Guidance on seeing patients during COVID Alert Level 3 (non-DHB)

Note: “Urgent Care” definition updated by Ministry of Health as at 24 April 2020

This guide is provided for Physiotherapists working in a non-DHB environment. DHB’s will have their own set of guidelines and protocols that DHB physios will need to follow.

This is a living document and will be updated as information from the Ministry of Health is released during the Alert Level changes. Please check it regularly for updates and changes.

Under Alert Level 3 the Ministry of Health has stated, ‘In Alert Level 3 the following guidance remains:

‘Virtual appointments should be provided where possible and is the preferred method of service delivery. Face-to-face appointments may be provided for urgent care only so long as professionals can take appropriate measures to manage public health.’

Despite the easing for face to face appointments under Level 3, telehealth will still be used for the majority of patients. It is only urgent cases where you can consider in your clinical judgement that you will undertake a face-to-face consultation. This means physiotherapy clinics cannot reopen their doors to see patients on a ‘business as usual’ basis.

If you are seeing a patient in the clinic or in the community that meets the urgent criteria (see below) for a face-to-face consultation, protocols and procedures need to be implemented by physiotherapists and clinics to maximise patient and staff safety.

There are two broad questions which need to be answered when assessing whether patients require face-to-face consultations:

Does the patient need to be seen face-to-face? (patient selection via the flowchart – see below). It is then your clinical judgement as to whether the presentation requires urgent care and cannot be provided via telehealth;

AND

How will the appointment be carried out, whether that be at a clinic, through a home visit or community based? It is preferable that patients are seen in the clinic where possible, to allow better control of health and safety concerns such as cleaning.

Criteria for seeing a patient for a face-to-face consultation

As stated above appointments will continue to be mainly provided via telehealth. Under Alert Level 3 some face to face appointments may be provided for urgent care appointments, but only so long as physiotherapists can take appropriate measure to manage public health risks. We expect physiotherapists to use a high level of clinical judgement when considering whether a patient meets the urgent criteria for a face-to-face consultation.

Currently the criteria for seeing a patient face-to-face for Alert Level 4 is as follows:

a condition which is life or limb threatening
treatment required to maintain the basic necessities of life
treatment to avoid a permanent, significant disability
treatment which cannot be delivered by a service which is currently operating such as A&E or urgent care/DHB services, or other health personnel already in contact with the patient.

Under Alert Level 3 the Ministry of Health has stated the following criteria for seeing an urgent care patient face-to-face:

“Urgent care” for community allied health professionals is defined by the Ministry of Health as:

a condition which is life or limb threatening or
treatment required to maintain the basic necessities of life or
treatment that cannot be delayed or carried out remotely without risk of significant harm or permanent and/or significant disability

AND

which cannot be delivered by a service which is currently operating or by health professionals that are already in contact with the patient.

[1] Resources for Health Professional is available here.

[2] The Board’s face to face contact logging form is here [note this form has been unpublished under Level 2]

If you are having difficulty reading the above flow chart a PDF version is available here.

Registering face-to-face consultations with the Physiotherapy Board

The Ministry of Health has announced that under COVID-19 Alert Level 3 if you do need to see a patient face-to-face, please register each face-to-face patient consultation with the respective authority. In the case of physiotherapists, this authority is the Physiotherapy Board.

During Alert Level 3 Physiotherapists are asked to submit a registration for each patient using the Face to Face registration form every time they have a face-to-face consultation.

Physiotherapists must also keep their own accurate and up to date record of each patient whom they have seen face-to- face, including names, phone numbers and addresses of any carer, guardian or support staff who were present during the consultation or in the clinic. This is to aid contact tracing, if it is later required.

The use of Personal Protective Equipment (PPE)

The bar set by the Ministry of Health for seeing patients face-to-face under Alert Level 3 is still high as it is only for urgent care appointments. There should not be the need to order large amounts of PPE. We have been instructed by the MoH that clinics are not to stockpile large amounts of PPE.

Overarching Requirements

Physiotherapists must:

continue to deliver services via telehealth unless the criteria within the flowchart for face-to-face clinic, community or home visits are met
where possible, undertake an initial telehealth consultation to establish the need for a face-to-face consultation
consider safety for themselves and 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
carefully consider the risks and benefits of a face-to-face consultation if patients are 70 years of age or over or have significant co-morbidities
know and understand relevant Health and Safety procedures and latest advice from Ministry of Health including ‘advice for all health professionals’
carry out a risk assessment and have a plan in place for the location of the treatment
adapt their practise to allow enough time between appointments to rebook patients, clean equipment and surfaces before another patient is brought into the clinic
keep staffing numbers within the clinic to a minimum. This includes a minimal number of support staff, if any
establish a plan of how to minimise contacts with multiple patients especially if working at different clinics

Further resources and information

Further and more detailed guidance, once it has been establised a face-to-face consultation is necessary for urgent care, can be found below as Appendix 1. Please use it to guide your practice under Alert Level 3.

Resources- from the Ministry of Health

Appendix 1: Guidance for the Five Stages of face-to-face contact appointments

This guidance applies once you have established via the flowchart that an appointment is for urgent care and a face-to-face consultation is necessary.

The key requirements are to have strict hygiene measures and physical distancing measures in place and to use personal protective equipment (PPE) when required.

Pre preparation

have knowledge and understanding of relevant and current Health and Safety procedures and advice from Ministry of Health including ‘advice for all health professionals’
carry out a risk assessment and have a plan in place for your premises e.g. identifying which door patients will enter and leave from
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
have cleaning materials and PPE sourced and in stock at the clinic
cleaning plan developed and implemented
all physiotherapists and support staff trained in new clinic procedures and all procedures provided to them
plan in place for how appointments will be handled if there is more than one patient to be seen in a session e.g. one patient in / one out, time between appointments or staggered times if there is more than one practitioner working in the clinic
ensuring no patient to patient contact; patients wait outside clinic and are contacted by phone to come in (i.e. no waiting area patients)
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.

Preparation

patient screened for COVID-19 signs or symptoms by phone or telehealth prior to offering a consultation in the clinic
determine if the patient requires input from any other service such as A&E or urgent care/radiology, prior to coming into the clinic
when making the appointment give clear instructions to patients regarding where to come, what to expect when they arrive, and how things may differ from their usual visits
register all face-to-face consultations with the Physiotherapy Board
ensure appropriate PPE is in place ready to be used (all staff to be trained as above)
only have one physiotherapist using each room (no sharing on other days)
limit points of entry to the clinic – preferably patients can enter one door and leave from another
all unnecessary items should be removed from the waiting room and surfaces kept clear and clean, including excessive furniture, wall hangings/posters, waste bins, water coolers etc.
areas of known contamination should be cleaned and disinfected
make it clear at the entrances that no walk-in appointments off the street are available.

During Clinic visit

patient again screened for any COVID-19 signs or symptoms prior to entering the clinic
require patient, and others, to ‘hand sanitise’ on arrival and departure from the clinic
physiotherapists fill out any paperwork and forms for the patient (sign with cleaned pen)
allow only the patient to be present in the clinic; a carer or guardian may be allowed to accompany the patient in appropriate circumstances so long as they are screened first and are free from COVID-19 signs or symptoms
confirm contact details for the patient and each person accompanying the patient and inform them that these details may be used for contact tracing, if required
maintain 2 metre separation where possible, for instance, during the subjective examination
follow PPE protocol as advised by the Ministry of Health
minimise contact time closer than 2 metres
follow all hand and hygiene practices
keep doors open (to the clinic, treatment doors if possible ajar)
close the clinic toilet to patients, and advise patients when making the appointment
minimise the use of equipment such as pillows for instance, which are not easy to clean or replace.

Post Clinic Visit

clean all equipment, pillows and plinths after each patient contact .
carry out correct steps for safe removal and disposal of PPE
follow cleaning protocol – wiping down all hard surfaces with detergent and water and then use a disinfectant
appropriate PPE should be worn for cleaning the room
PPE and waste should be disposed in a closed clinical waste bin and in accordance with clinical waste requirements

After clinic finished

physiotherapist showers, changes clothes and shoes at clinic
physiotherapist leaves clinic through different doors if possible (the clean side of clinic)
alternatively the Physiotherapist showers at home, cleans the shower before contacting anyone in their home bubble and hot washes their clothes and towels etc.