At the Journal of Aesthetic Nursing's annual conference, held in January of this year, delegates listened to a debate entitled ‘Is there anything wrong with providing aesthetic procedures as a mobile practitioner?’. When answering this question, all aesthetic nurse practitioners are urged to consider their responsibilities to their Nursing and Midwifery Council (NMC) Code of Practice, and ensure that they promote professionalism and trust at all times.
Helena Collier, in her keynote address, gave an appalling example of a surgeon who offered treatments in a hotel in conjunction with the consumption of alcohol. This is highly unprofessional and unethical practice, and should be condemned by this sector. In order to ensure the end of such practices, the JCCP have produced the new Premises Standards for Conferences, Exhibitions and Mobile Working. These standards require that JCCP registrants self-certificate any premises or areas where any of the following five modalities are performed:
The new standards include the following considerations:
Clinical environments will be assessed through a process of self-certification, and a self-certification tool has been developed for JCCP registrants to use as set criteria against work standards. This requires all premises to meet a minimum requirement, with additional requirements needed, depending on the treatment modality delivered.
Work standards by modality
The JCCP recognise that premises where aesthetic procedures are delivered vary from practitioners' and patients' homes to Care Quality Commission (CQC)-registered premises, and the scope of these guidelines is not to exclude businesses or individuals from attaining registration. However, the Trustee Board feel strongly that more invasive procedures require a separate set of criteria, and should therefore be performed in a clinical environment.
It's time for change
Cosmetic injectable procedures should be performed in clinical environments only, given that it has been reported that biofilm can develop after inoculation of just 40 bacteria (Alhede et al, 2014). Therefore, injections in carpeted environments are not appropriate.
Procedures should be performed in a clinical environment with minimal essential personnel present, in order to reduce the risk of cross contamination. If presentations or demonstrations are being given to large groups, then pre-recorded procedures, or live video links from a clinical room are more appropriate. Appropriate emergency medicines should be available to treat the patient immediately in the event of an adverse reaction.
The issue of confidentiality and consent must be addressed when a patient has volunteered for treatment during a conference demonstration. Many delegates take photos of patients during these demonstrations, which they might share with colleagues either in person or on social media platforms, such as Twitter and Facebook, which contravenes patient confidentiality.
| Minimum requirements | The minimum requirements set out the standards expected for all treatment modalities delivered. |
| Modality specific | Complete this section in addition to the minimum requirements, in premises where a specific modality is performed |
| Action plan | The action plan template can be used to develop and implement an action plan to take forward any areas of non-compliance |
| Frequency | A self-assessment should be performed every 12 months |
The response
Allergan has said that it is fully on board with the new premises standards. Galderma's Medical Director UK, Ireland, NCE Hub Dr Navin Chohan, said:
‘Galderma UK will support [the Premises Standards] in full. We intend to implement this both through training sessions we directly run or sponsor, and as a requirement for us to supply stock to a third-party requester for training purposes.’
Gemma Rabbetts, Clinical Education Manager on behalf of AlumierMD, has commented that she is happy to assist with implementation. Merz are also on board with the new standards, and have commented:
‘Merz, through the Merz Institute of Advanced Aesthetics (MIAA), are committed to delivering the highest standards in educational and training practice. We therefore welcome the publication of the JCCPWS 006 Work Standards and we are committed to ensuring that our events programme incorporates these valuable recommendations.’
Texoane have also said that they are in support of the new standards:
‘Teoxane and the JCCP are absolutely aligned regarding standards of treatment environments. Patient safety is always the first consideration when approaching a dermal filler treatment and therefore the environment of injecting must be suitable. The guidelines wwill certainly be used when identifying spaces to perform live injections at Teoxane Medical Education events.’
Lisa Mason, Director of Medical Services at sk:n, can also confirm that sk:n will be holding their 13th Medical Convention this year, and will only hold live demonstrations via satellite link to a clinical environment, or feature pre-recorded demonstrations at this event. Speaking about the JCCP Premises Standards, Dalvi Humzah said:
‘It's good to see the earlier work coming into fruition! It certainly does capture what is required for patient safety. Interestingly at a recent conference-the Pharmaceutical company I was working with and discussed this situation with last year - decided not to have any live demonstrations at the conference. All demonstrations were filmed in a clinic beforehand and appropriately edited—it made the event run smoothly on time and the educational content was appreciated by the delegates as appropriate and less of a “show”.’
Victor Ktorakis, Senior Environmental Health Officer and JCCP Trustee representing Environmental Health, has shared the new Premises Standards with as many local authorities as possible, including the London Special Treatments Group, to ensure that the standards are available to officers inspecting premises. The Royal Society of Medicine (RSM) have also been consulted.
Mobile working
All of this raises the question of whether mobile working for aesthetic practitioners is appropriate. Health Improvement Scotland have produced guidance for independent clinics where services are provided in a service user's home (Health Improvement Scotland, 2016). The recommendations are:
Regulation 15 of the Health and Social Care Act (2008) is also relevant here. The intention of this regulation is to ensure that the premises where care and treatment are delivered to patients are clean and suitable for the intended purpose.
Conclusion
It is hoped that the new Premises Standards will help aesthetic practitioners to assess the premises in which they deliver non-surgical treatment and provide education or training. The minimum requirements for dermal filler procedures can be viewed in Table 2, for the reader's further reference.
| Standard 1 | Management of medicines | Yes/No | Evidence/comments | |
|---|---|---|---|---|
| A | Is there evidence that only licensed, approved products are used which have been sourced from official outlets or product manufacturers? | |||
| B | Are emergency medications readily available with a list of drugs maintained regularly? | |||
| C | Is there a procedure log book in place to record all medicines administered, including serial, batch numbers and expiry dates of medicines? | |||
| D | Is there a medicines management policy in place detailing the process for storing, prescribing, handling, administering and disposing of medicines? | |||
| E | Is there evidence of an audit trail of medicines received? | |||
| F | If gas cylinders are present for emergency use they are stored and handled in a safe manner in accordance with current regulation? | |||
| G | Are Patient Safety Alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS) readily available? | |||
| H | Is there a system in place to report suspected problems using the yellow card system? | |||
| I | Has a safer sharps risk assessment been completed and control measures in place? | |||
| Assessment of Standard 1: | Met | Part met | Not met | |
| Standard 2 | Infection control | Yes/No | Evidence/comments | |
| A | Is there a designated clinical area where the modality is performed? | |||
| B | Are floors of a material impervious and easy to clean? If individual floor tiles are used are tiles sealed? Is the floor free from carpet? | |||
| C | Are all ceilings, fixtures and fittings free from damage, with a smooth impermeable surface that is easy to clean? | |||
| D | Is there a dedicated clinical hand wash sink in the clinical area which is not for dual purpose? | |||
| E | Premises and equipment are kept clean and cleaning must be done in line with current legislation and guidance. | |||
| F | Premises and equipment should be visibly clean and free from odours that are offensive or unpleasant. | |||
| G | Are all cleaning materials and equipment, for example, cloths (re-usable and disposable), mops, buckets, aprons and gloves colour coded. The method used to colour code items should be clear, permanent and in accordance with existing local practice | |||
| H | Needles, gloves and aprons are single use only. | |||
| I | Is there evidence of a cleaning schedule including disinfection between patients? | |||
| J | Are liquid soap dispensers available with single use liquid soap cartridges or bottles? | |||
| K | Are there wall-mounted disposable paper towels next to the hand basin? | |||
| L | Is there a foot operated pedal bin placed near to the wash basin for the disposal of used paper towels? | |||
| M | Is there suitable cleaning materials or spill kits for the cleaning of blood or bodily fluid spillages? | |||
| N | Is the door to the clinical area lockable? | |||
| Assessment of Standard 2 | Met | Part met | Not met | |
| Standard 3 | Waste management | Yes/No | Evidence/comments | |
| A | Do sharps containers comply with the British Standard BS7320 and UN3291 and carry the ‘kitemark.’ | |||
| B | Are sharps containers sited abo ve floor level and below shoulder level? | |||
| Standard 3 | Waste management | Yes/No | Evidence/comments | |
| C | Are needles and clinical waste collected by licensed contractors with transfer documents available? | |||
| D | Is there a foot operated pedal bin for clinical waste? | |||
| E | Is there a waste management policy detailing how waste is disposed of? | |||
| Assessment of Standard 3: | Met | Part met | Not met | |
| Standard 4 | Personal protective equipment (PPE) | Yes/No | ||
| A | Is PPE located close to the point of use? | |||
| B | Is PPE stored to prevent contamination in a clean/dry area until required for use and expiry dates adhered to? | |||
| C | Is single-use PPE used? | |||
| D | Is PPE disposed of after use into the correct waste stream? | |||
| Assessment of Standard 4: | Met | Part met | Not met | |
| Standard 5 | Data protection | Yes/No | Evidence/comments | |
| A | Is there a documented privacy policy available for patients to view? | |||
| B | Are clinical records kept in lockable rooms or cabinets? | |||
| C | Is access to lockable rooms or cabinets where clinical records are kept restricted to authorised staff? | |||
| D | If private prescriptions are used are they kept locked away with sufficient control measures in place? | |||
| E | Are there adequate processes in place for the safe disposal of confidential information? | |||
| Assessment of Standard 5: | Met | Part met | Not met | |
| Standard 6 | Advertising and marketing | Yes/No | Evidence/comments | |
| A | Do adverts allow sufficient time between consultation and treatment in order for the client to consider consent? | |||
| B | Is factual information about DF given in a balanced and factual manner? | |||
| C | If images are used on the premises and/or the associated website are claims realistic about treatments outcomes? | |||
| D | There are no promotional tactics, such as ‘two-for-one’ offers to encourage patients to make ill-considered decisions? | |||
| E | Is advertising aimed at adults only and not targeted at teenagers below the age of eighteen? | |||
| Assessment of Standard 6: | Met | Part met | Not met | |
Further reading
The full Premises Standards can be accessed via the JCCP website at www.jccp.org.uk