Reopening Our Practices: Some Things to Consider

A Preparation Resource Document

Thank you to the Dr. Ida Rolf Institute for sharing the below helpful information to consider when you are re-opening your SI Practice.

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Outline:


Introduction:

COVID-19 is a coronavirus known as SARS-CoV-2. The virus is thought to spread mainly from person to person through respiratory droplets produced when someone breaths, coughs, or sneezes. It appears to be highly contagious and has a higher mortality rate than most flu viruses. You have no doubt seen a plethora of information on COVID-19 over the past several months. There are multiple sources that are useful to get further information. These include the CDC (cdc.gov), the WHO (who.int), and your state and local government sites. You can visit  worldometers.info/coronavirus/ for the latest COVID-19 numbers globally and in your area.

When we reopen our practice, we need to be aware of the risks of the virus and how to mitigate the potential transfer of the virus. For those of you who have worked in sterile environments or have trained in gowning, you know this is no easy task. Health worker gowning techniques are very complex to avoid contamination and extensive training is needed. (See YouTube Video).

While we are not in that environment, it is important to consider that clients could be asymptomatic while being positive for COVID-19. The statistics on this vary from 5-80% who are asymptomatic carriers and so until reliable testing is available we will not know. The reliability of testing is not 100% (the-scientist.com, New York Times article)

Imagine if that client has sneezed on themselves prior to visiting your office. There may be a virus on their skin, clothing, and shoes. The virus is known to survive on some surfaces for up to 3 days – possibly more. Due to the lipid membrane around the virus, the virus can be killed with soap and/or alcohol/disinfectants. How can we mitigate the potential for contamination of our office areas and surrounding areas? A long discussion of the myriad of considerations necessary to operate safely can be found in the following video presented by The Healing Cocoon & Massage Therapy Radio. Ruth Werner, Diana Thompson, and Melanie Hayden dive into a conversation about what the future might look like. Watch the video on YouTube

You can also find information on the American Massage Therapy Association® (AMTA) website.

A good way to start is to imagine that you’ve sprayed fine red chalk on someone.  Imagine now that that is virus particles.  When they approach your office, how can you eliminate the spread of the chalk on surfaces in and around your office? While no measures will completely ensure that we don’t spread the virus through our practice, there are ways to mitigate potential contamination.

DISCLAIMER ALERT: There is no way to completely eliminate the potential for the fine red chalk (e.g. COVID-19) to contaminate your office.  Therefore, you should think very hard about how and when to open your practice. Your local conditions may impact that decision. Your own health may also impact your decision – including whether you are older, have pulmonary issues, are immunocompromised, or have other underlying health concerns.  You also need to consider others that you could transmit the virus to, such as family and friends. You may want to consult with your doctor before opening your practice.

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Some Reference Resources:

  1. Check with your local and state governments to determine if there are specific requirements in your area.
  2. You should also check your state licensing board if you are governed by a board in your state. They may have issued specific guidelines or requirements.
  3. You can also get state by state links to recommendations through the FSMTB
  4. The CDC lists soap and water and alcohol above 60% as a disinfectant. They also list EPA registered household disinfectant appropriate for wiping down surfaces. There is more information at the CDC website on appropriate disinfectants (View Guidelines PDF).

Here are Some Ideas You Might Consider for Your Practice:
 
Again, remember – these are suggestions.  Be aware that these recommendations alone will NOT Fully ELIMINATE the possibility of cross-contamination in your office.

Before Clients Arrive

  1. If they have any symptoms of illness (cough, sneezing, weakness, temperature, sore throat, etc.) they should postpone their appointment.
  2. Ask clients to shower and dress in clean clothes before they come to your office.
  3. Ask clients to wipe down their car with alcohol before driving to your office.  This should include the steering wheel, knobs, seat, door handles, turn signals – any surfaces that they come in contact with while driving.  These surfaces may have been contaminated on previous outings.
  4. Ask clients not to stop at other stores or venues before visiting.  This ensures they don’t contaminate themselves prior to their appointment.
  5. Shoes may be contaminated with the virus – consider a place outside your office, or preferably outside the building where they can remove their shoes.
  6. If possible, have hand sanitizer at your entrance so clients can sanitize their hands prior to entering the building.

What We Should Consider

  1. You may decide to take clients' temperature upon arrival.  Fever is not considered medically relevant unless it is above 100.4 F (38 C) (webmd.com).  See more information below under “other devices to consider”.  It’s important to realize that people can be infected and liable to infect others even though they have no fever.  That means that checking temperatures will not detect 100% of infectious clients.  In addition, there is evidence that individuals may actually spread greater amounts of virus into the air during the very early days of their infection before they show any symptoms or elevated temperature.   That is why it is so important to treat every client as potentially infected and able to leave viruses in the air and on surfaces.
  2. You may also check clients' blood oxygen levels (“oximeter” is discussed more below). Blood oxygen drops below normal in most cases of pneumonia. Clients can have COVID-19 pneumonia and still be asymptomatic. See more information below under “other devises to consider”.
  3. Obviously, we must change any sheets, pillowcases, blankets between clients.  Consider having a non-porous plastic zip bag to store dirty linens. This can then be cleaned with alcohol once you are washing contaminated linens.
  4. Surfaces that are porous can’t be wiped down between clients.  Pillows are one such example.  To avoid contamination there are numerous suppliers of heavy-duty vinyl zippered pillowcases.  You can use this under your regular pillowcase and clean it with alcohol between clients. Similarly, if you use other porous items on your massage table, like fleece pads, fleece heating pads, etc., these should be covered with a plastic/vinyl cover, so it can be wiped down.
  5. Disinfect the surface of your massage table between clients.
  6. Disinfect office chairs, desk surfaces, doorknobs (essentially anything your clients' contact). If you have multiple offices in your building, coordinate with all practitioners so that building surfaces are wiped down between each and every client. Every surface that a client touches needs to be sanitized!
  7. Clients typically use the bathroom upon arrival or upon departure – wipe down the bathroom immediately after use and before any other clients can use the bathroom. If you share a bathroom with other practitioners, you might implement a procedure to ensure that other clients don’t enter until the room is disinfected.
  8. You might consider a plastic tub or hanging rack for clients to put their clothes onto when they change for a session.  The tub or rack can be sanitized between clients minimizing contamination on other surfaces from clothing.
  9. Floors are a potential vector for transmission. Consider whether you want clients to wear socks when walking around. Hardwood floors can be disinfected just like other surfaces.  Carpeted floors present a unique challenge.
  10. While we can’t socially distance, we can minimize our own contact with clients to areas that we can wash thoroughly between visits. Wearing a short-sleeve shirt will minimize clothing contact. Arms and hands can be scrubbed between clients.  After arms and hands are cleaned, then scrub face. Do this AFTER cleaning the office and wiping down surfaces including doorknobs.
  11. Skin to skin contact can be a source of the virus. Therefore, consider whether you want to work with clients using gloves and/or arm coverings.
  12. You may also elect to wear an apron to avoid contaminating your clothing.  If a cloth apron is used, it should be discarded with dirty linens between clients.  There are also plastic healthcare worker aprons that could be worn and sanitized between clients with soapy water or sanitizer.  Lastly, disposable aprons are available that could be changed between clients, but this poses a cost and environmental concern to be considered.
  13. Wear an N95 or N100 mask to protect yourself and your client. Use proper technique for donning a mask (CDC has recommendations).
  14. Supply new surgical masks to clients to wear during their visit. This will reduce the possibility that they enter with a contaminated mask. Have clients take masks home with them. Surgical masks for clients can be found for less than $2 each.  However, until all essential health care workers have necessary PPE supplies this could impact when we re-open our practices.
  15. Provide them with safety references for extending mask life.  You may find guidance for this on the CDC website.
  16. Cleaning your laundry. When you take your plastic zip bag with dirty sheets outside remember to disinfect the bag before placing into your car. Remember, sheets could contain the virus.  Consider how and where you want to wash your linens.  If you wash at home, consider a protocol to avoid contaminating your home. One possibility is letting the linens sit for 5-7 days before washing as a means of letting the virus “die-off” before opening your dirty sheets to your house or laundromat.

Devices to Consider

  1. High-Efficiency Particulate Air (HEPA) Filter Systems.  These capture particles much smaller than the size of the coronavirus and could filter your office air throughout the day. HEPA filters vary widely in price depending on their quality and the amount of air you need to filter (e.g. square footage - $150 to $1000+). See hunterpureair.com for examples of HEPA filtration systems.
  2. No-Touch Infrared Thermometers (mentioned above). There are “no-contact” infrared thermometer devices available for under $100. However, if you decide to implement temperature readings, you should thoroughly research the accuracy of your device and understand that for infrared technology the surface temperature may not accurately reflect core body temperature as it can be affected by atmospheric conditions that your clients are exposed to prior to entering. Remember that people infected with COVID-19 can transmit the virus prior to becoming symptomatic (prior to getting a fever or other symptoms). Consumer Reports has a summary of device accuracy, repeatability, and features.
  3. Oximeters:  Oximeters measure blood oxygen levels. Normal: A normal arterial blood gas (ABG) oxygen level for healthy lungs falls between 80 and 100 millimeters of mercury (mm Hg). If a pulse scan oximeter is used to measure your blood oxygen level (SpO2), a normal reading is typically between 95 and 100 percent. However, in COPD or other lung diseases, these ranges may not apply, so be aware that people with certain lung issues may not be applicable to normal oximeter testing ranges. Pulse scan oximeters are generally less than $100 and touch the skin (finger clamp) so you would need to be sanitized between uses. Remember that people infected with COVID-19 can transmit the virus prior to becoming symptomatic (e.g. prior to getting pneumonia/low blood oxygen).
  4. Ozenators: There is no credible evidence that adding ozone to indoor air will reduce the concentration of or inactivate the coronavirus. Ozone above a very low concentration is a known irritant of lung tissue and might thereby actually render an individual more susceptible to infection.
  5. Be aware that there are misleading articles circulating about UV light, chlorine, and high temperatures and other means to kill COVID-19. Many of these inaccurate articles are not only ineffective but may be harmful. Sunlight, cold temperatures, and snow also are ineffective at killing coronavirus (see CDC and WHO website).

It is crucial to realize that the risk here is not only that you and/or your clients might become infected, but the larger risk is to all of the others, including family members, friends, and coworkers, who would be at risk for infection from an individual who became infected in your office.  We will only be successful at winding down the rate of infection in society as a whole if everyone is careful to take precautions in their personal and business lives.
 
Finally, remember that these are just some suggestions to consider. We are dealing with a virus that is deadly. Even healthy and young people have died from COVID-19. Also, while you could acquire the virus and not have significant symptoms, you could be transmitting the virus on to others. There is additional information on the DIRI website under CoronavirusFor all of the above reasons, you should carefully and seriously think through your protocols for operation and when it is possible to safely open your practice. 

Feel free to call or write if you have any questions.

Rich Ennis, Board Chair
On behalf of the Dr. Ida Rolf Institute®

Eric Jacobson, PhD and Vaclav Kremin, PhD.
On behalf of the Dr. Ida Rolf Institute Research Committee

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