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FAQs: RMTs’ return to practice, interim guidelines

On May 15, 2020, CMTBC published Interim guidelines for RMTs’ return to practice  in Phase 2 of BC’s Restart Plan. CMTBC’s guidelines are consistent with direction provided by BC’s Provincial Health Officer and with requirements set by WorkSafeBC, which has jurisdiction over practice settings in which there are employees.

CMTBC will update the frequently asked questions on a regular basis.

FAQs POSTED ON MAY 20, 2020:

Did Canada’s Chief Public Health Officer say that we should all wear masks?

On May 20, 2020, Canada’s Chief Public Health Officer, Dr. Theresa Tam, issued a general recommendation that non-medical masks or face coverings should be worn if physical distancing cannot be maintained. However, this was a recommendation, not an order; and Dr. Tam’s recommendation was not intended to override the public health guidance issued by authorities in the respective provinces. As outlined by the Public Health Agency of Canada’s updated information on non-medical masks and face coverings, the recommendation applies “particularly in crowded public settings, such as stores, shopping areas, [and] public transportation”.

On the same day, BC’s Minister of Health Adrian Dix, and Provincial Health Officer Dr. Bonnie Henry, released a joint statement that said the following about masks:

“Today, the federal government spoke to the use of non-medical masks or cloth face coverings in public settings. When it is difficult to keep a safe physical distance for an extended period of time – for example, when you are on transit – this is a good way for you to protect those around you.

“We have to remember that face coverings keep our droplets in and don’t prevent transmission from others. The best ways for us to stay safe is to wash our hands, maintain a safe physical distance from others and keep our ‘rules’ for social interactions top of mind.”

BC’s government and public health authorities have not mandated the use of masks.

To be clear, CMTBC is not discouraging mask use by RMTs and/or their patients. It remains a choice to be made jointly by both of them, following discussion, and in the context of all of the other steps the RMT has put in place to mitigate risk in the treatment environment. RMTs are free to use their professional judgment about wearing a mask while providing treatment, or recommending mask use to a patient. Remember, however, that all public health guidance, including today’s, has stressed that other steps – including distancing (where possible), hand hygiene, cleaning, and (for RMTs) careful screening – remain more important than mask use in preventing the spread of COVID-19.

For the pre-screening requirement to confirm the patient’s health (and my own), can I send an email the day 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?

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.

The importance of the pre-screening process underscores that it is your responsibility to ensure the patient fully understands they are not returning to “normal”, or even “new normal”. They are coming for massage therapy in an environment where you have done everything you can to minimize the risk of transmission of the virus that causes COVID-19.

Pre-screening prepares you and your patient for the informed consent discussion when they first return for treatment after the cessation of massage therapy. Your informed consent discussion will address the fact there is always a risk, and that you have done everything you can to minimize the risk.

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 must confirm they have not travelled outside of BC in the previous 14 days. Could you clarify what I’m supposed to do?

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. In the days from May 15 to May 19, Dr. Bonnie Henry reminded British Columbians that although many BC residents work in industrial camps in northern Alberta and return home to BC on their breaks, there has been an outbreak of COVID-19 in one of those work camps.

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?

After the initial signed informed consent has been obtained, and your patients rebook to see you for continuing treatment, you must comply with the Consent Standard of Practice, which is to obtain 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.
  • 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.
  • 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”.

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 outline 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 … 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.

The College appreciates the work done by the RMTBC and by insurance companies to support clinicians at this time. However, 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:

What does “required” mean? Some of the requirements don’t make sense in my practice environment, and some are impossible (e.g. cleaning the building elevator).

There are two key pillars underlying low risk return to practice. One is the need for registrants to follow the guidelines of their regulatory college, as emphasized by BC’s Provincial Health Officer.  The other is the individual judgment of health professionals, and in Dr. Henry’s words, their accountability “to ensure the health and safety of their patients and clients, colleagues, and support staff in every healthcare setting.”

RMTs practice in a wide variety of settings, and it is always possible that something that may be critically important in one setting is inapplicable in another. RMTs are expected to think critically, apply their own professional judgment, and be guided by their underlying responsibility to create an environment conducive to health and safety.

In that sense, RMTs are required to consider carefully every element of what is in the “Required” section of the guidelines, and incorporate each element in their own plan unless that element is not applicable to the RMT’s treatment environment.

Why are masks not required?

The use of masks has been a complex issue since the outset of the COVID-19 pandemic. Medical-grade masks (N95, P100, plexi shields) have been in short supply and should be going to frontline health care workers.  Cloth or surgical masks provide little or no protection to the wearer, but may protect those around the wearer from the wearer’s respiratory droplets.

Masks are only one part of the guidelines, and RMTs are not discouraged from using them and/or offering them to patients if this is requested and enhances a patient’s feeling of safety. On the other hand, mask use can be problematic, and masks themselves can be a vector for viral transmission if not properly handled, or if re-used without proper sterilization. The guidelines instead emphasize screening, self-assessment, hand hygiene, distancing (expect for actual treatment), and honest communication. RMTs should not be treating anyone who is symptomatic.  Yes, there is a risk of asymptomatic transmission, but that risk is very low if all other measures are followed carefully.  If that were not the case, the Provincial Health Officer would not have allowed resumption of care.

On page 4 of COVID-19: Infection Prevention and Control Guidance for Community-Based Allied Health Care Providers in Clinic Settings (PDF), issued May 15, 2020 by BC Centre for Disease Control, BCCDC states: “Personal Protective Equipment is the last and least effective of the infection prevention and exposure control measures and should only be considered after exploring all other measures. PPE is not effective as a stand-alone preventive measure. PPE must be suited to the task and must be worn and disposed of properly.”

Can I resume practice on (or after) May 19, 2020?

Yes, as long as you have a plan that addresses CMTBC’s interim guidelines, have shared it with your patients, and are prepared to practice in accordance with the guidelines.  However, if you need more time to prepare, or do not yet feel ready to return to practice, that is fine – there is no requirement to return until you are ready.

CMTBC encourages a gradual return to practice, to provide time to ensure that your safety protocol is being followed consistently.

For RMTs at spas, are we opening in Phase 3 or in Phase 2?

Spas and similar environments – i.e. in which RMTs share space with unregulated practitioners and service providers – were originally part of Phase 3, but are now included in Phase 2.  RMTs practicing in such environments must still have a plan that is consistent with CMTBC’s interim guidelines. In addition to communication with patients, the RMT will communicate the return to practice plan to those with whom the RMT shares space, and possibly also with the managers or owners of the space.  Massage therapy treatment provided in any treatment environment must be done in accordance with CMTBC’s interim guidelines.

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.

Why is the RMT opening and closing doors, instead of the patient?

Before COVID-19, RMTs’ choices about opening/closing doors varied considerably. Much of the variation depends on the practice setting, e.g., are there many people (patients and practitioners) in a multi-disciplinary setting?, or is it a home-based (or sole proprietor in a commercial location) setting?, is it a mobile practice?, or other.  The basic idea is that the RMT knows that he/she is washing and cleaning regularly within the treatment setting; the patient is coming in from outside and is more likely to be a transmission vector.  However, the RMT can adapt this principle as required for it to make sense in the treatment environment.

The interim guidelines need to be interpreted by CMTBC’s 5,400+ registrants in a wide variety of practice environments. The intention of door-opening/closing by the RMT is to minimize hard-surface touch-points, and to keep it within the health professional’s control to maintain a safe environment for the RMT as well as the patient.

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