Good Practice in a Time of Pandemic

  •   March 16, 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.

We also recognize that there is an abundance of information (and misinformation) available through mainstream media, social media, and other sources and that it can be difficult to know what information to trust. Physiotherapy Alberta is not the expert when it comes to COVID-19, or pandemics in general. For these topics we defer to the expertise of Alberta’s Chief Medical Officer of Health, Alberta Health, the Public Health Agency of Canada, and the World Health Organization. When there is disagreement between recommendations of different organizations, we defer to our local experts at Alberta Health and Alberta’s Chief Medical Officer of Health, recognizing that recommendations and actions should reflect local context and circumstances.

The Evidence-Informed Practice Standard of Practice was not written with pandemics in mind. However, the expectations that “the physiotherapist incorporates evidence-informed practice in all aspects of physiotherapy service delivery” and “integrates critical thinking and professional judgment into client-centered care” still apply to this situation. As health professionals, physiotherapists have a duty to be informed and to share credible information with their patients, peers and broader community. You can find information about COVID-19 through the following sources:

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

Health Canada

WHO

Physiotherapy Alberta has received many calls from registrants regarding pandemic considerations specific to physiotherapy practice, to that end, the remainder of this article will focus on frequently asked questions and our current recommendations for clinicians.

How should I clean/maintain my clinical environment?

The Infection Control Standard of Practice includes the expectation that the physiotherapist:

“Adheres to best practices of infection prevention and control in physiotherapy practice according to applicable legislation, regulatory requirements, standards, and guidelines.”

To be clear, the standards and guidelines referred to include those developed by Physiotherapy Alberta and those of other agencies including Alberta Health, the Public Health Agency of Canada, and the World Health Organization.

Some key points regarding environmental cleaning include:

  • COVID-19 is currently thought to be spread through contact with respiratory droplets, either following a cough or sneeze, or from contact with contaminated surfaces where droplets precipitate.
  • There is a difference between cleaning and disinfecting surfaces. Cleaning refers to the removal of visible dirt and debris. Disinfection inactivates disease producing micro-organisms. Effective environmental cleaning for COVID-19 requires both cleaning and disinfection. For more information, see Environmental Cleaning in Public Facilities and the Infection Prevention and Control Guide.
  • As part of their routine clinical practice, physiotherapists and physiotherapist assistants should already be cleaning and disinfecting surfaces such as treatment beds between patients.
  • Increased daily cleaning and disinfection of high touch surfaces such as doorknobs, light switches, staff rooms, desktops, washrooms, telephones, keyboards and pin pads is advised.
  • Removing items that cannot be easily cleaned (e.g., newspapers, magazines, stuffed toys) from waiting rooms and shared staff areas is also advised.
  • For more information, see the Government of Canada recommendations for community-based measures to limit the spread of COVID-19

Should I continue to see patients in my outpatient setting?

The Safety and Risk Management Standards of Practice require that physiotherapists maintain “a safe environment for clients, health-care providers, her/himself, and others” and participate “in risk management activities to promote quality physiotherapy services.” Physiotherapists need to create a safe practice environment and implement measures to address specific risks relevant to their practice environment and population served.

In the case of COVID-19 the key public health focus is on limiting the spread of the disease both among patients and from patients to staff. Measures to consider may include:

  • Cancelling group exercise or education classes, particularly among at-risk populations.
  • If group classes continue, limiting class sizes and increasing space between participants, consistent with Alberta Health recommendations for gatherings.
  • Screening patients for signs and symptoms of COVID-19 prior to or upon arrival at their appointment and re-scheduling appointments for patients who:
    • Are showing signs of respiratory illness including dry cough, fever, and fatigue/extreme tiredness,
    • Have had contact with someone who is ill,
    • Have been directed to self-isolate, or
    • Have recently travelled internationally.
  • Encouraging individuals in high-risk groups to re-schedule non-urgent appointments.
  • Eliminating penalties for missed or cancelled appointments related to respiratory illness and proactively communicating this to patients.
  • Communicating measures in place within your practice to mitigate the risk of spreading infection.
  • Providing facilities for patients to clean their hands upon arrival at their appointment (either using alcohol-based hand sanitizer or soap and water).

I’m a business owner. What do I need to do?

Business owners are subject to Occupational Health and Safety legislation which requires that they create a safe work environment and provide appropriate controls to address identified risks in the workplace. Meeting these requirements includes educating employees about risks, providing supplies necessary to mitigate risks, and encouraging appropriate use of supplies and behaviours to mitigate the risk of spread of COVID-19. Examples may include:

  • Provision of PPE
  • Providing facilities for and encouraging frequent hand hygiene
  • Providing supplies for environmental cleaning
  • Ensuring staff are aware of relevant sick leave policies, encouraging those who are ill to stay home

Employers need to consider implementing the measures suggested by Health Canada to mitigate the spread of COVID-19 as appropriate for their work environment. These measures include enabling remote working where possible, staggering start and end times to reduce the need to travel at peak times, increasing space between workstations and treatment beds.

The Government of Canada recently announced that the waiting period for access to Employment Insurance would be waived for individuals required to stay home under quarantine from COVID-19. The Government of Alberta recently announced that workers would be entitled to 14 days of paid job-protected leave if they are required to self-isolate, are ill or are caring for a loved one with COVID-19, however, details about how this will work were not available at the time of writing.

Employers need to be aware of this information and updates as they become available.

One of my staff is currently out of the country. What do they need to do when they get back?

We strongly recommend that members and their employers abide by the direction provided by Alberta Health and Alberta’s Chief Medical Officer of Health. Direction on self-isolation protocols can be found on Alberta Health’s website. Recognizing that staff who have been out of the country may not have been paying attention to local news, employers are encouraged to be proactive in communicating this information to staff before the staff member arrives for their first day back to work.

What about PPE use? Should patients be wearing masks and gloves? What about staff?

It depends.

If you are working with patients with presumptive or confirmed COVID-19 you need to follow IPC recommendations consistent with the directions of Alberta Health and your point of care risk assessment. Alberta Health recommends that people who are sick should wear surgical masks to help reduce the spread of infection. Alberta Health Services has a number of resources available on a range of topics

However, PPE supplies are not infinite and therefore it is important that they be used appropriately. At this time, Alberta Health does not recommend use of surgical masks by healthy people as they “can create a false sense of security” and can serve as a vector of infection as people touch their faces in order to remove the mask. Similarly, use of non-sterile gloves when using high contact surfaces can create a false sense of security and discarded gloves can serve as a reservoir for infectious agents if not discarded properly.

You can find a robust collection Alberta Health Services resources related to COVID-19 on their website.

Can I deliver services using telerehabilitation?

Telerehabilitation is an option for the delivery of physiotherapy services. Physiotherapy Alberta has a Telerehabilitation Resource Guide available for reference if you are considering delivering services in this manner.

However, it is essential that members do their due diligence when setting up these services. It is critical that members consider:

  • Privacy and security of patient information and the technical specifications of the platforms considered.
  • Patient appropriateness. Not all patients are best served using this type of technology. The Standards of Practice regarding quality and safety of care apply to all practice, regardless of the method of delivery of care. Can you provide quality care to your patients using this mechanism?
  • Patient consent. Patients need to consent both to physiotherapy and to physiotherapy using this method of delivery and need to understand the risks and benefits of receiving telerehabilitation services. Physiotherapy Alberta has developed a patient information handout regarding telerehabilitation to address some common questions regarding this type of service.
  • Their own competence to perform assessments and deliver services in this manner. This includes both competence to use the technology in question and to deliver physiotherapy services using telerehabilitation technologies.

Can I decline to provide treatment to a patient with COVID-19?

The Code of Ethical Conduct states that physiotherapists do not “refuse care or treatment to any client on the prohibited grounds of discrimination as specified in the Canadian Human Rights Act** as well as on the grounds of social or health status.”

When it comes to patients seeking care due to a diagnosis of COVID-19, the physiotherapist cannot decline to provide care on the basis of their diagnosis. Some patients with COVID-19 develop pneumonia and may benefit from physiotherapy intervention. For other patients, COVID-19 may exacerbate pre-existing conditions resulting in hospitalization and the need for physiotherapy intervention.

However, the physiotherapist must use measures to prevent the spread of infection, including appropriate use of PPE and point of care risk assessment when delivering care. Under Occupational Health and Safety legislation, workers have the right to decline unsafe work, and this includes declining to treat patients if PPE is not available.

In the case of a patient who is seeking care for an unrelated condition and who is exhibiting symptoms of a respiratory illness, has been directed to self-isolate, or who has a concurrent diagnosis of COVID-19, it is recommended that the physiotherapist reinforce the directions of Alberta’s Chief Medical Officer of Health and Alberta Health regarding self-isolation and reschedule the patient’s appointment for a future date.

Should we all go get tested?

Alberta Health Services has developed an online screening tool to help to identify people who do not required a COVID-19 test. Testing is a topic of much discussion and debate, however, in the words of the Chief Medical Officer of Health, Dr. Deena Hinshaw: “You don’t need a lab test to do the right thing. If you are sick you need to stay home... People should not rely on a test result to take the appropriate actions of limiting spread to others.”

There has been much discussion about “flattening the curve” in recent days. Physiotherapists have a role to play in helping to prevent the spread of COVID-19, educating the public and providing services to patients with a diagnosis of COVID-19. We strongly encourage all clinicians, managers, business owners and organizations to stay abreast of new developments as they arise and to critically evaluate how they deliver services and actions they can take to help mitigate the spread and manage the care of patients who develop COVID-19.