Physiotherapy During the Coronavirus Outbreak

Hello and welcome back to the ThreeSpires Physiotherapy blog where we take a look at all things physiotherapy and health related. I have been holding off writing this blog for a few weeks as I wanted to see how things would change in terms of government advice, advice from our professional body the Chartered Society of Physiotherapy (CSP) and the feasibility of seeing selected patients given the restrictions we face. Our main concern here at ThreeSpires Physiotherapy has always been the well-being and health of our patients and physiotherapists and as such we wanted to make sure that we had everything necessary in place. Things have now settled a bit more, our advice from the CSP and the government seems clear and also we have had sufficient time to prepare for seeing patients in terms of infection control, PPE and having sufficient protocols and patient information. As such we are now able to start seeing some (not all) selected patients for whom the benefits of physiotherapy outweigh the risks of viral transmission. Below I have outlined our general approach to physiotherapy at present and the process we are using to judge which patients we can see at present.

Virtual First Approach:

Although we are now able to see some patients face to face it is important that we attempt to minimise viral transmission via the use of a virtual first approach to physiotherapy (as recommended by our professional body the CSP here: document https://www.csp.org.uk/news/coronavirus/clinical-guidance/face-face-or-remote-consultations/guidance-england)

This put simply means that at present we are trying to manage most of our patients (past and new) via either a telephone conversation (free of charge) or more formally via a video call (charged for). For any new patients we are now sending out a large amount of information regarding Coronavirus transmission and risk and also triaging patients based on the information they give us. At this point we attempt to give as much advice as is possible and safe over the phone and then if appropriate we will offer a video call consultation as a way of assessing and treating their condition without them having to risk a face to face consultation. This has worked very well for many patients but clearly for some will not be sufficient. More information regarding our video call consultations is available here.

Face to Face Physiotherapy

Now clearly there are some patients for whom a video assessment will not be satisfactory and they will have needs that cannot be met through a video call. In these cases we now have a process where by we judge the merits of physiotherapy versus the risks of Coronavirus transmission and ensure that the patient and their relatives are fully informed so that they can make a well informed decision. To do this we now have in place the following process which we appreciate is much more onerous for our patients but does ensure that they have sufficient information and time to make a good and safe decision with guidance from ourselves:

•  A phone call discussion to evaluate the need for physiotherapy, this can partially be done via email if needed but at some point it will be necessary to have a conversation over the phone to discuss in detail the documentation that has been sent over and some of the benefits and risks involved. During this triaging process information will be gathered to assess what category of risk Coronavirus presents to the patient, their family and any members of their household and also more detail about their exact needs for physiotherapy. It is at this point that usually  the appropriateness of a video call will be discussed. If it is decided that neither advice over the phone or a video call is likely to be sufficient then documentation and information regarding our Coronavirus policies, risks of transmission and protocols for infection control and PPE will be sent over either via email or post.  Should you wish to understand the likely risk category you are in for Coronavirus then information regarding risk from the NHS can be found here at https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk-from-coronavirus/whos-at-higher-risk-from-coronavirus/

• Once the patient (or relative) has had sufficient time to read through the material sent over a second phone call will take place. At this point we will triage their case and discuss with them in detail the potential benefits of physiotherapy and also the risks of viral transmission. Also a more extensive discussion will take place regarding their risk category as defined by the NHS with an in depth discussion about past medical history and also any members of their household who may have health conditions (https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk-from-coronavirus/whos-at-higher-risk-from-coronavirus/  ). We will also discuss our infection control protocols (more detail of which can be found below). We appreciate that this is very time consuming (and potentially frustrating) for our patients but it is vital that we ensure the safety of both our patient and our treating physiotherapists.

• If after this discussion and examination of the benefits of physiotherapy versus risks of viral transmission the patient still wishes to be seen face to face we will need to consider the merits of their case on an individual basis. As a minimum any patient wishing to be seen by one of our physiotherapists (face to face) must meet one of the following thresholds: 
  • Seeing a physiotherapist at home will enable them to avoid a GP contact or significantly reduce the likelihood of a GP contact.
  • Seeing a physiotherapist at home will enable them to avoid a hospital admission or reduce the likelihood of a hospital admission.
  • Seeing a physiotherapist at home will reduce the likelihood of a significant reduction in mobility, function or quality of life. Examples of this can include (but this is not exclusive) inability to go to work, increasing burden in care staff or a reduction in the ability to care for oneself.

 Due to the varied nature of our patient cohort it is pretty much impossible to describe every single possible situation and each case and patient will be treated separately. If after a discussion there is a clear argument that the patient needs to be seen face to face then the reasoning and discussion will be documented clearly. This may well mean that initially for some patients the benefit of face to face physiotherapy will not be sufficiently great to outweigh the risk of viral transmission. This is unfortunate and frustrating but the safety of our patients is our top priority. Hopefully the above information makes clear the process that we must go through at present to provide physiotherapy and also some of the reasoning for the choices that we are making. I think next we should take a look at some of the specifics of a face to face session and what it will involve:

Infection Control & Personal Protective Equipment (PPE)

 As part of our commitment to deliver physiotherapy safely both for our patients and our physiotherapists we have a clear protocol regarding infection control and the use of personal protective equipment (PPE) during all face to face physiotherapy sessions. We appreciate that this may make a physiotherapy session seem and look different to how it did in the past but this I unavoidable if we are to practice safely. As such all of our physiotherapists or rehab assistants will be wearing the following as a bare minimum during any physiotherapy session:

• Disposable Gloves: these will be single use and must be disposed of at the end of each session.
• Disposable plastic apron:  these will be single use and must be disposed of at the end of each session.
• Fluid-repellent surgical mask: these will be single use and will cover the mouth and nose and be disposed of at the end of a session.

 If the physiotherapist judges that there is a risk of fluid or aerosols being generated (such as from a cough or a sneeze) then they will also wear a face visor but they will discuss this with the patient at the time. I think that all of us as physiotherapists appreciate that this may make communication difficult at times and will also change how a session feels but at least this way we can offer physiotherapy to selected patients safely.

 Accessing & Leaving the Property

In order to maintain social distancing before wearing PPE and also minimise the risk of viral transmission we have a protocol for accessing and leaving a patient’s place of residence. This is discussed in advance with the patient so as to minimise the chances of any confusion, reduce the risks to other members of the household and also to provide re-assurance as to what the physio will need to do:

At present all of our physiotherapists or assistants will be doing the following:

•  On arriving at the property we will clean the door bell or knocker with a sanitising wipe and then knock or ring the bell. At this point our physio will step back at least 2 to 3 metres and wait for access to be granted.
• Once the patient or relative allows entrance, our physio will then ask for this person to step inside the property and move at least 2 metres away from the inside door (the principle being that until wearing PPE you need to maintain 2 metres distance). At this point they will also ask to be directed to a bathroom or toilet where they can wash their hands and put on their PPE (as detailed above).
• Once they have put on their PPE they will then go in, meet the patient and conduct the session.
• At the end of the session they will ensure that they have a clear exit path through the front door that does not require them to touch any handles or meet anyone. To ensure this they may well open the exterior door and any interior doors that block their way. They will discuss this with the patient at the time. At this point they will then return to the toilet and take off their PPE and bag it up. If at this point the patient has no symptoms of Covid-19 then this bag can be disposed of in their domestic waste (making sure at all time to stay 2 metres away from the patient or any family members.)
• Once the PPE has been bagged up and disposed of the physio will leave the property and return to their vehicle and will use alcogel to sanitise their hands further and prevent any cross contamination.

Hopefully the above makes it clear what anyone having face to face physiotherapy sessions should expect in terms of entering and exiting their property and the routine needed by our physios in order to minimise viral transmission.

Disposal of PPE:

Once the session has concluded and the physiotherapist has taken off their PPE and is ready to dispose of it, you need to be aware of the protocol for disposal of this PPE. The physiotherapist will have placed all of their waste in a refuse bag and tied it up. They will then either place it in a domestic rubbish bin inside the property or in the domestic waste bin outside. This bag can be disposed of as normal domestic waste at your property as it is classified as uncontaminated waste unless you, a member of your household or the physio has symptoms of COVID-19 (new continuous cough, shortness of breath, fever) www.gov.uk/ government/publications/covid-19-stay-at-home-guidance 

 Should anyone in the household have symptoms or either yourself or our physio develop symptoms in the session then we need to treat this waste differently. In this case we need to treat it as contaminated and take it away with us for disposal separately.

Further Considerations in the Session:

If at all possible, the physiotherapist will conduct the session outdoors so as to minimise the risk of viral transmission through aerosol. We appreciate that usually this will not be practicable and instead our physios will attempt to make sure that there is as much airflow through the room as possible by opening windows and exterior doors. This will be discussed in the session as appropriate.

If you start to develop symptoms of Covid-19 before the session with our physio we would very much appreciate it if you could inform us and our physio as soon as practicably possible so that we can cancel the session. If our physiotherapist has any symptoms then they will call as soon as possible and cancel the session. This is necessary in order to minimise risk of viral transmission.

 FAQs for Physiotherapy During Coronavirus Outbreak

 Below are some common questions regarding physiotherapy during the Coronavirus outbreak. I have tried to cover most things but if you have other questions please do not hesitate to get in touch either via phone 07884 281623 or via email: enquiries@threespiresphysiotherapy.co.uk

• Do you need to use my bathroom? Yes, if at all possible. Our safety procedures require that our physiotherapist enters your property and stays 2 metres away from you until they have put on their PPE. Ideally this is done in your bathroom as this allows the physiotherapist to wash their hands. They will then take off their PPE at the end of the session in your bathroom.

• Why are you using PPE? It is thought that Coronavirus transmits through aerosols such as water droplets in the atmosphere and through touching surfaces and then touching one’s own face or mouth. PPE reduces the risks of this happening and is required by Public Health England at present.

• Will we be able to socially distance during my session? This is unlikely for most physiotherapy sessions and is the reason for needing to use PPE throughout the session. Most physiotherapy involves close contact with patients.

• I am in a high risk category and have been shielding. Can I still have physiotherapy? This will depend upon the results of our triaging and risk assessment process. It will be necessary to show clearly that the benefits of physiotherapy are clear and significant for you.

• Could we have a session without PPE? The answer is unfortunately no. Risk of viral transmission is too great and current guidance is that we must wear PPE.

• I have recently been discharged from hospital after an episode of Covid-19. Can I have physiotherapy? Yes, but you will need to go through our triaging and assessment process and our physiotherapists will need to wear PPE.

• Why have you sent me so much information? I just want physiotherapy! We understand that we have sent a large amount of information to you regarding our procedures, our triaging, our PPE usage and the virus itself. This is because the situation we find ourselves in is extremely new and it is important that we ensure that you are fully informed so that you can make informed decisions and understand clearly the benefits and risks of physiotherapy.

• Can I have more than one session? Yes, but our physiotherapist in conjunction with yourself will need to make a decision on a session by session basis as to the need for physiotherapy. This will be clearly documented in your notes.

• Can we shake hands? Unfortunately not! We understand completely that this will feel very strange but we need to reduce the risk of viral transmission as much as possible.

• How can I pay? If possible, we would prefer you to pay via bank transfer to minimise risk of viral transmission.

Okay, hopefully this article has given you a fair amount of detail and information about how our physiotherapy service is operating and helping patients during the Coronavirus outbreak and how things have changed and the precautions we are taking to ensure that we are operating safely. As mentioned if you need any more information or have any question please get in touch.