Following the advice from our regulating bodies and governing organisations from 18th May 2020, we gradually began the process of re-opening our Complete Physio clinics post lockdown.
We had concluded that for many of our patients to achieve their best possible outcome, they would greatly benefit from being treated and managed with face-to-face consultations.
We knew this would be a huge challenge for us as an organisation and for our individual practitioners. We were aware this would also pose an unfamiliar experience for our patients and we were determined that we would focus on three main principles:
Hygiene – All reasonable infection prevention and control measures must be in place and compliant with Public Health England guidelines.
Confidence – Patients, staff and general public must have confidence in Complete Physio’s ongoing strong commitment to ensure all safety measures are in place and followed at all times
Communication – Complete Physio must be forthcoming with communication to patients, staff and general public at all times – via website updates, newsletters, direct communication with all patients booking to attend, and on-site information from staff.
Preparing the clinics – what changes can patients expect?
Once we had made the decision to re-open our clinics, a huge amount of work was required to ensure that we could provide the most COVID secure environment for our staff and patients.
The biggest initial challenge was gathering and assessing all the relevant information to clearly understand all the rules and regulations that we needed to adhere to in order to operate safely. We developed our local policies and guidelines for Complete Physio – ‘COVID-19: reopening and returning to business’.
We were able to establish reliable supplies of all the appropriate virucidal cleaning products and personal protective equipment (PPE) in line with Public Health England and government guidance (see Government’s Infection & Prevention Control Policy and Guidelines), and the appropriate regulatory body (Chartered Society of Physiotherapy), which gave specific guidance regarding requirements for clinicians providing face-to-face consultations and also for patients attending clinic. This required practitioners to wear masks, gloves, aprons and visors (visors were only required for certain high risk situations). Patients were recommended to wear masks and gloves in line with government guidance.
Signage was required in all clinics, identifying specific keys areas such as the PPE stations at the entrance of the clinic, and separate patient waiting rooms. Additionally, signs reminded patients to wear a mask, and take their temperature on entering the clinic. Patients were asked to wash or sanitise their hands on arrival, and to observe social distancing guidance (staying 2 metres apart wherever possible).
We incorporated the additional steps of staggering clinic times and scheduling gaps between patient consultations to allow for cleaning of the waiting area and clinic rooms. This also helped to minimise the number of patients in the waiting area at any one time. All the clinic spaces were professionally deep cleaned and additional professional cleaning was organised.
COVID-19 Policies and training
Once the clinics were prepared and we had acquired PPE all our staff had to undertake specialised training. This included COVID-19 ‘return to work’ training, implementing every aspect of our COVID secure and infection prevention and control policies. They also had to familiarized themselves with the updated COVID-19 information from government and their own respective regulatory bodies, i.e. Public Health England, the Chartered society of physiotherapy (CSP), The General Council for Massage Therapies (GCMT) or The Association of Soft Tissue Therapists (SMA), and the Health and Care Professions Council (HCPC) alongside their normal mandatory infection control training.
Screening patients for face-to-face consultations
As the lockdown restrictions began to ease physiotherapists were given guidance regarding patients who could be regarded as suitable for face-to-face consultations. The emphasis remained for managing patients via online/remote appointments where possible and appropriate.
Consequently, we at Complete set up a two-stage screening process to ensure face-to-face consultations were indicated and appropriate. The first stage involved either a phone conversation or an email being sent by our administrative team to any patient requesting a face to face appointment
The screening criteria is outlined below:
- Do they (or does anyone that they co-habit with) have symptoms of covid-19, or had symptoms of covid-19 within the last fourteen days?
- Has the patient been advised to self-isolate or quarantine in the last 14 days?
- Does their clinical presentation require a face-to-face consultation or could the consultation reasonably by provided remotely?
- Patients are also screened for specific high-risk criteria. Covid-19 high-risk criteria include age > 70, BMI >40, BAME ethnicity, weakened immune system, comorbidities that cause immunosuppression, diabetes, rheumatoid arthritis, pre-existing infections, long term steroid use, and a known cancer diagnosis and currently having active treatment.
- Whilst Complete Physio continue to take all reasonable steps to minimise any risks to patients (including observing social distancing measures, infection control and PPE) patients are advised that physiotherapy may have inherent risks in that it often requires close physical contact (<2m for >15mins) which may increase risks of exposure and transmission of COVID-19. We ask all patients to provide consent that they are aware of this issue.
- Patient are asked to provide consent to share their email and telephone contact details with NHS track and trace service should they be required to do so.
The answers to the above questions were screened by our clinical directors and clinic managers at Complete and formed part of the risk assessment process.
The clinical judgement of the directors/managers was based on the information provided and we contacted patients to request further information where necessary. Examples of the type of criteria that we deemed to warrant a face-to-face consultation is outlined below (this list is not exhaustive):
- Patient’s symptoms are deteriorating despite undertaking remote physiotherapy consultations.
- Patient has failed to improve despite attempts using a range of reasonable approaches that have been performed under remote consultation.
- Patient’s presentation requires a physical assessment in order to screen for signs and symptoms that may significantly change a patient’s treatment or management e.g. to assess for possible serious or sinister pathology.
- Patient’s clinical history suggests the need for an assessment e.g. diagnostic ultrasound scan or treatment e.g. injection, which cannot be provided remotely.
As part of the new COVID-19 measures that we introduced to all our clinics, and for our staff and patients, we believed that it was our professional duty to undertake an audit to ensure that they were being implemented and to identify any issues that we needed to address or improve with our processes. We were keen to review our procedures and demonstrate to staff, patients and public health bodies that we, as a company, had been diligent in adhering to the guidance, but also acknowledging the need to test these processes and improve where necessary.
The daily cleaning and environment are checked and audited at each site regularly. However, for the next stage we wanted to audit two further aspects of our processes:
- Auditing the pre-screening process of patients prior to for face-to-face consultations.
- Auditing treating clinicians’ documentation of consent and their appropriate clinical reasoning for face-to-face consultations.
Two identical audits took place a month apart, reviewing over 200 patients’ notes. Firstly, the audit examined whether patients had been pre-screened using the criteria highlighted above and whether the screening document had been attached to the patients’ medical files.
Secondly, we audited whether all treating clinicians had documented consent for treatment and whether clinicians had been explicit in clinical reasoning/risk assessment as to why that patient required a face to face consultation (i.e. which infection control measures had been implemented and the benefits of treatment).
The results of the two audits were fed back to the Complete directors, administrative team and treating clinicians. The audit consequently allowed insight into our screening and booking processes which have allowed subsequent streamlining and greater efficiencies. This has resulted in a more robust and also much quicker journey for screening and booking for face-to-face consultations. Improvements and updates in our clinical notes sections and document storage systems have improved our patients clinical screening processes and will allow for improvement in future audits and data collection to help improve our services. We feel confident that every step has been reviewed to maximise the safety of our staff and patients. Our processes as always will be subject to ongoing audit and reviews and a COVID specific audit tool has been integrated into our general clinical audit tools.
NHS COVID-19 app
From 24th September the NHS COVID-19 app went live. At all of our clinics we now have QR code posters situated in the entrance and waiting room.
When patients attend one of our clinics, they are encouraged to download the NHS COVID-19 app and scan the QR code on the poster when they arrive.
By encouraging the use of the app, if patients attend the clinic and later test positive for coronavirus, other app users who were in the clinic at the same time may be contacted if local public health teams think this is required.