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Interim Guidelines for Return to Practice

November 19, 2020: Provincial Health Officer issues additional COVID-19 restrictions and orders: see news story.

November 4, 2020: CMTBC’s Interim Guidelines for RMT practice in the pandemic environment are updated to clarify that pre-screening is an essential part of risk mitigation. Patients are asked by their RMT to complete the BC COVID-19 Self-Assessment Tool 24 to 48 hours prior to their massage therapy appointment, and respond appropriately if the self-assessment outcome instructs the patient to get a COVID-19 test and self-isolate, and/or call 8-1-1, or take other action that indicates their health is at risk.

November 2, 2020: CMTBC’s Interim Guidelines are updated in consultation with Iridia Medical Inc., Vancouver, and are consistent with current recommendations from BC’s Provincial Health Officer Dr. Bonnie Henry, and the BC Centre for Disease Control.

View useful summaries from the BC Government, BC COVID-19 provincial support, Phase 3

Flu shot (November 2020), RMTs and their patients can reduce the risk of co-morbidity of COVID-19 with seasonal influenza by getting a flu shot. This is consistent with guidance provided by BC’s public health authorities. It is not within RMTs’ scope of practice to recommend or require that their patients get a flu shot.

THE BIG PICTURE

On May 6, 2020, Premier John Horgan announced BC’s Restart Plan, easing restrictions on a number of activities, including health care services delivered in the community. BC’s Restart Plan was signed both by the Premier and by Provincial Health Officer Dr. Bonnie Henry.

Registered massage therapy is included on page 14 of BC’s Restart Plan, “Restoration of health services” under enhanced protocols. RMTs have an ongoing duty to deliver care in a way that minimizes the risk of spread of the virus that causes COVID-19.

CMTBC, as the authority that regulates the massage therapy profession in British Columbia, has developed Interim Guidelines for Return to Practice as the “enhanced protocols” under which RMTs are permitted to practice in the context of COVID-19 in the community.

The Interim Guidelines are based on the following principles:

  • The guidelines are consistent with public health and safety guidance provided by BC’s Provincial Health Officer, BC’s Centre for Disease Control and WorkSafeBC.
  • RMTs will permit only pre-screened, healthy individuals – including themselves – into their practice environment.
  • Effective communication is key; direct person-to-person contact cannot always be replaced by forms and automated protocols, even if automation eases an RMT’s workload.
  • RMTs will assess risk at the point of care, and this may result in cancellation of a booked appointment at the time of the appointment.
  • Personal protective equipment (PPE) may be used but is not mandatory. If used, PPE does not replace or reduce the need for other protective measures:
    • pre-screening,
    • physical distancing (except for treatment),
    • hand hygiene,
    • avoid touching the face, and
    • frequent cleaning of all contact surfaces.

YOUR SAFETY PLAN

RMTs must develop a safety plan for clinical practice that addresses the requirements set out below. Your plan must be communicated to patients, colleagues, and others who need to know the steps you are taking to minimize risk of exposure to the novel coronavirus.

Your plan will:

  • Ensure that only healthy people will be permitted in the practice environment (including the RMT and clinic staff),
  • Describe pre-screening processes that protect patients, therapists and staff,
  • Describe physical distancing measures that have been implemented outside the treatment room (2 metres / 6’ wherever possible),
  • Detail hand hygiene and cleaning protocols,
  • Describe how you are providing fresh air in your practice environment; e.g., if you have an HVAC system, don’t shut it off, keep air circulation flowing, consistent with recommendations from WorkSafeBC,  
  • Ensure that communications to patients and colleagues are clear, shared by all, and consistent,
  • Be shared with co-workers and everyone who shares the practice environment with you,
  • Adapt as needs emerge and new information is available, and
  • Minimize risk to all.

These guidelines are called “Interim Guidelines” because they are updated as required, to reflect new guidance provided by relevant governmental authorities. CMTBC’s key touchpoints for guidance are:

“Does my plan have to be submitted to CMTBC for approval?”

  • No. However, it must be available to patients and colleagues, and to CMTBC on request. It is also possible that WorkSafeBC may conduct an inspection; providing a copy of your safety plan will facilitate that process.

CMTBC’s Interim Guidelines for Return to Practice were developed in consultation with Iridia Medical Inc. (team led by Dr. Allan Holmes, MD, FRCP), and a panel of RMTs. Iridia Medical continues to provide guidance and support as required with updates and revisions to the guidelines.

Please note that the Interim Guidelines contain links to resources on external websites which are frequently updated. If you encounter a broken link, please email [email protected] to advise CMTBC.

Requirements for RMTs’ return to practice in BC

CMTBC’s Interim Guidelines represent best practices that must be followed by RMTs to minimize risk of transmission of the COVID-19 virus.

Your professional judgment and choices will determine whether and how you implement additional measures specific to your practice setting, your professional insurance requirements, and your patients’ needs.

Provision of RMT services in the context of COVID-19 requires clear and thoughtful communication that is based on trust between an RMT and a patient.

1. Self-assess for symptoms and return when healthy: For patients, RMTs, and clinic staff

PRE-SCREENING – PRIOR TO ARRIVAL

  • Patients must be informed about the safety procedures you’ve implemented, before or at the time of booking an appointment. Clear information must be included in all your communication tools – website, online booking system, phone message, and auto-responses to email enquiries.
  • Informing your patients includes advising prior to arrival at your practice about options for use of personal protective equipment including masks (PPE, see #6, below), and your rationale. Public health authorities expect everyone to wear a mask in all indoor public spaces (e.g., clinic area prior to entering the treatment room); patients should be advised to wear a mask when they arrive.
  • At the outset, it is your responsibility to advise your patient that informed consent is required. This includes ensuring that your patient understands that while you’ve taken measures to minimize risk of viral transmission, the nature of massage therapy means that physical distancing is not possible in the treatment room. Consistent with CMTBC’s Consent Standard of Practice, it is your responsibility to explain both the risks and the potential benefits of treatment, and to make decisions in your patient’s best interests.
  • Thorough and honest pre-screening for symptoms of COVID-19 must be completed.
  • Patients will be asked if they have travelled outside British Columbia in the previous 14 days. This provides an opportunity for the RMT to learn about the patient’s risk mitigation while travelling, and to consult 8-1-1 as necessary for information and support.
  • 24 to 48 hours prior to patient’s appointment, ask patient to complete the BC COVID-19 Symptom Self-Assessment. If the self-assessment tool instructs patient to book a test for COVID-19 and self-isolate, and/or to call 8-1-1, do not book the massage therapy appointment until the patient is cleared of risk of COVID-19.
  • If you delegate pre-screening duties to staff, colleagues, or if you have automated the screening process, you remain responsible for the quality and completeness of pre-screening, and for reviewing the information provided by patients.
  • RMT and clinic staff must use the BC COVID-19 self-assessment tool and must stay home/cancel appointments if experiencing COVID-19 symptoms.
  • Patients at greater risk: take additional precautions, discuss alternatives for care, postpone treatment – explore options. RMTs may provide massage therapy when the patient and therapist agree that the benefits of care outweigh the risk to the patient. 
  • Patients who are health care workers (HCWs) who have been exposed to patients with COVID-19: RMTs can consult the risk assessment tool offered here, BCCDC’s Exposures and return to work for health care workers. If the HCW falls into the Low Risk category, treatment can be provided; ask the patient to wear a surgical mask.   
  • Your cancellation policy should be relaxed to ensure honesty and compliance with pre-screening questions.

SCREENING UPON ARRIVAL

  • Ensure that all practitioners who share the practice environment have a common understanding of operational procedures and that all practitioners will apply them consistently.
  • Upon patient’s arrival, the RMT and patient will run through the BC COVID-19 Self-Assessment Tool outcomes again – confirm mutual safety and trust in moving forward.
  • The RMT should cancel treatment if the patient doesn’t meet the pre-screening criteria on physical presentation at the practice environment.
  • Pre- and during clinic visit: Ensure patient feels empowered to make their own decision on what they need to feel safe in order to receive treatment.
  • For patients at greater risk: if pre-screen results indicate “go ahead”, assess necessary precautions on arrival when RMT sees the patient’s presentation.

RESOURCES

  1. BC COVID-19 Symptom Self-Assessment tool
  2. BC Centre for Disease Control, Symptoms
  3. BC Centre for Disease Control, Clinicians should consult with their local Medical Health Officer for guidance related to suspected cases
  4. CMTBC, Consent Standard of Practice
  5. BC Centre for Disease Control, Travel
  6. BC Centre for Disease Control, Exposures and return to work for health care workers
  7. BC Centre for Disease Control, BC Health Care Worker Exposures Risk Assessment Tool

2. Physical Distancing

RECEPTION / entry

  • Clearly-understood distancing protocols – staff, RMT and patient must maintain 2 metres / 6 feet of distance in clinic areas other than the treatment room, as best as possible within the practice setting.
  • Reduce traffic; stagger appointment start- and end- times. Are chairs needed? Rearrange appointment process to prevent or minimize in-clinic waiting.
  • Consider creating floor/counter/wall markings showing 2 metres/6 feet of distance, and create one-way traffic flow wherever possible.
  • Patient must arrive unaccompanied unless patient is a minor who requires parent/guardian, or infirm and needs assistance.
  • Patient is required to wait outside (in their car, or an area suggested by RMT or clinic staff) and not in reception, until it’s time to enter.
  • Make use of alternate entries/exits in practice environment to assist with distancing.

THERAPISTS’ SHARED AREAS, multi-practitioner setting, e.g., kitchen, lockers, charting stations

  • Have separate, distanced work-stations; or require therapists to use personal devices to access scheduling and accounting programs. Minimize the use of shared equipment including computers and phones.
  • Storage/meals/coats, extra clothes, etc., will be specific to each practice setting.

TREATMENT ROOM

  • It is not possible to maintain physical distancing in the treatment room.
  • Pre-screening, physical distancing, hand hygiene, and enhanced cleaning help reduce the risk of transmission, and enable return to practice while minimizing risk of harm.

WASHROOM FOR PATIENT USE

  • Physical distancing in washroom for patient use will be specific to practice setting. Hygiene, sanitation, and distancing must all be considered, and clear instructions shared with patients in advance of arriving at the practice environment.

ELEVATORS/STAIRS/OTHER, IF USED TO ACCESS CLINIC

  • Will be specific to practice setting, similar to washroom for patient use. Be aware of opportunities for incidental contact that violates physical distancing requirements, and place appropriate signage.

RESOURCES

  1. BC Centre for Disease Control, Physical Distancing
  2. BC Centre for Disease Control, Physical Distancing poster (available in several languages)

3. Hand Hygiene

RECEPTION / ENTRY

  • Patient washes hands upon entry with soap and water for at least 20 seconds, followed by thorough drying – must be done on arrival into and departure from the clinic.
  • If soap and water are not available, provide alcohol-based hand sanitizer for patient’s use on arrival and prior to departure.
  • If hands are visibly soiled, they must be cleaned with soap and water as opposed to using alcohol-based hand sanitizer. RMT must wash hands often, using soap and water for a minimum of 20 seconds each time.
  • Hand-washing protocols are posted in reception area, in the treatment room, and at sinks (including bathroom for patient’s use if applicable).
  • If payment occurs in the reception area, a wireless point of sale system with tap feature should be used or arrange e-transfer for payment. Receipt is emailed to patient. Cash is not preferred but may be handled provided that anyone doing so sanitizes their hands immediately afterwards.

IN THE TREATMENT ROOM

  • Door opening and closing during and at the end of treatment, RMT attends to hand sanitization as needed for self and/or patient.
  • Hand washing/drying and sanitization options should be available for RMT and patient.
  • Hand washing should occur before and after treatment (both RMT and patient).
  • If RMTs or patients wear masks, they must
    • Clean their hands prior to donning and immediately after removing the mask, and
    • Avoid touching or adjusting the mask while in use.
  • If payment occurs in the treatment room, a wireless point of sale system with tap feature should be used or arrange e-transfer for payment. Receipt is emailed to patient. Cash is not preferred but may be handled provided that anyone doing so sanitizes their hands immediately afterwards.
  • Attach safety posters from BC Centre for Disease Control next to sink, setting out proper handwashing guidelines.

RESOURCES

  1. BC Centre for Disease Control, Hand washing 
  2. BC Centre for Disease Control, Hand Hygiene poster
  3. BC Centre for Disease Control, Common questions about COVID-19

4. Face Touching Avoidance – e.g., avoid touching eyes, mouth, nose

  • Share information about the reason for ‘no face touching’; coronavirus can be spread by touch if a person has used their hand/s to cover a cough or a sneeze.
  • Provide tissues if an itch must be addressed; tissues must be available in reception, treatment room, washroom.
  • RMT must discuss use of masks by RMT and/or by patient, as well as the need to sanitize hands before and after touching a mask, if used.
  • If RMT is accustomed to sweating during her or his work, a head band should be used, or a hand towel should be available to wipe the forehead and face as required to avoid sweat from dripping into eyes necessitating touch.

RESOURCES

  1. BC Centre for Disease Control, Hand washing
  2. BC Centre for Disease Control, Masks

5. Enhanced Cleaning

  • All therapists and staff will practice consistent cleaning protocols.
  • Clean visibly soiled surfaces, followed by disinfection.
  • Clean and disinfect all high-touch surfaces in between patient treatments, regardless of appearance.
  • Linens (including blankets) must be single use only, then laundered in hot soapy water.
  • Frequently clean and disinfect common areas and high touch surfaces, at least twice a day, e.g. light switches, window coverings, cell phones, tablets, chairs, stools, table surfaces.
  • Remove all clutter, fabric furnishings and decorations that cannot be sanitized after touch.
  • Frequently clean and disinfect (at least three times per day, more if possible):
    • handles: doors, cabinets, faucets, fridge, microwave, etc.
    • electronic device keyboards and mice, phones,
    • arm rests of chairs,
    • desk and table surfaces,
    • water cooler.
  • Ensure the treatment room is thoroughly cleaned between patients:
    • Sanitize the treatment table and table adjustment levers after each treatment.
    • Clean equipment and supplies (table levers, lotion bottles, etc.) immediately after each patient.
  • Adapt use of thermophores, other thermal agents, hydrotherapy supplies, and tools, to ensure that objects that are in direct contact with the patient can be thoroughly sanitized (e.g., thermophore/table warmers/other must be covered).
  • Attach Cleaning and Disinfectants for Clinic Settings poster from the BC Centre for Disease Control in reception area, washroom for patient use, treatment room.
  • Post a schedule of cleaning and disinfecting routine (area, last completed, initials); demonstrate that equipment touched by patient is cleaned prior to use.
  • Air purifier / filter in the treatment room may be helpful if room has no windows or external air exchange. Use of an air purifier / filter is at the RMT’s personal preference and discretion. View WorkSafeBC resources about ventilation and air circulation.

WASHROOM FOR PATIENT USE

  • All contact areas must be cleaned and disinfected several times a day. Ensure that soap is available for hand washing, that clean material is provided for drying hands, and that wipes (or paper towels, tissues) are available for contact with doors and touch-surfaces.

ELEVATORS/STAIRS/OTHER IF USED TO ACCESS CLINIC

  • All contact areas must be cleaned several times a day, e.g. doors, elevator buttons.
  • Provide wipes if available.
  • If wipes are unavailable, provide paper towels or tissues for patients to use as a barrier when contacting high-touch surfaces.

RESOURCES

  1. BC Centre for Disease Control, Cleaning and Disinfectants for Clinic Settings, Poster
  2. BC Centre for Disease Control, COVID-19 Infection Prevention and Control Guidance for Community-Based Allied Health Care Providers in Clinic Settings
  3. Government of Canada, Hard-surface disinfectants and hand sanitizers
  4. BC Centre for Disease Control, Wildfires and concern about air quality
  5. BC Centre for Disease Control information for patients, Cleaning and Disinfecting the home
  6. WorkSafeBC, ventilation and air circulation

6. Personal Protective Equipment (PPE) and mask use

CMTBC does not mandate the use of PPE. The RMT may decide whether to use personal protective equipment for themselves and/or for their patient/s.

October 2020: Public health authorities expect everyone to wear a mask in shared indoor spaces (e.g., clinic area, washrooms).

November 2020: CMTBC strongly encourages the use of non-medical masks by both RMTs and patients in the treatment room.

  • RMTs are reminded that protective measures such as hand hygiene, enhanced cleaning, and avoidance of face touching are critically important and cannot be relaxed even if masks are worn.
  • The RMT must have additional cloth or paper/disposable masks available for patient’s use if requested, and for RMT’s use if patient requests it.
  • If a patient wears a mask in the treatment room, RMT must accommodate that choice and adjust treatment positioning as appropriate if needed.
  • The RMT may require patients to wear masks, and may refuse to treat patients who will not wear a mask provided that (1) this is communicated to the patient in advance of the appointment; and (2) the RMT considers accommodations or provides alternatives for patients who are unable to wear masks.
  • It is the RMT’s responsibility to use and clean or replace their mask correctly. There are many kinds of masks in use and CMTBC cannot be prescriptive about protocols; please follow BCCDC recommendations.
  • RMTs may use their professional judgment to decide whether to use gloves, protective goggles, and other commercially available PPE.

RESOURCES

  1. BC Centre for Disease Control, Masks
  2. BC Government News, Masks and COVID-19: one of the important layers to protect yourself, your community, by Dr. Bonnie Henry

7. Professional Obligations

  • RMTs are reminded that if they are exhibiting signs of respiratory illness, including cough, runny nose or fever, they must not provide in-person care and should not be in attendance at clinics or other practice settings where other staff and patients are present.
  • CMTBC regulates massage therapists, and not clinics. CMTBC’s guidelines apply to RMTs and RMT-practice; it is an RMT’s responsibility to clarify the guidelines in their practice, rather than rely upon clinic owners to do so.
  • RMTs who practice at multiple locations, including mobile, must be particularly conscientious about others’ safety protocols while also maintaining their own protocol.
  • Professional liability insurance:
    • RMTs in practice are required by CMTBC’s Bylaws to carry professional liability insurance.
    • The coverage terms of policies can vary.
    • RMTs are advised to contact their insurer to determine whether or not they are covered for claims related to COVID-19, e.g. alleged transmission of the virus.
    • RMTs are advised to follow the guidelines or requirements of their insurance provider as long as the insurer’s guidelines do not conflict with or contradict CMTBC’s guidelines.
  • No duty or obligation to return to practice:
    • The existence of CMTBC’s Interim Guidelines for Return to Practice should not be interpreted as requiring RMTs to engage in practice if they individually assess the risk of practice as one they are not prepared to take.  
    • The decision to return to practice is a matter of individual judgment and requires that RMTs follow the guidance of CMTBC and governmental authorities, including public health authorities.
  • RMTs who are employees of a clinic, spa, or who have employment contracts:
    • RMTs are bound by their obligation and duty to CMTBC, their regulatory body as a health professional, irrespective of employment agreements.
    • RMTs in this work setting must clarify their relationship with their employer.
    • An RMT should consult legal counsel if needed, as CMTBC does not provide legal advice; or, alternatively, if the RMT is a member of a professional association, the association may provide advice and/or support.
  • Patient reports COVID-19 following treatment and/or alleges they caught COVID-19 from RMT:
    • The RMT must immediately call public health at 8-1-1, report the alleged transmission, and follow the guidance of public health authorities.
    • If the RMT is working in a team setting, it is the RMT’s duty to immediately inform his or her colleagues of transmission risk.
    • The RMT must report to their insurer in accordance with the requirements of their insurance policy.
  • Can an RMT limit their liability for potential COVID-19 transmission by having the patient sign a waiver?
    • This is a legal question and CMTBC does not provide legal advice to registrants. 
    • RMTs have a professional obligation to obtain informed consent to treatment, consistent with CMTBC’s Consent Standard of Practice.
    • In the current environment of COVID-19 risk, informed consent requires that the patient is informed that:
      • any massage therapy treatment involves some risk of COVID-19 transmission;
      • the RMT is following a protocol to reduce or mitigate risk, but that risk cannot be reduced to zero;
      • the patient consents to treatment despite some risk; and
      • the RMT documents the patient’s consent.
    • This is not a new requirement, but the appropriate negotiation of consent is significant in the context of COVID-19. Proper adherence to consent procedures may also have the incidental effect of reducing the chances for RMT liability, although that is not their purpose.
  • RMTs practicing in personal services businesses such as spas or other environments shared with unregulated practitioners:
    • must communicate his/her plan to (1) the person(s) in control of the environment, e.g. owner or manager; and (2) any non-regulated practitioners with whom space is shared, and must obtain the understanding and agreement of either or both to abide by common safe-practice protocols.

Additional Resources

Additional Resources


RMTs should also consult the following
:

CMTBC’s Interim Guidelines for Return to Practice were developed in consultation with Iridia Medical Inc. (team led by Dr. Allan Holmes, MD, FRCP), and a panel of RMTs.

Please note that CMTBC’s Interim Guidelines contain many links to resources on external websites which are frequently updated. If you encounter a broken link, please email [email protected] to advise CMTBC.

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