Good Practice: How to Practice Safely When Working Alone
November 4, 2020
The role of the Practice Advisor is to provide guidance to regulated members regarding how to meet the Standards of Practice, including when they set up new physiotherapy practices. Over the last few years, many Alberta physiotherapists have established new mobile and sole-provider physiotherapy businesses. It is important for these physiotherapists to be aware of the potential risks and hazards when working in isolation so they can proactively develop strategies to minimize risks and prevent or manage adverse events or challenging situations. This article will provide some food for thought and suggestions to help ensure safe service delivery when working alone.
What risks or hazards are we talking about?
When physiotherapists deliver services in a clinic, they usually work with others, have control over the environment, and can put processes in place to ensure the practice environment is clean, uncluttered and safe. However, when service is delivered in the patients’ home there is significantly less control over the worksite.
Not all environments are appropriate for delivery of physiotherapy services
Hazards that may be encountered when working in a patient’s home include:
Clutter limiting the space available for service delivery.
Infection prevention and control risks due to pets, cleanliness of the environment or hygiene concerns.
In the context of COVID-19, there is also the risk that travel between patient homes will expose the physiotherapist to the virus and result in them becoming a vector for transmission.
Developing a process to identify potential hazards and strategies to manage them is important. Having infection prevention and control policies and procedures in place will help keep both you and your clients and families as safe as possible.
Not all interventions are appropriate in solo practice environments
Adverse events can occur in any treatment environment, but in a clinic you may have other people to provide assistance in the event of an emergency. If you are alone you are faced with the challenges of dealing with the event, managing the patient and their family’s needs, and notifying emergency personal. Having a plan to deal with these situations will help you stay calm and manage the situation in a safe and efficient manner. Physiotherapists must develop plans to manage any foreseeable risks to their in-home or sole-provider physiotherapy practice.
There are some interventions or activities that may not be appropriate to deliver outside of a formal clinic environment due to the presence of unexpected environmental factors or the absence of additional supports. For example, offering sharp wound debridement, spinal manipulation, needling or pelvic health interventions in the patients’ home are examples of practices that, while they are not prohibited in these settings, require you to consider how you will ensure the privacy and safety of the patient while providing a risky or sensitive intervention. The risks of encountering a challenging situation may outweigh the benefits of providing this care in the home.
Not all patients are appropriate for in-home or sole provider services
It is important to understand that when you provide care in a patient home or your own residence, the intervention may take on a more informal feel. This can lead to a risk of a blurring of therapeutic relationship boundaries.
In addition, although uncommon, physiotherapists may be faced with a challenging situation or confrontation with an aggressive or potentially violent patient and/or family member. If faced with such an event, the physiotherapist needs to have a plan for how to respond and deescalate the situation. How will you protect the patient, yourself and any other individuals in the area?
What can you do to protect yourself and your patients?
Careful reflection and an awareness and understanding of potential hazards, risks and challenging situations will help you prepare for and manage them.
Infection prevention and control measures
Sit down and develop your infection prevention and control (IPC) policies and procedures. You may not control the patient’s home environment, but you do have control over what you bring into the environment and what you opt to do onsite. As a regulated physiotherapist you are expected to comply with infection prevention and control measures to support the health and safety of clients, health-care providers, yourself, and others.4
Hand hygiene is widely recognized as the single most important IPC practice to break the chain of transmission by acting on one of the primary modes by which infectious agents are spread – health-care workers.3 Hand hygiene using alcohol-based hand sanitizer (with an alcohol concentration between 60-90%), or hand washing using soap and water is an essential element of all IPC efforts.3,5 Physiotherapists are expected to practice routine hand hygiene according to any practice setting or disease-specific recommendations that may apply, and consistent with the World Health Organization’s “5 Moments for Hand Hygiene:”3
Before touching a patient
Before clean/aseptic procedures
After body fluid exposure or risk
After touching a patient
After touching patient surroundings
You must have access to hand hygiene facilities, either in the form of alcohol-based hand rub or hand washing facilities. Similarly, physiotherapists will need to bring PPE appropriate to their interventions (including gloves, gowns, and medical masks), and products to clean and disinfect equipment used.4
As with any clinical environment it is essential that proper cleaning and disinfection of equipment and tools is completed between patients. Having a consistent process to clean and disinfect items you have brought into the home is key.
The first step that must be taken immediately prior to providing any care is the performance of a Point of Care Risk Assessment (PoCRA). A PoCRA involves looking at the specific environment, task, and the status of the patient to identify any risks to the delivery of care. While physiotherapists may associate PoCRAs with the process used to identify personal protective equipment (PPE) requirements and infection control processes,2 performing a PoCRA can assist you when deciding what measures need to be implemented to minimize risks, or to determine if a situation is not safe enough to continue. If you determine that the environment or intervention is not safe, you may need to discontinue or postpone treatment. This decision must be communicated to the patient and/or family and plans developed for future interventions in a safe environment.
Identification of potential hazardous situations, medical emergencies, or possible adverse events that may be associated with your clinical practice.
Plans that outline strategies to prevent critical events and how the provider will manage the situation should it arise.
You need to have the information required to manage events. You should have important medical and patient information close at hand including the complete address/location of the residence to provide EMS services, a summary of key medical information that may be required by EMS, and the contact information for the patients’ emergency contact. You also need to have access to a phone to call for help.
The information mentioned above is generally collected prior to seeing the patient or at the first assessment.
Policies that ensure the implementation of the plan. A critical event management plan is only useful if you know what needs to be done and consistently follow the procedures outlined for each patient and/or for the practice as a whole.
Processes to ensure follow up analysis on any incident or close call that reflect on what actions were taken and any changes to the plan required to ensure future incidents are handled appropriately and safely.
Working alone resources
Although not common, physiotherapists may face the risk of violence in the workplace, particularly if working alone. It is important that you recognize the potential that a patient, family member, caregiver, or other party can become aggressive, threatening your personal safety or that of your patient.
There are some steps you can take to minimize the risks and to manage a challenging encounter should it arise. They include, but are not limited to6:
Screening patients/family if you are going into the home to identify potential areas of conflict.
Not working alone if you have concerns about the patient and/or the home environment.
Being aware of the area you will be treating in and ensuring you have a route/plan to remove yourself from a situation should it turn dangerous.
Ensuring someone knows where you are/when you arrive and leave.
Having a cell phone or other method to call for help.
Undertaking training in de-escalation plans/techniques.
It is also important to realize you are not expected to put yourself in a dangerous situation. When a patient or other individual in the home threatens physical, verbal, emotional or sexual abuse you have the right to refuse treatment.
The following resources provide more information for working alone and should be reviewed by physiotherapists providing care in isolation.
Preplanning is key to successfully negotiating these scenarios and keeping everyone safe.
Every practice site, patient interaction, or intervention has inherent risks. Some are more obvious than others and some risks are more significant than others. Sometimes a challenging situation arises that we did not see coming at all. Reflecting on your practice model, performing a hazard assessment and identifying potential risks to your patient can assist in developing policies, processes and strategies to address them and will help ensure you are providing physiotherapy services in the safest way possible.