspected or confirmed COVID-19, physiotherapists must not deliver in-person services if they do not have the appropriate PPE to provide services safely.
Private Practice Clinics and Ambulatory Care Settings
Physiotherapy services in private practice or ambulatory care settings are only considered urgent if:
- Services cannot be provided using an alternate form of delivery, such as telerehabilitation.
- In the absence of physiotherapy services, the patient will require health-care services in an emergency department setting (e.g., severe pain requiring physician intervention or prescription medication to manage that pain).
- The patient is an essential service provider (e.g., health care provider, first responder) who is unable to work due to an acute injury or exacerbation or a pre-existing condition, whether that injury is WCB compensable or not.
- The patient is seeking services related to a recent surgery or removal of a cast/immobilizer.
- In the absence of physiotherapy services, the patient’s functional status will deteriorate to the point of requiring invasive management or hospitalization in the foreseeable future.
In the case where the treating clinician does not provide telerehabilitation, but services could reasonably be provided using this method, the physiotherapist is expected to provide a referral to a telerehabilitation provider.
Clinicians who provide ambulatory care services in AHS or Covenant Health facilities (e.g., wound care clinics, cast clinic, chronic pain clinics) are directed to follow employer directions for provision of care and protocols for patient screening, point-of-care risk assessment, hand hygiene and use of PPE. Physiotherapists should direct questions regarding appropriate use of PPE to their employer’s Infection Prevention and Control experts.
Private providers (i.e., private clinics) must develop protocols for screening of patients for urgency of care need, screen urgent patients for signs/symptoms and risk of COVID-19 prior to patient attendance at the clinic, conduct point-of-care risk assessments, and employ hand hygiene and environmental cleaning measures according to the recommendations of Public Health Officials.
In the presence of suspected or confirmed COVID-19, physiotherapists must not deliver in-person services in private clinics.
Long-term Care and Continuing Care Environments
Physiotherapy services in these environments would not typically be considered urgent. Recognizing that the patient population residing in these settings is also one of the most high-risk patient groups for negative outcomes from COVID-19, service provision should be the exception, and should only be provided if:
- Physiotherapy care has been initiated as part of urgent discharge from acute care, subacute or rehabilitation settings, with the intent of preventing hospital readmission or establishing patient care needs to enable ongoing patient safety in the long-term care or continuing care environment.
- Physiotherapy interventions are required to maintain an individual in their current living environment and prevent hospital admission due to imminent functional decline.
Physiotherapists must follow facility protocols for patient screening, point-of-care risk assessment, and use of PPE. Questions regarding appropriate use of PPE should be directed to facility-based staff with Infection Prevention and Control expertise.
Physiotherapists must also engage in routine practices such as frequent hand hygiene and respiratory etiquette. Physiotherapy Alberta encourages managers and clinicians to consider the following actions to reduce the risk of becoming a vector for the spread of infection among this fragile patient group:
- Assigning patients with suspected or confirmed COVID-19 to a limited group of staff.
- Consider sequencing of patient care services to patients with confirmed or suspected COVID-19 after services to non-COVID-19 patients have been provided.
Other Methods of Service Provision
At present, telerehabilitation services may continue, as they do not include close personal contact. Physiotherapy Alberta acknowledges that telerehabilitation services may be employed to provide both urgent and non-urgent physiotherapy services at this time. Not all patients and conditions are well suited to telerehabilitation and clinicians may not have the individual competence to deliver services via telerehabilitation. Physiotherapists are directed to critically review their ability to deliver services using telerehabilitation, take action to address competence gaps and develop criteria for patients who are appropriate for this method of service delivery.
We note that there are several platforms available for physiotherapist use which also adhere to privacy and security expectations for patient health information, therefore our expectation is that physiotherapists will employ secure platforms when providing these services.
***Regardless of the information contained in this update, the orders of the Chief Medical Officer of Health and the Government of Alberta will always supersede the directions and guidelines provided by Physiotherapy Alberta.
Posted: March 29