Infusing Standard Precautions for Infection Control in Occupational Therapy Telehealth With Children

The COVID-19 pandemic has caused a profound effect on the health and well-being of individuals worldwide. In the Philippines, the withstanding quarantine protocols have affected the occupational therapy practice, which has adopted a telehealth strategy. Filipino occupational therapists (OTs) working with children have to infuse concepts of standard precautions of infection control to prevent infection and transmission in their virtual sessions. This innovative practice has been delivered through telehealth services. This case report highlights the importance of family collaboration, activity analysis, evidence utilization, and infusing standard precautions in children’s daily occupations. OTs should consider these “new approaches” in the “new normal” and beyond.


INTRODUCTION
The ongoing COVID-19 pandemic has placed the entire world at a standstill in controlling the virus's spread while trying to go on with our lives. It has had a tremendous effect on an individual's health and well-being, the nations' economy, and the world as it deals with an unprecedented global health issue. In the Philippines, records show that the number of infected individuals has breached 600,000 this March 2021. 1 Despite enforcing a longstanding quarantine since March 2020, the infection rate continues to grapple the country. In the earlier phases of the pandemic, the national government enforced cessation of various transactions that needed face-to-face interactions. This included the conduct of various forms of occupational therapy services. In response, the Philippine Academy of Occupational Therapists provided guidelines in the continuation of occupational therapy services within the virtual environment through telehealth. 2,3 This case study reports on observations and experiences of the authors on the innovative practices employed by Filipino pediatric OTs in infusing standards precautions for infection control in telehealth services.

OCCUPATIONAL THERAPY AND TELEHEALTH
Telehealth is the evidence-based practice of using various information and communication technologies to deliver direct and indirect health-related services that transcend the physicality of location. 4 Telerehabilitation is a specific direct service delivery approach within telehealth, which aims to appropriate rehabilitation services, including occupational therapy. Even prior to the pandemic, OTs have tried to utilize the virtual and digital environments in service delivery. Telerehabilitation provides service users an alternative model for occupational therapy delivery that can bridge distance and offer innovative interventions within the client's contexts. 5 Thus, the World Federation of Occupational Therapists' endorsement of the use of telehealth as a means to resume occupational therapy services was not surprising. 4 OTs utilize telehealth in various capacities: evaluation, intervention, monitoring, supervision, and consultation.
In the Philippines, the practice of occupational therapy is predominated by pediatric practice. 6 OTs meet the clients in hospitals, clinics, schools, or their homes. Sessions last between 30-60 minutes, with frequencies depending on the child's condition. The COVID-19 pandemic has greatly impacted this practice. 7 For reasons of high community transmission, vulnerability of the child's health, and the increased risk of infection between child and therapists, telehealth was adopted immediately and later on recommended by the national professional organization.

INNOVATIVE TELEHEALTH APPROACHES IN TEACHING STANDARD PRECAUTIONS FOR INFECTION CONTROL
Telehealth encompasses a wider-range of healthrelated services regardless of professional activity (e.g., telerehabilitation, telemedicine, teletherapy). Telehealth reflects the scope of services that OTs may provide. Standard precautions of infection control refer to guides on how individuals can reduce the risk of transmission of pathogens. 8 This includes hand hygiene, personal protective equipment (PPE), respiratory hygiene, and cough etiquette. Commonly, OTs are educated on these and are expected to follow these standards in their practice. However, with the current COVID-19 pandemic, standard precautions of infection control are adopted at a public health level to prevent transmission and infection. Innovative approaches are needed to infuse standard precautions in occupational therapy with children delivered via telehealth. This report entails the authors' observation and conversations within their professional networks on how standard precautions are infused in the OT practice via telehealth in the year. The observed innovative and creative approaches are summarized below.
It takes a village. Family collaboration is a key strategy in telehealth and telerehabilitation. 5,9 This will involve advanced planning with the child and their family in setting goals, identifying the relevant activities and materials needed, strategies in monitoring the child's performance, and coaching the family itself. Involving the family ensures the transfer of learning from the virtual environment into the physical one.
Activity analysis . OTs need to match the complexity of standard precautions constructs to the child's developmental age capacity and the resources available to both therapists and child. 5,9 While some children require the processing of the pandemic issue; others may benefit from direct teaching of hand hygiene or proper wearing of face masks and shields. Internet connectivity issues should likewise be considered in deciding whether some activities will be best done synchronously (i.e., during actual telehealth sessions) or asynchronously (e.g., curated videos, digital print resources).

Utilization and contextualization of evidence.
One of the challenges in telehealth is developing and curating resources to use during sessions. 5,9 Due to the pressing issues of clients' needs, OTs need to maximize available resources from trusted organizations (e.g., World Health Organization, Center for Disease Control, Save the Children). This reduces the cost and the efforts compared to developing de novo digital materials. However, the contexts of how these materials have been developed may not always apply to the Philippine setting. Hence, OTs need to be mindful of adopting, adapting, or contextualizing these materials to make them relevant to their clients.

Standard precautions and promotion of occupations.
Admittedly, the concepts of infection control might be too complex of a concept for children with varying developmental skills. However, integrating it with the child's occupations and routines allows the idea to be more accessible. OTs teach hand hygiene (i.e., handwashing or alcohol hand rub) using songs and videos integrated into the telehealth routine (i.e., child and therapist wash were their hands at the start of the session). Donning and doffing of face masks and shields can be taught directly; integrating arts and crafts where the child can make or design their own allows the activity to be more interesting and increases wearing compliance. For older children or those with better cognitive skills, processing the situation (e.g., home quarantine, online schooling) using cognitive-behavioral strategies may be useful. It allows for an understanding of the situation and a collaborative plan on how children should behave to manage their health by preventing virus infection and transmission. The integration of standard precautions for infection control into the child and the family's occupations is a recommended strategy that supports successful telehealth sessions.

IMPLICATIONS
OTs working with children with disabilities will need to reconcile the indelible mark that the COVID-19 pandemic has left in the "new normal." 3,10 Standard precautions should not be limited to the OTs, but a necessary construct infused within children's occupations. In addressing activities of daily occupations, hand washing should be framed within hand hygiene guides. Wearing of clothing items may likewise be conceptualized to include PPEs (face mask, face shields). In promoting health management, both the child and their families must be informed of proper coughing etiquette. Using canonical occupational therapy strategies such as activity analysis, and habit and routine training is useful in infusing standard precautions into telehealth services. OTs need to be empowered on telehealth services through continuing professional development. More importantly, occupational therapy educational programs should take cue with the pandemic situations and address this by incorporating global health and telehealth topics in their courses. 11

CONCLUSIONS
Telehealth has provided OTs an alternative avenue to continue their services even in the time of the COVID-19 pandemic. Infusing standard precautions for infection control into telehealth services is an innovative strategy to prevent infection and transmission among children with disabilities and their families. For successful integration, Filipino OTs collaborate with the child's family in developing activities grounded on existing evidence from health and children's advocacy organizations. Henceforth, standard precautions may be normed within the context of occupation in the "new normal" to support children's occupations, health, and wellbeing.