These are times of precaution and prevention in the spread of the contagion COVID – 19. We need to be cautious but less anxious during these tough times. There are many Non COVID-19 groups of patients who require Physiotherapy and Dental treatment to enhance health outcomes. Hence, physiotherapy and dental services are essential to these groups of patients. As a healthcare community, we have the responsibility to rehabilitate the needs of the population. We cannot outweigh the risk of infections to the healthcare of the community. To provide the essential rehabilitation and dental services and to minimize or avoid the risk of infection there is a need to develop standard operating procedures for physiotherapy and dental practice. Aashas health care has developed a Standard Operating Procedure(SOP) for out-patient physiotherapy clinical practice. SOP designed is in the wisdom of the Aashas senior physiotherapists and Dental surgeon for safe clinical practice, as there are no mandatory protocol nor a supplement to existing SOP designed by various health care organizations. We need an SOP in place to ensure the safety of patients, administrative staff, and healthcare professionals. We have to provide the treatment in a safe environment and adopt safe treatment procedures. There’s a great need for every member of the clinic to be aware of the COVID-19 SOP to clinical practice. The SOP will be reviewed and modified as we continually understand the infection control strategies and the contagion better. The information provided is sourced from WHO, Ministry of health, and population websites.
Standard Operating Procedures
For the outpatient physiotherapy practice
- 2.1 TRIAGE
- 2.2 ROLE OF THE DEPARTMENT’SFRONT OFFICE
- 2.3 WHO DO WE TREAT?
- 2.4 WHERE DO WE TREAT
- 2.5 MACHINES & ACCESSORIES THAT CAN BE USED
- 2.6 PPE FOR THE THERAPIST
- 2.7 TREATMENT PROCEDURE
- 2.8 DURING DENTAL TREATMENT
- 2.9 PROTOCOL FOR DENTAL OPERATORY
- 3.0 BETWEEN THE PATIENTS
- 3.1. AFTER DENTAL TREATMENT
- 3.2 DECONTAMINATION OF THE PATIENT TREATMENT AREA
- 3.3 BEFORE LEAVING THE OPERATORY
- 3.4 FOLLOW UP
- 3.5 BILLING
Disclaimer: This material is for informational purposes only. It does not replace the advice or guidelines from the Government. Aashas makes every effort to provide information that is accurate and timely but makes no guarantee in this regard. You should always refer to the Government guidelines and WHO guidelines. In this nature of COVID-19, these guidelines may become invalid in a short time.
2.1.1 The patient triage is carried out by the screening team (Front office/Clinician) at the entry point of the clinic (Annexure I). The declaration form is handled by the front office/clinician. The process of triage should be carried out at every visit by the patient
2.1.2 Please make a separate file for the declaration form for any future references. The entire form needs to be filled. In the presence of respiratory symptoms, the patient will not be taken for therapy. The positive respiratory symptoms do not declare that a patient is a COVID-19 positive.
2.1.3 The patient is counseled and referred to a nearby fever clinic.
2.1.4 The other patients are taken for the evaluation and treatment
2.2 ROLE OF THE DEPARTMENT’S FRONT OFFICE
2.2.1 Ensure the patient uses their own mask. No mask – No Treatment. The clinic may offer the patient to buy a mask at the clinic.
2.2.2 The team fills in a patient card/assessment sheet (date, referral/walk in, full address, phone number, ID proof)
2.2.3 The patient card is to be given to the physiotherapist (Do not give card/assessment sheet to the patient). Take the patient along to the respective therapist and to the designated area of treatment.
2.2.4 Ensure the seating of the patients and attenders are spaced apart by 6 feet. Attenders may be asked to stay in the waiting area when their support isn’t required.
2.2.5 Attender may not be required for some patients who are independent.
2.3 WHO DO WE TREAT?
Essential Physiotherapy Needs
2.3.1 Some of the Musculoskeletal, Neuro, Paediatric, Sports, Geriatric patients who fall under essential service needs.
2.3.2 Essential physiotherapy needs for the following conditions at OPD set up.
- a. Post-fracture rehabilitation
- b. Post-surgery rehabilitation
- c. People with acute pain who cannot take pain killers
- d. Post-neurological disorders (Stroke, Multiple Sclerosis, Traumatic brain injury, Spinal Cord Injury)
- e. Pediatrics- Children with non-compromised cardiovascular and pulmonary issues, Cerebral palsy GMFCS- 4 & 5 (proceed with caution) Good general health·
- f. Any other conditions at the discretion of the clinician.
2.4 WHERE DO WE TREAT
2.4.1 Exercise therapy area for the exercises which will be disinfected.
2.4.2 The therapy couches and pillows with rexine to be used preferably as they can be disinfected well.
2.5 Machines & Accessories
2.5.1 US Therapy, Hot Packs, IFT (No Vacuum), TENS, Muscle stimulator
2.5.2 Cycle, treadmill, Parallel bar, Physio Ball
2.5.3 Paediatric tools, toys that can be easily disinfected
2.5.4 Patient can use their own tubes and bands
2.6 PPE & Hand hygiene for PHYSIO
2.6.1 Use Mask (N95 where appropriate & 3 Ply surgical mask)
2.6.2 Use face shields
2.6.3 Use disposable gloves in between patients
2.6.4 Wash hands with anti-bacterial hand wash before and after the treatment session (For more information- Annexure-II)
2.7 TREATMENT PROCEDURE
2.7.1 The evaluation and the treatment will be carried out by the same physiotherapist (in case the clinic has more than one physiotherapist) preferably on the same couch.
2.7.2 Use a fresh towel to cover the patient while assessing and treating the patient. The towel is to be left in a designated container after use. Advise the patient to carry his/her own towel if required for the future sessions in a clean bag.
2.7.4 The therapists will use a new set of gloves from the point of evaluation till the end of treatment. Do not touch other surfaces while using the gloves except the exercise tools/machines and patient. Discard the gloves after the treatment ends
2.7.5 Remove the gloves as explained in Annexure II and discard it in the designated bin. Use alcohol-based hand rub/wash your hands before you handle your files/patient cards. Do not hand over the clinic cards/files to the patient 2.7.6 Ensure all the equipment, surfaces that person got in contact to be disinfected as suggested in Annexure III 2.7.7 Avoid using the phone while the gloves are on
2.8 DURING DENTAL TREATMENT
2.8.1 Preparation of patients with antimicrobial oral rinse ( 1.5% hydrogen peroxide or 1 % povidone-iodine solution) to reduce viral load in respiratory and oral secretions. Commercially available betadine mouthwash or gargle has a 1-5% concentration and can be effectively used.
2.8.2 The minimum rinsing time is 1 minute which effectively reduces viral load by 97%. Traditionally used chlorhexidine based oral rinse are least effective against novel coronavirus and should not be used Prefer extraoral dental radiographies, such as panoramic radiography and cone-beam CT over intraoral radiographs as alternatives during the outbreak of COVID-19.
2.8.3 For the treatment of patients with trauma or inflammation without aerosol generation DHCP should use enhanced grade-2 protection. Apply and use the rubber dam with high vacuum suction apparatus Use of waterless and motor-driven handpieces as a replacement for air-driven high-speed water-cooled handpieces Chemo mechanical cavity and access preparation and minimization of handpiece usage.
2.8.4 For endodontic procedures, pulp exposure could be made with chemomechanical caries removal under rubber dam isolation and a high-volume saliva ejector after local anesthesia; pulp devitalization can be performed to reduce the pain.
2.8.5 Use of extraoral suction apparatus with barrier mechanism and perform the dental procedure under indirect vision.
2.8.6 Clear barriers and suction devices are currently being used by ENT specialists and Anesthesiologists for procedures that pose risk of exposure to respiratory and oral secretions.
2.8.7 Special handpieces with anti-retraction mechanism and backflow preventive mechanism can reduce the risk of clogging and harboring microbes causing a risk of cross-transmission Minimal use of ultrasonic scalers for periodontal procedures and maximizing the use of aerosol freehand instruments When using high speed turbocharging handpieces and oral ultrasonic scalers DHCP should use enhanced grade-3 PPE.
2.8.8 Keep the aerosol generating procedure to minimum and if absolutely required it should be scheduled as the last procedure so that post procedure the whole operatory can be disinfected and prepared for next patient Installation and use of HEPA air filters in procedure room if feasible use of disinfectants in dental water supply system 0.01% Sodium hypochlorite.
2.9 PROTOCOL FOR DENTAL OPERATORY
3.0 BETWEEN THE PATIENTS
Allow at least 20 minutes of off time between patients. SARS COV-2 virus has been shown to be present in air for up to 15 minutes. Allow time for the virus to settle on surfaces that can be disinfected. Once the oral treatment is completed, each chair used by the patient should be wiped with 75% ethanol or 2,000 mg/L disinfectant containing effective chlorine Follow all the IPC protocols Use and change disposable barriers for dental chairs, headrests, and frequently touched parts as light handles between patients Clean and disinfect the taps, drainage points, splashbacks, sinks, spittoons, aspirating units at the end of each session Disinfect the PPE between patients with alcohol-based sanitizers spray. Keep a separate area for donning and doffing the PPE. Visibly soiled PPE when used in Aerosol generating procedure should be immediately disinfected and prepared before it can be used again for the next patient.
3.1. AFTER DENTAL TREATMENT
Post-op instructions should include a reminder to report any signs or symptoms of COVID-19 within the next 14 days. The patient should use predetermined transport routes to minimize exposure for staff, other patients and visitors, Patient using a medical mask and follow the ‘No Touch’ principle (patient is not permitted to touch anything on the way to out of the treatment center). Dental auxiliaries should follow the principle of Decontamination with standard guidelines from manufacturers for every dental equipment. Treating dental personnel (dental surgeon and specialist) can go for doffing procedures. Any of the free dental health care workers (i.e. dental auxiliaries) can help the patient to proceed forward toward the service fee management area.
3.2 DECONTAMINATION OF THE PATIENT TREATMENT AREA
3.2.1 A time interval of 15 minutes must pass after the patient has left the operating room before cleaning and disinfection can start. Waste management must follow well-defined rules. Cleaning should be focused on the physical removal of foreign material (e.g., dust, soil) and organic material (e.g., blood, secretions, excretions, microorganisms). Cleaning physically removes rather than kills microorganisms. Regular cleaning is accomplished with water, detergents, and mechanical action. The basic principles of cleaning and disinfecting apply to all patient care areas. Where possible, dedicate cleaning supplies in higher risk areas (e.g., isolation, delivery, and operating rooms). Spraying of disinfectants is not recommended. If such spray is used, sufficient time should be allowed to decant the air droplets into the floor. It is recommended to use disinfectant spray and fumigation at the end of the day.
The amount of time required to wait after completion of AGP depends on room ventilation specifications. If you are unsure as to your operatory ventilation specifications, the recommendation is to allow 207 minutes for aerosols to settle before disinfecting the operatory. (Centers for Disease Control and Prevention 2003
3.3 BEFORE LEAVING THE OPERATORY Remove the protective mask/goggles and protective clothing when leaving the clinic; perform personal hygiene after work and have situational awareness about what your hands touch. Frequent handwashing and the use of alcohol-based hand sanitizer are absolutely a must.
3.4 FOLLOW UP
3.4.1 Follow up dates to be mentioned in the patient card/assessment sheets.
3.4.2 The treatment sessions can be regular.
3.4.3 The screening to be carried out during the next follow up
3.5.1 Payment preferably through online methods
3.5.2 Hand wash or use hand rub after collecting a cash payment
Note: If the patient has arrived from a containment zone or visited a containment zone in last 14 days, please advise him/her to visit the OPD after 14 days. If the body temperature is above 100-degree Fahrenheit avoid the treatment. If the patient has taken paracetamol avoid the treatment. If the patient has fever, cough, respiratory symptoms, request them to visit the fever clinics.
ANNEXURE – I SELF DECLARATION FORM ANNEXURE- II
Place the mask carefully, ensuring it covers the mouth and nose, and tie it securely to minimize any gaps between the face and the mask. Avoid touching the mask while wearing it.
- a. Remove the mask using the appropriate technique: do not touch the front of the mask but untie it from behind. After removal or whenever a used mask is inadvertently touched, clean hands using an alcohol-based hand rub or soap and water if hands are visibly dirty.
- b. Replace masks as soon as they become damp with a new clean, dry mask.
- c. Do not re-use single-use masks.
- d. Discard single-use masks after each use and dispose of them immediately upon removal.
- e. Staff – Front Office: 3 Ply Surgical mask, Face shield.
- f. Physiotherapists : 3 Ply Surgical mask, face shield, PSI Apron ( Knee length/ Full length). N95 may be used while treating the areas like shoulder, neck, and face, Nitrile gloves.
- g. Mask management: For any type of mask, appropriate use and disposal are essential to ensure that they are effective and to avoid any increase in transmission. The following information on the correct use of masks is derived from practices in health care settings.
- More information on usage of masks: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-andanswers-hub/q-a-detail/q-a-on-covid-19-and-masks Method reusage of N95 mask – https://www.youtube.com/watch?v=b4vF_B9FFxk&feature=youtu.be Information on donning and doffing of PPE : https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf
Note: Gloves can give a false sense of security. You can easily contaminate yourself with gloves if you don’t use them properly Please watch and relate the shared information to your clinic environment. The video is about cross-contamination while using gloves by Nurse Molly Likely https://www.youtube.com/watch?v=dXU6VjjLFsw
ANNEXURE – III
Hygiene and Disinfectants Follow WHO guidelines of hand hygiene, and 5 moments of hand hygiene. https://www.who.int/gpsc/5may/tools/who_guidelines-handhygiene_summary.pdf Information of Disinfectants: https://www.sciencealert.com/here-s-the-expert-advice-on-which-cleaning-productstouse-against-coronavirus Guide to local production of hand rub https://www.who.int/gpsc/5may/Guide_to_Local_Production.pdf
- Dr. Amir Neupane MPT, MSK & Sports Medicine
- Dr.Anamika Rajbhandari, BDS
- Contributed by:- Dr. Dipika Hada BPT, MPH / Dr.Riya Shrestha, BDS Dr. Sabita Prajapati BPT/ Dr.Suvani Baral, BDS Dr. Januka Karki BPT/Dr. Neelazma sthapit, BDS Dr. Anju Shrestha BPT/ Dr. Shakila Khanal, BPT