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Introduction
This guidance document is based on the Ministry of Health’s Guidance for Community Allied Health Professionals and applies mainly to physiotherapists working outside of the DHBs. Therefore, please adjust the guidance to suit your working environment whether it be clinic or community based.
While much of the information contained may be useful to those working in DHB’s, please check with your manager if you are a DHB physiotherapist as protocols and procedures may vary between organisations.
Ministry of Health’s guidance for face-to-face consultations during Alert Level 2
Under Alert Level 2 the Ministry of Health has stated for community allied health, scientific and technical providers,
‘When the country does move into Alert Level 2 the following changes can occur:
Please note ‘telehealth and virtual appointments are still the preferred option in Alert Level 2. Please exercise extra caution when treating vulnerable groups.
Practitioners will be able to see patients in person if the following processes are in place:
- Screening for COVID-19 symptoms prior to in person appointment
- Physical distancing measures
- Infection prevention control measures including PPE where required
- Practitioners will be able to travel within and to the neighbouring regions to provide care to patients and receive training.
- Group treatment (e.g. exercise classes) can occur so long as physical distancing is in place’.
While physiotherapy clinics can reopen for routine face-to-face consultations under Alert Level 2, protocols must be implemented by physiotherapists and clinics to maximise patient and staff safety, including ongoing risk assessment and appropriate infection prevention control procedures. Despite the easing for face-to-face consultations under Alert Level 2, telehealth should still be considered especially for vulnerable patient groups.
Overarching Requirements at Alert Level 2
Physiotherapists must:
- be aware that under Alert Level 2, there may still be some community transmission of Covid-19. An extremely high level of vigilance is required. Physiotherapists must use a high level of clinical judgement at all times when assessing and treating patients in order to keep themselves and the public safe
- have knowledge of and understand the most current Health and Safety procedures, and the latest advice from Ministry of Health
- consider their own safety and that of their own bubble as well as the patient’s safety
- screen patients for COVID-19 signs or symptoms when making the appointment and again on arrival. If they are deemed to be a risk, do not allow them into the clinic or see them in the community until they have medical clearance. Consider using telehealth services
- carry out a risk assessment and have a plan in place for the premises they are working in whether that be in a clinic or the community. Risk assessment during Alert Level 2 should be ongoing and continuous
- maintain a log of all patient and staff contacts in case contact tracing is required
- adapt their working practises to allow enough time between appointments to carry out necessary duties including cleaning equipment, surfaces and their own hands before another patient is brought into the treatment room
- carefully assess the risks and benefits of a face-to-face consultation if patients are 70 years of age or over or have significant co-morbidities or vulnerabilities. Consider using telehealth services.
Once it has been established a face-to-face consultation is necessary, see below for further guidance.
Appendix 1: General practise guidance
and
Appendix 2: Adapting practise for face-to-face consultations.
This guide has been written for the clinic setting, therefore adjust the guidance to suit your working environment.
Appendix 1: General practice guidance
Screening
Screening or risk assessment of patients and any support persons for risk of COVID-19 prior to face-to-face consultations is mandatory. Patients should be screened when booking the appointment and then re-screened when they arrive at the clinic or you arrive at their home. When making an appointment for a face-to-face consultation, advise patients if they do develop symptoms between booking and attending their consultation, they must to call to cancel the face-to-face consultation and seek medical advice.
If the patient, support person or someone within their bubble whānau have any symptoms on screening do not allow them into the clinic or see them in the community until they have medical clearance.
The principle is: if you are sick, you stay home and get tested.f
Risk screening should be based on the case definition which can be found here
There is further guidance on how to screen patients in the following the document: Personal protective equipment (PPE) requirement for community care providers who are providing care in people’s place of residence
Further guidance for community based respiratory physiotherapists will follow shortly.
Clinic log and contact tracing records
Physiotherapists and clinics must keep their own current and accurate record of each patient whom they have seen face-to-face. This includes their full name, phone number, address, arrival and departure time. If there is a support person with them, their details are also recorded. This information will be used to aid contact tracing, if it is later required.
This clinic log should also include staff arrival and departure times. Ensure staff contact details are up to date.
The use of Personal Protective Equipment (PPE)
The Ministry of Health has provided guidance around the requirements for PPE; the main page which includes FAQs can be found here. Please read all guidelines relevant to your working environment. Most community and clinic-based physiotherapists however should be included in the following category:
In general, the Ministry of Health advise that if a patient has been screened as above, is not symptomatic, the physiotherapist is not undertaking an aerosol generating procedure, and there is no exposure to bodily fluids, then physiotherapists are not required to wear PPE.
The Ministry has confirmed this advice also applies to close up manual therapy techniques such as cervical mobilisation. Physiotherapists or patients however, may still choose to wear a mask if they wish.
The only departure from this advice for those patients who are at a higher risk of severe illness from COVID-19. If a patient is part of a vulnerable group and maintaining physical distancing of at least 2 metres is not possible, the physiotherapist should wear a surgical mask, irrespective of the type of care to be provided.
PPE gloves/gowns are otherwise only required if there will be exposure to bodily fluids. Vomiting is not considered an aerosol generating procedure so for those working in vestibular rehabilitation, business as usual PPE should be worn for this treatment.
For specific advice on PPE for aerosol generating procedures please see the Ministry of Health website.
We would advise keeping a small supply of PPE on hand however generally physiotherapists should not need to order large amounts and the Ministry have asked clinics not to stockpile. The latest advice from the Ministry of Health regarding the sourcing of PPE, is that ‘if you cannot get PPE from your usual supplier, contact the emergency management officer at your local district health board (DHB)’.
We understand there are still challenges for many trying to source PPE from DHBs; we suggest where possible, contacting local suppliers.
Working with vulnerable people
The government guidance for Alert Level 2 states ‘People at high risk of severe illness such as older people and those with existing medical conditions are encouraged to stay at home where possible and take additional precautions when leaving home. They may choose to work’.
Physiotherapists must carefully weigh up the risks and benefits of seeing patients who may have vulnerabilities to COVID-19, for face-to-face consultations, whether that is in the community or in clinic. They must discuss the risks and benefits with the patient and/or carer before deciding and continuing to make a face-to-face consultation appointment. Physiotherapists can still use telehealth if a face-to-face consultation is not appropriate. If it is decided a face-to-face consultation is appropriate, screening and the use of a surgical mask for the physiotherapist is required as stated above.
Working at multiple sites
We would recommend avoiding working across multiple sites, however where this is not possible, adapt your practice to minimise cross contamination. Examples of this could be a change of uniform, good hand hygiene, car cleaning, staffing roster changes or timetable alterations to minimise the number of sites visited on one day.
What to do if your workplace has a suspected case of COVID-19
If a staff member, patient or visitor becomes a confirmed or probable COVID-19 case and has been at your premises or seen in the community while potentially infectious there are standard processes that will be followed. Please click here for more information
Appendix 2: Adapting practise for face-to-face contact consultations
Pre preparation
have knowledge and understanding of relevant and current Health and Safety procedures and advice from Ministry of Health.
- carry out a risk assessment and have a plan in place for your premises and staff, including support staff and contractors/students/patients/those in their bubble whānau
- instruct staff/contractors/students/commercial cleaners or their bubble whānau to stay away from the premises if they have any COVID-19 symptoms
- consider limiting points of entry to the clinic – preferably patients can enter one door and leave from another or have open doors so there is no touching when entering / exiting premises
- select PPE as recommended by Ministry of Health, source PPE via DHBs, and train staff on its use, including donning, removing and disposing of PPE
- develop and implement a cleaning plan for your working environment. Currently the Ministry of Health recommend normal cleaning procedures are to be carried out for non Covid-19 patients, however we strongly advise increasing cleaning of all surfaces in the clinic including door handles, plinths, equipment, keyboards and phones
- have cleaning materials and PPE, if recommended, sourced and in stock at the clinic
- train all physiotherapists and support staff in new clinic procedures and ensure all procedures are provided to them
- ensure there is adequate physical spacing in the clinic waiting room area to avoid patient to patient contact and patient to reception staff contact. Space seating in waiting room at least one metre apart
- use signage and floor markings to remind patients/staff about physical distancing and hand hygiene
- ensure physical spacing between physiotherapists within office reception and non-treatment space
- consider splitting staff including support staff into teams, working in separate shifts. If team A is unable to work due to the need to self-isolate, team B may still able to operate.
- set up a register of who has been in the clinic with current contact details confirmed (including staff members) in case contact tracing is later required
- have signage in place around the clinic including signs to remind of physical distancing, no contact physical greetings and hand hygiene
- do not allow walk-ins off the street. Use signage at the entrance to advise them to call reception from outside so they can be screened before a face-to-face consultation is made.
- make available obvious locations for patients to sanitise wash/ their hands pre clinic entry and at reception
- all unnecessary items should be removed from reception and waiting areas,
- surfaces kept clear and clean, remove magazines, pamphlets, excessive furniture, wall hangings/posters, waste bins, water coolers etc.
- read Ministry of Health guidance on how to keep your home bubble safe
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