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Best Practices for Virtual Care

Virtual Care

 

Virtual care/telehealth refers to “the delivery of health care services, where distance is a critical factor, by all health care professionals using [communication technologies] for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.”[1]

Virtual care and musculoskeletal healthcare 

 

Musculoskeletal conditions are leading causes of disability globally.[2] Evidence suggests that rehabilitation through real-time virtual care/telehealth (videoconferencing) and telephone-based interventions are effective for improving pain and function in individuals with spinal conditions, osteoarthritis and other musculoskeletal conditions.[3-6] Ruling out serious pathologies, and providing education, exercise and self-management strategies are essential first-line management for musculoskeletal conditions. Many clinical practice guidelines recommend that this first line management is effective in improving function, facilitating recovery and maximizing independence. [8-11] Patients and caregivers have demonstrated satisfaction with the convenience, usefulness, and perceived benefits of telehealth.[7] Through their training and experience, and through a number of evidence-based options within the chiropractic scope of practice, chiropractors can have a positive impact on people’s health even in the absence of hands-on assessment or manual therapy.

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Clinician Summary

CCGI Clinician Handout_telehealth_Page_1
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Patient Handout

Core elements of virtual health

Key considerations for virtual care delivery

Evidence-based recommendations that can be delivered through virtual care

Guidance for returning to practice during COVID-19

Core elements of virtual care 

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  • Intended for the delivery of healthcare services. Delivery should be professional, focused, and within scope of practice, the same as during in-person services.

  • Intended to overcome geographic, transportation, and physical distancing barriers.

  • A variety of Information and Communication Technologies (ICT) can be used (e.g., telephone, internet, mobile phones, videoconferencing, virtual reality).[1]

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Key considerations for virtual care delivery

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  • Patient and clinician location requirements: private, quiet, good lighting for videoconferencing, camera placement and method of propping up device for video conference such as the whole body is in view (e.g., to be able to demonstrate and review exercises).

  • Patient and clinician technological requirements: charged electronics, connection speed, signal strength, wireless earbuds or computer speakers to continue communication while demonstrating or reviewing exercises. Develop a contingency plan with the patient in case of technological issues (e.g., have the patient’s telephone number on hand to continue the telehealth visit in case of disruption due to technological issues).

  • Patient prop requirements: loose clothing for movement, short/removable clothing for visual inspection, space and flooring for exercise prescription.

  • Clinician prop requirements: contemporaneous documentation including informed consent, space and flooring for exercise prescription, access to supporting documents such as pictorial or video instruction.

  • Unique virtual care consent considerations: verification of identity for new patients, limitations to examination, right to privacy, right to opt out, risks, clinician disclosure and patient consent if being recorded.

  • Emergency contact information: clinician should ensure they have the local emergency contact information for the patient in case an emergency arises and no one is with the patient to contact EMS.

  • Patient prep video: consider developing a pre-virtual care video for the patient to review prior to the assessment in order to prepare for the consultation and outline expectations. 

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Evidence-based recommendations that can be delivered through virtual care [8-11]

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Ensure care is patient centered.

  • Use a biopsychosocial approach to care that takes into account the individual patient’s context.

  • Listen attentively to patients’ concerns, health goals, values and preferences.

  • Communicate effectively and engage in shared decision-making with the patient.

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Screen for risk factors of serious pathology (“red flags”).

  • Conduct a thorough history.

  • If risk factors are present, refer the patient to the appropriate healthcare provider or services.

  • Examples include suspicion of infection, malignancy, fracture, inflammatory causes of pain, severe and progressive neurological deficit (including cauda equina syndrome) and serious conditions that can present as musculoskeletal pain (e.g., aortic aneurysm).

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Assess barriers to recovery (psychosocial factors or “yellow flags”).

  • Screen for anxiety and depressive symptoms, sleep disturbances, fear/kinesiophobia catastrophizing, recovery expectations and expectations of passive treatment. Patients with these findings may require co-management or referral.

  • Be aware of the patient’s context - yellow flags may worsen during a period of crisis and/or further exacerbate pain (see examples of assessment tools at https://www.ccgi-research.com/outcomes-psychosocial). 

  • Address the modifiable barriers:

    • Educate and reassure patients about the benign and self-limiting nature of their musculoskeletal condition and the importance of maintaining activity and movement.

    • Reassure patients that it is normal to feel some anxiety, distress or anger.

    • Listen to the patient’s concerns, discuss them and adjust their care plan accordingly.

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Conduct a clinical examination.

  • Conduct a thorough health interview.

  • Use valid and reliable patient-reported questionnaires and outcome measures (see examples).

  • Conduct a physical examination. While there are limitations to the lack of a hands-on physical exam possible with telehealth, a modified virtual exam may allow for a clinical impression and for an initial treatment plan to be started. A modified virtual exam may include:

    • Observing the patient’s appearance and emotional status (e.g., does the patient look well, unkempt, worried, well-rested, intoxicated; signs of physical trauma)

    • Observing the patient’s posture, range of motion, movement patterns, and muscle strength as per clinician direction (e.g., demonstrate how to go through the ranges of motion to the patient).

      • This can be achieved with functional movements (gait, squatting, standing from sitting position​, reaching, heel/toe walking, limb movements.

    • Asking the patient to self-palpate or self-examine under your guidance. You may send instructional photos or videos to facilitate this.

    • You may recommend to the patient that it may be helpful to have a family member present during the examination with patient consent (in case the patient falls, etc.). You may ask for an emergency contact number (e.g., of a family member living with the patient or a neighbor).

  • Once major pathology has been ruled out; and based on the interview and modified physical examination, you may classify/diagnose the patient’s condition with emphasis on a clinical impression vs. frank diagnosis (e.g., non-specific neck or back pain, shoulder strain).

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Provide patients with education/information about their condition and self-management strategies.

  • Communicate your clinical impression.

  • Communicate the patient’s apparent progress at subsequent visits.

  • Communicate your recommendations.

  • Promote shared understanding and shared decision making regarding the patient’s plan of care.

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Address physical activity and exercise.

  • Prescribe exercise (e.g., maintenance of usual activities, mobility, range of motion, stretching, strengthening, aerobic or general exercises).

  • Demonstrate and/or observe performance of exercise.

  • Provide written, image or video exercise references (see examples).

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Address supportive self-management strategies and factors contributing to the patient’s experience.

  • Educate patients on the public health measures related to the current pandemic (as outlined by national and provincial health authorities).

  • Educate patients on self-management strategies, such as:

    • Promote healthy lifestyle behaviours (e.g., activity, nutrition, sleep) / behaviour modification. 

    • Active coping strategies for pain, anxiety, stress, and depressive symptoms.

    • Address sleep disturbances.

    • Teach mindfulness practices.

      • Direct patients to various resources (Youtube, apps (Insight Timer, Calm, etc.).​

    • Teach pacing activities.

    • Help patients locate online social support programs.

  • Support patients to self-manage through techniques such as cognitive behavioural therapy (CBT) and motivational interviewing if the chiropractor is trained in these approaches (or refer to other healthcare providers qualified in providing these services).

  • Provide resources (see examples).

  • Many of the behavioural components of self-management are not only potentially helpful for managing pain and musculoskeletal conditions, but likely also for emotional distress related to the current pandemic.

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Monitor patient progress.

  • Remind patients to contact you or another healthcare provider if certain signs and symptoms (red flags) occur (see patient handouts as examples).

  • Ask the patient’s permission to follow-up with them as appropriate (suggest timeframes).

  • Evaluate patient progress using validated outcome measures (see examples). These include pain intensity, function, quality of life, and self-rated recovery.

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Guidance for returning to practice during COVID-19

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Disclaimer

This guidance provides basic information only. It is not intended to take the place of medical advice, diagnosis or treatment. Please check national, regional and local public health websites, and regional regulatory websites regularly for updates other information.

Guidance for re-opening healthcare practices

 

Healthcare professionals must consider the following information in deciding which services they can safely resume in-person, guided by best-evidence and with appropriate hazard controls, sufficient PPE, and which services should continue to be provided remotely:

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Screening patients for COVID-19

 

All health facilities should undertake active and passive screening before seeing their patients:

  1. Active screening:

    • Over the phone before scheduling appointments ​

    • Upon entry at the health facility 

  2. Passive screening:​

    • Signage at points of entry of the facility and at reception​

    • screening messages communicated on voicemails and websites 

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If a patient has possible COVID-19 symptoms (link to symptoms), the patient should be deemed to have a positive screen. 

Possible COVID-19 symptoms

 

Most common symptoms include: 

  • cough 

  • fever 

  • difficulty breathing 

  • pneumonia in both lungs 

Other symptoms may include:

  • chills 

  • fatigue 

  • headache 

  • sore throat 

  • runny nose 

  • stuffy or congested nose 

  • lost sense of smell or taste

  • hoarse voice 

  • difficulty swallowing 

  • digestive issues (nausea/vomiting, diarrhea, stomach pain

  • presence of skin rashes and red/purple lesions on fingers and toes

  • for your children and infants: sluggishness or lack of appetite 

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Positive screening - what to do

 

If a patient screens positive prior to their appointment, they should be asked to rebook their appointment for when they are no longer symptomatic and, are outside the 14-day period.

A patient who screens positive should be advised to:   

  • Self-isolate for a minimum of 14 days (click here for an informative video)

  • Complete a provincial online self-assessment tool to determine if testing for COVID-19 is needed 

  • Consult provincial telehealth resources for further instruction 

  • Call 911 if seriously ill and in need of immediate medical attention

 

Please refer to your provincial associations for more detailed information.

Advice for patients to help prevent the spread of COVID-19

 

Patients should be careful to practice good hygiene:

  • Practice physical distancing of at least 2 meters

  • Minimize contact with those who are sick

  • Avoid touching your eyes, nose and mouth

  • Stay home when you are sick

  • Cover your cough or sneeze with a tissue, then throw the tissue in the trash

  • Wash hands frequently for at least 20 seconds

  • Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe

  • If you suspect you may have COVID-19, call ahead before visiting your doctor

Use of personal protective equipment (chiropractors, patients, office staff)

 

Judicious use of personal protective equipment (PPE) is based on a Point of Care Risk Assessment (PCRA) that every healthcare worker must perform before every patient interaction. PCRA is not a new concept; it is already performed daily by healthcare workers of all disciplines for their own safety and the safety of their clients. PCRA is a systematic process for reviewing work activities, evaluating possible hazards and risks, and implementing sustainable control measures. [12, 13]

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An essential element of the PCRA strategy is active and passive screening procedures. Practice active screening over the phone, before scheduling appointments, and upon entry to the clinic. Patients should also have access to a self-assessment tool before arriving to the clinic. Practice passive screening through messages on voicemail and websites. A sign at the entrance asking patients to self-assess, and to put on a mask and re-direct if at risk is also passive screening. [14, 15]

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All patients should be provided access to hand sanitizer, tissues, and a hand’s free waste receptacle for their used tissues at their primary access point. This can be at the main entrance or upon entering treatment rooms, or both. [14]

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Staff should wear procedure masks at all times if they are involved in direct patient contact or cannot maintain adequate social distancing from patients or coworkers. These should be immediately removed and disposed of when wet or after caring for any patient with confirmed or suspected influenza-like illness. [16]

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Patients, clients and visitors who do not screen at risk that are in a shared space at a distance greater than 2 meters apart may not require PPE. [16,17]

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Any patient interaction with someone with suspected or confirmed COVID-19 requires, at minimum, contact and droplet precautions (gloves, face shields or goggles, gowns, procedure masks). If working within 2 meters of a suspected or confirmed case of COVID-19, PPE includes use of NIOSH-approved N95 or better respirators, gloves, face shields or goggles with side protection, and fluid resistant gowns. 

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Resource: Sourcing personal protective equipment during the COVID-19 pandemic

Sanitation and hygiene

 

Basic principles of infection control should be adopted: In addition to the use of PPE (described above), this involves an emphasis on hand hygiene. Wash hands often for at least 20 seconds using soap and water. Hand hygiene should be performed after each patient interaction and when leaving the patient-care environment. If a procedure mask or other PPE was worn, hand washing should be performed upon removal of the PPE. Encourage patients to wash their hands (with soap and water or hand sanitizer) when they arrive and before they leave. [12, 19-22]

 

Chiropractic adjusting tables differ from traditional examination tables and represent a special consideration as patients lie prone with their face on a face-piece and with hands in contact with table hand rests. Tables should be covered in non-porous material such as vinyl. After each patient interaction on the table, face paper should be removed from the headpiece so the headpiece is exposed. Then apply disinfectant solution to the entire surface including face rests, structural components, chest piece, crevasses between the table pieces and hand rests. [23] Approved hospital-grade disinfectant should be used and manufacturer recommendations should be followed. Material and equipment used to clean and disinfect should be disposable. [17, 24, 25]

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Any areas that patients occupy should be cleaned and disinfected. All visibly soiled surfaces should be cleaned before disinfected. Particular attention should be paid to high touch surfaces in both patient and common spaces (e.g. door handles, chair arm rests, front desk, bathroom surfaces). [15, 17]

Physical distancing

 

Reconfigure clinical spaces (treatment areas, waiting areas, administration areas), alter staff schedules, and alter patient booking practices to allow for maximum adherence to physical distancing and regional public health guidance. Care must be taken to minimize risk of spread to elderly, those with co-morbid health conditions, and other at-risk populations. This may include preferential scheduling strategies [26, 27]

 

Patients whose active or passive screening raise suspicion of COVID-19 should be directed to follow the instructions of public health officials including stay at home. Appointments should be rescheduled for a future date. [27, 28]

Waiting Areas

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Patient bookings should be scheduled in a manner than ensures no more than 10 patients gathered in waiting areas. If patients must attend with children or other family members, those individuals must be included in the maximum number of people allowed in the area.

 

Should scheduling errors result in more than 10 people, alternate waiting areas should be planned.​ Alternative solutions to waiting in the office should be considered, such as asking people to wait in their vehicles and text messaging or calling when appointments are ready.

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All non-essential items should be removed from the patient waiting areas, including magazines, toys, and remote controls. 

Other measures to consider

 

All healthcare workers and staff should be aware of early signs and symptoms of acute respiratory infection (such as fever, cough, shortness of breath) and should monitor at home. Any healthcare worker, staff, or volunteer with symptoms of respiratory infection should not come to work. [17]

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Remind all patients to cover their nose and mouth when coughing or sneezing with a tissue or their elbow. [14, 17]

 

Utilize single-use equipment in place of shared equipment when possible (e.g. therapy bands in place of hand weights). Reduce the use of shared high-touch items where possible (e.g. strategies such as increasing credit limits on point of sale machines, allowing online payment for applicable services, decreased utilization of cash and cheque currencies, utilizing singer-user phone headsets if possible, use of digital communication in place of print where appropriate). Minimize personal belongings in the workplace. [17, 29]

 

Healthcare workers are encouraged to call their local Public Health unit if they are aware of a patient who has visited their clinic and is now testing (or has tested) positive for COVID-19. [17]

Additional resources

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References

  1. Organization WH. A health telematics policy in support of WHO's Health-For-All strategy for global health development: report of the WHO group consultation on health telematics, 11-16 December, Geneva, 1997. 1998. https://apps.who.int/iris/bitstream/handle/10665/63857/WHO_DGO_98.1.pdf?sequence=1&isAllowed=y (accessed April 6, 2020).

  2. Disease GBD, Injury I, Prevalence C. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017;390(10100):1211-59. doi: 10.1016/S0140-6736(17)32154-2 [published Online First: 2017/09/19]

  3. Cottrell MA, Galea OA, O'Leary SP, et al. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Clin Rehabil 2017;31(5):625-38. doi: 10.1177/0269215516645148 [published Online First: 2016/05/04]

  4. Kairy D, Lehoux P, Vincent C, et al. A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation. Disabil Rehabil 2009;31(6):427-47. doi: 10.1080/09638280802062553 [published Online First: 2008/08/23]

  5. Grona SL, Bath B, Busch A, et al. Use of videoconferencing for physical therapy in people with musculoskeletal conditions: A systematic review. J Telemed Telecare 2018;24(5):341-55. doi: 10.1177/1357633X17700781 [published Online First: 2017/04/14]

  6. O'Brien KM, Hodder RK, Wiggers J, et al. Effectiveness of telephone-based interventions for managing osteoarthritis and spinal pain: a systematic review and meta-analysis. PeerJ 2018;6:e5846. doi: 10.7717/peerj.5846 [published Online First: 2018/11/07]

  7. Orlando JF, Beard M, Kumar S. Systematic review of patient and caregivers' satisfaction with telehealth videoconferencing as a mode of service delivery in managing patients' health. PLoS One 2019;14(8):e0221848. doi: 10.1371/journal.pone.0221848 [published Online First: 2019/08/31]

  8. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med 2020;54(2):79-86. doi: 10.1136/bjsports-2018-099878 [published Online First: 2019/03/04]

  9. Cote P, Heather H, Ameis A, et al. Enabling recovery from common traffic injuries: A focus on the injured person. 2015. https://www.fsco.gov.on.ca/en/auto/Documents/2015-cti.pdf (accessed April 6, 2020).

  10. Bussieres AE, Stewart G, Al-Zoubi F, et al. Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative. J Manipulative Physiol Ther 2018;41(4):265-93. doi: 10.1016/j.jmpt.2017.12.004 [published Online First: 2018/04/03]

  11. Bussieres AE, Stewart G, Al-Zoubi F, et al. The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline. J Manipulative Physiol Ther 2016;39(8):523-64 e27. doi: 10.1016/j.jmpt.2016.08.007 [published Online First: 2016/11/12]

  12. Health. GoCP. Coronavirus disease (COVID-19): For health professionals. 2020 [Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals.html#w.

  13. Control. SHRIPa. Point Of Care Risk Assessment (POCRA). 2010 [Available from: https://www.saskatoonhealthregion.ca/about/IPCPolicies/20-25.pdf.

  14. [Ontario] MoH. Covid-19 Guidance: Primary care providers in an acute setting. 2020 [Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_primary_care_guidance.pdf.

  15. [Ontario] MoH. Covid-19 Guidance: Community labs and specimen collection centres. 2020 [Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_community_labs_guidance.pdf.

  16. Networks. AHSPC. PPE Distribution process to non-PCN Primary Care Providers. 2020 [Available from: https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-covid-19-ppe-distribution-non-pcn.pdf.

  17. [Ontario] MoH. Covid-19 Guidance: Acute Care. 2020 [Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_acute_care_guidance.pdf.

  18. [Ontario] MoH. Joint Statement: Covid 19 and Health and Safety Measures, including Personal Protective Equipment. 2020 [Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/2019_covid_joint_statement.aspx.

  19. Ontario. CoPo. COVID-19 (Coronavirus) FAQ. n.d [Available from: https://www.collegept.org/registrants/practice-advice/covid-19-faqs.

  20. Health. GoCP. Routine practices and additional precautions for preventing the transmission of infection in healthcare settings. 2014 [Available from: https://www.canada.ca/en/public-health/services/infectious-diseases/nosocomial-occupational-infections/routine-practices-additional-precautions-preventing-transmission-infection-healthcare-settings.html.

  21. Control. BCfD. Prevention & risks: Hand washing. n.d. [Available from: http://www.bccdc.ca/health-info/diseases-conditions/covid-19/prevention-risks/hand-washing.

  22. Organization. WH. Infection prevention and control during health care when COVID 19 is suspected. 2020 [Available from: https://apps.who.int/iris/rest/bitstreams/1272420/retrieve.

  23. Puhl AA RC, Puhl NJ, Selinger LB, Injeyan, H.S. An investigation of bacterial contamination on treatment table surfaces of chiropractors in private practice and attitudes and practices concerning table disinfection. . AJIC. 2011;39:56-63.

  24. Evans MW, Breshears, J., Campbell, A. et al. . Assessment and risk reduction of infectious pathogens on chiropractic treatment tables . . Chiropr Man Therap 2007;15(8).

  25. Evans MW Jr RM, Floyd R, et al. . A proposed protocol for hand and table sanitizing in chiropractic clinics and education institutions. J Chiropr Med. 2009;8(1):38-47.

  26. Chiropractic. WFo. Coronavirus Disease 2019 (COVID-19):Advice for chiropractors. 2020 [Available from: https://www.wfc.org/website/images/wfc/Latest_News_and_Features/Coronavirus_statement_2020_03_17.pdf.

  27. Association. PACa. Social distancing and physiotherapy. 2020 [Available from: https://www.physiotherapyalberta.ca/covid_19_pandemic/#social_distancing_and_physiotherapy.

  28. Health. GoCP. COVID-19 Pandemic Guidance for the Health Care Sector. 2020 [Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/covid-19-pandemic-guidance-health-care-sector.html#a322.

  29. Thomas P. BC, et al. . Physiotherapy management of COVID-19 in the acute hospital setting: clinical practice recommendations. . Journal of Physiotherapy. 2020:In press.

Last Updated July 6, 2020

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