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FAQs: RMTs’ return to practice, interim guidelines (COVID-19)

CMTBC posts Interim Guidelines for RMTs’ Return to Practice in the context of COVID-19.

RMTs’ requests for interpretation of the Guidelines are summarized here, in “Frequently Asked Questions” (FAQs). CMTBC updates this webpage on a regular basis.

RMTs can contact practiceadvice@cmtbc.ca with questions about the FAQs below, or with other questions related to the Interim Guidelines for Return to Practice.

Reminder: please call 8-1-1 for health-related questions. The phone number for non-medical information about COVID-19 is 1-888-COVID19 (1-888-268-4319) 7.30 am-8pm, 7 days a week. Please consider book-marking BCCDC resources at a glance in your browser. 

FAQ POSTED ON NOVEMBER 17, 2020

It sounds like masks are mandatory now, is that correct?

CMTBC follows the guidance and direction of public health authorities; in BC, that means Dr. Bonnie Henry and her team at the Office of the Provincial Health Officer, and the BC Centre for Disease Control. On November 16, 2020, Dr. Henry clarified her guidance on the use of masks; please read her words on the BC Government News website. CMTBC strongly recommends that people follow Dr. Henry’s expectation that masks are worn indoors, including in the treatment room. In circumstances where a mask cannot be worn for any reason, RMT discretion is required, including clear communication with the patient and consideration of what accommodations it may be possible to provide.

FAQs POSTED ON NOVEMBER 4, 2020

Now that we have 48 hour pre-screening, are we no longer allowed to book patients the day before an available appointment? (note: the Interim Guidelines were amended on Nov. 4, 2020, to 24 to 48 hours pre-screening)

Context for the reply: CMTBC’s Guidelines are for all registrants; some work as employees and do not necessarily have established therapeutic relationships with their patients. The Guidelines must be interpreted and applied by each RMT to their own practice.

Regarding the 48 hour pre-screening, in response to RMTs’ feedback, CMTBC has amended the Interim Guidelines to read 24 to 48 hours.

On November 2, 2020, when CMTBC’s pre-screening timeframe changed from one day to two days, the intention was not to make it harder for RMTs to manage their practice, but to provide greater flexibility. CMTBC is mindful that patients will have different levels of awareness when it comes to COVID-19 precautions, and may not necessarily self-monitor to the degree required to be able to safely receive health services. RMTs are highly sensitized to COVID-19 precautionary measures; some patients are not. Further, many RMTs are now treating new patients; this was not the case in the spring of 2020, when most RMTs turned down appointments from new patients.

Contact tracing has advanced since early 2020, and public health authorities have adapted their approach. CMTBC has consistently followed the guidance of public health authorities.

On Wednesday November 4, 2020, CMTBC amended the Interim Guidelines’ pre-screening to read that 24 to 48 hours prior to a requested appointment, a patient must complete the BC COVID-19 Self Assessment Tool and if required to book a COVID-19 test and/or self-isolate and/or call 8-1-1, they cannot book an appointment for massage therapy until they are cleared by public health.

Pre-screening provides the patient with early notice that they need to take precautions (e.g., self-isolate until public health clears them of COVID-19 risk).

Advance pre-screening also provides the RMT with information that allows for booking, cancellation, tentative booking, or whatever the RMT has determined is the best way to manage their practice in the fluid environment presented by COVID-19 management and risk mitigation.

The 24 to 48 hour pre-booking window provides an opportunity for the RMT to cancel the appointment if necessary and bring in a wait-listed, pre-screened patient for the available booking.

RMTs are reminded that there is an element of professional discretion in application of the guidelines, because not all RMT practices are the same, or even similar.

The RMT’s focus should be on the critical importance of pre-screening, and on communicating with patients (and potential patients) the rationale and need for honest and reliable pre-screening. CMTBC’s Interim Guidelines are designed to help RMTs and the public understand that a therapeutic alliance is a two-way street, based on communication, trust, and informed consent.

If someone does not let us know about their BC COVID-19 Self-Assessment Tool results until the day before, do we have to cancel their appointment?

It is at the RMT’s discretion. Factors that may come into consideration include how well the RMT knows the patient, how recently treatment was provided (a week ago? A month? Pre-pandemic?), if the patient is new to the RMT’s practice, how the RMT communicates the pre-screen requirement (personally, by phone, via an online booking app, other). The goal is to minimize risk of COVID-19 transmission; each RMT is best able to judge whether or not to book or cancel an appointment.

Could you clarify if same-day bookings with screening is allowed?

CMTBC suggests “extreme caution with respect to same-day appointments” – please see the October 6, 2020 FAQ for further information.

FAQ POSTED ON OCTOBER 27, 2020:

A patient tested positive for COVID-19.  Can I still go to work? An earlier FAQ (May 29, 2020) says we have to close the entire clinic – have you updated this information?

The RMT who treated the patient should call 8-1-1 immediately and follow the advice provided by public health, which is specific to your location and the requirements of contact tracing.

FAQ POSTED ON OCTOBER 6, 2020:

A member of my family is sick. Can I still go to work?

CMTBC follows the direction of public health authorities for all health related COVID-19 questions.

Where a member of the RMT’s family (or close connections who share the home with the RMT) becomes sick, the RMT should contact 8-1-1 for guidance related to the need to self-isolate, get tested or monitor symptoms.

I have experienced a number of same-day cancellations due to a patient’s sickness or symptoms, that leave openings in my schedule. Can I fill these openings with patients from my cancellation list without having completed the required pre-screening? [updated November 4, 2020]

The Interim Guidelines for Return to Practice stress the importance of ensuring that all who enter an RMT’s place of work are healthy.  It is an RMT’s responsibility to minimize the risk of transmission of the novel coronavirus. Same-day appointments are not consistent with CMTBC’s Interim Guidelines Section 1: Pre-screening.

Let’s take a look at why the College recommends extreme caution with respect to same-day appointments.

Pre-screening allows an RMT to inform patients of safety protocols and gain assurance that all those who enter an RMT’s place of work will consider the protocols, ask questions about the rationale for them, provide their informed consent to the safety protocols, and comply when they arrive for their massage therapy appointment. By asking patients to take the BC COVID-19 Self-Assessment 24 to 48 hours before an appointment, an RMT engages their patient in a process of decision-making that impacts not just themselves, but all those with whom the RMT and the patient interacts.

Upon a patient’s arrival at the RMT’s place of work, repeating the COVID-19 self-assessment ensures that no new symptoms have developed, thus minimizing risk of transmission of the novel coronavirus. Pre-screening is always advisable for new patients, if the RMT is accepting new patients. CMTBC has heard from RMTs who have a wait-list of patients requiring subsequent appointments. Some RMTs ask wait-listed patients to do daily self-screening, so they fall in the category of having completed COVID-19 pre-screening, if a same-day cancellation/appointment becomes available.

No matter how the pre-screening and pre-appointment screen is completed, RMTs are reminded that the point is to have an authentic discussion that provides both the patient and the therapist an opportunity to choose to proceed, or to step back from treatment that day.

My patients have requested heat during treatments. Am I able to use a thermophore, table warmer or other thermal agents during treatment? [updated November 2, 2020]

Short answer, yes. Regular cleaning and disinfection minimize the risk of transmission of the novel coronavirus.

The College understands that many RMTs have successfully incorporated vinyl covers for heating devices. This is acceptable, where the vinyl (or other) cover of the heating devices (such as a thermophore) provides a surface that can be thoroughly cleaned after each use. RMTs need to consider if the heating (or cooling) agent and any high-touch surfaces associated with its use can be properly sanitized between patients. This includes not only coverings, like pillowcases and towels (e.g., some RMTs use multiple layers of towels around a heating device, and launder the towels after each use), but the thermal agent itself. A thermal agent that cannot be properly sanitized must not be used.

FAQ POSTED ON JULY 13, 2020:

I want to travel outside of BC – carefully, of course, minimizing contacts with others – and so do my patients, but CMTBC’s Interim Guidelines say that patients must confirm they haven’t travelled outside of BC in the previous 14 days. Why is CMTBC setting a higher restriction than BC’s Restart Plan? [updated November 2, 2020]

While Phase 3 allows for smart, safe and respectful travel within BC, caution is still needed. BC’s Provincial Health Officer, Dr. Bonnie Henry said in a news conference in July 2020, “The whole plan… is making sure that we don’t ever have to go back to shutting everything down like we did in March…  We know so much now about being able to control … the spread [of COVID-19] in the community…”

CMTBC’s pre-screening guideline states that patients will be asked if they have travelled outside of BC in the previous 14 days. If they have travelled outside of BC, they need to tell you about it. This creates an opportunity for you to have an important conversation about the nature of their safety protocols at a time when patients are likely to have increased their level of contact with people outside their immediate “bubble”.

RMTs play an important role in controlling the spread of the COVID-19 virus. Part of this role includes meaningful patient screening.

Discussing travel outside of BC is one way that you keep the discussion relevant, even if you – and your patients – feel there is a minimal risk of transmission.

BC’s Centre for Disease Control provides detailed information on what to consider when travelling; for example:

  • Travel within BC: “Know before you go”. Some towns, communities and regions are eager to welcome BC visitors with safety measures in place while others might be hesitant to welcome outside visitors at this time.
  • Travelling between provinces: British Columbians travelling to other provinces or territories should check the region’s public health information to find out about local travel restrictions and follow public health guidance. The BC Government website offers information on inter-provincial travel.

It is important to consider the added potential risk of viral transmission that travel creates simply by coming into contact with more people.

BCCDC Public Exposures lists flights, places and events with confirmed cases of COVID-19.

FAQ POSTED ON JULY 7, 2020:

Am I required to add the COVID-19 pre-screening and in-person screening results to the patient’s health record? A potential patient completed my COVID-19 screening and won’t be coming in for treatment, and asks that the results be deleted. [updated November 4, 2020]

Screening for COVID-19 is the highest-priority safety protocol in CMTBC’s Interim Guidelines because it ensures that only healthy people enter your practice environment. Both pre-screening (ideally, by phone 24 to 48 hours in advance of an appointment) and in-person screening (immediately prior to treatment) are safety measures that minimize the risk of transmission of the COVID-19 virus. This question asks if the screen results are also necessarily part of the patient health record, as per CMTBC’s Bylaws.

RMTs apply the COVID-19 screens in varied ways that include question/answer over the phone or having the patient complete BC’s COVID-19 Self-Assessment via an app downloadable on the patient’s smart phone. Not all COVID-19 screening results end up as an electronic or paper record.

For many RMTs who use electronic booking systems, the screening results are built into the RMT’s intake system, and in these cases the results become part of the file for that individual.

The College has been asked if a potential patient completes an RMT’s COVID-19 pre-screening and does not proceed with treatment, can their COVID-19 screening answers be destroyed? The answer to this question is not found within College Bylaws because the COVID-19 screen is not necessarily related to massage therapy. However, the screen results are personal information and handling of this information is addressed by the Personal Information Protection Act (PIPA). RMTs are advised to contact the Office of the Information and Privacy Commissioner for BC to request guidance about retention and destruction of personal information that does not become part of a patient health record with the RMT.

For patients who received massage therapy from an RMT prior to COVID-19, the pre-screening and in-person screening results are personal information, but they do not necessarily form part of the patient record that an RMT must retain for 16 years as per College Bylaws. In most instances the information provided in the COVID-19 screen does not directly relate to elements of the treatment plan for which a patient seeks massage therapy. It is possible in some cases that there may be overlap between screening results and the information required in a patient record; in such cases, the RMT should ensure that the clinical record contains any medical history provided by the patient that may be relevant to that patient’s treatment.

FAQs POSTED ON MAY 29, 2020:

My patient asked if she has to cancel her appointment, because the BC COVID-19 Self-Assessment Tool advised her to self-isolate. She has a mild headache and runny nose which she says is due to seasonal allergies. Do I have to cancel the appointment? [updated October 27, 2020]

The short answer is “yes”, but there is room for the RMT to apply clinical reasoning and professional judgment in consultation with public health, 8-1-1.

CMTBC’s Interim Guidelines for Return to Practice include a pre-screening requirement that assesses the health of patients who wish to book with RMTs, and of RMTs and their staff.

RMTs are accustomed – pre-COVID-19 – to treating patients with headaches, allergies, muscle aches, and underlying health conditions. Some of these symptoms and conditions are exacerbated by seasonal allergies, and in other circumstances, seasonal allergies alone can result in some of the symptoms listed by the COVID-19 assessment tool.

RMTs have asked the College, “do I have to turn away every patient who has mild cold-like symptoms?” While it may be difficult to accept, under present circumstances the answer is “yes” if you don’t have a previous therapeutic relationship with the patient, and don’t know their seasonal patterns of wellness and discomforts. If you are familiar with the patient’s seasonal fluctuations and know about their allergies, and can confirm that their symptoms are limited to the patient’s most common allergy-symptoms, you may choose to accept the appointment under enhanced protocols (e.g., require mask use even if you don’t regularly do so).

Advise the patient to call 8-1-1 to explain their results and their discussion with you, and have the patient ask for advice from the provincial health authority.

We appreciate that in many cases, perhaps even most, the patient may have nothing more than a seasonal allergy. But this cannot be assumed to be true in every case, and the assessment tool asks about “symptoms”, not about patient or RMT assumptions about the most probable underlying reason for those symptoms. While it may be disappointing for the patient to have to wait a bit longer to receive treatment, the priority has to be safety, including the safety of the RMT’s other patients. Open and honest communication with the symptomatic patient about the reasons for deferring treatment, and stressing the need to avoid risk and to follow public health guidance, may be helpful.

My clinic has developed a version of BC’s COVID-19 Self-Assessment Tool which is included in an email sent to patients as part of the pre-screening. This is good enough, right?

The short answer is, it depends.

If you follow-up the pre-screening email with a phone call to discuss the patient’s answers to the COVID-19 Self-Assessment Tool, you may learn that the patient has a headache which is why he booked a massage therapy appointment. Further, you may know the patient’s pattern of headaches, and you may also know underlying conditions that exacerbate the headache presentation at this time (e.g., increased desk work with online meetings as a result of isolation measures). A headache is a positive sign in the online tool, which results in the instruction, “Please get assessed for a COVID-19 test, and self-isolate for at least 10 days.”

The RMT’s professional judgment may help put the patient’s concerns at ease, by advising the patient to call 8-1-1 and discuss their result. The 8-1-1 advisor may request that the patient come in for COVID-19 testing, or agree that the massage therapy can go ahead. Either way, the 8-1-1 consultation determines the next step.

Do I have to get written consent to treat every time my subsequent patient receives massage therapy in the new COVID-19 environment, or just the first time?

Written consent must be renewed in your presence when your patient first returns to massage therapy in the COVID-19 environment. This is consistent with CMTBC’s Consent Standard of Practice which states in Section 10 : “An RMT renews consent when the treatment approach changes for any reason, and revises the treatment plan or creates a new one.”

The treatment approach has changed to include risk mitigation measures for transmission of COVID-19. Take the opportunity to invite your patient to ask questions and engage with your new protocols for everyone’s safety.

For subsequent treatments, ongoing consent is verbal (and charted by you), as before, until such time as there is a significant change in your treatment approach or treatment plan.

Please make sure you differentiate between consent and a waiver. CMTBC’s FAQs posted on May 20, 2020 address this issue.

I would like to provide massage therapy to front-line health care workers who have been in COVID-19 wards, but I’m not sure what to do. What are the requirements? [updated November 2, 2020]

RMTs must apply the assessment tool provided by the BC Centre for Disease Control, Exposures and return to work for health care workers, in consultation with the health care worker. Spend time on the BCCDC webpage and read the fine print of the assessment tool (the diagram with green, yellow, red risk indicators), and ask your patients questions to help you determine the risk level.

CMTBC’s Interim Guidelines state that if the health care worker falls into the “Low Risk” category, treatment can be provided if the patient wears a surgical or medical mask which they will have access to because they use PPE in their work environment.

Why does CMTBC refer to WorkSafeBC in the interim guidelines?

WorkSafeBC oversees practice environments with employees covered by WorkSafeBC. BC’s Restart Plan relies on collaboration between all provincial government ministries, WorkSafeBC, BC’s Provincial Health Officer Dr. Bonnie Henry, and the BC Centre for Disease Control.

As the regulatory body for RMTs, it is important that CMTBC draws your attention in the interim guidelines to WorkSafeBC requirements for those RMTs whose practices must meet WorkSafeBC requirements. Further, WorkSafeBC requirements are best practices during COVID-19 measures, and your patients will be familiar with these practices in other activities of daily living, including grocery shopping.

My patient whom I treated a few days ago called to say they are sick with symptoms of COVID-19 (or, are awaiting a COVID-19 test, or, have tested positive for COVID-19). Is it just me who needs to stop treating patients, or does the entire clinic need to close? [updated October 27, 2020]

In this scenario, the patient receiving treatment at the clinic may have spread the virus to any person with whom they came into contact at the clinic. Or, the patient may have come into contact with COVID-19 after being at your clinic.

You should contact public health at 8-1-1 for guidance and direction on how to proceed. Make sure you have as much information from your patient as possible, to help you answer questions from public health when you call 8-1-1.

BC’s Centre for Disease Control provides information about contact tracing on their website.

FAQs POSTED ON MAY 20, 2020:  [updated November 4, 2020]

For the pre-screening requirement to confirm the patient’s health (and my own), can I send an email 24 to 48 hours before the appointment, instead of making personal phone contact? Or can our clinic receptionist make the phone contact before a patient comes to the clinic for an appointment?

It’s not a yes or no answer, and this is why: pre-screening is critical to safe delivery of massage therapy in this time of COVID-19; it is not a rubber stamp. Pre-screening allows you to welcome patients whom you believe to be healthy into your treatment setting, and lets you reassure your patients that your health is good and that your risk to them is minimal. A meaningful, honest discussion about your own health and that of your patient is part of the screening process.

We understand some RMTs are completing the pre-screen by email or having a receptionist complete these duties. While this is not ideal, it is acceptable provided that the RMT oversees the content and training of a receptionist in the pre-screen process, and has an honest, comprehensive discussion with the patient in person on their arrival. While it may not always be possible to provide a private space to have a confidential check-in with a patient, the RMT should confirm the patient’s good health on arrival and prior to entering the treatment room where physical distancing is not possible.

Do I have to pre-screen before every treatment, once a patient has returned to my practice and is receiving treatment on a weekly basis?

Yes. You cannot control your patient’s behavior between appointments – where they have been, whom they have seen, nor their possible risks of infection – and you are wise to maintain the pre-screen protocol.

Remember that the pre-screen is a two-way discussion – the patient deserves to know your movements that fall outside of recommendations by public health authorities, in the same way that you are entitled to know the patient’s movements that fall outside of recommendations by public health authorities.

I live and work near the BC/Alberta border – many of my patients travel back and forth all the time. The required BC COVID-19 Symptom Self-Assessment Tool screens for travel outside of Canada, but CMTBC’s Guidelines say in the pre-screening section that patients should tell me if they have travelled outside of BC in the previous 14 days. Could you clarify what I’m supposed to do? [updated November 2, 2020]

Dr. Bonnie Henry, BC’s Provincial Health Officer, continually asks British Columbians to stay close to home, and engage only in essential travel.

BC Centre for Disease Control’s webpage on travel provides the following guidance:

Outside of Canada:

“Unless you are exempt, all travellers arriving in B.C. from outside of Canada are required by law to self-isolate for 14 days and complete a self-isolation plan … More information is available on the BC Government website for returning travellers.”

Outside of BC:

“British Columbians are encouraged to stay in their own communities and avoid non-essential travel at this time. As the province moves into phase 2 and phase 3 of B.C.’s Restart Plan, more guidance on travel within the province will be provided. This includes trips to smaller communities, cabins and campgrounds.”

There is an element of discretion for RMTs to consider how well they know the patient, when the question about travel about BC is asked. CMTBC’s Interim Guidelines state, “Patients must confirm they have not travelled outside British Columbia in the previous 14 days”. This gives you the opportunity to clarify where the patient has been.

If the patient has visited an area where the incidence of COVID-19 is high, you can factor that into your risk assessment.

The 14 day period is specified in CMTBC’s guidelines because that is generally the timeframe when symptoms present, post-infection.

If you know your patients and the incidence of COVID-19 in the community they visit in Alberta is low or non-existent, you can modify this in your pre-screen. It’s included as a requirement to draw attention to the increased risk of travel, and to provide RMTs an opportunity to keep themselves and their patients well informed about risk factors.

How about the informed consent part – do I have to renew that each time a patient returns, after their initial return to my practice?

No. Signed informed consent must be obtained the first time a subsequent patient returns to your practice under COVID-19 measures. When that patient rebooks for continuing treatment, you must comply with the Consent Standard of Practice by obtaining verbal consent if anything has changed. If nothing has changed, you are required to remind the patient to ask questions about treatment at any time, or to end the treatment if at any time the patient feels uncomfortable (section 9 of the consent standard).

Please clarify the consent requirement – there are a lot of new consents required, is that right?

Fundamentally, the consent process, and the reasons for it, have not changed.

If you previously had an informed consent process in your practice that conformed with requirements set by CMTBC’s Consent Standard of Practice, it probably looked something like this:

  • On initial intake, you would describe your practice framework to a new patient, explaining that you will take a clinical history (question/answer about the patient’s medical history) initially and ask from time to time if anything has changed.
  • You would explain that at every session, prior to providing massage therapy, you will conduct an assessment to clearly focus on the patient’s presenting complaint, or to monitor improvement over time.
  • Further, you would explain that following treatment, you might re-assess, and you would provide home care – activities that the patient will do at home to improve their condition, including stretches, strengthening exercises, and possible adaptations to daily activities.
  • You would also describe potential benefits and risks of receiving massage therapy, and point to alternatives for care.
  • You would then request signed consent, demonstrating that the patient understood your framework for clinical care, understood the benefits and potential risks, and consented to your approach.

Sections 9 and 10 of the Consent Standard of Practice state that “before the delivery of a subsequent treatment, an RMT renews consent if appropriate” and that “[an] RMT renews consent when the treatment approach changes for any reason” [emphasis added].

What is new as a result of COVID-19 is that the context of care for every RMT and for every patient has changed, which means that RMTs are now required to renew written consent with each patient returning for massage therapy. Specifically, RMTs must include the risk of transmission of the COVID-19 virus, and the steps taken by the RMT to reduce the risk.

RMTs are not required to create a new form – they are required to obtain informed consent in the new context of care, including the risk of transmission of COVID-19 virus, and the patient must sign the consent.

But I’ve seen a form that is called COVID-19 Patient Intake Consent, with checkboxes my patient has to check. Isn’t that the consent form?

No. A document of this nature is not a consent document; it is a waiver that may have been circulated by your professional association, or by your professional liability insurer. A waiver is a legal document that is intended to release the RMT from liability if the patient contracts COVID-19 while in the clinic or while receiving treatment from the RMT. Whether a waiver will actually have that effect is a complex issue that will depend on the facts of the individual case.

RMTs should do their due diligence, which means following CMTBC’s guidelines for delivery of care, as advised by Dr. Bonnie Henry in her letter to BC’s regulated health professionals dated May 15, 2020 (PDF). Key messages in Dr. Henry’s letter include:

“Your respective regulatory colleges have developed a set of guiding principles to help you resume in-person care in … [community] settings.

“… I encourage you to look to your health authorities, regulatory college, and WorkSafe BC to ensure that you have strong infection prevention and control protocols and occupational health and safety practices to prevent the spread of COVID-19 in the workplace. This includes risk-based and symptom assessments prior to entering the workplace and appropriate use of personal protective equipment.”

These principles, clearly articulated by Dr. Bonnie Henry, are the pillars of CMTBC’s Interim Guidelines for Return to Practice, on which RMTs are basing their own return-to-practice protocols for their patients.

It is important to be clear on the difference between informed consent to treatment and a waiver of liability. These are different documents and concepts, which exist for different purposes.

FAQs POSTED ON MAY 15, 2020:  [updated November 2, 2020]

I rent my treatment room to other practitioners when I don’t use it; may I continue to do this?

You may, but it is your responsibility to ensure that all practitioners who use your space are aware of and follow your safety protocol.  As BC’s Provincial Health Officer said in her letter dated May 15, 2020 (PDF), health professionals are “accountable to ensure the health and safety of their patients and clients, colleagues, and support staff in every healthcare setting”.

How do patients sign informed consent in a no-touch / low-touch environment?

As they do now. If patients sign on a tablet, provide them with a sterilized tablet and wipe it again after they have signed; if on a paper form, do the same with the pen that is handed to the patient

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