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Level 2 guidance

Guidance on seeing patients at Alert Level 2 (non DHB setting)

Last updated  1/09/20

Please note this guide is a living document and will be updated as information from the Ministry of Health is released during the Alert Level changes. Please check both the Board and the Ministry of Health website regularly for updates and changes.

Introduction

This guidance document is based on the Ministry of Health’s Alert Level 2 Guidance for Community Allied Health Professionals and applies mainly to physiotherapists working outside of the DHBs. When more information is released by the Ministry of Health this guidance will be updated Therefore, please adjust the guidance to suit your working environment whether it be clinic or community based and check regularly for updates on the Board and Ministry of Health websites.

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 are 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’. Please note regional restrictions on gatherings and class sizes may vary.

While physiotherapy clinics and services can open 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 management, and appropriate infection prevention control procedures. Under Alert Level 2, telehealth should be considered especially for vulnerable patient groups.

Overarching Requirements at Alert Level 2

Physiotherapists must:

  • be aware that under Alert Level 2, there may 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 whānau as well as the patient’s safety
  • screen patients for COVID-19 signs or symptoms and carry out a risk assessment questionnaire 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
  • have an MoH COVID app/ QR code in place for their premises and encourage it’s use
  • also maintain a log of all patient, visitor 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 please adjust the guidance to suit your working environment.

 

Appendix 1: General practise guidance

Screening

Screen or risk assess patients and any support persons for risk of COVID-19 prior to face-to-face consultations using a risk assessment questionnaire. Patients should be screened when booking the appointment and then re-screened when they arrive at your premises 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  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 onto the premises or see them in the community until they have medical clearance.

The principle is: if you are sick, you stay home and get tested.

Further guidance on how to screen patients can be found here:

 

Clinic log and contact tracing records

All businesses and services must display the official NZ COVID Tracer QR code posters wherever customers or visitors enter the premises. This includes physiotherapy services. Physiotherapists should actively encourage all patients, support persons, contractors, and staff to use the code.

Physiotherapists and clinics must also 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 further 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.

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.
  • read the ‘Public health guidelines for businesses operating under the relevant Alert Levels’. 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 and train staff on its use, including donning, removing and disposing of PPE
  • develop and implement a cleaning plan for your working environment. The Ministry of Health recommend normal cleaning procedures are to be carried out for non Covid-19 patients, however we strongly advise continued increased 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 be 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

Preparation

  • screen patients for COVID-19 signs or symptoms by phone or telehealth by using a risk assessment questionnaire prior to their consultation at the clinic i.e. at the time of booking. If doing a community visit, ensure no one in the house you are visiting has any symptoms or has been ill recently. 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
  • screen patients for vulnerabilities such as elderly or having significant co morbidities which may mean they need to be assessed or treated at a different location, time or by telehealth.
  • 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 an 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. Inform them they can bring their own masks if they wish
  • ensure appropriate PPE is in place, ready to be used if required (all staff to be trained as above)
  • ensure thorough cleaning is undertaken of all equipment (including keyboard and mouse), that has been touched or used between patients
  • avoid sharing of clinic equipment between clinicians and patients. Where this is not possible, thorough cleaning of the touched equipment is required (such as tape measures, tendon hammers, gym equipment).
  • areas of known contamination should be cleaned and disinfected regularly (lift buttons, stair well handles etc.)
  • keep entrance and exit doors open to clinic where possible

 

 

During Clinic visit

  • re-screen patient for any COVID-19 signs or symptoms on arrival. If they are deemed to be a risk, do not continue with the clinic consultation or see them in the community until they have medical clearance
  • require patient, and others, to ‘hand sanitise’ on arrival and departure from the clinic
  • physiotherapists are to fill out any paperwork and forms for the patient (sign with cleaned pen), if contactless forms are not available (as when doing Telehealth).
  • where possible 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 current 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. Enter them onto the clinic log
  • maintain at least one metre separation where possible, for instance, during the subjective examination
  • follow all current PPE requirements as advised by the Ministry of Health
  • minimise contact time closer than one metre
  • follow all hand and hygiene practices
  • minimise the use of equipment such as pillows for instance, which are not easy to clean or replace. Alternatively use single use coverings for the pillows and plinths such as towels or paper towels.

 

Post Clinic Visit

  • follow cleaning protocol; include all equipment used, pillows and plinths after each patient contact. Clean equipment and surfaces including high touch points in the car, scooter, motorbike or bike etc taken to get to the appointment(s). Don’t forget to clean your keys!
  • carry out correct steps for safe removal and disposal of any PPE used
  • PPE and waste should be disposed in a closed clinical waste bin.

 

After clinic finished

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