On September 20, 2020, the Colorado Department of Public Health and Environment issued Public Health Order 20-35. This order essentially updates Public Health Order 20-28.

Updated 10.28.2020 – We are currently on the 4th amended PHO 20-35. Overall, Appendix G still applies and has not changed. See below for Appendix G. Each chiropractor shall adhere to the restrictions on the number of people in your office limits based on what level your county is in. Denver County is currently in Level III.

The new AMENDED PUBLIC HEALTH ORDER 20-35 implements levels of restrictions for individuals, businesses and activities to prevent the spread of COVID-19 further in Colorado. Those Levels are as follows: 

II. Safer at Home Levels

Effective September 15, 2020, Safer at Home consists of three levels that counties qualify for based on meeting three specific metrics. Counties will begin in the level that most closely fits what they have already been approved for in the preceding Safer at Home framework, and if the county falls out of compliance with one or more of the metrics associated with that level, they will have two weeks to develop and implement mitigation strategies to get back into compliance with the metric […]

Level 1.

• The metrics for Level 1 are as follows:
  • New COVID-19 cases are at an incidence of no greater than 75 per
    100,000 in a two week period;
  • The percent of positive test results over a rolling 14 day average is no
    greater than 5%; and
  • Hospitalization rates are stable or declining in the preceding 14 day
    Period.
• Operating capacities, maintaining Distancing Requirements for non-household
  members, for designated sectors and activities in Level One are as follows:
  • Limited Healthcare Settings may operate at 50% of the posted
    occupancy limit, not to exceed 50 people, per room.

Level 2.

• The metrics for Level 2 are as follows:
  • New COVID-19 cases are at an incidence of no greater than 175 per
    100,000 in a two week period;
  • The percent of positive test results over a rolling 14 day average is no
    greater than 10%; and
  • Hospitalization rates are stable or improving in the preceding 14 day
    Period.
• Operating capacities, maintaining Distancing Requirements for non-household
  members, for designated sectors and activities in Level One are as follows:
  • Limited Healthcare Setting smay operate the same as Level 1.

Level 3.

• The metrics for Level 3 are as follows:
  • New COVID-19 cases are at an incidence of no greater than 350 per 100,000 in a two week period;
  • The percent of positive results over a rolling 14 day average is no greater than 15%; and
  • Hospitalization rates are increasing in the preceding 14 day period.
• Operating capacities, maintaining Distancing Requirements for non-household
  members, for designated sectors and activities in Level One are as follows:
  • Limited Healthcare Settings may operate at 25% of the posted
    occupancy limit, not to exceed 25 people, per room.

The best resource for tracking each county and what level each county is current in can be found here: https://covid19.colorado.gov/data/covid-19-dial/covid-19-dial-dashboard. Here chiropractors will be able to click on their county and see which safer at home level they are at as well as the corresponding data of two week cumulative incidence, two week positivity rate and hospital stabilizations. 

APPENDIX G: LIMITED HEALTHCARE SETTINGS

I.         Limited Healthcare Settings may operate at the level described in Section II of this Order for which the county in which they operate is approved, and must follow the requirements included in Section III.C of this Order, as well as all of the requirements of this Appendix. Limited Healthcare Settings may conduct voluntary and elective surgeries and procedures in limited healthcare facilities and offices with required personal protective equipment (PPE) in accord with the priorities, requirements, and specific criteria below.

A. Employers and sole proprietors of Limited Healthcare Settings must implement the following measures within the overall workplace, including administrative and front office operations, to minimize disease transmission:

1. The practice must have access to adequate PPE in order to sustain recommended PPE use for its workforce for two weeks without the need for emergency PPE-conserving measures. If a practice proposes to extend the use of or reuse PPE, it must follow CDC guidance.1
2. The practice must implement strict infection control policies as recommended by the CDC.2
3. The practice must ensure a minimum of 6 feet of separation between clients and patients, when not directly performing service, and all settings offering services in individuals rooms must comply with the requirements of this Order for each room.
4. The practice must post signage for employees and patients on good hygiene and safety measures being taken.
5. The practice must minimize in-home and in-facility services with remote alternatives whenever possible, such as drive-by services or virtual meetings.
6. Practices must maintain a plan to reduce or stop voluntary and elective surgeries and procedures should a surge/resurgence of COVID-19 cases occur in their region.

B. Employers of Limited Healthcare Settings must implement the following measures regarding employees to minimize disease transmission:

1. Services with close, direct personal contact must implement the following:
   1. wear medical grade mask and gloves at all times; however, acupuncturists may substitute good hand hygiene by thoroughly washing hands before and after seeing each patient for the gloves if their licensing requirements and standards so allow;
   2. change gloves and wash hands between every patient;
   3. clean and disinfect all shared equipment and tools between every patient; and
   4. maintain a detailed log of patient interactions to enable contact tracing if it becomes necessary. The log should include name, date, details of services performed, and location of contact, as well as the contact’s phone number
   5. for services where the client cannot wear a mask, the employee or practitioner must wear a face shield in addition to their mask.
2. Services with low personal contact must implement the following:
   1. maintain a minimum of six 6 feet of separation between customers;
   2. require face coverings and, if feasible, gloves for any customer interactions; and
   3. provide guidance on strict hygiene precautions to employees.
3. The practice must require all administrative personnel to wear a facemask, that can be cloth if necessary, unless the individual cannot medically tolerate a face covering, or is performing one of the enumerated activities in Section II.M of Executive Order D 2020 138, as amended and extended. In order to ensure staff can take off their masks for meals and breaks, scheduling and location for meals and breaks should ensure that at least a 6-foot distance can be maintained between staff when staff needs to remove their mask. It is important for healthcare settings to emphasize that hand hygiene is essential to maintaining employee safety, even if staff are wearing masks. If the facemask is touched,adjusted or removed, hand hygiene should be performed.

C. 6-foot distance can be maintained between staff when staff needs to remove their mask. It is important for healthcare settings to emphasize that hand hygiene is essential to maintaining employee safety, even if staff are wearing masks. If the facemask is touched, adjusted or removed, hand hygiene should be performed.CLimited Healthcare Settings must implement the following measures regarding customers to minimize disease transmission:

• The practice must provide services by appointment only, do not allow walk-ins or waiting for an appointment;
• The practice must require patients to wear face coverings; if a patient does not have a mask, a “disposable medical mask” could be provided;
• The practice must conduct symptom checks for all patients, decline to provide services to anyone who has symptoms, and refer them to their primary care physician. A sample form can be found here; and
• The practice must provide contactless payment options whenever possible;
• The practice must follow Distancing protocols of maintaining at least a 6-foot distance between individuals wherever possible such as in waiting rooms and other small spaces, and should use physical barriers within patient care areas when possible.
• The practice must appropriately schedule patients, so that providers have sufficient time to change PPE and ensure rooms and equipment can be cleaned and disinfected between each patient.
• The practice should continue to maximize the use of telehealth and virtual office or clinic visits.
• The practice should use virtual waiting rooms when possible, with patients who are able to wait in their cars not entering the office until they can be moved immediately to an exam room.
• The practice should implement source control for everyone entering the office or clinic, including requiring all patients and visitors to wear a cloth mask when entering any healthcare building, and if they arrive without a mask, one should be provided.

D. As best practice, it is recommended that if performing voluntary and elective surgeries and procedures, Limited Healthcare Settings reassess their operations every two weeks, in order to ensure:

1. All of the above approaches and criteria are being met;
2. Procedures are prioritized based on whether their continued delay will have an adverse health outcome.
   1. Voluntary and elective surgeries and procedures should be prioritized based on indication and urgency3;
3. Strong consideration is given to the balance of risks versus benefits for patients in higher-risk groups such as those over age 65 and those with compromised immune systems or lung and heart function;
4. All patients are pre-screened for COVID-19 risk factors and symptoms prior to delivering care, via telehealth when applicable; and
5. Compliance with the guidance and directives for maintaining a clean and safe work environment issued by the CDPHE and any applicable local health department for critical businesses is maintained, including compliance with Distancing Requirements and all PHOs currently in effect to the greatest extent possible.