Are you able to provide a comprehensive pelvic health assessment virtually?
What are reasonable risks when providing services virtually?
Are you able to provide supervision of physiotherapists virtually?
The Virtual Care Guide touches on the provision of appropriate care but this article will delve a little deeper and provide some more context to the above questions. What are some other questions you should be asking yourself when considering providing services to your clients virtually?
- Is virtual care the most appropriate available method to deliver services for this client?
- What is your client’s preferred method of service delivery?
- Does this client require an in-person physical examination to complete a comprehensive assessment and determine an accurate diagnosis and treatment plan?
- Does the client have physical, sensory, and/or cognitive impairments that prevent the delivery of safe and effective virtual care?
- Do existing barriers create additional risk or decrease the quality of care that can be delivered virtually?
Questions like these are important to keep in mind when it comes to evaluating the appropriateness, risk, and safety of the services you are delivering. It is also important to be honest and transparent regarding whether you can accurately form a diagnosis and treatment plan from your virtual assessment. It is important that you are consistently using critical thinking, your professional judgment and some healthy second-guessing for each client that you see virtually to establish answers to the questions above.
This article will review three scenarios that occur in practice and will consider the question of whether or not these virtual services are appropriate.
Scenario #1
Janice is suffering from incontinence and wants to book an appointment with a pelvic health physiotherapist. She phones a clinic to enquire about booking an appointment and is told that they can book a virtual session to assess her condition and provide a treatment plan that can be delivered virtually. Due to her busy schedule Janice feels like this is a great option.
Eight weeks after the assessment Janice is reporting worsening symptoms. After the last treatment session online, the physiotherapist has Janice come in for an in-person visit and internal pelvic health exam. Due to the findings on the internal exam, the physiotherapist discusses with Janice that the initial diagnosis and treatment plan were incorrect. Now that the physiotherapist was able to complete a comprehensive assessment, they alter the treatment plan and assure Janice that they should be noticing improvements in a few weeks. However, Janice is very unhappy with this as she feels she has wasted two months of her time, money, energy and is worse off than when she started.
Key Takeaways
- Client preferences do not supersede a physiotherapist’s judgment. If you cannot complete a proper assessment and form an accurate diagnosis virtually you cannot assign a treatment plan. If you find yourself in a similar situation you must discuss that with your client and provide them with options for an in-person assessment.
- There are certain areas of practice that make it extremely challenging to provide a complete assessment and generate an accurate diagnosis without some form of hands-on assessment. Pelvic health physiotherapy is just one example.
Scenario #2
Gita is an elderly client who resides in a continuing care home. Physiotherapy services are usually provided virtually to the residents from a physiotherapist named Wayne. Wayne works remotely for a company that provides services to multiple different care homes. Gita has started experiencing episodes of intense vertigo and is scheduled to see Wayne this afternoon.
Wayne reviews Gita’s intake form and identifies a few concerns regarding her overall medical history but feels that he can continue with her assessment. During the assessment Wayne completes his subjective history and screens for neuro and other potential concerning symptoms. Based on everything he has seen he feels the most likely issue is BPPV and wants to have her go through Dix-Hallpike testing and feels she can self-administer the test with the health-care aide in the room.
Unfortunately, as Gita lays back her symptoms come on very strong and she panics. She tries to sit herself back up but rolls off the bed and vomits onto the floor. Fortunately, there are no major injuries and the health-care aid is able to call the nursing staff in to assist Gita. Wayne apologizes to Gita that he put her in a situation that he was not prepared for. He talks to Gita about next steps and that due to the severity of her reaction that they would proceed with an in-person assessment in the future. He provides her with some other options in her area that she can also follow-up with if she does not wish to continue with him.
Wayne contacts his employer to discuss what occurred and plans are put in place to educate the other physiotherapists from this situation. Updates are made to their policy and procedure manuals highlighting potential risks with assessment of vertigo virtually and other related issues.
Key Takeaways
- Impairments such as vertigo, balance issues, traumatic brain injuries, etc. can create unsafe conditions for providing virtual care. It is important to consider the risk to the client’s safety and ensure that you have plans in place for adverse events.
- The condition and assessment technique used in this scenario had increased risks associated with them. It could be argued that this client was not appropriate for virtual care. Or that the PT should have chosen different assessment tools or done a better job anticipating the adverse reaction. It is important to use your professional judgment and some healthy second guessing to evaluate decisions around whether virtual care is an appropriate option for the client.
Scenario #3
Garth has recently been injured and has been in a large city hospital where he is being seen at the wound care clinic. He really wants to get discharged home to be closer to family as he recovers but he still needs ongoing care for his wound. The distance from his home to the city hospital and the frequency of wound care interventions mean it isn’t feasible for him to go back and forth to receive that care.
The physiotherapists from the wound care team reach out to the physiotherapist at the local hospital to see if they can discharge him there. Although the physiotherapist at the local hospital has started a wound care course and would be happy to see Garth for ongoing care, he is not yet competent to provide the level of care needed. They discuss various options to try to get Garth home and they look at providing supervision virtually. As they discuss this idea they search the College’s webpage on Restricted Activities and find the following regarding supervision of restricted activities.
The supervising physiotherapist must:
- Be satisfied with the knowledge, skills, and judgment of any individual whose performance of a restricted activity they are supervising.
- Provide supervision in accordance with supervisee’s competence and registration status, and the restricted activity considered.
- Use direct or indirect supervision strategies, in accordance with the supervisee’s skills and competence, to supervise physiotherapists on the General Register who are developing their skills and competence to perform the restricted activity.
- Be present in the treatment room or cubicle, able to observe and promptly intervene if required, when providing direct supervision of restricted activities performed by regulated members as required by this standard.
Due to the competence and skills of the physiotherapist in Garth’s community and the risk factors associated with the restricted activity, they decide that they cannot provide supervision virtually; therefore, Garth is unable to receive the care required at his hometown hospital from the physiotherapist. He is disappointed that he cannot go home yet but understands that he needs appropriate care to ensure his wound heals properly.
Key Takeaways
- Client preferences alone should not dictate whether or not virtual care is provided. Professional responsibilities and adherence to the Standards of Practice create rules and guidance for physiotherapists to follow.
- Supervision can occur virtually but physiotherapists must be knowledgeable about the context in which it is or is not appropriate. Any direct supervision of a restricted activity must be done in-person where the supervisor is present and able to intervene if required.
Conclusion
These scenarios provide real clinical context to the appropriateness of virtual care. When assessing a client virtually the physiotherapist must consider what is feasible, accurate, and comprehensive. The questions listed at the start of this article should always be considered along with a healthy dose of second guessing. It is ok to stop an assessment or treatment if you feel that it is not safe or appropriate to continue and make arrangements for in-person care.
If you have any questions about this or other areas of practice, you can reach out the Professional Practice Team at the College of Physiotherapists of Alberta.
Actionable Items
Reflect on the care you are providing:
- Is it appropriate or beneficial for the client?
- Can you form an accurate diagnosis from the virtual assessment?
- Do you have appropriate safety protocols in place for your virtual clients?
Review your options:
- Do you have the ability to refer your virtual clients on to someone they can see in person?
