Commonly touched areas of clinics should be cleaned daily, including door handles and hard surfaces using detergent such as sodium hypochlorite or 70% alcohol wipes
Many clinics have been temporarily closed due to the COVID-19 pandemic and subsequent lockdown, with the aim of protecting patients, the public and staff (Lacobucci, 2020) from coronavirus. Now, with Government guidelines, industry guidance and the easing of lockdown restrictions, many clinics are reopening, or planning to reopen, imminently.
The regulatory bodies of the industry have published guidance entailing their opinion and recommendations regarding reopening following the pandemic. These include the British College of Aesthetic Medicine (BCAM), the British Association of Cosmetic Nurses (BACN), the Joint Council of Cosmetic Practitioners (JCCP) and Save Face.
Throughout this article, I will review the current guidance (at the time of writing) from the aesthetics regulating bodies. My aim is to present a summary of key points and ensure that patient and staff safety is being achieved, while simultaneously providing patients with the excellent care they require. Box 1 also details a checklist for all practitioners to follow and ensure patient and staff safety.
Box 1.Checklist
- Risk assessment
- Patient journey
- Clinic
- Staff
- Cleaning
- Common areas including waiting room, toilets and staff room/kitchen
- Treatment rooms
- Hand hygiene
- No-touch hand sanitisers around the clinic
- Handwashing signage
- Personal protective equipment (PPE)
- Disposable gloves
- Disposable aprons
- Surgical, FFP2 and FFP3 masks
- Eye protection
- Donning and doffing education
- Clinic
- Social distancing measures
- One-way system
- Physical barriers
- Brochures/magazines removed
- Warning and educational notices
- Sign for toilets closed
- Staff
- Changing area
- Uniforms provided
- Uniform washing facilities/advice
- Staff feedback and support
- Triage
- Initial consultation
- Email/discussion of clinic changes/measures taken for patient and staff safety
- Screen for COVID-19 symptoms
- Courtesy call prior to treatment
- Staggered appointment times
- Patients attend alone
- Minimal make-up, baggage and jewellery
- Patients
- Temperature check
- Provide patient with PPE
- COVID-19 instant tests
- Consent and COVID-19-related additions
- Treatments
- Low- and high-risk procedures and their implications on PPE
- Payments
- Cleaning
- Online payments
- Pre-payments
COVID-19
Coronavirus, a potentially fatal disease and the cause of the COVID-19 pandemic started in December 2019 (Lai et al, 2020). The mode of transmission is primarily through direct contact from person to person, including respiratory droplets from coughing and sneezing (Rothan and Byrareddy, 2020), as well as contact with contaminated surfaces (Public Health England (PHE), 2020). These routes of transmission are important to understand, as these are the factors to consider for aesthetic practice adaptations, with the aim of preventing the transmission of COVID-19.
When to reopen
For many aesthetic practitioners, the right time to reopen felt like the million-dollar question. Government guidelines were changing constantly, and regulating bodies were unable to provide practitioners with the answers being sought, as they were themselves in the process of producing guidelines.
Once the regulating bodies released their guidelines, in my opinion, there were two main suggestions of reopening. Firstly, we were exempt from closing and secondly, we should wait until we were told we could reopen.
BCAM hired a Queen's Counsel (QC) to investigate the Government guidance stating we were exempt from closing due to providing medical or health services (CO, 2020), to which the QC agreed, and subsequently advised their members that legally they could remain open, as long as they adhered to Government guidance and performed medical procedures (BCAM, 2020).
The JCCP (2020) suggested waiting until 4 July to reopen, as that was the date the Government had initially proposed for the reopening of beauty salons. The guidelines were then changed at the end of June, stating that ‘beauty type establishments’ were not to reopen on 4 July, and further guidance would be given in due course. The discussion then became ‘are aesthetic treatments classed as beauty or medical?’.
Insurance companies and the General Medical Council (GMC) informed me we could practice, as long as we adhere to the Government guidelines and safety measures.
Considering this information, it is an individual choice for practitioners on when to reopen. Patient and staff safety, as well as practical and ethical considerations, need to be taken into account—as do the type of procedures they will be undertaking, and whether they would be classed as medical or cosmetic, as well as low- or high-risk.
» Patient-treating staff are recommended to wear single use disposable gloves and aprons, as well as an FFP2 mask if performing a non-saerosol-generating procedure, or an FFP3 mask if performing an aerosol-generating procedure «
Risk assessment
Examining all aspects of the practice and patient journey will be fundamental in ensuring safety at every possible opportunity. Patient, staff and practitioner safety is of paramount importance. Each of those should be assessed, as well as the treatments offered and plans of how to reduce the transmission of infection should be implemented.
Cleaning
Commonly touched areas of the clinic should be cleaned daily, including door handles and hard surfaces using detergent such as sodium hypochlorite or 70% alcohol wipes (Kampf et al, 2020). Treatment rooms should be cleaned in-between patients, areas include those that may have been touched by patients such as the treatment couch, chairs and iPads. (Save Face, 2020). Ventilation devices could be an option for windowless rooms (PHE, 2020).
It is also worthwhile producing a cleaning checklist in all appropriate areas (BACN, 2020), which can be ticked off through the day. This can ensure protocols are followed, especially in a busy clinic with new protocols.
Hand hygiene
Using recommended alcohol-based hand rub to inactivate the virus (Kratzel et al, 2020) or washing your hands with soap and water (World Health Organization, 2020) for 20 seconds are highly recommended ways to prevent transmission of infection. All staff should adhere to this, and patients should be offered the opportunity to wash their hands on arrival and prior to departure.
No-touch hand sanitisers are a great way of ensuring adherence to hand hygiene, and they can be placed around the clinic (Kapoor, 2020).
Personal protective equipment
There is a lot of information regarding the correct personal protective equipment (PPE) and depends on whether staff members are patient-facing or not. Staff who are not patient-facing could potentially work from home if logistically possible, for example, call handlers.
Patient-facing staff can be subdivided into two categories: patient-treating (practitioners and therapists) and non-patient-treating (reception staff).
Patient-treating staff are recommended to wear single-use disposable gloves and aprons, as well as an FFP2 mask if performing a non-aerosol-generating procedure (AGP), or an FFP3 mask if performing an AGP (JCCP, 2020). Fit testing is important to ensure there is an adequate seal between the mask and the skin. Masks can be worn for each patient or one per session (Save Face, 2020).
Full-face visors or eye protection glasses are recommended to protect the eyes against contamination by respiratory droplets (Save Face, 2020). The practitioner must decide which is appropriate, depending on the treatment being performed.
Practitioners must take into account the length of patient contact and type of procedure. For example, treatments to the mid-face and lower-face prevent the patient from wearing a mask, thus presenting a higher risk (Radonovich Jr et al, 2019). It is recommended that all non-treating staff wear surgical masks and adhere by the standard infection control measures.
All staff should be taught the correct techniques of donning and doffing PPE (JCCP, 2020). Guidance of how to do this can be found on the Government website (PHE, 2020).
All PPE should be purchased from trusted suppliers and CE approved, as well as having the documentation they have passed the EU regulations for health and safety (Health and Safety Executive, 2020).
Clinic
Social distancing measures should be implemented, for example, floor markings 2 metres apart and reduced seating, again spaced 2 metres apart (JCCP, 2020). This may be reduced in the coming months, so current guidance should be adhered to.
One-way systems are beneficial to avoid patients crossing paths (BCAM, 2020) and can be created (where space allows) with the use of floor markings. Clinics can be creative and use their brand colours to keep their clinic theme consistent.
Physical barriers should be placed where possible, for example, acrylic partitions between the patient and receptionist to reduce possible exposure to the virus (Kapoor, 2020).
All areas should be decluttered, and brochures or magazines should be removed (JCCP, 2020); however, notices at entrances warning not to enter if unwell (BCAM, 2020), as well as signage in the appropriate areas educating patients on hand washing, for example, should be placed and laminated so that they can easily be seen by patients and regularly cleaned.
Clinics should avoid offering beverages, and also discourage patients from using toilet facilities where possible (BACN, 2020).
Staff
It is recommended staff have a changing area to change into their uniform at the beginning of their shift, and then back into outdoor clothes at the end of the shift. Washing uniforms on site is preferred, as opposed to taking them home to wash (BCAM, 2020).
Personally, when I change out of my scrubs, they are placed carefully into a washable laundry bag, which is closed and can be put straight into the washing machine. This avoids reopening the bag to take out my scrubs and put them into the washing machine. Some guidance recommends when staff arrive home from work, they should remove their shoes, wash their clothing and shower immediately (Adams and Walls, 2020).
Many staff members will feel anxious and worried while reopening, so it is important to support them through this. Confidence will be gained from the implementation of the guidelines and recommendations, as well as educating everyone as to why each one is important. If your staff feel safe and comfortable, this will radiate to your patients and they in turn should feel more at ease.
Triaging
Triaging of patients is a great way to screen for symptoms of COVID-19, reduce the patient time in clinic and any unnecessary face-to-face consultations (BCAM, 2020). Screening questionnaires including the patient's medical history, concerns and symptoms of COVID-19 (Save Face, 2020) can be pre-completed, emailed back and discussed over a video consultation; however, remember to use General Data Protection Regulation (GDPR)-protected software (BACN, 2020).
All staff, from receptionists to practitioners, should be trained to identify the symptoms of COVID-19, which can include (but are not limited to) a high temperature, a new, continuous cough and a loss of taste or smell (NHS, 2020). This is important for screening, and if a patient is in clinic and staff become aware they have symptoms, precautions can be taken, including advising test and trace, as well as self-isolation (Department of Health and Social Care, 2020).
A courtesy call the day before, or on the day of treatment, is another reassuring way to screen for patient symptoms, as well as offer any further advice or information for the visit to the clinic. During this call, or the booking process, patients should be encouraged to attend alone (Kapoor, 2020) and also wear minimal make-up (JCCP, 2020) and jewellery. Ideally, patients are pre-booked in advance and ‘walk-in’ patients are discouraged, due to the lack of pre-screening (BACN, 2020).
When booking in patients, guidelines recommend staggering appointment times, providing a gap between patients. This reduces congestion (BCAM, 2020) and provides ‘cleaning’ time for practitioners in between patients.
» Practitioners should presume that every patient who enters their clinic could be infected and, therefore, must ensure all practical precautions are taken to protect both patients and staff by using a risk assessment to implement thorough safety protocols «
New protocols should be explained to patients within an email or over the phone during the booking process (BACN, 2020) to ensure they know what to expect. Many patients will be nervous coming to the clinic, so explaining the safety measures could help to reassure them, as well as demonstrating that you are taking all the precautions necessary for their safety.
Seeing patients
Numerous discussions have been had on symptom screening of patients as they enter the clinic, for example, checking patients' temperature on entry to the clinic with a thermometer. This may not provide a satisfactory test due to the subclinical cases, asymptomatic cases or those who are in the incubation period of the disease (Gostic et al, 2020).
Surgical masks are recommended for patients, as well as shoe covers to prevent the spread of fomites (Kapoor, 2020). Be aware that there may be a risk of patients slipping, which could also prove to be a hazard.
Patients should be taken straight from entry through to the consultation room (BACN, 2020), as this reduces their time in the waiting area. One option is to ask patients to remain in their cars and calling them in by mobile when the practitioner is ready for them.
Instant COVID-19 tests
A number of clinics offer instant COVID-19 tests prior to treatments, with a result in 15–30 minutes. These screen patients to see if they are currently infected with COVID-19 or if they have antibodies to the virus, proving that they have previously been exposed or have had the virus. The current Government stance on this is to be careful, as there is not enough information known about the accuracy of many of these tests (PHE, 2020). Therefore, if this is a service a practitioner wishes to provide, ensuring a reputable supplier is imperative.
Consent
We will need to take our time to discuss the risks and benefits of treatments, including the additional risks posed by having treatments in the current climate. Consent forms should be amended to include COVID-19-specific adverse effects, for example, transmission of COVID-19 from the clinic and delayed hypersensitivity reactions (JCCP, 2020), to name a few.
Within the consent form, it should be noted that a lockdown could be imposed at any time if the rate of infection increases. If this should occur, it may be difficult to arrange a follow-up or emergency treatment, should the patient need one if clinics were to close (Save Face, 2020).
In addition to the above, it would be useful to be fully paperless, and, ideally, the patient can sign the consent form on a tablet using a gloved finger or stylus. Of course, the tablet would be cleaned after every use (BACN, 2020), and the stylus could be discarded or kept by the patient.
Treatments
A number of practitioners will offer a reduced treatment menu (Aesthetic Medicine, 2020) by avoiding higher risk procedures, including microdermabrasion and platelet rich plasma (BACN, 2020). ‘Plume-generating’ or ‘aerosol-generating procedures’ include laser and ablative plasma and, again, guidelines suggest these should be delayed until the benefit outweighs the risk (Save Face, 2020).
Lip augmentation with dermal filler has been included in aerosol-generating procedures by the JCCP (2020). While augmenting the lips, airborne particles from saliva should be taken into consideration as a risk (BACN, 2020), and this will likely be a personal choice by the practitioner whether to offer it or not.
Some guidance suggests gargling with hypochlorous agents such as Clinisept+ to reduce the risk when treating the lips, as they could represent an area with a higher viral load if treating an asymptomatic patient (Save Face, 2020).
Payment
All guidance states that payments should be taken by card, and clinics could go one step further by taking payments through an online payment system, so that the patient's card does not touch the card machine. If this is not possible, cleaning the machine after each use is recommended (BACN, 2020).
An alternative option is to take payment prior to the patient attending the clinic. This helps in two ways: there is no need for a card or cash transaction at the clinic, and it also reduces the time that the patient is in the clinic.
Mobile practice
Many practitioners offer a mobile service, and the risk with this in the current situation could be higher as there is no control over the patient's premises. Therefore, there is no way to risk assess the practice fully, so it is not a supported practice (BACN, 2020; JCCP, 2020).
Conclusion
Practitioners should presume that every patient who enters their clinic could be infected (Kapoor, 2020) and, therefore, must ensure all practical precautions are taken to protect both patients and staff by using a risk assessment to implement thorough safety protocols.
It should also be remembered that this is likely to be the ‘new normal’ for the foreseeable future, so we should take the time to get comfortable working with these protective strategies in place.
Although there is a risk with each patient, by putting as many precautions in place as possible, we can reduce this risk and hopefully get back to doing the work we are so passionate about, including seeing and treating patients and creating exceptional results for them.