At this point everyone is likely aware of the virus COVID-19 and the impact it is having on the United States. What we haven’t heard is how it is formally being addressed in the physical therapy community. In my research on social media, as of Sunday, March 15th, not a single therapy provider has formally reduced patient contact in any way. Companies have been addressing the issue only by advising employees to stay home if sick, with no other changes to patient care.

The CDC itself has published that the virus is “spread from person-to-person most frequently happens during close exposure to a person infected with COVID-19”. Close contact is defined by being within 6 feet of an infected person for greater than a few minutes. And what healthcare worker has the most close contact with patients over a prolonged period of time? Physical and occupational therapists. Most therapy sessions can be up to an hour of patient contact certainly within 6 feet of our patients.In a study of 8 VA nursing homes it was found that PTs have an average 16.7 direct patient contacts per hour and OTs had 15. That is almost 3 times higher than the average resident to staff contact. Due to worsening insurance reimbursement, outpatient clinics are forcing therapists to see multiple patients at a time. This is crowding PT gyms with patients ending up certainly more than 6 feet from each other and little time to wipe down every item a patient comes into contact with before the next patient use.

But we were taught standard precautions at school, right? Therapists have to be great at infection control. Not quite. A study of a PT school lab of swabs on tables and equipment found 15% of samples to have an active culture of Staphylococcus aureus and 2% to actually have MRSA. What about pediatric clinics? A study of 8 ball pits used in clinics found 8 opportunistic pathogenic bacteria and 1 opportunistic pathogenic yeast D. You may think we should no better by now, but that study was published in 2019. Outpatient clinics can’t be that bad, right? In a studytesting of the tips of ultrasound gel bottles, 3.6% of the swabs were positive for MRSA and 52.7% positive for non-specific bacterial contamination. Testing the heads of the ultrasound machines found 35.5% of those sampled had non-specific bacterial contamination.

Testing how gross PT clinics are and what a bad job we are doing does not seem to be a popular research topic, but these cases should be a testament in the dire situation of poor infection control in the therapy setting. Even though we all try our best, it’s a tough situation we are up against and it severely puts those we are trying to help at risk. We all know how easy it is for one of our patients to get sick and how severe an illness can be for them. If this is the normal situation, what are we supposed to do now with a national emergency of a global pandemic? Is the situation even that serious?

I want to tell you why I am writing this article. This is my stepdad.

Yesterday on the phone my mom said he had a very bad cold. He is 73. I can’t imagine life without him. They live in Upstate NY and he has not been a confirmed case at this time (my mom says he is “too stubborn” to get tested), but I am scared. It’s one thing to see numbers on the news, it’s another thing to think of something happening to someone you love. I’m writing this article in hopes that other people won’t have to worry like me. I’m writing this in hopes that we can make a change in the rehabilitation profession to keep those we serve, to keep our communities safe. But what should we do?

If you are a visual person, like me, take a look at the example simulation animations provided on the Washington Post website to demonstrate the exponential curve of COVID-19. Blue dots represent healthy people and red dots represent those with COVID-19. It provides a visual of several different community intervention options, most of which end up with most of the screen being red dots, meaning they ultimately don’t work. The only scenario that did work and “flattened the curve” of the exponential spread of COVID-19 is called “social distancing”.

What is social distancing? The CDC defines social distancing as it applies to COVID-19 as “remaining out of congregrate settings, avoiding mass gatherings, and maintaining distance (approximately 6 feet or 2 meters) from others when possible.” That is why stadiums, schools, events and such are being cancelled, because people end up being very close to one another.

But is it even that serious? Isn’t it just like the flu? Absolutely not. Dr. Howard Lusk, MD states “COVID-19 is a severe respiratory illness caused by the virus named SARS-CoV2. It is a novel virus, which means that no one in the world has antibodies to it because no one has ever been infected by it before. As such, when the COVID-19 virus invades our body we do not have antibodies. We do not have a template to utilize from a previous exposure to rapidly create a defense against the virus. Because no one has antibodies, everyone is at risk for catching the virus, becoming ill, and spreading the virus so that it can infect those around you”. The virus disproportionally effects those over 60, often those who seek therapy services the most. Many younger people think that this makes it not so important, but please, think of my stepdad. Think of your parents, your grandparents your community leaders and so on. They matter, we all matter and need to work together to keep our communities safe.

For many, social distancing seems extreme. However, at this time, an effective quarantine is not possible as the US does not have anywhere near enough tests to cover those who may be infected. Dr. Ashish Jha, MD of the Harvard Global Health Institute says, “When you look at what’s happening across the country, with school closures, the NBA, and March Madness, all that being shut down, it’s basically because we can’t test anybody. We have lost the most powerful tool we have for fighting this disease. And so we’re having to resort to a whole lot of other things. And for us to not get really walloped by this infection, we have to implement very kind of draconian, difficult measures, like shutting down public meetings, like sending kids home, like ensuring people are not going to the office or going out to restaurants or movies. We’re going to have to do all of that until we really get a grip on the infection. If today, I, as a physician, wanted to test somebody that I was worried might have coronavirus, I can’t, generally, largely. Most Americans can’t get that test who need it.”

Dr. Asaf Bitton, MD, MPH of Ariande Labs also agrees, “At this point, containment through contact tracing and increased testing is only part of the necessary strategy. We must move to pandemic mitigation through widespread, uncomfortable, and comprehensive social distancing. That means not only shutting down schools, work (as much as possible), group gatherings, and public events, but also making daily choices to stay away from each other as much as possible”.

Dr. Jha also points out the need for this extreme of a measure: “The doubling time of this disease is six days. And another way of thinking about it is, my guess is, about 10,000 Americans probably have the infection today (Mar 12th). Officially, it’s only about 1,400, but my best guess is 5,000 to 10,000 Americans. That number is going to double in six days. It’s going to double again in another six days.

Dr. Lusk also speaks of the dire need for this level of intervention, “Who should follow our suggested social isolation measures? EVERYONE. If you do not need to go out for a mission-critical purpose, do not. Again, you WILL be saving the lives of at-risk members of your own family, as well as people you will never have the pleasure of meeting”.

But what should we as healthcare professionals do? Does social isolation apply to healthcare workers too? What do our governing authorities have to say on the subject Well, the answer could not be more vague when it comes to the CDC and CMS’s guidance on the situation. There is much information available for precautions for healthcare workers, but no mention who it applies to and how. Also, all instructions are only based on those with confirmed COVID-19 or “suspected individuals” which seems to mean those with active symptoms of fever, cough and shortness of breath, however even the CDC confirms the disease has at least a 4 day incubation period before showing symptoms with possible 2-14 days, so how can we tell who is “suspected” and who isn’t if people are not yet showing signs? And it has been said many times that we do not have adequate testing kits to test who truly is positive and negative for the virus, so how do we know who is even active?

As of March 7th, the CDC’s 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 (COVID-19) is listed here and could not be more confusing. It defines workers as high, medium or low risk, but is still highly difficult to thoroughly understand based on the lack of testing available to confirm cases. Of note is the instruction for healthcare providers (HCP) to monitor themselves for fever by taking their temperature twice a day, something none of my companies have told me to do.

As of March 15th the CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings does make some things very clear. It calls to “explore alternatives to face-to-face triage and visits”, “Cancel group healthcare activities (e.g., group therapy, recreational activities).” and “Postpone elective procedures, surgeries, and non-urgent outpatient visits” all 3 of which could apply to physical therapy.

These basically are a definite call for an end to all group therapy and an urge to postpone “non-urgent” outpatient visits, like therapy. The great question becomes, how urgent is therapy?

As of March 15th the CDC’s Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings clearly states, “Reschedule non-urgent outpatient visits as necessary”.

This document also makes the declaration to, “reschedule elective surgeries as necessary”. This inherently means there will be less PT patients such as the over 1.6 million total knee and hep replacements performed every year, all of which receive extensive PT.

What about my own setting, home health? The Center for Medicare and Medicaid Services issued this Center Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health Agencies (HHAs) with a specific section on therapeutic interventions:

“Patients with known or suspected COVID-19 should continue to receive the intervention appropriate for the severity of their illness and overall clinical condition. Because some procedures create high risks for transmission (close patient contact during care) precautions include: 1) HCP should wear all recommended PPE, 2) the number of HCP present should be limited to essential personnel, and 3) any supplies brought into, used, and removed from the home must be cleaned and disinfected in accordance with environmental infection control guidelines.”

Again the question is, who is “essential personnel”? And this also only applies to “known or suspected cases”, but with the lack of testing available and incubation periods, how would we know?

And then there is the issue of personal protective equipment (PPE). They must have meant personal since many companies are not providing proper supplies to their employees at this time. Did you know that for known or suspected COVID-19 the CDC recommended PPE is not only face mask/respirator and gloves, but also gowns and eye protection? Yes, eye shields or goggles since transmission may occur through droplets entering the eyes. I’ve never even worked somewhere that offered goggles. And don’t forget, this is even for suspected cases right now, which we do not have a confident definition of based on the incubation period and lack of testing.

So the big question is, what do we do? After completing my research, these are my personal recommendations:

Close all outpatient therapy clinics and switch to telehealth as able

All SNF, inpatient and acute treatments must occur in patient rooms only and wearing full PPE protocol of gloves, mask, gown and eye protection and not to treat unless these have been provided by employers

Keep home health visits to an absolute minimum for vital cases only, full PPE required to enter homes, use telehealth as able

Maintain these until the federal state of emergency and all local disaster protocols are lifted

It comes down to this: if we over-prepared and saved many lives, it was worth it than under-prepared and harmed many. Us therapists, we are a different kind of people. We put our patients’ needs above our own every day, skipping lunch to see a patient, making those extra coordination calls on personal time, spending our own money on equipment for our patients. Well now is the time we need to do something different for them. We took an oath the day we graduated to protect those in our care and this is how we do it.

Please, even if all these seems too extreme, think of people’s parents, grandparents, my own stepdad. I don’t know what I would do without him in my life. By taking these steps you will be stopping countless other Americans from feeling that too.

And a message from Spain, where the entire country is on lockdown. It says “Stay at home: help us”