PWTAG and ATACP Recommendations for safe aquatic physiotherapy in relation to Covid-19 Pandemic

The ATACP would like to inform our members the Pool Water Safety Advisory Group (PWTAG) have now archived their technical notes in relation to the Covid 19 Pandemic. However, their Code of Practice has been updated to reflect the need for improved pre swim hygiene, cleaning and chemical management https://www.pwtag.org/. The ATACP will follow their lead and archive Recommendations for safe practice aquatic physiotherapy in relation to Covid 19 Pandemic, but would like to highlight the following points to consider in continued safe aquatic physiotherapy practice:

1. PPE and social distancing has not changed for healthcare workers, therefore a type II surgical face mask must still be worn in the pool and social distancing of 2m maintained between patients/pool users/visitors. COVID-19 infection prevention and control guidance (publishing.service.gov.uk)
2. The updated PWTAG Code of Practice states the gold practice for

• Pre-swim hygiene: ‘To protect the public from transfer of disease and to keep disinfection at optimum levels, everyone should use the toilet and shower with soap before entering the pool. Good personal hygiene is essential prior to entering the pool water, making sure heads, armpits, genitals, anal area and feet are clean, free from invisible dirt, dust and microbial loading’.
• Cleaning pool surrounds/concourse should be ‘cleaned at the start of each day and as necessary thereafter. Cleaning in a pool environment will often require washing with soap and/or disinfection. For disinfection the UK government and WHO advise using a disinfectant solution of 1,000 mg/l available chlorine (or ppm av.cl.) This can be prepared by diluting 10ml of 10% w/w sodium hypochlorite with 1 litre of tap water this is equivalent to 100ml or half a cup of 10% strength sodium hypochlorite in a 10-litre bucket of water’.
• Cleaning equipment ‘should be frequently cleaned physically, and periodically disinfected with 1000mg/l chlorinated water solution and air dried prior to storage. Or alternatively, anything with an impermeable, non-porous surface could be wiped down with 60% v/v ethanol or 70% v/v isopropanol and then allowed to air dry.’
• pH level ‘recommended value of between 7.0 and 7.4 should be the range when using chlorine-based disinfectants and ideally 7.0 to 7.2 for a better disinfectant effect’.

Please note each hydrotherapy pool, and its environment, will need to be risk assessed and comply with local policies.

FAQs:

1. Can we treat more patients than 1:1 in the pool?
   It is important to follow the CSP and PHE guidance on social distancing. If you can maintain social distancing within the pool and its communal areas (e.g. changing rooms, showers, waiting areas, corridors) then it could be possible.
2. Do we still need to naked shower with soap before entering the pool?
   This has always been PWTAG’s stance on pre-swim hygiene and is the gold standard. Individual pool settings will need to risk assess the feasibility of achieving this. One suggestion if the pool has only open shower areas, which are not appropriate to shower naked in, is to request the patient soap showers at home prior to attending their appointment and then rinse shower immediately before pool entry.
3. Do we still need to disinfect our pool therapy equipment?
   Initially PWTAG stated pool equipment needed to be disinfected between individual patient use, when the guidance was reviewed earlier this year it was relaxed to after sessional use. Currently PWTAG state ‘periodically disinfected with 1000mg/l chlorinated water solution or impermeable, non-porous surfaces could be wiped down with 60% v/v ethanol or 70% v/v isopropanol’. Pre covid the ATACP stance was all equipment needed to be cleaned and disinfected at least weekly. We are aware departments used pool water to disinfect equipment, but pool water chlorine levels are too low (1-3ppm equivalent to 1-3mg/l) versus WHO recommended 1,000mg/l. Individual risk assessments will determine your view on ‘periodically’ disinfected. Note that most noodles and kickboards are closed cell with impermeable surfaces which can be wiped down using the medical disinfectant wipes.