CHP is interested in helping providers treat patients as safely as possible during this time of the COVID-19 pandemic. That means sharing information about how to prepare clinics and offices and mitigate the spread of the virus in the community. It is important to slow the spread of the virus to save lives and prevent healthcare systems and hospitals from becoming overwhelmed.
Massage therapy, acupuncture, chiropractic care, and naturopathic medicine often involve close contact with patients. Per the CDC, close contact occurs when people are within six feet of one another, and transmission of the virus occurs primarily when respiratory droplets from an infected person’s cough or sneeze are inhaled by or land on the mouth, nose, and eyes of another individual. Transmission also occurs when a person touches a surface contaminated with the virus and then touches their mouth, nose, or possibly their eyes.
It is important to think about unique risks that these treatment modalities may cause because of their physical nature. We encourage providers to have a clinic discussion about ways to limit risk of transmission from providers to patients and vice versa. One example of unique risk is when a provider performs manual therapy, massage, or chiropractic adjustments to a patient’s neck; the provider is often in a seated position with their face directly above the patient’s. Because the primary transmission is through respiratory droplets, the provider has an obligation to limit any such respiratory droplets from falling onto the patient. These droplets can also occur while talking – not just coughing or sneezing – and there is limited data that transmission of the coronavirus can occur in asymptomatic individuals. One suggestion is for the provider to turn their face away from the patient, suspend talking while treating a patient’s neck, or to avoid treating the neck all together, especially in a vulnerable patient populations such as older individuals or individuals with complicating health conditions. If you note other unique risks to integrative healthcare practices and their solutions, please feel free to share those with us at firstname.lastname@example.org.
If you plan to see patients with respiratory infections in your office, please refer to the full list of precautions and action steps for Healthcare Facilities from the CDC at https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html
The following list is intended for Healthcare Providers (HCP) who wish to treat only well patients at their clinics, with the understanding that it is still possible for a patient to begin to show signs of a respiratory infection for the first time during the treatment visit, and that there is risk of transmission from infected individuals who are asymptomatic.
Preparing Your Practice
We understand that healthcare clinics come in all sizes and have unique needs. Below is an adapted list of actions and steps from the CDC as well as examples of how these actions might look in your practice, with special consideration for chiropractic and naturopathic physicians, acupuncturists, and massage therapists.
Minimize Chance for Exposures
Ensure facility policies and practices are in place to minimize exposures to respiratory pathogens including SARS-CoV-2, the virus that causes COVID-19. Measures should be implemented before patient arrival, upon arrival, throughout the duration of the patient’s visit, and until the patient’s room is cleaned and disinfected. It is particularly important to protect individuals at increased risk for adverse outcomes from COVID-19 (e.g. older individuals with comorbid conditions), including healthcare providers (HCP) who are in a recognized risk category.
- When scheduling appointments for routine, non-illness care, instruct patients to call ahead and discuss the need to reschedule their appointment if they develop symptoms of a respiratory infection on the day they are scheduled to be seen.
Upon Arrival and During the Visit
- Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide patients and HCP with instructions (in appropriate languages) about hand hygiene, respiratory hygiene, and cough etiquette. Instructions should include how to use tissues to cover nose and mouth when coughing or sneezing, to dispose of tissues and contaminated items in waste receptacles, and how and when to perform hand hygiene.
- Visual alerts are generally available from your local health authority.
- A “Cover Your Cough” poster is available from the CDC at https://www.cdc.gov/flu/pdf/protect/cdc_cough.pdf.
- Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand sanitizer (ABHS) with 60-95% alcohol, tissues, and no-touch receptacles for disposal at healthcare facility entrances, waiting rooms, and patient check-ins.
Adhere to Standard and Transmission-Based Precautions
Standard precautions assume that every person is potentially infected or colonized with a pathogen that could be transmitted in the healthcare setting.
- Hand Hygiene
- HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing personal protection equipment (PPE), including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process.
- HCP should perform hand hygiene by using hand sanitizers with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to hand sanitizers.
- Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location.
- Personal Protective Equipment (PPE)
- Employers should select appropriate PPE and provide it to HCP in accordance with OSHA PPE standards at https://www.osha.gov/laws-regs/regulations/standardnumber/1910#1910_Subpart_I
CHP recommends that if a patient becomes symptomatic of a respiratory infection during their visit to your office, that you consider the following within the limits of the scope of your license where applicable:
- For patients with COVID-19 or other respiratory infections, evaluate need for hospitalization. If hospitalization is not medically necessary, home care is preferable if the individual’s situation allows.
- Patients should wear a facemask to contain secretions during transport. If patients cannot tolerate a facemask or one is not available, they should use tissues to cover their mouth and nose.
- Personnel entering the room should use PPE as described above.
- Once the patient has been discharged or transferred, HCP, including environmental services personnel, should refrain from entering the vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles (more information on clearance rates under differing ventilation conditions is available). After this time has elapsed, the room should undergo appropriate cleaning and surface disinfection before it is returned to routine use.
Implement Engineering Controls
- Design and install engineering controls to reduce or eliminate exposures by shielding HCP and other patients from infected individuals. Examples of engineering controls include:
- Physical barriers or partitions to guide patients through triage areas
- Curtains between patients in shared areas
- Air-handling systems (with appropriate directionality, filtration, exchange rate, etc.) that are installed and properly maintained.
Monitor and Manage Ill and Exposed Healthcare Personnel
- Facilities and organizations providing healthcare should consider implementing sick leave policies for HCP that are non-punitive, flexible, and consistent with public health guidance.
- Movement and monitoring decisions for HCP with exposure to COVID-19 should be made in consultation with public health authorities. Refer to the Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19) for additional information.
Train and Educate Healthcare Personnel
- Provide HCP with job- or task-specific education and training on preventing transmission of infectious agents, including refresher training.
- Ensure that HCP are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin, and environment during the process of removing such equipment.
Implement Environmental Infection Control
- Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly.
- Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed.
- Refer to the EPA website for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2 at https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2
- Management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures.
Establish Reporting Within and Between Healthcare Facilities and to Public Health Authorities
- Communicate and collaborate with public health authorities.
- Facilities should designate specific persons within the healthcare facility who are responsible for communication with public health officials and dissemination of information to HCP.
- Communicate information about known or suspected COVID-19 patients to appropriate personnel before transferring them to other healthcare facilities
Some clinics employ staff personnel, while others are sole practitioners. Not only is it important to anticipate protecting a clinic’s staff and providers, but also anticipating how a clinic may be able to continue to communicate and function if any individual from the practice becomes sick, has sick family members they need to attend to, or has children at home due to school closures.
- Actively encourage sick employees to stay home:
- Employees who have symptoms of acute respiratory illness are recommended to stay home and not come to work. Employees should notify their supervisor and stay home if they are sick.
- Consider sick leave policies that are flexible and consistent with public health guidance. Ensure that employees are aware of these policies.
- Talk with companies that provide your business with contract or temporary employees about the importance of sick employees staying home and encourage them to consider non-punitive leave policies.
- Do not require a healthcare provider’s note for employees who are sick with acute respiratory illness to validate their illness or to return to work, as healthcare provider offices and medical facilities may be extremely busy and not able to provide such documentation in a timely way.
- Employers should consider flexible policies that permit employees to stay home to care for a sick family member. Employers should be aware that more employees may need to stay at home to care for sick children or other sick family members than is usual.
- Separate sick employees:
- CDC recommends that employees who appear to have acute respiratory illness symptoms (i.e. cough, shortness of breath) upon arrival to work or become sick during the day should be separated from other employees and be sent home immediately. Sick employees should cover their noses and mouths with a tissue when coughing or sneezing (or an elbow or shoulder if no tissue is available).
- Emphasize staying home when sick, respiratory etiquette and hand hygiene by all employees:
- Place posters that encourage staying home when sick, cough and sneeze etiquette, and hand hygiene at the entrance to your workplace and in other workplace areas where they are likely to be seen.
- Provide tissues and no-touch disposal receptacles for use by employees.
- Instruct employees to clean their hands often with an alcohol-based hand sanitizer that contains at least 60-95% alcohol, or wash their hands with soap and water for at least 20 seconds. Soap and water should be used preferentially if hands are visibly dirty.
- Provide soap and water and alcohol-based hand sanitizer in the workplace. Ensure that adequate supplies are maintained. Place alcohol-based hand sanitizer in multiple locations or in conference rooms to encourage hand hygiene.
- Additional Considerations for Employers
- Employers should work with their local and state health departments to ensure appropriate local protocols and guidelines, such as updated/additional guidance for cleaning and disinfection, are followed, including for identification of new potential cases of COVID-19.
- Employers should educate staff and workers performing cleaning, laundry, and trash pick-up activities to recognize the symptoms of COVID-19 and provide instructions on what to do if they develop symptoms within 14 days after their last possible exposure to the virus. At a minimum, any staff should immediately notify their supervisor and the local health department if they develop symptoms of COVID-19. The health department will provide guidance on what actions need to be taken. When working with your local health department check their available hours.
- Employers should develop policies for worker protection and provide training to all cleaning staff on site prior to providing cleaning tasks. Training should include when to use PPE, what PPE is necessary, how to properly don (put on), use, and doff (take off) PPE, and how to properly dispose of PPE.
- Employers must comply with OSHA’s standards proper disposal of regulated waste, and PPE. See https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.132.
For more information for healthcare professionals from the CDC, visit https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html
For more information on COVID-19 visit https://www.cdc.gov/coronavirus/2019-ncov/index.html