Consensus guidelines for safe reopening after COVID-19

The reopening of society is likely to happen slowly and in a phased manner while keeping a focus on the strict infection control measures in the times ahead and is expected to remain for an extended period.

Many aesthetic clinics around the world are uncertain about the safe reopening and running of their businesses and the safety measures needed to protect their staff and patients from COVID-19 infection.

Appropriate precautions, up to date knowledge and strict safety measures will be needed, not just when the lockdowns are eased in most countries but also for the entire duration of the pandemic and beyond.

A global team of 10 experts in the field of aesthetic medicine have developed a set of consensus guidelines, currently published in Wiley Online Library, for scheduling of patients, patient evaluation and triaging, and for safety precautions about the different procedures. Procedures were categorised into low-risk, moderate risk, and high-risk based on the likelihood of transmission of SARS-CoV-2 virus from the patient to the treating physician or therapist. The full report can be access online*.

The consensus group comprised of one plastic surgeon, four dermatologists and five aesthetic physicians), all having experience in the working and administration of an aesthetic clinic. The participating members of the consensus group were from India, United Kingdom, Philippines, Australia, Sweden, Norway, Switzerland and South Africa. An online meeting of the consensus group members was held on April 27, 2020, using Zoom online app. The following items were proposed to all the participants, and a consensus was sought to establish the ‘preferred practices’ guidelines during the meeting:

  1. Guidelines for patient scheduling
  2. Patient evaluation and triaging; patient categorisation
  3. Guidelines for risk categorisation and safety precautions for the aesthetic procedures
  4. Guidelines for staffing in the aesthetic clinics
  5. Guidelines for general housekeeping in the aesthetic clinics

A ‘consensus reached’ was considered when at least 70% of participants agreed on the points discussed.

1. Consensus guidelines for patient scheduling

Advance scheduling should be made compulsory and walk-in patients should be discouraged. The booking is to be done on the phone or online by the trained clinic staff. The time gap between the appointments can vary in different clinics as per the size of the waiting area/ space between waiting chairs, the number of treatment rooms, the number of doctors and therapists to man the consultation/ treatment rooms, type/ duration of procedures and turnaround time of a patient from the time of arrival to time of exit.

The patient should be encouraged to visit the clinic alone or with only one attendant to avoid crowding in the clinic as carriers might be asymptomatic, and therefore, it would be wise to presume that every person walking in the clinic can be a potential source of infection. Most of the countries also have ‘contact tracing apps’ which work on Bluetooth. Ensuring that the patients coming to the clinic have this app downloaded on their phone, and both internet connection and Bluetooth are switched on would make for effective use of this technology.

2. Consensus guidelines for patient evaluation and triaging

Staff should be trained to take the necessary information on the phone at the time of making an appointment. This information should be rechecked when the patient arrives in the clinic. For unscheduled walk-ins, history taking becomes even more critical and must be done at the time of arrival.

Temperature recording with handheld, non-contact thermometers can be used for screening.

Experienced staff should be deputed to take the patient’s history of travel, occupation, contact and cluster (TOCC), and a declaration form along with a written informed consent document can be used to ascertain the following points:

T – Travel history including a detailed itinerary, transit locations and date of return
O – Occupation of the patient and spouse/ partner to be asked to check if it is a high-risk profession
C – A history of exposure to a test positive Covid-19 case should be asked
C – A history of living in or visiting a known Covid-19 positive cluster.

After categorisation of the patients based on TOCC history and presence or absence of signs/symptoms, only asymptomatic patients are to be taken up for an elective aesthetic procedure with due precautions.

3. Consensus guidelines for risk categorisation and safety precautions for aesthetic procedures

The procedures performed in an aesthetic clinic (office-practice) have been categorised by the expert panel as low-risk, moderate-risk, and high-risk based on the likelihood of transmission of the SARS-CoV-2 virus from the patient to the treating physician/therapist while performing the procedure. This categorisation is based on the assumption that all the patients seen in the aesthetic clinic could be asymptomatic carriers until proven otherwise. This assumption has to be made until the time COVID-19 testing of all patients coming to the aesthetic clinics is done as part of the initial screening process.

The factors taken into account by consensus group for the risk categorisation of the procedures were: the type of procedure (aerosol-generating procedure versus non-aerosol generating procedure); body part on which the procedure is being performed; and the duration of the procedure.

Contact with mucosa/saliva, body secretions during the procedure, minimally invasive or non-invasive nature of the procedure, and ability of the patient to be masked or not were also considered as important factors for risk categorisation. The aerosol-producing procedures such as laster treatment have the highest risk, and the long duration of a procedure also increases the risk due to longer contact time with the patient. Similarly, procedures involving the middle and lower part of the face would not allow the patient to be masked at the time of the procedure, thus increasing the potential for transmission to the treating physician.

The general guidelines for aesthetic procedures also included minimum conversations with the patient during the procedure, not allowing the patient attendant to be in the procedure room, and also avoid the helping staff/nurse to be in the procedure room while the procedure is being performed, if possible. Try to minimise the duration of the procedure where possible to reduce exposure time.

Cleaning of all surfaces (procedure chair/bed, inspection lights, instrument tray/trolley) and the apparatus being used with sterilising solution should be done after each procedure.

For laser hair removal, all patients should be asked to shave at home before the procedure to reduce contact time with the staff. Lip injections with soft-tissue fillers would require that patients be asked to rinse the mouth with 1.5% hydrogen peroxide or 0.2% povidone-iodine for 1 minute right before the procedure.

The high-risk procedures may be deferred for sometime after lockdown is lifted in the respective countries. However, when the high-risk procedures are performed, certain procedure-specific steps will be required in addition to the recommendations provided for the moderate risk procedures. For example, when aerosol-generating lasers are used, a cover with a transparent membrane such as polyvinyl clingfilm should be encouraged to reduce the splatter of the aerosolised cellular debris (like for tattoo removal with Q-switched lasers), keeping in mind the potential power loss when the laser passes through the membrane. Additionally, a plume evacuation system with filters that remove particulates up to 0.1micrometer, known as a ULPA (ultra-low particulate air) filter, can be used.

LOW RISK

Injectables  (Botulinum  toxin, dermal  fillers)  for upper  third  face and extra-facial sites

Injection  Lipolysis on  extra-facial sites

Cryolipolysis on the body

Non-ablative  fractional  resurfacing lasers for extra-facial sites

HIFU,  extra-facial parts

RF tightening for extra-facial areas

PRP therapy for scalp, body areas

LHR upper face and body areas with contact cooling device

Low-level light therapy (LLLT)

Chemical peels

Body treatments with EMS devices

IV injection therapy

Sclerotherapy

Hydrafacial

MODERATE RISK

Injectables (Botulinum  toxin,

dermal fillers) for middle and lower third face

Injection  lipolysis  on  submental area

Cryolipolysis for double chin

Non-ablative fractional  resurfacing lasers  for facial sites

HIFU,  face

RF Tightening for facial area

PRP therapy for face

LHR on the middle and lower face with contact cooling device

Microneedling procedures  (with  or without RF) on the face and extra-facial sites

Thread  lifting  on  the  face  and extra-facial sites

Invasive  RF  devices  for  face  and extra-facial sites

Soft-tissue fillers in the lips

Soft-tissue  fillers/  PRP  in  the genital area

RF/ lasers for genital area

HIGH RISK

Aerosol-generating  procedures (AGPs)  or plume  producing procedures    such  as  Q-switched Nd:YAG, Alexandrite, Ruby lasers, Pulsed-dye  laser,  ablative resurfacing  lasers  (fractional  and non-fractional),

LHR  with  non-contact  cooling devices (generating plume)

Electrofulguration, Electrocautery

MicrodermabrasionJet infusions / facials

Dermajet devices

Micropigmentation, Microblading

Body  treatments  with  plasma devices

4. Consensus guidelines for the staff rotation and training in the aesthetic clinics

The consensus was that the older staff members (>60 years) or those with associated comorbidities like diabetes, pulmonary conditions, cardiac conditions should be given leave or given work in areas with limited patient contact. Staff can be posted for shorter working hours than usual and should be called in rotation. At any given time, 33% to 50% of staff should be working at the clinic. Staff must get training in donning and doffing of personal protective equipment and should be provided with appropriate PPE.

Staff should be encouraged to do frequent hand washing with soap and water for at least 20 seconds. In between, hands disinfectants can also be used. Staff should also be retained
for phone booking, patient interviews on the phone, documentation of patient details and history, getting informed consent signed, social distancing and hand hygiene.

5. Consensus guidelines for general housekeeping in aesthetic clinics

  • Physical barriers: Plastic/acrylic windows panels or glass partitions, should be used if possible to reduce exposure of the staff to the COVID-19 virus. This could be done at the registration desk and the payment section of the clinic.
  • Sanitising stations: Special stations should be installed at clinic entrances, registration counters, and other high contact surfaces for hand sanitisation (preferably contact-less).
  • Shoe-covers should be available for clients at the clinic entrance so that they do not bring in the fomites with their shoe soles. Surgical masks and caps should also be provided at the entrance for clients who come in without wearing a mask.
  • Seating arrangement: Chairs in the waiting area should be spaced about 2 metres apart. In case of joined seating, distance seating could be maintained by strapping down alternate seats in the middle using ribbons or tape, making them unfit for use.
  • Waiting area decongestion: Waiting area congestion can be avoided by scheduling appointments with appropriate turnaround time between two patients. The clients could also be asked to wait in their vehicles if they arrive before the appointed time or until the doctor is ready to see them.
  • HVAC: Humidity and temperature control are usually maintained by a single unit, in most aesthetic clinics. In that case, it is recommended that it should be set to vent open mode. Maximum air changes possible should be facilitated, depending on the design of the clinic. A fan may be placed to change the direction of the flow of air away from the treating physician/therapist. Hospitals/ clinics may look into adding HEPA filters at more places in their existing HVAC systems.
  • Non-essential material: Care must be taken to remove all non-essential material like brochures, magazines, and newspapers from the offices and waiting rooms, as these could be a potential source of contamination.
  • Cleaning guidelines: Cleaning staff must wear surgical masks, shoe covers, gloves, and protective eye covering. Floors and all surfaces should be cleaned with 1% sodium hypochlorite solution or phenolic disinfectants. Most alcohol-based solutions like isopropanol or ethanol, also significantly reduced viral titers. Since the virus can survive for days on metallic surfaces like taps, flush handles, doorknobs, door handles, and handrails, these should be cleaned with a 60–70% alcohol-based sanitiser three to four times a day. Cleaning schedules should be developed, with the frequency of cleaning changing if surfaces are high-touch/ low-touch, the type of activity taking place, and the infection risk associated with it and the probability of contamination. No-touch waste bins should be placed in each procedure room, office, waiting area, and restrooms should be lined with disposable liners.
  • Food/beverages & Pantry: Pantry utensils for the staff should be disposable. Clients should be encouraged to carry their water bottles with them. The practice of serving tea, coffee, and other beverages should be discouraged. Pantry area should be disinfected every two hours, and items like tea kettle handles and external surfaces should be disinfected after each use.

During COVID-19 pandemic, strict patient screening, social distancing, use of PPEs, and taking extra precaution during ‘high risk’ aesthetic procedures can help in keeping patients as well the clinic staff.

While not intended to be complete or exhaustive, the consensus guidelines provide sound infection control measures for aesthetic practices. Since guidelines regarding safety measures and use of PPEs may vary from country to country, the local guidelines should also be followed to prevent COVID-19 infection in aesthetic clinics. AMP

* Krishan Mohan Kapoor MCh, DNB, MBA ; Vandana Chatrath MD; Sarah Gillian Boxley MBBS FRACGP FACAM; Iman Nurlin MD, Philippe Snozzi MD, Nestor Demosthenous MBChB, MSc, BSc ; Victoria Belo MD; Wai Man Chan MD; Dr Nicole Kanaris MBBCh; Puneet Kapoor MD, MB2, COVID-19 Pandemic: Consensus Guidelines for Preferred Practices in an Aesthetic Clinic, https://onlinelibrary.wiley.com/doi/epdf/10.1111/dth.13597