COVID-19 Pandemic

On June 9, 2020 Premier Kenney and Dr. Deena Hinshaw, Alberta’s Chief Medical Officer of Health,  announced that Stage 2 of Alberta’s reopening strategy will start on June 12, 2020. This is paired with the understanding that the current state of public health emergency will not be extended when it expires on June 15, 2020. While these are positive signs, the announcement does not mean that the risk of COVID-19 has come to an end or that the virus has stopped circulating in our communities, a fact frequently highlighted by Dr. Hinshaw.

In some ways, the implication of allowing more businesses to open and reducing restrictions applied to other businesses means that the risk of virus transmission is increased as more people are out in public, making it more important than ever to have measures in place to mitigate the spread of COVID-19. While it is fair to ask what stage 2 means for physiotherapists, it may be easier to comment on what it does not mean.

When the public health emergency was declared on March 17, 2020, it provided the Government of Alberta with certain legislated powers to act to mitigate the spread of COVID-19. However, the Chief Medical Officer of Health’s ability to issue public health orders is not limited by the expiry of the public health emergency – a point that both Dr. Hinshaw and Premier Kenney made clear during the June 9, 2020 press conference. As both stated, the public health orders and directions of the CMOH will remain in place for the foreseeable future, and new measures may be implemented by the CMOH if needed to further mitigate the spread of COVID-19.

So, what does this mean for physiotherapists?

It means that the order that allowed physiotherapists to re-open on May 4 remain in effect and that physiotherapists need to continue doing what they are already doing, consistently following the directions outlined in the Guidance for Resuming Physiotherapy Practice During a Pandemic.

Continue practicing physical distancing in clinical spaces, continue frequent and effective hand hygiene, continue screening patients and staff for signs/symptoms and risks of COVID-19 before they enter the practice setting, and continue with rigorous environmental cleaning and disinfecting practices. 

Some of these measures are designed to decrease the volume of direct interpersonal contact patients and providers experience and thus the risks that such contact poses, by decreasing the volume of patients in clinical settings and the number of patients seen in a day. Other measures have this effect, even though that may not be the intent of the measure. This has clear implications for physiotherapy business owners, and physiotherapists working in fee for service practice settings.  

While CMOH Order-16-2020 removed prior restrictions on in-person health services, allowing physiotherapists to resume non-essential/non-urgent health services with the condition that they do so in compliance with guidance from Physiotherapy Alberta and the Workplace Guidance for Community Health Settings included in the order, it is not business as usual.

Moving to Stage 2 does not change this fact. The knowledge that COVID-19 continues to circulate in our communities means that any services provided must be delivered with caution and after careful consideration of whether the anticipated benefits of in-person services outweigh the risks. This is particularly true when physiotherapists work with seniors, individuals who are immunocompromised, or others who are at increased risk of severe outcomes if they contract COVID-19.

Many of the patients that physiotherapists routinely treat fall into these categories, therefore telerehabilitation remains a recommended method of service delivery to provide care while reducing risk, even as Alberta moves to Stage 2. It is recognized that not all patients are appropriate for telerehabilitation services, just as not all patients are appropriate for in-person services at this time. 

Realizing that the measures in place which decrease the number of patients that can be seen in a day will continue as Alberta progresses through the stages of relaunch, physiotherapists will need to make decisions regarding patient prioritization and which patients are most likely to benefit from or are in greatest need of in-person services for some time. This is unfamiliar and uncomfortable territory for many physiotherapists. For this reason, Physiotherapy Alberta previously published guidance on patient prioritization; however, physiotherapists will need to adapt this guidance to their specific practice context.

What about exercise and the reopening of exercise facilities?

Exercise is one of the best evidenced interventions that physiotherapists employ in their practices. The announcement that exercise facilities will be allowed to re-open as part of Stage 2, rather than Stage 3 as originally thought, has significant implications for physiotherapists, especially those whose practices are co-located in gyms or other exercise facilities (e.g., yoga studios). Here’s what physiotherapists should know:

• Exercise has been identified as one of the highest risk activities.
• There are specific directions from Alberta Health regarding how these facilities can resume safe operation, including:
  • Facility users are expected to undergo screening for symptoms and risks of COVID-19 and to engage in physical distancing.
  • Where possible, users are encouraged to bring their own equipment. If that is not possible, equipment should not be shared and must be cleaned and disinfected between users.

Physiotherapists who operate within exercise facilities should review the requirements that these facilities must adhere to in their entirety, communicate with facility operators regarding how to enable safe patient access, and consider the risks and merits of having patients perform exercise programs on site versus having them perform exercise programs in their own homes only.

Physiotherapists should also be aware that “with intense physical activity, masks create risks of negative health effects and ‘should not be worn’” (Return to Sport, Physical Activity and Recreation – Stage 2, pg. 10) and consider how this information applies to their practice.

Are there any other changes regarding mask use?

Continuous masking requirements and other information regarding mask use, discussed in the FAQ: Masks and Physiotherapy and Guidance document remain in effect for physiotherapists and other regulated health professionals.

Physiotherapists have a role to play in communicating the recommendations from the CMOH regarding use of masks by members of the public to their patients but should also keep in mind that some individuals are unable to wear face coverings due to respiratory conditions. Many of these individuals are the same people who are at increased risk of poor outcomes if they develop COVID-19, and as such, physiotherapists should again consider if the benefits of in-person services outweigh the risks, and how those risks can be effectively managed.

Protecting vulnerable populations

Another consistent message from both the CMOH and the Premier is that all Albertans need to help to build a “wall of protection” around our most vulnerable community members. While Stage 2 means that many restrictions are easing, the restrictions related to long-term care and supported living facilities remain in place. Physiotherapy staff working in these settings and those physiotherapists who provide privately paid mobile services to residents of these settings must comply with the directions of facility operators, and the Updated Operational and Outbreak Standards for Licensed Supportive Living and Long-Term Care issued under CMOH Order 23-2020.

All providers of mobile or home-based physiotherapy services are reminded that these practice settings pose some additional risks to physiotherapists and patients alike, most especially the risk of the physiotherapist becoming a vector of virus transmission as they travel between sites. Physiotherapists who provide mobile or home-based services are urged to employ an excess of caution when providing services, engaging in patient screening, continuous masking, frequent, routine hand hygiene, and rigorous cleaning and disinfecting practices as with other practice settings.

What about multidisciplinary practice?

The orders allowing resumption of non-urgent, non-essential health services in Stage 1 of the relaunch strategy only applied to health professionals regulated under the Health Professions Act. As such, health professionals such as acupuncturists, who are currently regulated under the Health Disciplines Act, and unregulated health providers, such as massage therapists and personal trainers, were not allowed to resume services. As Alberta moves into Stage 2 of relaunch, providers of wellness services are able to resume operations. Specific guidance is in place for these services. If a physiotherapy business employs health providers within this category, they must review and comply with the guidance provided by the Government of Alberta, in addition to the guidance provided by Physiotherapy Alberta.

The guidance for wellness services specifies that providers and patients accessing these services wear a “non-medical mask at a minimum”; however, where these services are provided in the context of a multidisciplinary clinic it is recommended that all health providers working within the clinic make use of the same PPE – a surgical or procedure mask.

The following  guidance from this resource is also of note for both massage therapists and physiotherapists who employ massage techniques in their physiotherapy practice:

• “Where massage occurs using oils or creams, hands should be washed with soap and water in a sink. Hand sanitizer is not effective on soiled hands.”

Conclusion

What we have seen from the press conferences in recent days is that the language used has pivoted to focusing on risk mitigation, rather than risk elimination. As Dr. Hinshaw has stated, there is no one re-opening scenario that is risk free. All we can do is balance risk with measures to manage those risks. This appears to be the direction the Government of Alberta is taking – allowing cautious re-opening while mandating that business owners take steps to make operations as safe as possible within the current context. As we approached Stage 1 of re-opening, Dr Hinshaw also commented that she thought and perhaps even hoped that businesses would publicize and highlight the steps that they were taking to keep patrons safe, using this information to reassure clients and to promote their business. Physiotherapists and physiotherapy businesses should consider doing exactly this, reassuring clients and promoting themselves as cautious, safe providers of essential health services.

With the announcements from Chief Medical Officer of Health (CMOH), Dr. Hinshaw, that health professionals delivering close contact in-person services must wear masks continuously and that members of the public should wear masks when in public spaces and unable to maintain two-meter physical distancing, Physiotherapy Alberta has received an increased number of calls regarding mask use. The answers to some of our most frequently asked questions are below.

What is required?

Continuous masking is an infection prevention and control measure employed in addition to other measures to prevent the spread of COVID-19. These other measures include screening patients prior to their attendance at a clinical setting, completing a point-of-care risk assessment, and frequent hand hygiene consistent with the WHO’s “5 Moments for Hand Hygiene.”

The CMOH has directed that health professionals wear masks when providing services and two-meter physical distancing cannot be maintained. The purpose of mask use is to prevent pre-symptomatic or asymptomatic spread of COVID-19 during the provision of close-contact health services.

When treating patients with confirmed or suspected COVID-19, masking is used in conjunction with other personal protective equipment (PPE), such as eye protection, gloves and gowns.

When treating patients who are asymptomatic and not suspected of having COVID-19, masking is in addition to the routine practices employed based on the nature of the patient’s physiotherapy care (e.g., use of gloves when providing pelvic health services). Physiotherapists are not expected to don eye protection, gloves and gowns when treating patients who are asymptomatic and not suspected of having COVID-19 unless the nature of their physiotherapy care would lead to the routine use of this equipment.

Why do I need to wear a mask?

As indicated in Alberta Public Health Disease Management Guidelines Coronavirus – COVID-19 (Section 7) a physiotherapist who may have been exposed to COVID-19 while working with an asymptomatic patient (e.g., a patient who later developed symptoms) is not considered a close contact of the patient IF they were using a surgical/procedure mask and routine, frequent hand hygiene.

This is important. If the physiotherapist was deemed to be a close contact of the patient, the physiotherapist would be required to self-isolate for 14 days from the time of exposure.

In addition, if a physiotherapist were to develop symptoms of COVID-19 but had been using a surgical/procedure mask and routine, frequent hand hygiene, the patients they had provided care to in the 48-hours prior to symptom development would not be considered close contacts of the physiotherapist and would not be required to self-isolate.

Wearing a mask and engaging in routine, frequent hand hygiene means that you may be able to continue to provide services even if one of your patients later develops symptoms and tests positive for COVID-19, and decreases the risk of you transmitting COVID-19 to your patients before you know you are ill.

What does continuous masking mean?

It means wearing a mask at all times and in all areas of the workplace, when in direct contact with patients or if you cannot maintain a two-meter physical distance from patients and others in the practice setting at all times. In other words, put a mask on at the start of your workday and wear a mask for the duration of your time at work, removing it only to replace it with a new, clean mask. 

How often and when do I need to change my mask?

 If you are treating patients who are asymptomatic and who do not have confirmed or suspected COVID-19, you can wear the same mask for as long as the duration of your shift.

However, you must change the mask if it becomes wet, soiled, or contaminated. Your mask must be changed if you touch or adjust it, as touching the mask contaminates it.

Do you mean that I don’t get to eat or drink for the duration of my eight-hour shift?

Moving your mask down or to the side so you can eat or drink requires contact with the mask and contaminates it. If you need to eat or drink, remove your mask while in a non-patient care area and while maintaining two-meters distance between yourself and anyone else in the area, discard your mask in a lined garbage can and replace the mask with a new one when you are done eating or drinking.

What type of mask should I wear?

The CMOH has indicated that health professionals must wear surgical or procedure masks. It is not acceptable to use a cloth mask or industrial mask in place of a medical-grade mask. Look for labelling indicating an American Society for Testing and Materials (ATSM) rating on the mask packaging or similar information indicating the mask is designed for medical use. For more information about masks, visit the Health Canada website.

This poster provides step-by-step directions on how to don and doff a procedure mask.

If you do not have a medical grade surgical or procedure mask you must cease to deliver in-person services until more masks have been obtained.

Physiotherapy Alberta recognizes the many implications this requirement will have on the ability to deliver in-person services to patients, which is why we continue to encourage the use of telerehabilitation to deliver physiotherapy services whenever possible.

Why can’t I use a cloth mask if I don’t have a surgical or procedure mask?

The effectiveness of cloth masks to prevent virus transmission has not been established scientifically and varies depending on the nature of the cloth used and the fit of the mask. In contrast, medical-grade surgical or procedure masks are tested and their effectiveness has been established in laboratory environments.

Directions from the CMOH that members of the public should wear a cloth mask when in public and unable to maintain a two-meter distance from others are based on the thought that a cloth mask may provide some barrier to transmission. For health-care professionals the standard of protection is higher.

Who needs to wear a mask?

Anyone who is delivering direct patient care, who is in a patient care area, or who cannot maintain a two-meter distance from others at all times must mask continuously.

• Physiotherapists and physiotherapist assistants who participate in patient care must mask continuously.
• Administrative staff, such as those working only in a reception area, must wear a mask unless there is a physical barrier between the staff member and others (patients and staff) in the setting, or they can maintain a two-meter physical distance between themselves and others.

Can I use a full-face visor instead of a mask?

Visors are classified as eye protection and are used as an alternate for safety glasses or goggles. Eye protection is required when working with patients with a known or suspected diagnosis of COVID-19 and is used in conjunction with a mask. Eye protection is not currently required when working with patients who are asymptomatic and not suspected of having COVID-19. Visors are not replacements for masks.

Do I need an N95 mask?

That depends on the context of your practice and the activities you are engaging in, but if you work in a private physiotherapy clinic providing orthopedic services, probably not.

N95 masks are required when performing aerosol generating procedures. Aerosol generating procedures include such activities as intubation, CPR, open suctioning, non-invasive ventilation, and the use of high-speed drills in dentistry.

Outpatient physiotherapy practice does not typically include any aerosol generating procedures, therefore private practice environments should not require N95 masks.

Physiotherapists working in hospital or other public facilities should discuss the activities they perform and the risk profile of those activities with infection prevention and control experts to determine if an N95 mask is required.

What about patients and masks?

The CMOH has indicated that members of the public should wear masks when in public spaces or unable to maintain two-meter physical distancing from others. This means that patients should wear masks when receiving in-person physiotherapy treatment.

However, the CMOH has also made it clear that medical-grade surgical or procedure masks must be reserved for use by health-care professionals, therefore the patient should be wearing either a cloth mask or an industrial (non-medical grade) mask.  

Can I require that my patients wear masks?

At this time, the CMOH has not ordered members of the public to wear masks. A physiotherapist can educate their patients about the CMOH recommendations regarding mask use and suggest or request that the patient wear a mask while attending their physiotherapy appointment. However, it is questionable whether the physiotherapist can require that a patient wear a mask or decline to provide services if the patient refuses to wear a mask.

If a physiotherapist requires a patient wear a mask, there are also implications regarding the physiotherapist’s responsibility to provide a mask for patient use which has implications for PPE availability.

If you are considering a policy of refusing to provide care if a patient declines to wear a mask, Physiotherapy Alberta strongly recommends that you contact a lawyer to discuss the human rights and other legal considerations related to such a policy.

Can I provide masks for my patients to wear?

As already indicated, medical-grade surgical or procedure masks must be reserved for use by health-care professionals.

If you choose to provide masks for patient use, they must not be taken from this supply.

You may choose to provide industrial masks (non-medical grade) for patient use at your own discretion, however this is not a requirement of Physiotherapy Alberta at this time. 

Where can I find masks?

Physiotherapy business owners are encouraged to procure masks through their regular clinic supply chain whenever possible.

In the event that those suppliers are not able to furnish the masks required, Physiotherapy Alberta registrants are directed to seek supplies through the links on the Alberta Biz Connect website. Numerous suppliers of medical grade masks (for health-care provider use) and industrial masks (for patient use) are listed on both the Rapid Response Platform and ATB Nexus platform linked to from the Biz Connect website.

For a limited time, the Government of Alberta is also allowing community health professionals to request masks from the Government of Alberta’s provincial repository. Some things that physiotherapists need to know before making these requests:

• Only one representative from each practice may make a request to the repository.
• You must access your pre-existing clinic suppliers and exhaust your supply chain prior to accessing the repository.
• All requests will be reviewed and provision of supplies is not guaranteed.
• Submitted requests must only be for a two-week supply
• There is a delay between request and receipt of equipment.

Registrants are advised that effective May 25, 2020 the Government of Alberta will be charging for products distributed through the provincial repository.

Please note the following information from the Government of Alberta:

• Fees charged will be based on average observed market prices.
• Fees will be charged on any supplies delivered from May 25^th onwards.
• If you received PPE prior to May 25^th, you will not be required to pay.

Effective June 30, 2020, access to the provincial repository will come to an end for community-based health professionals including physiotherapists.

After June 30^th, physiotherapists and physiotherapy business owners will need to obtain these supplies through their normal supply chains. Physiotherapists working for Alberta Health Services and long-term care facilities will not be affected by this change and will continue to receive masks and other PPE through their employers.

My employer is telling me that we do not have enough masks and is asking me to reuse my masks from one day to the next. What do I do?

Occupational Health and Safety legislation requires that employers put measures in place to address identified risks within a work environment. Due to the nature of physiotherapy practice and the directions from the CMOH, this includes provision of PPE appropriate for the patient population served and treatment methods used. At a minimum surgical/procedure masks must be provided for staff use. If PPE supplies are insufficient to protect staff, in-person services must be discontinued until sufficient masks are available.

At present, there is no approved method to re-process surgical/procedure masks. Used masks are a potential reservoir of infectious agents and must be discarded in a lined garbage can immediately after doffing. Retaining used masks or reusing masks is not acceptable practice.

If you have concerns about the risks and measures in place to protect you in the work environment, discuss them with your employer. If that doesn’t work or you still have concerns, you can contact the Government of Alberta OHS Contact Center. For more information about concerns regarding unsafe work, visit the Government of Alberta website.

Conclusion

It is essential that physiotherapists remember that masks are only one layer of protection, one measure that must be put in place to limit the spread of COVID-19. Masks are only effective if worn, donned and doffed appropriately and if used in conjunction with other measures such as routine, effective hand hygiene, environmental cleaning, physical distancing and patient screening.

It has been three weeks since community-based physiotherapy providers were first allowed to resume in-person services to non-urgent patients. Throughout the pandemic and particularly in the early days following the initial May 4th re-opening date, the ability to access PPE and other supplies has been essential to enable ongoing service provision, and safety for patients and providers alike.

As health professionals, physiotherapists know that the phased re-opening plan does not mean that the risks posed by COVID-19 have passed. Instead, re-opening signifies that measures are now available to mitigate the risks of COVID-19 and slow its spread. As such, we know that ongoing use of precautionary measures, including continuous masking, frequent hand hygiene, and enhanced environmental cleaning and disinfection will be in place for months to come. However, as with all emergency response situations, supports provided by government agencies will decrease as time passes.

Physiotherapy Alberta has received notification that access to the Government of Alberta provincial repository will be discontinued for all community-based health professionals, effective June 30, 2020.

What does this mean for community-based physiotherapists and physiotherapy businesses?

Throughout the pandemic, physiotherapy business owners have been encouraged to procure masks, hand sanitizer and environmental cleaning and disinfecting products through their regular supply chain. Access to the provincial repository was always a last resort to obtain these supplies.

After June 30th, physiotherapists and physiotherapy business owners will be required to obtain products through their normal supply chains.

Physiotherapists and business owners are directed to seek supplies through the links on the Alberta Biz Connect website if pre-existing suppliers are unable to furnish the products required. Numerous suppliers are listed on both the Rapid Response and ATB Nexus platforms linked from the Biz Connect website.

Until June 30^th, physiotherapy business owners may still access the Government of Alberta’s provincial repository. Some things that physiotherapists need to know before making these requests:

• Only one representative from each practice may make a request to the repository.
• You must access your pre-existing clinic suppliers and exhaust your supply chain prior to accessing the repository.
• All requests will be reviewed and provision of supplies is not guaranteed.
• Submitted requests must only be for a two-week supply.
• There is a delay between request and receipt of equipment.

Registrants are also advised that effective May 25, 2020 the Government of Alberta will be charging for products distributed through the provincial repository:

• Fees charged will be based on average observed market prices.
• Fees will be charged on any supplies delivered from May 25^th onwards.
• If you received PPE prior to May 25^th, you will not be required to pay.  

* Physiotherapists working for Alberta Health Services and long-term care facilities will continue to receive PPE including masks and other supplies through their employers.

The COVID-19 pandemic represents an unprecedented challenge to health-care providers and society at large. Physiotherapy Alberta recognizes the critical role that physiotherapists play in the health and wellbeing of Albertans. Whether working in a private practice clinic, a hospital, or any other setting where direct patient care is provided, we applaud the efforts that physiotherapists are making to serve patients and adhere to the instructions of public health experts.

We recognize that the situation is changing rapidly, which leads to uncertainty and anxiety, and sometimes makes it difficult to know what to do. Physiotherapy Alberta is committed to providing guidance to help physiotherapists address this challenge.

This document constitutes the requirements for Physiotherapy Alberta registrants to resume non-essential services while complying with the Chief Medical Officer of Health (CMOH) Orders and amalgamates directions previously provided to physiotherapists regarding re-opening in one document. The information provided in this document is informed by the directives of the CMOH and the CMOH Orders currently in effect, the Code of Ethical Conduct, and the Standards of Practice.

Note to readers: This document is current as of the date of publication and reflects the rules and requirements for Alberta physiotherapists. In the event of a discrepancy between this information and the directives of provincial public health authorities, the directions of provincial public health authorities prevail. Additional information will be provided to registrants and directives or CMOH Orders change or as new information becomes available.

Click here to read "Guidance for Resuming Physiotherapy Practice During a Pandemic"

Date: April 20, 2020

Physiotherapy Alberta has been promoting telerehabilitation since 2017; however, in the context of the COVID-19 pandemic, its use in physiotherapy practice has increased dramatically. While many people envision videoconferencing when they consider this format of service delivery, telerehabilitation or digital practice includes the remote delivery of physiotherapy using all forms of electronic communication technology. This can include text or email, video- or teleconferencing, and even robotics and virtual reality.

Click here to listen to the podcast.

This 75-minute session will provide an overview of the physiotherapy management of patients diagnosed with COVID-19, across the continuum of care.

The clinical features of COVID-19 are currently understood to parallel those of Acute Respiratory Distress Syndrome (ARDS).

The speakers will extrapolate from what is known about the management of ARDS to discuss the physiotherapist’s role in acute and critical care, post-ICU recovery and long-term management of COVID-19.

Presenters

Mark Hall, PT, PhD; University of Alberta Faculty of Rehabilitation Medicine, Department of Physical Therapy

Mel Major, PT, PhD Candidate; Amsterdam University of Applied Sciences / Amsterdam University Medical Centers Senior lecturer European School of Physiotherapy, Amsterdam University of Applied Sciences

Scotty Butcher, PT, PhD; University of Saskatchewan, School of Rehabilitation Science

Simone Hunter, PT; Breathe Well Physio, AHS-Foothills Medical Centre

Jessica DeMars, PT; Breathe Well Physio

Alya Bartlett, PT, MScPT, AHS-Foothills Medical Centre

Click here to watch.

Physiotherapy is a touching profession, so directions to practice physical distancing and avoid person-to-person contact during the COVID-19 pandemic don’t translate well when applied to physiotherapy treatment. As this pandemic has unfolded, direction to physiotherapists has centered around maintaining a safe practice environment through enhanced cleaning practices, increasing social distance in waiting rooms and treatment spaces, and encouraging those who are ill, both patients and physiotherapists alike, to stay home.

On March 27, 2020, Premier Kenney and Chief Medical Officer of Health Dr. Hinshaw announced new restrictions on businesses that involve personal contact due to the pandemic and the risks of transmission of the virus through person-to-person contact.

As a result, private practice physiotherapy clinics and other physiotherapy businesses were directed to close except when providing emergency and urgent services.

Click here to learn more about telerehabilitation and what qualifies as urgent care.

Physiotherapy Alberta has been asked by Alberta Health Services to provide direction on the capacity for registered physiotherapists to undertake nasopharyngeal swabs. Although nasopharyngeal swabbing is not part of a physiotherapist’s typical range of practice activities, consideration for this change is motivated by the exceptional need for competent practitioners who can undertake this activity during the COVID-19 pandemic.

Regulatory considerations

Performing a nasopharyngeal swab is a restricted activity in accordance with the Government Organization Act and is therefore regulated under the Health Professions Act and the Physical Therapy Profession Regulations. 

As per Schedule 7.1 of the Government Organization Act, it is a restricted activity to "insert or remove instruments, devices, fingers or hands 

(ii) beyond the point in the nasal passages where they normally narrow, 

(iii) beyond the pharynx

These activities are identified as basic restricted activities in Section 13 of the Physical Therapists Profession Regulation. As such, any regulated member of Physiotherapy Alberta is authorized to perform the activity provided they are competent to do so. Regulated members who are on the Provisional Register must be supervised by a regulated member on the General Register if they perform the activity. 

Advice to employers

Employers should be aware that nasopharyngeal swabbing is not an activity that is taught in entry to practice physiotherapy education. Physiotherapists must only perform those activities that they are competent in. As such, a physiotherapist would require additional training and assessment of their competence to perform a nasopharyngeal swab before being deployed to do so. As highly educated and conscientious health professionals, physiotherapists are likely well suited to undertake this activity once sufficiently trained. Physiotherapists have a professional obligation to decline work they are not competent to perform. 

Advice to physiotherapists

Physiotherapists are considered critical infrastructure within the health system, and under the provisions of the Public Health Act they may be deployed by the Minister of Health to fulfill critical needs within the health system. Although performing a nasopharyngeal swab is a new activity for most physiotherapists, this is an unprecedented situation in which the greater good calls all health professionals to contribute, as they are able in order to manage and hopefully stop the spread of COVID-19. Registered physiotherapists have a professional obligation to decline work they are not competent to perform; however, they also have a professional responsibility to consider the public interest and undertake all reasonable steps to become competent before making a conscientious decision to decline the task.

Physiotherapists with questions regarding this memo can contact the Practice Advisor, Nancy Littke at nlittke@physiotherapyalberta.ca

Date posted: April 2, 2020

Over the last few days, Physiotherapy Alberta has received a number of concerns and questions from stakeholders in the long-term care (LTC) and continuing care (CC) community in response to direction published on March 29 regarding urgent physiotherapy services. In response to these concerns, we would like to clarify earlier statements.  

Context matters

As in all things, the unique context of LTC and CC environments must be considered. This is what we know to be true:

• Patients:
  • This is not a homogeneous group. Some are relatively stable. Some are on a trajectory of gradual decline due to underlying conditions. Some are on a steeper trajectory of decline, with or without physiotherapy intervention.
  • In some cases, physiotherapy interventions decrease the speed of decline.
• Service providers:
  • Some settings have on-site physiotherapy services, some have limited physiotherapy consultation, others are unable to recruit physiotherapists.
  • In some cases, residents and families hire physiotherapists working in mobile practice to provide physiotherapy services.
  • Private providers delivering mobile services pose more risk to residents if they provide care in multiple settings, serving as a potential source of transmission between facilities.
  • Contractors who provide services to an entire facility may act in many respects as employees of the facility adhering to facility policies; however, those providing mobile services to individual patients are less likely to be subject to and adherent with facility policies.
  • Mobile practice physiotherapists are also subject to the Chief Medical Officer for Health’s directions regarding essential visitor restrictions.

Risk

Public health experts have clearly identified that COVID-19 poses a serious threat to people residing in communal living settings. Seniors and especially those with comorbidities, the very seniors who are commonly residents of LTCs and CCs, are at greater risk of severe disease and death from COVID-19.

During the April 2, 2020 press conference, Dr. Hinshaw identified that “there are nine outbreaks at continuing care facilities across the province” and “74 confirmed cases of COVID-19 in continuing care facilities” with more expected “to be confirmed in the coming days.” As Dr. Hinshaw said during that briefing, “we must all do our part in keeping the most vulnerable members of our society safe.”

As we have seen with the more notable national examples, such as Pinecrest Nursing Home in Bobcaygeon and the Lynn Valley Care Centre in Vancouver, people in these settings will die if we do not take this risk seriously.

This is not business as usual.

Defining urgent care in LTCs and CCs

Physiotherapists got into the profession to treat people, so not providing treatment (especially when a long-term patient-provider relationship is in place) is difficult and may create an ethical dilemma for many. That’s exactly the issue – treatment of this population, at this time, in this setting creates an ethical dilemma:

• Without treatment many patients will deteriorate and some may potentially die.
• With treatment, and despite clinicians’ best efforts, there is the real risk of exposing patients to COVID-19, with the potential of causing serious illness or death.

Direction provided on March 29, stated the following scenarios constitute urgent services in LTC:

• 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.

We received many comments indicating that prevention of hospital admission did not resonate for many residents of LTCs and CCs as their goals of care often stipulate that the patient not be transferred to hospital under any circumstance. Physiotherapists also argued that many of their interventions help to delay or prevent functional decline. Regardless of the patient’s goals of care, clinicians must make reasonable and well-judged decisions about what constitutes urgent care in LTC.

Here are some concrete examples of urgent care in this setting:

• Wound care of new or chronic wounds.
  • Includes provision of pressure relieving devices, debridement and dressing changes and use of modalities to promote wound healing.
• Management of acute respiratory infection or exacerbation of chronic respiratory conditions.
  • Physiotherapists must use appropriate precautions when providing this type of care, and follow all facility protocols for screening, point of care risk assessment and PPE use.
  • Physiotherapists must apply evidence-informed practice. COVID-19 is not currently thought to result in increased sputum production or retention, and therefore is not considered amenable to airway clearance techniques. However, those with underlying respiratory conditions may demonstrate an increase in sputum production and may be appropriate for these interventions.
• Sudden decline in previously stable mobility or transfer status.
  • We talked before about this not being business as usual. We also acknowledged that most residents of LTC or CC are on a trajectory of declining functional ability. This is often why they are admitted to LTC or CC to begin with.
  • When the trajectory of decline changes precipitously, physiotherapist intervention becomes urgent to stave off further progression.
  • The objective is to prevent a patient’s decline to the point of no longer being appropriate for a supported living environment and requiring LTC level care or requiring additional staff resources and equipment to manage basic care, transfer and mobility tasks in LTC facilities.

What about ACOT’s direction to occupational therapists?

We are aware that ACOT sent out messages to their members that may be perceived by some to differ from Physiotherapy Alberta’s messages to registrants. Each regulatory College must define urgent services, with consideration of the profession’s scope of practice and typical practice.

Having reviewed the message, we don’t perceive a gap in direction. Both Colleges are urging that only urgent care continue.

However, there is a difference in typical practice and service availability in this setting. While physiotherapists and physiotherapist assistants are often involved in group exercise programs and mobility practice, with the goal of maintaining functional abilities, our understanding is that although occupational therapists may be involved in functional activities and BADL training they are most commonly involved with the provision of adaptive devices, the provision and monitoring of splints to prevent or manage contractures, and the performance of bedside swallowing assessments. ACOTs position is that these are urgent care needs. Physiotherapy Alberta agrees and believes that this is aligned with our prior statements.

I have no patients to treat. Do I just stay home?

We have heard of physiotherapists who have said just that. If you are a mobile physiotherapy provider, that may in fact be the right thing to do.

For employees of LTCs and CCs, we encourage you to consider what you can do.

• A sudden decline in mobility and transfer status is an indication of need for urgent service. How are you monitoring for that decline? Are you checking charts or connecting more frequently with nursing staff and HCAs or monitoring RAI-MDS scores?
• Are you providing patients and their designated visitors with activities and exercises they can do in their rooms?
• Are you providing suggestions to HCAs and nursing staff of things they can incorporate into their basic care activities to either monitor for change in status or sneak a little bit of exercise into basic care?

I’m being told to help with nursing care. What am I supposed to do?

We know that all facilities are currently facing staffing challenges due to illness, self-isolation and quarantine requirements. Meanwhile, patients still require basic care – dressing, bathing, toileting. These are not physiotherapy activities, however if you are an employee in a LTC or CC and none of your patients meet criteria for urgent care, your employer may reassign you to other duties.

Registered physiotherapists have a professional obligation to decline work they are not competent to perform; however, they also have a professional responsibility to use the skills they possess for the betterment of society and the benefit of those they serve. During a public health crisis, physiotherapists can be redeployed to assist with basic care activities and can apply their patient handling skills to do so. When doing so, appropriate precautions and facility protocols must be followed.

Helping with nursing tasks is not physiotherapy and therefore is not subject to current physiotherapy-related urgent care orders. This is an unprecedented situation in which the greater good calls all health professionals to contribute, as they are able.

This is not business as usual.

Date Posted: April 3, 2020

As the implications of the COVID-19 pandemic have begun to be realized within the physiotherapy community, Physiotherapy Alberta has received a number of calls and inquiries regarding the provision of telerehabilitation services. We are also aware of the many comments made by individuals and organizations operating in other jurisdictions, and the rules and positions of regulatory bodies of other health professions providing health-care services within Alberta.

Physiotherapy Alberta’s perspective is that there is no “one size fits all” solution for addressing the health needs of all Canadians in the face of this pandemic. Direction from regulatory organizations, whether those of other professions from within Alberta, or physiotherapy regulators from other provinces, need to reflect the unique nature of the services provided by different health professions and the local context in which those services are being delivered.

Some health services cannot be delivered using digital technologies. All jokes aside, one simply cannot perform dental hygiene on one’s self. Fortunately, most physiotherapists have a range of tools in their toolkits for managing patient health needs. While some treatment methods, such as joint mobilization, spinal manipulation, or needling face the same barriers as those of dental hygienists, others such as patient education, exercise prescription and self-management recommendations are amenable to this format of service delivery.

For professions whose services can only be provided in-person (due to the nature of those services), the rules regarding the use of telerehabilitation will differ from those of Physiotherapy Alberta. While that may cause confusion or conflict in some cases, it is important to remember that each regulated health profession is governed by its own regulation under the Health Professions Act and its own set of Standards of Practice.

Registration considerations

As has been stated in prior Physiotherapy Alberta messages regarding telerehabilitation and COVID-19, our perspective is that this format of service delivery may be appropriate for some patients. However, it is unlikely to be appropriate for all patients seeking physiotherapy services.

Telerehabilitation services are subject to the same Standards of Practice as any other physiotherapy service. All members of Physiotherapy Alberta are authorized to provide telerehabilitation services as part of their existing registration. No special registration is required, provided you are delivering services within Alberta. If you are delivering services to patients residing in other jurisdictions, you need to contact the regulatory body in that jurisdiction to find out what rules apply to your practice. With individuals returning to their home provinces to weather the pandemic due to school and work stoppages, this becomes relevant, even if you are following your existing patients.

To better understand the rules regarding Cross-Border service delivery, refer to the Canadian Alliance of Physiotherapy Regulators guidance documents regarding cross-border services.

Getting started

While it may be tempting to jump in to providing telerehabilitation services in the face of declining ability to provide in-person services and declining patient attendances, business owners and clinicians alike are advised to take the time to set up their services in a way that is consistent with the Standards of Practice. Once established, it will be more difficult to correct any errors made during the set-up phase than it is to do it right the first time. Look at this as a new business offering and plan accordingly, as you would plan any other venture.

Platform selection

While Physiotherapy Alberta cannot provide direction on telerehabilitation platforms that are or are not acceptable for use by physiotherapists, members are urged to consider the following when reviewing potential platforms:  

• The relevant privacy legislation for private practice telerehabilitation services delivered within Alberta is PIPA, not PIPEDA or HIPPA.
  • Platforms often tout their compliance with PIPEDA or HIPPA, and there is some comfort in knowing a platform is compliant with this legislation, but it simply is not the legislation of note.
• It is essential that physiotherapists do some additional digging when deciding if a platform can address privacy requirements established by PIPA.
  • Is the platform “end-to-end” encrypted during transmission of the information?
  • Is the information collected and stored through the platform password protected and encrypted?
• What are the terms of service of the platform provider? What information does the platform collect and who has access to that information? How is information that the platform collects used by the platform provider?
  • Attentive readers may have heard about concerns raised recently in relation to the launch of Telus Babylon in Alberta and issues regarding the terms of service of the platform which reportedly grant access to private patient information to external organizations and governments.
  • As a rule, platform providers should not access patient private information and should not share that information with other parties.
  • Platform providers may track data related to business use (e.g., your behaviour when using the platform).
  • It is essential to read the terms of service, ensure that patient information is securely stored and protected from access by third parties, and ensure you understand what information the platform collects regarding your use/access to the platform and how that information is used.
• Where is the data stored?
  • There is no rule that requires data be stored within Canada or within Alberta, however; if data is crossing international borders that needs to be communicated to patients.
• What about patient records and video records of telehealth interactions?
  • Telerehabilitation visits are subject to the same Standard of Practice for Documentation and Record Keeping as other visits. Physiotherapists need to generate a record for each treatment or professional interaction completed. These records can be in paper or electronic format – consistent with the physiotherapy business’ usual practices.
  • Video recordings of telerehabilitation visits are not mandatory.
  • However, if the platform used generates a recording, that recording must be retained as part of the patient record. This has implications for ongoing record retention that physiotherapists and employers need to consider.

It is likely that physiotherapy businesses will be offered service contracts on a “take it or leave it” basis but that’s not an excuse to use a platform that is not secure. As we have stated before, patient health information is a regular target of computer hackers and attacks. With the significant influx of health information available online as a result of the rapid uptake of telerehabilitation by many health professions, clinicians and business owners are advised to use caution to ensure that private information remains private.

In recent days, some parties have suggested that the adoption of platforms that are not secure may be justified due to the extraordinary circumstances we find ourselves in. Physiotherapy Alberta does not share that perspective.

Remote working

The adoption of telerehabilitation services may also enable physiotherapists to work from home, consistent with the expectations articulated by the Chief Medical Officer of Health. While this is a good thing and may help physiotherapists to contribute meaningfully to flattening the curve, employers need to consider the privacy issues that can arise when having staff work from home using their own computers, tablets or phones to connect with patients or to complete record keeping duties. The Office of the Information and Privacy Commissioner has an excellent resource on the security risks of allowing employees to use their own devices for work purposes.

Physiotherapy businesses must also consider the risks involved in having employees store patient records in paper format within the physiotherapist’s home environment, and strategies to adopt to mitigate those risks.

Employers need to conduct a privacy threat assessment and employ policies and procedures to ensure the ongoing privacy of information that employees store within their homes or access from their own devices. This includes both the telerehabilitation visits and any recordings generated from them, and the patient records generated following a telerehabilitation visit.

Fees and billing

Physiotherapy Alberta has been talking about telerehabilitation since long before this pandemic became an international concern. We see these services as a key method for physiotherapists to provide care to patients with a wide range of needs and who face a range of barriers to access to service, (but we cannot claim that we anticipated a global pandemic would be one of them). We are adamant that telerehabilitation services must meet the same expectations for safety and quality as any other physiotherapy service and recognize the value that physiotherapy can offer to patients through telerehabilitation.

We believe that these services should be reimbursed accordingly. We have heard from members who have questioned whether it is justifiable to charge the same fee for a telerehabilitation visit as for in-person services. Our perspective is that there is no reason that the fees should differ based on the method of delivery, provided that the time spent with the patient and the quality of the services are equivalent, albeit potentially different in terms of the interventions provided.  

As with all physiotherapy fees, members are advised to set fees in accordance with their business model, the costs of providing service, and market forces. Fees must be transparently communicated and justifiable.

We do not support the provision of free services, whether telerehabilitation or other, as we see this as devaluing the services that physiotherapists provide and may have unintended impacts upon the quality of service provided. Members are reminded of the prohibition on advertising free services identified in the Advertising Standard of Practice.

Reimbursement for telerehabilitation services remains a concern for some providers. Physiotherapy Alberta is aware of recent changes by third-party payers to enable reimbursement of these services. Due to the fluid situation and reimbursement rules that they are currently faced with, members are advised to have their patients confirm with their extended benefit providers that telerehabilitation services are covered by their plan before providing these services.

In closing, it is important to recognize that not all patients will be appropriate to receive telerehabilitation services. Physiotherapists are encouraged to critically evaluate the services they provide and patient populations they treat, and to reflect on which patients can be managed using telerehabilitation technologies.

Physiotherapy Alberta recognizes that these are extraordinary times, and that new information arises each day. We will continue to provide updates as information relevant to physiotherapy practice becomes available and encourage members to check our website regularly.

Posted Date: March 26, 2020

While physiotherapy clinics may remain open until directed otherwise by the Government of Alberta and Chief Medical Officer of Health, they must also implement measures to limit the spread of disease. These measures include:

• Environmental cleaning and disinfection of surfaces.
• Screening patients for respiratory illness or risk factors for COVID-19 (e.g., recent international travel) before they attend their appointments and rescheduling patients as indicated.
• Use of frequent hand hygiene and respiratory etiquette by both staff and patients.
• Directing staff who are ill to stay home.
• Reconfiguring clinical spaces (treatment beds, waiting areas) and altering staff and patient booking practices to adhere to social distancing and maximum attendance instructions of public health officials.
• Conducting patient-specific risk assessments to determine patients who may need to be rescheduled for a later date due to their individual health needs or health status and discussing the results of the risk assessment with the patient.

Physiotherapy Alberta encourages members and clinic owners to take a risk-based approach to managing their business decisions regarding continuing or ceasing operations. Conducting a risk assessment of the practice environment, patient population and facilities available will help clinicians and business owners to determine their ability to continue to provide services.

Posted date: March 18, 2020

COVID-19 has many people, clinicians and patients alike concerned about their health and safety. Developments of the last few days highlight the fact that this is a fluid situation with new information and recommendations emerging daily. Like all health professionals and health organizations, Physiotherapy Alberta is working to remain abreast of and consider the implications of new developments. We strongly encourage all clinicians, managers, business owners and organizations to do the same.

Click here for more information.

Posted date: March 16, 2020

Alberta-specific information (including travel restrictions, local actions, etc.)

• https://www.albertahealthservices.ca/topics/Page16997.aspx
• https://www.alberta.ca/coronavirus-info-for-albertans

Health Canada

• https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/being-prepared.html
• https://www.canada.ca/en/public-health/services/diseases/coronavirus-disease-covid-19.html

WHO

• https://www.who.int/emergencies/diseases/novel-coronavirus-2019

Posted date: March 18, 2020

To support Alberta’s effort to meet critical personal protective equipment needs during the COVID-19 response, the Government of Alberta is managing all requests for PPE. Clinicians may submit requests for PPE, hand sanitizer, cleaning and disinfecting products to the provincial repository through this link.  

Please note the following regarding these requests:

• Only one individual may submit requests on behalf of a given practice setting.
• The practice’s existing supply chain must be exhausted before government assistance will be provided. 
• The submitted request must only be for a two-week supply.
• All requests will be assessed by infection prevention and control advisors and the practice may be contacted to discuss these requests. 
• Requests are coordinated from a provincial perspective in priority order and fulfillment is not guaranteed.