What does manual therapy treatment look like post-lockdown? Clinic owners Collette (B.OST) and Sean Bourke share a glimpse of the PPE protocol they have adopted to protect their patients and business.
Michelle Geslewitz·
The Village Osteopaths is a family-run osteopathy clinic based in Cheshire, United Kingdom, founded by Collette and her husband Sean in 2013. Collette is the principal osteopath at the clinic, while Sean looks after the business side of things. The clinic is focused on healing sports injuries, the elderly, new mums and babies, as well as specialising in The Perrin Technique to treat patients with ME/Chronic Fatigue Syndrome. Collette and Sean have steadily grown their business over the past seven years, and in 2019 won the award for best osteopathy clinic in Cheshire from GHP News.
Then, 2020 happened.
COVID-19 hit the UK hard. Like many other allied health clinics across England and Wales, The Village Osteopaths shut in March and remained closed through to the middle of June.
Collette and Sean have used the past few months in lockdown to tirelessly research and implement an impressive personal protective equipment (PPE) protocol for their reopening. They also digitised their clinic by trialing Cliniko. Initially, they found the process of sifting through available information overwhelming. They compiled information from sources like Public Health England, European Centre for Disease Prevention and Control, and their colleagues in Italy, and at long last, have now established an evidence-based protocol to continue their treatments safely.
Collette and Sean were kind enough to talk us through how they developed their PPE protocol and each step they now follow, in the hopes that it will help other clinicians who felt like they did in the aftermath of the lockdown.
Best practice for PPE may change as scientists learn about the virus, so it’s important to stay informed of the latest health guidance. This blog post is not a substitute for official advice, but we hope it inspires you in adapting your own clinic.
An effective PPE protocol not only protects the safety of patients and practitioners alike but also reduces the likelihood of the healthcare business experiencing more lost working days due to the need to self-isolate in the event of an infection outbreak. This was ultimately Collette and Sean’s rationale for investing their daily appointment time into stringent cleaning and stocking additional supplies.
Appointments at The Village Osteopaths involve close contact with patients and can sometimes last upwards of 30 minutes, so plans for when and how practitioners should safely don their equipment, what pieces of kit are necessary for practitioners to wear, and how to interact with patients are all essential parts of the plan to keep the clinic safe.
Though they had official guidance from the Institute of Osteopathy, for Collette and Sean, assessing their patients’ and practitioners’ risk of exposure to disease went far beyond a tick box exercise. They developed their own risk assessment based on the guidelines as well as the needs of their practice and how their clients interact with the physical environment in the clinic.
This is where their switch to Cliniko came into play, as ultimately they realised that a paperless clinic meant fewer surfaces for the spread of infection: ‘We were looking at using a patient management system before and GDPR brought that into clearer focus. For one reason or another, it went down on our list of priorities,’ explained Sean.
Collete elaborated: ‘We’ve just completely minimised the clinic [to protect from COVID-19], so we have fewer surfaces that we have to clean, and we did have a number of filing cabinets filled with plastic wallets which had notes inside. Sometimes the patients are seen by different osteopaths, and the evidence available at the time suggested the virus can last on plastic for days, so that was potentially a transmission risk.’
Cliniko isn’t the only digital tool that Collette and Sean are using to minimise the chance of infection. Collette said,
Rather than have Sean sitting behind a desk in the clinic, we now have a video device on the desk in the clinic, and he works from home. He can still see and speak to patients as they arrive. The fact that we have all the clinic notes and everything online and digitally available makes it much easier for him to navigate if a patient calls. He can still share notes with the osteopath working if we have a last-minute booking.
The Village Osteopaths have converted their reception area into space for clinicians to 'don' their PPE.
The Village Osteopaths also use a slightly older bit of equipment to protect their clinic from infection: the telephone. Twenty-four hours before each appointment, Sean pre-screens patients and asks them if they or a family member have experienced any symptoms of fever or a cough in the previous seven to fourteen days, and reminds them to bring a personal face mask for their appointment. This information is all conveyed to the osteopath on duty in the clinical notes.
If patients do not have their own masks available, the clinic has some on hand for sale. However, this has not been an issue to date.
Within the clinic premises, Collette and Sean have taken great care to think through each aspect of their regular day and make it safe. Their routine now includes the following steps:
When the osteopath on duty arrives at the clinic, they first sanitise their hands and then enter the specially designated ‘doffing’ (undressing) area. There, they remove the clothes that they wore on their journey into the clinic, place them in a perspex box, and then put on their clinic clothes (tunic, trousers, scrubs) for the day.
Collette explained this process is in place to prevent any aerosolised drops from contaminating the treatment areas.
Then, the clinician enters the ‘donning’ (dressing) area, where they put on nitrile gloves, plastic apron, and a fluid-resistant, surgical mask, or FFP3 model. They have a choice of goggles or a visor depending on their risk assessment for the day ahead. Collette explained:
In our area, the R number isn’t that low, so the virus is still circulating quite widely. Plus, we’re in such close proximity to patients for a prolonged period, if someone sneezes or coughs you can contract the virus through your eyes. So on our risk assessment, we’ve decided we need to wear eye protection to be safe...On our pre-screen call, we do ask if patients have any other conditions like asthma or hay fever that might increase their chances of sneezing or coughing. If they do have something like that, then we do just wear the full visor.
Donning & doffing guidelines for the UK are available on the Public Health England website.
Once the PPE is donned, the patient waiting outside is allowed into the clinic and escorted to the consult room where the treatment is performed.
Before the patient leaves the clinic, the practitioner removes their gloves and apron, which are the most highly contaminated pieces of PPE because they touched the patient. Once the patient has left the premises, the clinician re-enters the doffing room to remove their mask and eyewear.
Then the consult room is sanitised, with a special emphasis on disinfecting any ‘touchpoints’ in the clinic that the patient may have touched like bannisters or door handles. The treatment room is disinfected and aired out for a minimum of 15 minutes while the practitioner dons their fresh set of PPE.
This process is repeated throughout the day, with practitioners taking their clinic clothing home in a plastic bag to wash at 60°C degrees each night. The clinic is fully sanitised at closing time ready for the next day of treatments!
Collette and Sean had some issues initially with sourcing basic PPE equipment like masks, gloves, and gowns because supplies were diverted to the NHS. ‘Rightly so!’ Collette is quick to add. But since the initial outbreak of the virus in the UK, items have become a bit easier to get ahold of.
PPE has come from unexpected sources at times, including one donation of visors made by volunteers from a UK charity called 3D Crowd. Their usual supplier of PPE ran out of stock early on in the pandemic, so Collette and Sean have had to make use of their ‘Google-fu’ to find new suppliers to fill the gaps. Fortunately, the Institute of Osteopathy also put together a list of recommended PPE providers.
Adapting to the changes in protocol has also required some creative adjustments. In order to thoroughly disinfect their treatment rooms after use, Collette and Sean have repurposed a weed spraying canister for reaching all walls and surfaces with a specially-chosen disinfectant. Not to worry—this particular weed canister was only ever filled with proven COVID-busting chemicals that are non-toxic to humans.
For Collette and Sean, keeping clients informed throughout lockdown was a major priority. Before reopening they emailed their clients periodically with updates on when they would be able to take new appointments and measures they were adopting to prepare for reopening. They also decided that after seven years of service with no price rise, it was necessary to increase their fees.
We always try to make appointments as affordable as possible for our patients, but having been closed for three months and now needing a 15 minute gap between appointments for airing and cleaning...unfortunately we have had to increase our prices.
‘Everybody has been really understanding, which has been really great,’ said Collette. There hasn’t been one patient who has queried the price rise, probably because Collette and Sean have explained the circumstances behind it through their email newsletter.
In terms of other communication methods, The Village Osteopaths Instagram account is a fantastic example of how practitioners can document the changes they are making in response to COVID-19. On it, they’ve shared photos of each area of their clinic as well as the PPE they wear to help reassure patients their treatments are safe.
Collette and Sean painstakingly compiled the information they used to set up their PPE protocol from a variety of sources. Here is a tiny sample of what they referenced:
The Village Osteopaths’s risk assessment and full list of references is also available to view online.
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