March 17, 2020
Physiotherapists have a professional obligation as well as the legal requirement to provide clients with safe, competent and ethical care. As a regulatory body we recognize that the COVID-19 situation is an unprecedented and very fluid with conditions changing rapidly. It is also important to ensure that precautions are in place at the workplace to reduce the risk of spreading the virus. This means different things in different environments, so it is critical that you assess the risk for your situation/clinic and respond accordingly. Risk mitigation includes a range of options as outlined in the materials from Pubic Health. Here are some excellent public health sites that you should be checking regularly for accurate information and updates.
Further to that, here are some helpful points to consider when making service delivery decisions:
1. Prior to interaction with staff and others, patients should do the pre visit screening questions:
I. Have you returned to Canada from another country within the past 14 days? Note: This has been updated to returning from anywhere outside Nova Scotia</p>
II. Have you been in close contact (within 2 metres) with someone with a confirmed case of COVID-19?
III. Have you been in close contact (within 2 metres) with someone who has returned from another country in the past 14 days and who has a fever higher than 38C, a new cough or a cough that’s getting worse?
If patients “fail” the screening, they are told no visit, and to contact 811 or complete the self-assessment on 811 website, before they return to the clinic.
2. Physiotherapists have an obligation to maintain the standards of practice of the profession and, accordingly, must ensure that recommended Infection Control Practice Standard is upheld at their practice sites. This would include the social distancing of 2 metres as required by provincial government, routine/universal precautions with frequent cleaning of high touch surfaces. Appropriate masks (cover the nose and mouth) and hand sanitizer must be available onsite, or there must be an accessible sink with hand soap and hot water for proper hand washing. Viruses can live for several days on surfaces so thorough cleaning at least daily is essential to reduce germs and help to protect from contact with potentially contaminated droplet material.
3. Physiotherapists must use their professional judgement to determine whether a direct physical examination is required to complete the assessment or treatment plan or, are they able to deliver substantively similar care just as effectively and safely through Telepractice. (Physical, sensory, or cognitive deficits may impact the ability to deliver appropriate care via telepractice as would privacy and IT limitations/capacity).
A) For in clinic treatments the first step is to perform a visit screening a risk assessment. The screening must be done before each interaction with the patient in order to determine the interventions that are required to prevent the transmission of infection. Here is a good assessment tool… https://www.cdha.nshealth.ca/system/files/sites/documents/quick-reference-guide-ambulatory-and-primary-health-care-screening-march-14-2020.pdf.
In the clinic setting you should:
· clean and disinfect items like doorknobs, light switches, railings, toilets and tabletops daily or more frequently. Wash with soapy water first. Then disinfect using household cleaning products, following the directions on the label, or a solution of 1 part bleach to 9 parts water.
· Disinfect phones, remote controls, computers and other handheld devices with 70% alcohol or wipes.
· Wash or launder clothing, sheets and towels on a regular basis.
· Dispose of garbage on a regular basis. Wash hands after.”
B) If the decision is made to treat through telepractice please refer to our guideline. The same standards of practice apply for both direct and telepractice treatments. Patient must have a clear understanding of the “limitations that telehealth services present as compared to in-person treatment” and “specific differences between in-house care and telehealth.” There must be informed consent for participation of others if needed, for recording and transmission of information etc. Good resources for this are found here https://www.alliancept.org/publications/ under Guidelines.
We realize that when it comes to our civic duty to provide service, financial implications regarding work and our responsibility to our families there are often ethical dilemmas that need to be considered.
Physiotherapists could be considered negligent if they fail to meet their professional responsibilities and standards in providing care. This duty extends to a public health emergency or disaster. Physiotherapists and other health care workers may be forced to consider serious health risks to themselves or their families against their duty to care for the sick. These professional obligations can have limits. It is difficult to provide black and white rules around the duty to care especially around the extent to which physiotherapists may be required to risk their lives in delivering clinical care. The following guidelines will assist in making decisions in these areas but it is recognized that ongoing discussion with key stakeholders is necessary to further define the issues and appropriate policy decisions. Employers also have a duty to protect and support healthcare employees. This may include excluding some staff from certain duties; for example, it might be appropriate to reassign an immuno-suppressed caregiver from working directly with influenza patients. There will likely be significant physical, emotional or psychological distress associated with providing care in such situations and supports must be in place.
Ethical Values and Decision-Making Framework for Disaster/Emergency
1. Duty to Provide Care
Physiotherapists have a professional obligation to provide clients with safe, competent and ethical care during an emergency or disaster.
While there is an expectation that physiotherapists will provide care to the sick and absorb a certain amount of risk in doing so, there is not an expectation that they will place themselves at
unnecessary risk during a public health emergency. If a physiotherapist determines that they do not have the necessary competencies or physical, psychological or emotional well-being to provide safe and competent care, they may withdraw from the provision of care or refuse to provide care if they have given reasonable notice to their employer and appropriate action has been taken to replace them or resolve the issue.
Refusals to work should be handled by the employer in accordance with the Occupational Health
and Safety Act. Employers, however, should explore the reasons for the employee's refusal to
work and appropriately respond to legitimate concerns.
2. Protection of the public from harm
Health care professionals have a duty to protect the public from harm.
Physiotherapists must comply with infection control measures and quarantine requirements in a pandemic or infectious outbreak. Health care professionals should not work if they are ill themselves.
Liberty is the quality or power of being free and being able to make own choices.
Individual rights can be overridden for the common or societal good in an emergency or disaster.
Any restrictions to the liberty or freedom of any individual should be legitimate, necessary and
applied fairly and should be the least restrictive possible given the situation.
Privacy is freedom from unauthorized intrusion.
Individuals have a right to privacy but this is not absolute. Personal information of physiotherapists, patients and others should generally be protected unless a well-defined public health goal can be achieved by releasing personal information. Protection of public health may limit an individual’s right to privacy and confidentiality of health information. The harm of releasing information must be balanced against the benefits of reducing health risks to others. Quarantine for ill individuals including health care providers who become ill may be required, however, the least restrictive option for quarantine should be chosen.
Transparency means open information free of deceit or pretense.
Physiotherapists and other stakeholders have a right to receive truthful and complete information that is needed for them to fulfill their accountabilities safely, ethically and competently. They must be properly informed about issues, including risks and benefits of various decisions or options and have input into decisions directly affecting them.
6. Potential conflict between standards of practice and emergency agency policies/medical directives
It’s possible that emergency government or agency policy/medical directives may conflict with
The Colleges’ code of ethics and/or standards for practice.
The College should be consulted by members, employers and other key stakeholders when new care directives or policies are drafted that may impact member’s ability to maintain professional standards of care and practice.
If the emergency or disaster is prolonged, as for example in a flu pandemic, the College will work with health care facilities to ensure that managers and staff are knowledgeable about the College Standards for Practice and other resources.
Information specific to the disaster/emergency will be placed on the College website for easy access to members and the public.