Gradual restart of non-essential virtual and in-person care as of May 26, 2020
Directive #2, which previously limited the provision of non-essential care, was
revised on May 26, 2020 to allow for the gradual restart of non-essential virtual and in-person care.
The College of Dietitians of Ontario has developed the following guidance for dietitians gradually restarting non-essential virtual and in-person care. We will continue to update this guidance along with frequently asked questions as more information becomes available.
Content
The purpose of this guidance is to complement the Ministry of Health’s
COVID-19 Operational Requirements Health Sector Restart in helping dietitians take gradual steps for the return to non-essential dietetic services during the ongoing COVID-19 pandemic.
Dietitians must comply with both the College’s return to work guidance below and the Ministry of Health’s guidance COVID-19
Operational Requirements Health Sector Restart, prior to resuming non-essential dietetic services.
In addition, if you are working for an employer, you should follow your employer guidance and the
relevant health sector guidance provided by the Ministry of Health, including:
The following measures must be implemented by all dietitians in conjunction with any guidance provided by employers. Please review each section carefully. Some of these measures apply only to certain settings and must be applied in conjunction with any other guidance provided by the Ministry of Health.
a. Dietitians need to use their professional judgment considering the evolving nature of the pandemic and the need for a proportionate response.
b. Dietitians should complete risk assessments as identified in the Ministry Guidance COVID-19 Operational Requirements Health Sector Restart. Decisions about client visits must be in keeping with the principles set out in Directive #2:
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Proportionality (i.e., the capacity to offer services);
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Minimizing Harm to Clients (i.e., prioritizing services that can result harm if delayed too long);
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Equity (i.e., urgency, considering disadvantaged or vulnerable individuals);
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Reciprocity (i.e., monitoring the health care status of individuals who do not yet appear to require services immediately).
c. Services should be provided virtually whenever possible. This includes essential services that are currently being provided as well as non-essential services that have been deferred.
d. In-person services must only proceed when virtual service is not feasible and the anticipated benefits of such in-person services outweigh the risks to the client and the dietitian. Just because a dietitian can provide in-person service does not mean they should.
e. Dietitians should remain aware and keep updated as guidance may change. This information may be updated periodically as Ontario progresses through each phase of its recovery, and as new guidance or recommendations are made by the provincial government. Dietitians should regularly check for updates.
It is a requirement that dietitians conduct risk assessments of their practice including an organizational risk assessment and a point of care risk assessment as per the Ministry of Health’s direction COVID-19 Operational Requirements Health Sector Restart.
Dietitians need to apply the hierarchy of hazard controls as per the Ministry of Health’s guidance COVID-19 Operational Requirements Health Sector Restart.
Step 1 - Elimination and Substitution
Consider virtual practice first to eliminate risk. Can your service be provided virtually? Use your professional judgment.
Step 2 - Engineering and System Control Measures
If you must provide in-person service, plan your physical environment to reduce exposure for clients and staff (e.g. maintain physical distancing, consider plexiglass barriers, etc.).
Step 3 - Administrative Control Measures
If you must provide in-person service, implement policies, procedures, training, and education with respect to infection prevention and control (IPAC).
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Step 4 - Personal Protective Equipment (PPE)
Dietitians can only provide in-person service, if they have the appropriate PPE for the task, along with necessary education and training. Dietitians can source PPE through their regular supply chain or establish one.
For PPE suppliers see
Workplace PPE Supplier Directory. Public Health Ontario has a document that provides recommendations on the use of PPE for suspected or confirmed COVID-19 cases.
Dietitians must use their professional judgement to decide whether non-essential services must be provided in-person. In order to provide non-essential services in-person, Dietitians must follow the Ministry direction as stipulated in the
COVID-19 Operational Requirements Health Sector Restart with respect to the activities listed below. Please make sure to read the Ministry guidance carefully.
- Screening – Active and Passive Screening
- Positive Screening: Providing Care
- Testing
- Physical Capacity/Environment
- Critical Supplies and Equipment
- Health Human Resources
- Infection Prevention and Control
- Essential Visitors
- Occupational Health and Safety — PPE and Staff illness
- Applicable Resources
If after conducting the appropriate assessments and ensuring that all the Ministry operational requirements can be met, a dietitian determines that it is appropriate and possible to gradually resume non-essential services in person, the following should also be considered:
1. Client Appointments - Before an in-person visit
a. Create an alert on voicemails and/or your website instructing patients/clients to schedule appointments in advance.
b. Have a plan for managing walk-in or unscheduled visits, if necessary.
c. Have a process for booking appointments that includes having conversations with clients to inform them of public health measures you have implemented. Ensure your clients understand your IPAC activities and operational plans and obtain and document the client’s informed consent to attend an in-person visit. Informed consent includes discussing components such as:
- The nature of the in-person visit;
- Who will be involved in the visit;
- Reasons for the visit;
- Material effects, risks and side-effects of the in-person care;
- Alternatives to in-person care;
- Consequences of declining in-person care;
- The right to refuse or withdraw consent at any time; and
- Specific questions or concerns expressed by the client/substitute decision-maker.
d. Alternative solutions to waiting in the setting must be considered, such as asking people to wait in vehicles and texting or calling when appointments are ready, if applicable.
e. To help in contact tracing, consider maintaining a register of anyone entering your premises, including couriers and caregivers accompanying a client, etc. This registry should be kept privately and securely, until further notice, and should include the visitor name and telephone number. Explain to visitors that this information will be used for contact tracing only, should someone who visited the setting later be diagnosed with COVID-19. Anyone can refuse to provide their name and telephone number.
f. Develop an outbreak procedure checklist in the event a client becomes infected after being treated at facility.
2. Modifying Day to Day Practice
a. Have a plan for documenting your daily tasks, including your cleaning schedule with initials (who is responsible for cleaning what and how often and a record of sanitization, etc.), end of day tasks (e.g. checking supplies for the next day).
b. Consider using electronic payment devices when possible. Disinfect pin pads used to process payments between each client use. If you or staff must handle money, always ensure regular handwashing, and have minimum 70% alcohol-based hand sanitizer is readily available.
c. Aim to stay on time with appointments to minimize people having to wait together and consider timing of appointments for vulnerable/high-risk clients (e.g. immunocompromised clients).
Dietitians who are employers have a legal duty under Ontario’s Occupational Health and Safety Act to take every reasonable action to protect the health and safety of workers. This duty is particularly important in the context of COVID-19, where there is a need to protect workers and the public from contracting the virus. Specific requirements under the OHSA and its regulations are available at: Occupational Health and Safety Act
Review sector specific guidelines highlighted below and make reasonable efforts to implement the recommended actions for their sector and practice setting.
These guiding questions have been adapted from the
Health Profession Regulators of Ontario And should be read in conjunction with the Ministry of Health’s COVID-19 Operational Requirements Health Sector Restart
Please consider these guiding questions to assist your planning. These questions can also help with your decision on whether you can and should return to providing non-essential services in- person.
These questions should be read conjunction with the Ministry of Health’s
COVID-19 Operational Requirements Health Sector Restart and how to proceed in a safe and effective manner. This list is not intended to be exhaustive.
A. Planning for visits, including physical capacity/environment
1. What pre-appointment triage protocols will be implemented to prioritize client appointments?
2. Will a limit be placed on the number of individuals who can enter the practice environment at the same time?
3. What protocols will be implemented to manage the flow of individuals in and out of the practice environment?
4. Do changes to the air quality systems need to be made?
5. Can walk-in clients be reduced or eliminated, e.g., phoning prior to arrival?
6. How will clients be separated from staff and each other?
Will certain areas of the practice be unavailable to clients?
B. Organizing Waiting Rooms for Social Distancing
1. Will waiting room materials be removed, e.g., magazines, pamphlets, toys?
2. What steps will be taken to arrange/organize waiting rooms, so they satisfy physical distancing measures (e.g., spacing chairs, etc.)?
3. Will products or devices that are for sale to the public/clients be removed or placed behind a barrier or display case?
4. What physical changes to the facility need to be made to provide adequate barriers during the appointment/procedure?
5. How will clients be separated from staff and each other?
6. Will certain areas of the practice be unavailable to clients?
7. Will certain areas of the practice be unavailable to clients?
8. Can appointments be scheduled to prevent or reduce client interaction? If not, how will clients be separated to ensure physical distancing is maintained?
C. Planning for other visitors
1. How will a list of all visitors, including clients, vendors, staff, etc., to the facility be maintained to aid in contact tracing should there be a confirmed infection, including the time of entry and departure?
2.. Are additional privacy measures necessary (e.g. contact tracing register)?
D. Considerations for planning, including infection prevention and control
1. What cleaning/disinfecting measures will be taken prior to any client arrival and departure?
2. What documentation will record the times and specific areas in the facility/clinic that were cleaned/disinfected?
3. How frequently will cleaning/disinfecting be required, e.g., will the facility be closed for certain hours/days to facilitate cleaning/disinfecting?
4. What equipment/device cleaning/disinfecting needs must be considered?
5. What can be reused with appropriate cleaning/disinfecting?
E. Staff and Healthcare Professionals
1. What procedures are in place to ensure staff do not come to work sick?
2. How have public health guidance materials been used to ensure staff are screened at the beginning of each shift?
3. How will staff be separated from clients and each other? What face coverings will be required at which contact points?
4. How will form completion, payment processes be changed to reduce physical contact? What staff training is required, if any?
5. Will outbreak procedures be developed for professionals/staff, e.g., checklist of what to do if clients call with COVID, or staff develop COVID after being at facility?