Covid-19 protocol

Protocol for seeing clients – Covid-19 Revised 10th July 2020 (to increase treatment room use to 3 and return of reception staff)

NOTE

Covid-19 is a notifiable disease and therefore if an osteopath is contacted by the clinical contact tracing team, the osteopath will need to give out names and contact details (phone and email, no other information) of their patients due to the over-riding duty to Public Health.

This is intended to be a working document, based on best practice and current knowledge (WHO, PHE, HSE). It has been developed based on information provided by the Institute of Osteopathy but also from looking at other professional situations including dentistry and blood transfusion service where practitioners need to get closer than 2 metres in order to deliver treatment. The aim it to mitigate the risks of transmission of Covid-19 while also recognising that no protocol can completely eliminate that risk.

Initially, the Institute of Osteopathy was recommending full PPE i.e. scrubs, gown, disposable apron, mask, visor and gloves and masks for clients while the blood transfusion used social distancing and masks for staff only. Until very recently dentists were not allowed to perform any procedure that produces an aerosol, even though they already wear masks and glasses to protect themselves, so effectively not able to work at present. So there does appear to be a marked difference in the interpretation of the same set of rules.

I’ve divided the protocol into sections to try to separate out the different areas that need to be considered but it is long and likely to increase as we increase both types and numbers of practitioners.

The Centre

  1. Sign on door saying The Centre is only open to pre-booked clients
  2. Automatic dispenser for hand sanitiser, table with sign asking clients to use this to wash their hands and then use the bell to let the practitioner know they’ve arrived
  3. Where a client needs a mask, this will be placed on dispenser or on the table with the bell. Clients should use the hand sanitiser before putting on the mask. Masks should be worn while at The Centre and only removed after leaving – NB wash hands before removing mask carefully, and then wash hands again after removing. Masks should be managed carefully to avoid risk of contamination – disposed of or washed, as appropriate
  4. Clients to be met at the bottom of the stairs by practitioner and temperature may be checked before admission
  5. Door at top of the stairs to be propped open
  6. Clients will be shown straight into treatment rooms
  7. Toilet facilities to be available as required – sign on toilet and wall asking clients to close the toilet seat before flushing to reduce risk of transmission
  8. Where one treatment room is in use: Client to be shown out directly. Where more than one treatment room is in use: Client will be shown out by practitioner or escorted to reception. Receptionist (Practice Manager in the first instance, then trained staff) will take fees, book next appointment and ensure client can leave safely. Reception has been set up to allow for one client to sit, pay, etc and allow for social distancing. Receptionist can enter and leave the room still allowing for social distancing to enable them to ensure that clients can arrive and leave without overlap. Receptionist will clean surfaces after client leaves. If reception chair is occupied, clients will remain in treatment room until reception has been cleaned ready.
  9. All surfaces within treatment rooms to include couch, chairs, table, iZettle to be cleaned between clients
  10. All surfaces from front door to treatment room to be cleaned between clients . Once more than one treatment room is in use, this responsibility will fall to the receptionist, who will be the Practice Manager, in the first instance. She will be responsible for cleaning after each client arrives/leaves to ensure it is clean for the next client arriving/leaving and this will take priority over all other responsibilities. Where there is no receptionist for whatever reason (including lunch breaks), practitioners will be responsible for cleaning before and after their clients. At present, practitioners are working different and/or additional hours to ensure they can continue to see similar numbers of clients in ways that work for them.
  11. Where clients have used the toilet, this will also be cleaned between clients, where practical, and regularly during the day, when not. When more than one treatment room is in use, the priority will be to ensure each client can arrive and leave safely and the toilet will be cleaned as soon as possible after use. To date, the toilet has been cleaned after every use.
  12. Carpets in treatment rooms to be steam cleaned daily.
  13. Entrance to The Centre will be limited to practitioners, their clients and the Practice Manager and all should use hand sanitiser on arrival. If anyone else needs to access The Centre, e.g. workmen, they will be escorted by a practitioner or the Practice Manager at all times and the Practice Manager will be responsible for ensuring they comply with this protocol and also for ensuring that The Centre has been cleaned in accordance with this protocol after their visit.
  14. In addition to the cleaning conducted above, The Practice Manager is responsible for ensuring that The Centre has a thorough clean each week, according to the cleaning schedule. This includes steam cleaning all carpets in treatment rooms and communal areas, including stairwell and entrance.

Clients

  1. All new clients will need to be pre-screened to determine both their risk of exposure to Covid-19 but also to ascertain that face to face treatment is both indicated and necessary. Wherever possible, as much of the case-taking will be undertaken during this telephone / online consultation to minimise the time that clients need to attend The Centre. The Centre is doing what it can to mitigate the risk but the fact that there is still a risk in attending will be explained to clients for their express consent. In line with government advice on facial coverings in confined areas, clients will be asked to wear a mask when attending The Centre, ideally water resistant as this is required by IO to meet their standards. Only clients who pass this screening process will be seen at The Centre at this time. Clients will be given instructions of who to contact if they develop symptoms of Covid-19 or are unable to attend for any other reason and asked to inform The Centre if they develop symptoms within 2-14 days of attending The Centre (dependant on practitioner/modality). Depending on the modality/practitioners, clients may be asked to sign a consent form confirming that this has been explained to them and / or confirm that they do not have symptoms of Covid-19 before the start of each treatment session. The only exception to pre-screening will be where a practitioner needs to see a new client at short notice such that there is insufficient time to conduct a pre-screening call. In such cases, clients will be screened for symptoms on arrival, as all other clients, and case taking will take place in the treatment room. Such cases are at the discretion of the individual practitioner.
  2. All current clients who wish to attend The Centre and have not attended since before lockdown, will be asked to confirm they are well when they book appointments. The current system will be explained and clients will be asked to attend at their appointment time wearing a face covering (these can be provided, where necessary). Dependant on practitioner and modality they may also receive a pre-appointment screening call (see 1) and be asked to sign a consent form.
  3. Clients are asked to attend on time as there is no reception or waiting facilities available so clients cannot arrive early.
  4. Clients booked in appropriately to allow for cleaning between clients – initially one client an hour, while we work everything out. If timings allow, this may be reduced.
  5. Initially, as each practitioner returns to practice, appointments will be offered to existing clients only, while practitioners get familiar with the systems in place. Once each practitioner is happy that the systems in place are effective and workable for them, appointments will be offered to new clients. However, new clients can be seen during this initial trial if the practitioner assesses that this is appropriate and necessary to meet clinical need.
  6. Some practitioners will handle their own diary initially to ensure they meet their professional requirements. In such cases, The Centre will take client details and pass them to practitioners to follow up directly.
  7. Only one person to attend per appointment, unless the practitioner deems it necessary for more than one person from the same household to attend, e.g. parent and child, someone requiring assistance to attend etc.
  8. Once more than one treatment room is in use, use of the reception area will ensure that clients do not interact while at The Centre, reducing the risk of cross contamination. Clients may be asked to wait in the treatment room after treatment if this proves necessary to ensure clients do not overlap in reception or communal areas.

Practitioners

  1. Practitioners will use the hand sanitiser on the way in.
  2. Practitioners will change in the toilet before starting and clothes will be bagged up and placed in the cupboard in the toilet.
  3. Practitioners will wear appropriate PPE as stipulated by their professional body. All practitioners will wear face coverings, preferably moisture resistant face masks, independent of any other requirements.
  4. Wash hands. Clean surfaces with viricidal spray.
  5. Clean any surfaces touched on the way in, particularly the front door handle, hand rail and handle of door at top of stairs and toilet with viricidal spray or wipes.
  6. All pillows used are covered in plastic and will be sprayed with viricidal solution between clients. Pillowcases can be used as long as they are changed between clients and the pillow sprayed with viricidal spray between clients. Pillowcases need to be bagged up before cleaning for the next client.
  7. After showing the client out, via front door, all surfaces will be cleaned with viricidal spray/wipes to include door handles, hand rail, desk, chairs, iZettle, pens and toilet, if used by either client or practitioner in the appointment slot. If more than one treatment room is in use, Receptionist is responsible for communal areas.
  8. Currently the recommendation is to air the room between clients.
  9. Where more than one treatment room is in use during a session, practitioners need to be mindful of timings of all treatment rooms to ensure social distancing for both clients and practitioners. In general, clients will leave directly or via reception. If reception is busy, clients should wait in the treatment room with the door open and the receptionist will advise once reception is available.
  10. At the end of the session:
    1. Any rubbish produced during a session should be placed in the bin and the bin should be tied up, dated and placed in Room 4 for 72 hours prior to disposal.
    2. Bag containing pillowcases etc should be moved to hall.
    3. Wash hands then clean treatment room wiping all surfaces with viricidal spray/wipes, steam carpet in treatment room
    4. Clean any other communal spaces used during session e.g. reception, kitchen.
    5. Use toilet to change back into clothes and bag up and seal clothes, gowns etc used during the session. These should be taken home and washed appropriately. Surfaces should be cleaned and the toilet area should be sprayed with viricidal spray and the door shut.
    6. Clean any handles etc touched on the way out using a wipe and dispose of safely.
  11. Other practitioner’s professional bodies might require different protocols and it will be necessary to ensure that these do not conflict.

Other issues

  1. If a practitioner or a member of their household develops Covid-19 symptoms, they and their families will self-isolate for 7/14 days in line with government recommendations. If the practitioner tests negative for Covid-19, they can return to work as soon as they have recovered, assuming their household members are also well and have tested negative (where tested). Practitioners who have worn PPE in accordance with this protocol and that of their professional body are highly unlikely to have passed it on to their clients but will, as a courtesy, inform any clients seen in the previous 2-14 days (dependant on practitioner/modality).
  2. If a client becomes obviously unwell with symptoms suggestive of Covid-19 such as a temperature, dry cough etc, during treatment then they will be advised to get tested and required to leave immediately. The practitioner will advise the practice manager and the practitioner will cancel any further clients, undertake a deep clean and remove themselves from the premises. They and their families will then isolate for 14 days. If the client tests negative for Covid-19, the practitioner can return to work. Osteopaths who have used PPE in accordance with this protocol and that of their professional body do not need to self isolate.
  3. If a client advises The Centre that they have developed symptoms within 2-14 days of visiting The Centre (dependant on practitioner/modality), they will be advised to get tested and asked to inform The Centre of the results. The practitioner and their families may need to isolate for 14 days, dependant on the guidance of their professional body. Under this protocol, clients are escorted from the front door to the treatment room and escorted out via reception to ensure they do not meet other clients. Therefore the risk to other clients is minimal and, under current guidance, there is no need to contact other clients who have visited The Centre either at the same time or since. Osteopaths who have used PPE in accordance with this guidance and that of their professional body do not need to self isolate. The iO has suggested that in these circumstances, practitioners should inform clients as a matter of courtesy but this is currently under review given that it will raise anxiety levels when the risk to clients is very low.

NB

The protocol is aimed at reducing the risk of exposure to the virus for everyone entering the practice but particularly the risk of spread from client to client. There is still a slight risk that a client could pass it to a practitioner but, based on current understanding, it seems unlikely as the practitioner will be wearing a water-resistant mask and following strict protocols regarding clothing, hand washing etc. Throughout it must be remembered that The Centre is not sitting in isolation and clients are exposed wherever they interact with others and some people even seem to develop symptoms after several weeks isolating alone at home, adhering to the highest possible hygiene standards (e.g. washing shopping or quarantining) by mechanisms that are still unclear.

At present, people are not being asked to isolate unless directly in contact with someone with Covid-19 symptoms but that may change with the move to track and trace so the current protocol anticipates that.

Basic masks protect others rather than the wearer which is why iO is requiring water-resistant masks which protect the wearer. However, if both people are wearing basic masks, then each is protecting the other. It is unclear how easy it will be for both clients and practitioners to obtain sufficient quantities of water-resistant masks in which case, any mask would be deemed better than no mask. The Centre will also have a supply of visors which can be used in any situation where they are considered necessary and these could be used in conjunction with basic masks too.