As part of our return to work we are following the guidelines set out by the Chartered Society Of Physiotherapy…

Face-to-face or remote consultations: supporting you to make safe decisions about patient contact

This guidance aims to provide you with a pathway to interpret national guidance and work within the legal, regulatory and professional frameworks that govern safe physiotherapy practice when considering how to phase a re-start of your practise and its offer to your client group. 

While each country and crown dependency is at a slightly different phase of re-starting services, all are making preparations for a phased restart. Nowhere do these changes signal a return to ‘business as usual’, however, you will want to prepare your practice and its capability to offer face to face appointments when virtual means of delivering physiotherapy are not effective or appropriate. Our advice will help you to decide whether your practice is ready to restart beyond offering remote services.

Legal, regulatory and professional requirements, PPE, and infection control are largely the same throughout the UK. It is recommended that regardless of where you practice in the UK that you follow this guidance to ensure the safety of your patients, yourself, your staff, and the wider public. This will serve to ensure consistency of approach by the profession during this time.

Your duties as a registrant mean you will need to demonstrate how you have considered all aspects of this advice in relation to undertaking consultations with patients. The links used to support this resource are those of the UK Government unless there is a difference between it and that of the relevant devolved nation. 

Key factors in making your decisions 

Our advice directs members to consider a number of key factors when undertaking decisions to see patients face-to-face or not. 

These factors include: 

• Legal, regulatory and professional responsibilities 
• Risk assessment of the working environment for which you are responsible 
• Infection prevention and control measures 
• Access to personal protective equipment 
• ‘Virtual first’ approaches 
• Patient risk assessment and clinical reasoning 
• Patient consent for treatment

Factor 1: Legal, regulatory and professional responsibilities

You must work within the legal, regulatory and professional frameworks that guide the safe management of patients, the safety of the wider public and everyone who works in the practice environment for which you are responsible.

Legal

• Current Government guidance on business operation, social distancing and shielding. You must be clear that while the trajectory of change will be the same for each country the timescales will be different. You must, therefore, read the government guidance for the country in which you work.
  • Scotland
  • Wales
  • Northern Ireland
  • Isle of Man
  • Guernsey
  • Jersey
• CSP’s Duty of Care guidance

Regulatory

• HCPC Guidance on Covid-19
• HCPC guidance on Adapting my Practice in the Community
• HCPC Standards of Proficiency– consider how they relate to your practise, and practices

Professional

• Follow the CSP flowchartfor each and every patient attendance and follow-up
• Be clear you are taking a Virtual First approach at all times

Principal/employer

• Demonstrate through documented evidence that you are compliant with Health and Safety at Work Act (HASAWA) in relation to Covid-19 and your duty to provide asafe workplace in the United Kingdom and Northern Ireland.
• Demonstrate through documented evidence that you are compliant with Health and Safety Executive (HSE) requirements in relation to Covid-19 and your duty to provide a safe workplacein the UK and Northern Ireland.
• Put procedures in place to manage staff self-monitoring of Covid-19 symptoms including any need to self-isolate
• Put procedures in place to manage staff access to testing for Covid-19
• Implement Standard Operating Procedures (SOPs) that clearly demonstrate how you are:
  • Identifying risk
  • Managing risk
  • Establishing a safe environment
• Implement Standard Operating Procedures (SOPs) to show that:
  • The clinic has a decision-making process for offering virtual and/or face-to-face appointments
  • The clinic has robust record keeping procedure for both virtual and face-to-face appointments
• Implement a system to identify which patients are in the clinic at any one time should the need for contact-tracing arise

Factor 2: Risk assessment of the working environment for which you are responsible*

A full risk assessment of the working environment for which you are responsible must be undertaken and documented, and you must demonstrate that all measures designed to mitigate risk and fulfil legal and regulatory obligations are in place.

• Maximise all opportunities for a remote virtual consultations

Reducing footfall

• Complete a remote triage to screen for Covid-19 symptoms in patient and their household members
• Implement a system to ensure all written communication is sent electronically or by post
• Implement systems and processes to enable electronic prescribing if applicable
• Implement a system for remote review of patients seen face to face if possible
• Place appropriate signage to advise that walk-in services are not available
• Implement a system to ensure appointments are only made by phone/e-mail to minimise contact with reception staff

PPE

• Procure appropriate PPE stock for use by staff
• Consider whether you will ask patients to wear a face-covering

Social distancing

• Government guidance on Social Distancing
• Consider if you can conduct sessions outdoors
• Consider how people enter and leave your premises 
• Consider check-in/check-out procedures to ensure patients are kept 2m apart including cashless payments
• Adapt your waiting rooms to ensure patients do not overlap (1 in 1 out) and people are kept 2m apart
• Consider using floor markings to map out 2m distances
• Consider installing screens and barriers at receptions areas
• Consider how people flow through the clinic, ideally in a one-way system
• Develop a protocol for when patients ask to be accompanied by a relative
• Develop a protocol for when patients ask to have a chaperone and/or translator present
• Enable staff to work remotely whenever possible

Limiting spread

• Place relevant posters in the clinic to raise awareness
• Remove all non-essential items from waiting rooms and consider how you will clean non-disposable items such as clipboards and pens
• Implement hand decontamination facilities (hand-washing and hand sanitiser)
• Develop a policy and protocol for cleaning clinic rooms after each patient
• Train all clinic staff in infection control procedures
• Consider reducing the numbers of appointments offered to allow for cleaning between patients
• Implement policies and procedures for cleaning of phones, desks and other tools used by staff in clinical areas

*If you work in people’s homes or a care home you may not have ultimate responsibility for your work environment but you should still follow guidance on how to work safely.

• How to work safely in domiciliary care
• How to work safely in care homes

Factor 3: Infection prevention and control (IPC) measures

You must follow Public Health England (PHE) Covid-19 infection prevention and control (IPC) guidelines.

• PHE guidance on Infection Prevention & Control for Covid-19
• Develop protocols and systems to manage and monitor and any risks that the clinic environment may pose
• Develop a protocol for cleaning clinic rooms after every patient and other clinic areas as required
• Procure all appropriate cleaning products
• Provide suitable accurate signage on Covid-19 IPC for people coming into clinic
• Implement telephone screening of all patients before their appointment to ensure those with suspected Covid-19 symptoms do not enter the clinic to reduce the risk of transmitting infection to other people
• Train all your staff so that they are aware of and discharge their responsibilities in the process of preventing and controlling infection
• Put a system in place to manage the occupational health needs and/or obligations of your staff in relation to, symptom management and self-isolation  
• Put in place appropriate hand decontamination (hand-washing and hand-sanitising) facilities
• Procure a sufficient supply of relevant PPE suitable for the clinic activities undertaken and patients who may be treated
• Procure  the correct colour-coded waste bags
• Safe management of healthcare waste
• Implement arrangements for the storage of waste bags before collection
• Procure appropriate services to collect and dispose of waste in line with current legislation
• Train all your staff in appropriate hand decontamination processes, PPE requirements and waste collection, storage and disposal

Factor 4: PPE

You must provide and use appropriate personal protective equipment (PPE) and have systems and policies in place that govern its use.

• PHE requirements for PPE in community and outpatient settings for Covid-19 positive or suspected patients. This guidance is the same across the UK. 
• PHE PPE requirements for treating non Covid patients   
• Consider whether to ask patients to wear face coverings if they attend for face to face appointments
• Know the PPE that any non-clinical staff in your practice will be required to use, including for any cleaning that must be undertaken?
• Know how to risk assess for the correct level of PPE at each consultation (see PHE tables)
• Procure all the necessary PPE
• Train yourself and your staff how to don and doff PPE
• Put in place appropriate processes and methods to dispose of PPE
• Develop and document a PPE protocol that includes all the processes and procedures for safe and appropriate management of PPE

If you are working in a domiciliary and or care home setting

• Know how you will transport PPE supplies
• Know ‘sessional use’ of PPE in domiciliary settings and care homes
• Know how you will dispose of PPE
• Have a process in place for hand decontamination

Factor 5: Virtual first approaches

A ‘virtual first’ approach with remote consultations must remain standard practice during this period.

• Initial contact and triage assessment should be conducted via remote means, with opportunities for remote virtual consultations maximised
• Justify and document why a remote consultation is not possible
• Check for Covid-19 High Risk Red Flags of
  • Age > 70
  • BMI >40
  • Weakened immune system
  • Comorbidities that cause immunosuppression
    • Diabetes
    • HIV/AIDS
    • RA
    • Pre-existing infection
    • Alcohol abuse
    • Smoking
    • Long term steroid use
    • People with known cancer diagnosis and currently having active Rx
• Screen for clinical red flags relevant to the body areas in question
• Consider whether you need to send this patient directly to an appropriate urgent/emergency NHS pathway
• Know how to manage the condition using diagnostic safety-netting initially
• Check the relevant timescales for the symptom development of potential differential diagnoses in order to provide timely virtual follow-up
• Organise a timely virtual follow-up to monitor symptom progression where necessary
• Provide clear warning of red-flag warning symptoms that are relevant to the bodily area in question
• Provide clear signposting information to urgent and emergency NHS services
• Provide clear direction about when and how to contact the clinic by phone if symptoms do not improve within the expected timeframe
• Document advice and assessment findings in the patient’s clinical record

Factor 6: Patient risk assessment and clinical reasoning

You must undertake a risk assessment and make a clinically reasoned decision for offering either a face-to-face or remote consultation for each patient and for each of their planned contacts. You must document your rationale for these decisions.

• Undertake a Covid-19 symptom screening check at virtual triage assessment 
• Check during virtual assessment for Covid-19 high-risk red flags:
  • Age > 70
  • BMI >40
  • BAME ethnicity
  • Weakened immune system
  • Comorbidities that cause immunosuppression
    • Diabetes
    • HIV/AIDS
    • RA
    • Pre-existing infection
    • Alcohol abuse
    • Smoking
    • Long term steroid use
• People with known cancer diagnosis and currently having active Rx
• Screen for clinical red flags relevant to the bodily area in question that may direct referral for urgent clinical services or routine imaging diagnostics
• Initial contact and triage assessment should be conducted via remote means. Opportunities for a remote virtual consultation should be maximised, including watchful-waiting
• Know whether the patient has a clinical condition that aligns to NHS clinical priorities (England only) of increasing urgent clinical care provision, routine diagnostics, planned surgery or rehabilitation 
• COVID-19 prioritisation within community health services (England only)
• Identify if your patient is shielding or not
• Ensure you have the appropriate PPE to wear
• Know whether you need to ask the patient to wear a face-covering
• Ensure the patient is able to comply with social-distancing requirements including for those patients who request a chaperone to be present
• Ensure you have appropriate Infection Control and Prevention provisions in place

Factor 7: Patient consent for treatment

You must engage your patients in discussions regarding the rationale for remote or face-to-face consultations. If both parties deem it necessary to proceed with face-to-face care, the patient should be made aware of all current risks associated with this approach. They must give their consent and you must document these discussions and the outcome.

• Understand your duty of care
• Understand the frameworks that guide informed consent
• Document why you have judged a virtual appointment is not indicated for any patients, where this is the case
• Explain the safety measures you have in place to address the risksof Covid-19 in attending a face to face appointment
• Discuss why a F2F appointment is clinically justified where this is the case
• Explain to patients the policy and procedures for attending clinic face to face
• Explain to the patient the close contact that may be required during a F2F session
• Discuss with patients attending face to face that they may be required to attend wearing a face-covering
• Explain to patients the cleaning processes in place in treatment areas
• Document any questions individual patients raise related to attending face to face related to Covid-19
• Train all your staff in appropriate consent for treatment procedures