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Level 3 guidance

Guidance on seeing patients at Alert Level 3 (non DHB setting)

Last updated 12/08/20

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 the Board and Ministry of Health website regularly for updates and changes.

This guidance document is based on the previous Alert Level 3 Ministry of Health’s 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.

As previously 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.’

Under Level 3, telehealth will  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 open 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:

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

AND

  1. 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.

Under the previous Alert Level 3 the Ministry of Health 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.

 

Registering face-to-face consultations with the Physiotherapy Board

At the current Alert Level 3 it is no longer a requirement by the Ministry of Health to log all face-to-face patient contacts with the Board so long as you have the MoH COVID app / QR code in place and you ensure both you and your patients use this when entering the clinic or doing offsite visits, as appropriate.

All businesses must display a QR code for the NZ COVID Tracer app

If this is not possible please register each face-to-face patient consultation with the Physiotherapy Board here.

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 further aid contact tracing, if it is later required.

 

The use of Personal Protective Equipment (PPE)

The expectations set by the Ministry of Health for seeing patients face-to-face under Alert Level 3  are  high as it is only for urgent care appointments. The Ministry of Health current (as at 12 August 2020) advice re use of PPE is here

In general, if a patient is deemed to be urgent AND passes the screening test/risk assessment  then a surgical mask and hand hygiene is required. N95 masks are only to be used for aerosol generating procedures.  If patients DO NOT pass the test or have risk factors – ideally do not see them face to face.  If you are seeing them and there are risk factors post screening then additional use of gown and eye protection is required.

Updated PPE guidance for Cardio Respiratory Physiotherapists is expected from the Ministry of Health next week – as soon as we have this confirmed we will share this.

 

Overarching Requirements

Physiotherapists must:

  • 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 whānau 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. This includes cleaning of 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!
  • 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.

 

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.

Screening

Screen or risk assess patients and any support persons for risk of COVID-19 prior to face-to-face consultations. 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.

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

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
  • apply for a QR code for your place of work. Where the QR code cannot be used, register 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 per day
  • 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. Alternatively use single use coverings for the pillows and plinths such as towels or paper towels.

 

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 hot 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)
  • ensure door handles, keys and high touch surfaces are cleaned before leaving
  • alternatively the Physiotherapist showers at home, cleans the shower before contacting anyone in their home bubble whānau and hot washes their clothes and towels etc.

 

Further resources from the Ministry of Health