When resuming services, physiotherapists will face difficult decisions regarding which patients to see in person and the prioritization of service provision. Key factors that will contribute to the imbalance between the availability of, and demand for, services include:
- Residual demand for service related to restrictions and delays in care during the peak of the pandemic.
- Decreased system capacity due to staff availability and structural changes to the design of the practice environment (discussed in detail under the Business Practices section of this document).
- Availability of PPE and disinfecting products to enable in-person services.
While the perspectives of the patient and referral source are to be respected, the physiotherapist is accountable for prioritizing access to in-person services based on their clinical judgment. When determining priority for in-person care, physiotherapists are encouraged to reflect upon the following considerations, in addition to the CMOH Orders:
- Acuity of the patient’s condition, including considerations such as recent surgery, removal of cast or immobilizer or recent motor vehicle accident.
- Functional impairment/impact of the condition on health-related quality of life, including inability to work, regardless of whether the injury is WCB compensable or not.
- Likelihood that in the absence of physiotherapy services the patient will require services in an urgent care or emergency department setting.
- Appropriateness of service provision via telerehabilitation.
- Necessity of services which can only be provided in person.
- Duration of patient wait times for care.
Ongoing pandemic best practices
COVID-19 is expected to continue to circulate in the general population for an extended period of time. As such, ongoing measures to control the spread of the disease are anticipated. Such measures may include ongoing requirements to practice physical distancing and increased screening for signs, symptoms and risk factors for COVID-19.
In this context, physiotherapists are directed to:
- Adhere to all CMOH directives and Alberta Health directions regarding infection prevention and control measures applicable to the practice environment, including continuous masking, frequent performance of hand hygiene and environmental cleaning to enable safe practice.
- Establish robust policies, procedures and organizational cultures that ensure that no workers associated with the practice attend work when sick.
- Continue to employ self-isolation measures consistent with Alberta Health directions if staff members develop signs and symptoms of COVID-19. Workers must not return to work, until 10 days have passed from symptom onset or until symptoms resolve, whichever is longer.
- This guidance is subject to change and physiotherapists are directed to stay up to date with the directives of the CMOH.
- Employers may set additional requirements for return to work, provided those requirements are not less stringent than those established by the CMOH.
- Consider formal staff screening upon arrival at work, such as symptom checklists and encouraging staff to monitor their temperature prior to attending work.
- Screen patients prior to their attendance at the practice environment for signs, symptoms or risks factors for COVID-19, including asking about:
- Current symptoms of COVID-19, such as cough, fever, shortness of breath, runny nose or sore throat, and less common signs and symptoms. For a full list of signs and symptoms of COVID-19 see the Alberta Health Services COVID-19 Self-Assessment.
- Recent international travel.
- Unprotected close contact with individuals who have a confirmed or presumptive diagnosis of COVID-19 (e.g., without appropriate PPE in use).
- Encourage patients to make use of COVID-19 screening tools available through Alberta Health Services.
- Defer in-person services until signs and symptoms have resolved and at least 10 days from their onset, if patient screening reveals risk factors, signs or symptoms of COVID-19.
- Screen patients for signs and symptoms upon arrival.
- In the event that a patient attends the practice environment while exhibiting signs and symptoms consistent with a respiratory illness, whether COVID-19 is suspected or not, the physiotherapist must:
- Provide and have the patient don a surgical mask and complete hand hygiene.
- Isolate the patient from others in the clinic.
- Explain the concern, discontinue and reschedule the appointment.
- Clean and disinfect the practice area immediately.
- Physiotherapists have the right to refuse to provide in-person services to a patient if the patient appears to be experiencing symptoms of COVID-19 and the practice lacks the necessary equipment, facilities and environmental cleaning and disinfection resources to provide a safe practice environment.
Environmental cleaning practices
COVID-19 is currently thought to primarily spread through contact with respiratory droplets, or from contact with contaminated surfaces.
Cleaning and disinfecting products
Practice settings must establish effective cleaning and disinfection practices. Effective environmental cleaning for COVID-19 requires both cleaning and disinfection of surfaces within the practice environment. Cleaning refers to the removal of visible dirt and debris. Disinfection inactivates disease producing agents.
- Virucidal disinfectants or diluted bleach solution must be used to complete the disinfection step of cleaning and disinfecting surfaces.
- If using bleach, physiotherapists must follow label directions for proper dilution ratios.
- Virucidal disinfectants must have a DIN number. Physiotherapists must check the Health Canada database to confirm that the virucide in use is effective against COVID-19.
- Cleaning and disinfecting products must be used according to manufacturer’s directions for application and contact time.
- Cleaning products that do not have a DIN or are not bleach (e.g., vinegar, tea tree oil) must not be used in clinical practice as they are not proven effective and approved for use.
Frequency of cleaning and disinfection:
The frequency of cleaning and disinfection is dependent on the nature of use/contact of the surface/item in question:
- Patient care/patient contact items must be cleaned and disinfected between each patient/use. Examples include but are not limited to:
- Treatment beds.
- Exercise equipment.
- Goniometers and reflex hammers.
- Pin pads used to process payment.
- High touch, non-patient care items must be cleaned and disinfected no less than twice a day, and more frequently as use and circumstances warrant. Examples include but are not limited to:
- Doorknobs and light switches.
- Hydrocollator handles.
- Washrooms, sinks/faucets and hand sanitizer dispensers.
- Treatment area counter tops, staff room desktops, clipboards, pens and shared computers.
- Telephones, keyboards and mobile devices.
- Other surfaces in the practice environment, even those not classed as high touch can be a potential reservoir for infectious agents. Cleaning and disinfection of these surfaces should occur when visibly soiled, and routine cleaning and disinfection should occur at an increased frequency compared with past practice. Examples include but are not limited to:
- Legs and undersides of treatment beds.
- Cubicle curtains.
- Items that cannot be effectively cleaned and disinfected between use must be removed from the clinic environment (e.g. magazines or toys in waiting areas). This includes but is not limited to exercise equipment if it cannot be properly disinfected, chairs and other items with porous fabric upholstery, and treatment beds with torn surfaces or patched with tape.
Practices will need to allocate staff resources, time and supplies to enable this cleaning.
- Establish clear responsibilities and accountabilities for staff involved in cleaning and disinfection activities.
- Allocate PPE (gloves and masks) for use during cleaning and disinfecting activities, according to product specifications, to protect workers engaged in these activities.
- Reinforce and recognize the vital importance of this work.
Where feasible, physiotherapists should avoid sharing equipment (e.g., goniometers, reflex hammers, pens) or treatment rooms. All shared equipment must be cleaned and disinfected between patients according to manufacturer’s directions. Treatment rooms should be allocated to a single health professional per shift.
Hand hygiene and personal protective equipment
Hand hygiene is recognized as the single most important IPC practice to break the chain of transmission of infectious diseases. Hand hygiene can be completed using alcohol-based hand rub, or through hand washing using soap and water.
When hands are visibly soiled, they must be cleaned with soap and water as opposed to using alcohol-based hand rub.
- Physiotherapists are expected to practice routine hand hygiene consistent with the World Health Organization’s “5 Moments for Hand Hygiene”:
- Before touching a patient.
- Before clean/aseptic procedures.
- After body fluid exposure or risk.
- After touching a patient.
- After touching patient surroundings.
- Physiotherapists must also avoid touching their face and always practice respiratory etiquette by coughing or sneezing into their elbow or covering coughs and sneezes with a facial tissue and then disposing of the tissue immediately.
- Patients should be asked to complete hand hygiene using soap and water or alcohol-based hand rub at the following times:
- Upon arrival at the practice setting.
- Before and after use of weights, exercise equipment or similar shared equipment.
- Prior to processing payment.
- Prior to departure from the practice.
The topic of mask use has been source of confusion during the pandemic. However, on May 4th, the Government of Alberta issued CMOH Order 16-2020. Appendix A of this document - Workplace Guidance for Community Health Care Settings provides additional information relevant to the use of masks in the practice environment. Through this Order, the CMOH directed that:
- All staff providing direct patient care must wear a surgical/procedure mask continuously, at all times and in all areas of the workplace if they are either providing direct patient care or cannot maintain two-meter distance from patients and co-workers.
- Staff who do not work in patient care areas (e.g., administration staff) must also wear a mask continuously if a physical barrier (e.g., plexiglass) or two-meter physical distancing cannot be maintained.
- Under Occupational Health and Safety legislation, employers are required to provide masks for use by staff and volunteers consistent with the CMOH’s directions.
For greater clarity, if a practice does not have surgical/procedure masks available for staff/volunteer use, physiotherapy services must not be provided. It is not acceptable to substitute a cloth mask for a surgical/procedure mask for any reason.
The use of other PPE in the practice environment must follow the directives and recommendations provided by the CMOH. This includes directives that are role-based (e.g., administration vs direct patient contact) or specific to the practice context (e.g., mobile practice in LTC setting vs. private clinic).
When using surgical/procedure masks, physiotherapists must:
- Perform hand hygiene prior to donning and immediately following doffing of the mask.
- Avoid touching or adjusting the mask while in use.
- Discard masks appropriately.
- Discard masks when soiled or wet.
The intent of this practice is to prevent asymptomatic or pre-symptomatic physiotherapists from infecting patients and others in the practice environment. Note that masks do not need to be changed between each patient unless they have become soiled or wet.
The CMOH Order also emphasized that staff and volunteers must not be at work if they are sick with COVID-like symptoms including cough, fever, shortness of breath, runny nose or sore throat.
The availability and use of masks by the physiotherapist does not alter this direction.
The ongoing availability of masks will factor into the ability to provide in-person health services. PPE supply should be factored into decision-making regarding the provision of in-person services and ongoing use of telerehabilitation to deliver services.
Businesses will need to make long-term operational changes to comply with the orders of the CMOH and contribute to efforts to limit the spread of COVID-19.
These changes may include, but are not limited to:
- Reconfiguring treatment spaces, offices and waiting areas to ensure physical distancing is maintained among patients, between patients and staff when not engaged in direct patient care, and among staff.
- Considering the installation of physical barriers (e.g., clear plastic barriers) at reception desks.
- Restricting access to the practice environment to those who must be present, including patients, patient chaperones or companions, and staff members.
- If chaperones/companions are present, they are included in the maximum number of people the practice environment can accommodate while maintaining two-meter physical distancing from other patients and staff.
- Ensuring that booking practices (duration of treatment visits and number of patients in the practice at any given time) comply with ongoing directives regarding physical distancing between patients during treatment sessions and provide adequate time to clean and disinfect clinic equipment between patients.
- Physiotherapists should reflect on the risks of cross contamination posed by treating more than one person at the same time and the measures available to mitigate those risks.
- Physiotherapists are strongly encouraged to treat patients at a 1:1 ratio.
- Group classes are not appropriate given parameters for physical distancing and risks of cross contamination described above.
- Encouraging patients to arrive no more than five minutes before their scheduled appointment time, or to wait in their vehicles until called/texted that the physiotherapist is ready to see them.
- Providing facilities (alcohol-based hand rub or soap and water) so that patients may perform hand hygiene upon arrival at the practice, before and after use of shared equipment (e.g., exercise equipment) and before leaving the practice.
- Limiting the exchange of paper with patients and where possible implementing secure methods of electronic information and resource sharing.
- Offering contactless payment options.
- Ensuring that linens are laundered and dried on the highest temperature setting available and are thoroughly dried.
- Directing patients who are ill or under quarantine to reschedule their appointments and stay home.
- Reconsidering (and communicating) changes to cancellation policies to patients, avoiding unintentionally incentivizing patient attendance when ill.
- Complying fully with any and all directives from public health officials including but not limited to cleaning and disinfection requirements, lawful release of patient information to enable contact tracing and staff quarantine orders in the event that a patient treated in the practice later tests positive for COVID-19.
While extensive information about COVID-19 is publicly available, clinicians should not assume that patients understand:
- The mechanisms and risks of transmission of COVID-19.
- The nature of close contact in physiotherapy practice.
- The requirement that physiotherapists engage in continuous masking.
- The infection prevention and control measures employed in physiotherapy practice.
Practices are required to post information regarding the following topics within the practice environment in locations where it is likely to be seen by patients, staff and others:
- Physical distancing.
- Hand hygiene (including hand washing and use of alcohol-based hand rub).
- How to help limit the spread of infection.
At a minimum this information should be posted at entrances, and in treatment areas and washrooms.
Records of attendees
For the purposes of complying with public health tracing of close contacts, owners/operators of businesses where physiotherapy services are provided must keep detailed records of all individuals who access the site, including:
- Up to date staff/volunteer contact lists consisting of:
- Phone numbers.
- Additional information:
- Roles and positions of persons working at the practice.
- List of staff/volunteers onsite at any given time.
- Names of patients in the workplace by date and time (arrival and departure).
- Names of staff who worked on any given shift.
If other individuals are onsite (patient companions, repair people) their name, contact information and date and time onsite should also be recorded.
Sharing information with public health officials
If a staff member, volunteer or patient is confirmed to have COVID-19 and it is determined that other people may have been exposed to that person, AHS will contact the practice to provide directions. Physiotherapists and business owners are directed to work cooperatively with AHS, providing records/contact lists to enable contact tracing and ensure that those exposed to the individual receive the correct guidance from public health officials.
Other business considerations
The Government of Alberta has provided direction to businesses regarding measures to put in place within work environments to limit the spread of COVID-19, including:
- Limiting the number of people onsite
- Staggering start and end times, and break times
- Limiting the hours of operation and setting specific hours for at-risk patrons
- Avoiding in-person meetings (e.g., staff meetings)
- Ensuring physical distancing between workstations
Additional recommendations can be found on the Government of Alberta Biz Connect website. Employers are reminded that they are subject to Occupational Health and Safety legislation and Employment Standards and are advised review these considerations as business resumes.
As the first wave of the pandemic wanes, physiotherapists and businesses providing physiotherapy services will need to take stock of lessons learned and will need to prepare for the anticipated next wave. Considerations will include:
- Replenishing supplies, including cleaning and disinfecting supplies, gloves and surgical/procedure masks.
- Re-evaluating services offered.
- Developing competence to support future services (e.g., continuing education in telerehabilitation service provision).
- Reviewing clinic policies and procedures including clinic layout, booking practices, billing practices, patient screening practices; evaluating what worked well and what did not.
Physiotherapists are strongly encouraged to retain and refine new practices that have been adopted and which will likely need to continue during future waves of the COVID-19 pandemic and other infectious disease outbreaks.
Employers may also wish to consider organizational policies regarding vaccination and measures they can put in place to encourage staff vaccination.
Physiotherapists and business owners should also consider the additional stress that COVID-19 has created for physiotherapists and are encouraged to review their individual and organizational strategies and resources to address workplace burnout, stress and anxiety and the risks these conditions pose to provider well-being and competent practice.