New Protocols for In-Person Clinical Operation for Health Professionals

WorkSafeBC has just released what will be required of regulated health professionals such as myself, as a Dietitian to safely run an in-person clinical practice in British Columbia during the ongoing Covid-19 outbreak, and it is much more involved than I imagined when I wrote a recent article. As well, these protocols are in addition to the obligations required prescribed by our professional college, as well as to abide by any relevant orders, notices, or guidance issued by the provincial health officer, and the relevant health authority, in my case Fraser Health.

The WorkSafeBC protocols include sections on Understanding the Risk, Selecting Protocols for the Workplace, as well as detailed Protocols for Health Professionals.

Understanding the Risk

The WorkSafeBC website outlines that the virus that causes COVID-19 is spread in several ways, including through droplets when a person coughs or sneezes, and from touching a contaminated surface before touching the face. It is outlined that risk or person-to-person transmission is increased the closer a healthcare professional comes to other people, the amount of time a healthcare professional spends near them, and the number of people seen by a healthcare professional.  The site emphasizes that “physical distancing measures help mitigate this risk”. The WorkSafeBC website also emphasizes that the risk of surface transmission is increased when many people contact same surface, and when those contacts happen in short intervals of time, therefore “effective cleaning and hygiene practices help mitigate this risk”[1].

Selecting Protocols for the Workplace

The WorkSafeBC website notes that there are different protocols which offer different levels of protection and emphasize that “Wherever possible, use the protocols that offer the highest level of protection and add additional protocols as required”[1].

WorkSafeBC Covid-19 Hierarchy of Controls [1]
Elimination – first level protection –  Limit the number of people in the workplace  by implementing work-from-home arrangements where possible, limiting occupancy, rescheduling work tasks, or by other means. Rearrange work spaces to ensure that health professionals are at least 2 m (6 ft) from co-workers, customers, and other members of the public.

Engineering controls – second level protection : if it is not always possible to maintain physical distancing, then install barriers such as plexiglass to separate people.

Administrative controls – third level protection – WorkSafeBC encourges the establishing of clinic rules and guidelines, such as cleaning protocols, making sure there is no sharing of equipment, and implementing one-way doors, or walkways, in order to minimize risk.

Personal Protective Equipment (PPEs) – fourth level protection – If the first three levels of protection aren’t enough to control the risk, WorkSafeBC recommends considering the appropriate use of non-medical masks, and to be aware of limitation of non-medical masks to protect the wearer from respiratory droplets.

Protocols for Health Professions

The list of protocols for healthcare professionals is extensive and includes several categories, including those for;

(a) hygiene, cleaning and disinfection – Ensure adequate hand washing facilities are available, and provide approved alcohol-based hand sanitizers,
Encourage staff and clients to practice hand hygiene upon entering and exiting the clinic. Identify all common areas such as clinical space, washrooms, etc. and high contact surfaces such as door handles, stair rails and develop and implement a cleaning and disinfection schedule and associated procedures. Increase cleaning and sanitizing of shared equipment and facilities (e.g. scales, washrooms). Develop and implement protocols for sanitizing treatment areas and equipment to prevent surface transmission between clients. Ensure safe handling and effective application of cleaning products.

(b) modifying staff areas and workflow – Work remotely whenever possible, develop and enforce policy that staff stay home when sick, hold meetings virtually through use of teleconference or online meeting technology and where in-person meetings are required ensure people are positioned at least two metres apart. Consider staggering start times / appointment times to reduce the number of people in the workplace at a given time. Minimize the number of co-workers that staff are interacting with, prioritize the work that needs to occur at the workplace in order to offer services. Minimize the shared use of equipment where possible, consider the requirement for staff to have dedicated work clothes and shoes, provide a place for staff to safety store their street clothes while working and change in/out of clothes to prevent cross-contamination upon entry and exit. Consider adjusting the ventilation such as increasing the amount of outdoor air while maintaining the indoor air temperature and humidity at comfortable levels for building occupants. 

(c) scheduling appointments and communicating with clients – Determine how many clients can be within the clinic at a given time while maintaining at least two metres of physical distance and do not book appoints above this number. In order to accommodate physical distancing, appointment times may need to be staggered. When speaking with clients during scheduling and appointment reminders, ask clients to consider rescheduling if they become sick, are placed on self-isolation, or have travelled out of the country within the last 14 days and attending appointments alone where possible, and not bring friends or children. Consider emailing the client forms that need to be filled out so clients can complete them prior to arriving, and clinics with a website should consider posting information on modifications made to the location and appointment visit procedures.

(d) reception – Post signage at the entrance and within the clinic to assist with communicating expectations, such as hand hygiene, physical distancing, respiratory etiquette, reporting illness or travel history, occupancy limits and no entry if unwell or in self-isolation. Consider placing lines on the floor to mark a two metres distance from the reception desk. Consider use of a transparent barrier such as a plexiglass shield around reception desk, when there is insufficient space to maintain two metre distance between staff and clients. Screen all clients when they check-in for their appointment by asking if they have symptoms associated with COVID-19, have been advised to self-isolate, or have travelled outside of Canada within the last 14 days. Clients that respond in the positive should be asked to leave and reschedule the appointment when deemed clinically appropriate. During transactions, limit the exchange of papers such as receipts if possible and where possible, payments should be accepted through contactless methods.

(e) waiting area – Arrange the waiting area in a way that allows at least two metres of physical distance between each client and consider removing extra chairs and coffee tables from the area to support this. Remove unnecessary items and offerings such as magazines etc. and use disposable cups or single- use items where necessary for beverages. Instruct clients to arrive no more than five minutes before their expected appointment. Where room size or layout presents challenges to physical distancing, consider alternative approaches, such as asking clients not to enter the clinic until they receive a text message or phone call to advise that their appointment can start.

(f) provision of health servicesConduct appointments virtually where clinically appropriate, conduct a point of care assessment for risk of COVID-19 for every client interaction and health services should not be performed on ill or symptomatic clients. Where the client requires timely treatment, ensure PPE is used in accordance with BC-CDC guidance. When possible, the clinical staff should position themselves at least 2 metres from the client and where physical distancing cannot be maintained consider the use of barriers and masks to reduce the risk of transmission. Clients should be required to wear masks for services in order to protect workers and workers should also wear masks to protect clients. Consider treating only one client at a time to minimize risks associated with moving between two or more clients, ensure clients are positioned at least 2 metres apart and shared equipment is cleaned and disinfected between uses by clients. If products / equipment is shared, they must be cleaned and disinfected between uses. Practice effective hand hygiene after each client by washing hands with soap and water or using an alcohol-based hand sanitizer approved by Health Canada. Where feasible, workers should avoid sharing equipment or treatment rooms and treatment rooms should be allocated to a single worker per shift.

(g) preparing for the next appointment and the end of the day – Ensure waiting and treatment areas and equipment are sanitized to prevent surface transmission between clients. Commonly touched surfaces and shared equipment must be cleaned and disinfected after contact between individuals even when not visibly soiled. Towels or any other items contacting a client are to be discarded or laundered between each use. Change into a separate set of street clothes and footwear before leaving work and work clothing should be placed in a bag and laundered after every shift. Shower immediately upon returning home after every shift.

As well, the WorkSafeBC website has protocols for documentation and training of staff, as well as links to the various professional colleges for health professionals to check additional requirements for their profession.

The Effect of these Necessary Protocols

These enhance protocols take time away from healthcare professionals being able to schedule actual clinical appointments. They require PPEs to be available and provided when necessary, as well as require extra time and labour for cleaning and disinfecting waiting areas, office equipment and washrooms, and to dispose of the waste. As much as we would all like things to “return to normal”, there is the need to accept that for now, this is the “new normal”.

For clinical practices that require a clinician to touch a client in the provision of services, such as in dentistry or registered massage therapy or physiotherapy there is no choice, but this is not the case in my practice. Thankfully, we are living in an era where there is secure video conferencing available which is ideal for the services that I provide as a Registered Dietitian, and is recommended by WorkSafeBC as the first approach when possible in the provision of health services.

Use of professional HIPAA and PIPEDA compliant telemedicine software

I have been providing Distance Consultations for over a decade; which are virtual ‘face-to-face’ visits that are functionally indistinguishable from the in-person services I provided prior to Covid-19. They are a very efficient use of my client’s time, as well as my own, and no PPEs are required, no disinfecting or extra hand-washing, or sanitizing of waiting areas, office space and washrooms between each client, and appointments are not spread out through the day due to the need to carry out decontamination tasks between clients.

I use secure HIPAA & PIPEDA compliant telemedicine software – with no download required.

During virtual appointments my clients and I see each other’s faces when we meet, and can comfortably talk, laugh and even sneeze without concern, and weight obtained from people’s own scales is more than adequate for the types of clients I see — and I provide my clients with written instructions for measuring their waist circumference the same way I would do it if they were in my office.

More Info?

If you would like more information about the different type of Dietetic services I provide, please have a look under the Services tab or in the Shop. If you have any service-related questions please feel free to send me a note using the Contact Me form above and I will reply as soon as I can.

To your good health!

Joy

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References

WorkSafeBC – Health professions: Protocols for returning to operation,  https://www.worksafebc.com/en/about-us/covid-19-updates/covid-19-returning-safe-operation/health-professionals

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