








key: cord-323965-6mzzibj8
authors: Kapoor, Krishan Mohan; Chatrath, Vandana; Boxley, Sarah Gillian; Nurlin, Iman; Snozzi, Philippe; Demosthenous, Nestor; Belo, Victoria; Chan, Wai Man; Kanaris, Nicole; Kapoor, Puneet
title: COVID‐19 Pandemic: Consensus Guidelines for Preferred Practices in an Aesthetic Clinic
date: 2020-05-16
journal: Dermatol Ther
DOI: 10.1111/dth.13597
sha: 
doc_id: 323965
cord_uid: 6mzzibj8

BACKGROUND: Strict infection control measures in response to the current COVID‐19 pandemic are expected to remain for an extended period. In aesthetic clinics, most procedures are provided on one to one basis by the physician or therapist. In such a scenario, guidelines detailing the infection control measures for aesthetic clinics are of particular importance. METHODS: An online meeting of an international group of experts in the field of aesthetic medicine, with experience in administration of an aesthetic clinic, was convened. The meeting aimed to provide a set of consensus guidelines to protect clinic staff and patients from SARS‐CoV‐2 infection. RESULTS: Consensus guidelines for ‘preferred practices' were provided for scheduling of patients, patient evaluation and triaging, and for safety precautions about the different procedures. Procedures were categorized 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. CONCLUSIONS: While not intended to be complete or exhaustive, these 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. This article is protected by copyright. All rights reserved.

The current global pandemic of the SARS-CoV-2 virus that causes COVID-19 respiratory tract infection 1 2 3 is likely to last for a long time. Most of the countries have imposed lockdowns 4 and introduced strict infection control measures. 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 5 .

Appropriate precautions, up to date knowledge, and strict safety measures will be needed, not just when the lockdowns are eased in most countries 6 but also for the entire duration of the pandemic. There is a likelihood of patient overload during this period, and staying prepared is going to be the right strategy for this situation 7 . The safety precautions need to be extended much beyond the lockdown period in every country. No laxity in these precautions should be allowed to happen even if the curve of COVID-19 cases flattens or falls near the baseline.

While many medical practices are being run with online consultations 8 , aesthetic clinics come in a category of medical services where most of the procedures are provided on one to one basis by a doctor/ therapist. Many countries have decided to allow the opening of practices requiring one-on-one contact like dental, physiotherapy, aesthetics, provided they strictly follow the guidelines detailing the infection control measures 9 10 . Aesthetic clinics across 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. A set of consensus guidelines for 'preferred practices' in aesthetic clinics is proposed in this paper for maintaining a high level of safety for the patients coming to the clinic for treatment as well as for the doctors/ therapists performing the procedures.

Multiple factors could lead to transmission of COVID-19 from a patient to the healthcare worker and vice versa, especially in an aesthetic clinic.

• Coughing or sneezing by patients and accompanying persons in the waiting areas 11 . Speaking loudly or deep breaths also generate aerosols.

• Small procedure rooms 12 with limited or no natural ventilation • Central air conditioning having a single cooling unit and multiple room vents in most aesthetic clinics, without HEPA (High Efficiency Particulate Air) filtration as present in most operating rooms 13 • Inadequate distance between the patient and treating doctor or therapist 14 • Some of the procedures could take a long time with a patient, e.g., Full Face Ultherapy treatment, Whole body laser hair reduction • Repeated handling of equipment like touch screen, desktop, patient chairs by doctor/therapist and initial screening and handling of patient forms, cash, credit card by the front office staff

The consensus group comprised of ten experts in the field of aesthetic medicine (one plastic surgeon, four dermatologists, and five aesthetic physicians), 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. Following items were proposed to all the participants, and a consensus was sought to establish the 'preferred practices' guidelines during the meeting.:

Guidelines for patient scheduling 2. Patient evaluation and triaging; patient categorization 3. Guidelines for risk categorization and safety precautions for the aesthetic procedures 4. Guidelines for staffing in the aesthetic clinics

Guidelines for general housekeeping in the aesthetic clinics A 'consensus reached' was considered when at least 70% of participants agreed on the points discussed.

The consensus group decided to provide guidelines on ways to reorganize the aesthetic practices while simultaneously instituting safety measures. The government and the health authorities in each country are likely to review the infection control strategy and measures regularly, and new updates may come in the future 16 . Although cases of COVID-19 infection can happen despite strict measures, the infection is less likely to spread in aesthetic practices with the proposed infection prevention measures. Each aesthetic clinic must assess its business model and local conditions and accordingly adopt these guidelines into its daily functioning. In addition to the infection control measures listed in this article, the requirements and precautions advised by the public health authority of their respective country must be followed by the clinic

Patient scheduling is a critical step for the safety of patients, doctors, therapists, and clinic support staff.

Sticking to the guidelines for 'social distancing' will ensure safety for everyone present in the clinic.

Advance Scheduling should be made compulsory and walk-in patients should be discouraged. The 

The staff should be trained to take the necessary information on the phone at the time of giving 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. However, they could be impractical not only due to a shortage of locally available equipment, and patients taking paracetamol to bring down the fever before arrival but also for suspected COVID-19 patients who do not exhibit any fever 18 .

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 (Table 1) can be used to ascertain the following points 19 .

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

After categorization of the patients based on TOCC history and presence or absence of signs/symptoms, only patients in Category A are to be taken up for an elective aesthetic procedure with due precautions, as shown in Figure 1 .

The procedures performed in an aesthetic clinic (office-practice) have been categorized 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 categorization 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.

This article is protected by copyright. All rights reserved.

The factors taken into account by consensus group for the risk categorization of the procedures werethe type of procedure (aerosol-generating procedure versus non-aerosol generating procedure), body part on which the procedure is being performed (face/body)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 categorization (Table 2 ) ( Figure 5 ). The aerosol producing procedures have the highest risk 20 21 22 , and the long duration of a procedure also increases the risk due to longer contact time with the patient 23 . 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 22 . Based on the categorization, guidelines for PPE were also given ( Table 3) .

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 minimize the duration of the procedure where possible to reduce exposure time 24 . Cleaning of all surfaces (procedure chair/bed, inspection lights, instrument tray/trolley) and the apparatus being used with sterilizing solution should be done after each procedure 25 . For LHR, all the patients should be asked to shave at home and come for 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 26 .

The high-risk procedures may be deferred for sometime after lockdown is lifted in the respective countries 24 . 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 aerosolized cellular debris (like for tattoo removal with Q-switched lasers), keeping in mind the potential power loss when the laser passes through the membrane 27 . Additionally, one can use plume evacuation systems with filters that remove particulates up to 0.1micrometer, known as a ULPA ( ultra-low particulate air) filter. 28

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 29 . Staff can be posted for shorter working hours than usual and should be called in rotation 30 . At any given time, 33% to 50% of staff should be working at the clinic 31 . Staff must get training in donning and doffing of personal protective equipment and should be provided with appropriate PPE 32 33 . The 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. The staff should get training for phone booking, patient interviews on the phone, documentation of patient details and history, getting informed consent signed, social distancing, and hand hygiene 34 (Figure 2 ).

The following guidelines apply to sanitation and logistics for aesthetic clinics. • Security desk: Security guards at the entrance should wear surgical masks and maintain a two-hourly handwash protocol. The physical distance of at least 1 m should be maintained 36 .

• Sanitizing stations: Special stations should be installed at clinic entrances, registration counters, and other high contact surfaces for hand sanitization (preferably contact-less) ( Figure 4 ). 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 37 .

• Seating arrangement: Chairs in the waiting area should be spaced about 2 meter apart ( Figure 3 ). 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 38 .

• 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.

• • 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. The staff should be trained to use electronic modes of information sharing like e-mail, This article is protected by copyright. All rights reserved.

o Outdoor areas: Outdoor areas of the clinic would need less intense disinfection by being exposed to sunlight and air currents. However, cleaning and disinfection of frequently touched surfaces should be carried out here as well.

o Patient examination tables or procedure chairs: These should preferably be covered with disposable sheets, which must be discarded after each use 49 . In case disposable sheets are not available, cotton sheets could be used and machine-washed with a regular detergent after every use. Mattresses and edges of the tables and examination/procedure chairs must be sanitized using a 60-70% alcoholbased sanitizer. If that is not available, then a 1% sodium hypochlorite solution could be used. • 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 safe from COVID-19 infection. The patients with minimum risk of transmitting COVID-19, based on the risk categorization, can be taken for elective aesthetic procedures. Appropriate use of PPEs and other precautions can be taken by treating clinic staff as per the risk category of the aesthetic procedure.

The 'preferred practices' suggested by the consensus group provide the basis for sound infection control for aesthetic clinics, though these may not be complete or exhaustive. In addition to the consensus guidelines, those provided by the health authorities in each country should also be followed. This article is protected by copyright. All rights reserved. protective equipment as per the consensus recommendations for a "low-risk" procedure. In this instance, as the treatment area is the upper face, the patient is also able to wear a face mask (contributed by Wai Man Chan) Footer-* The site at which the procedure is being performed, especially mid and lower face, prohibits the use of a mask by the patient. Since social distancing can also not be maintained, it potentially increases the probability of transmission. **contact with oral mucosa/ secretions and genital mucosa/ secretions. EMS-electromagnetic muscle stimulation, LHR-laser hair reduction, PRP-platelet-rich plasma, AGP-Aerosol generating procedure, HIFU-High intensity focussed ultrasound, RF- 

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Name & Address of the clinic Name of the patient: Age of the patient: Name of spouse/ partner: Name of accompanying person/ persons Present Residential Address: Permanent Residential Address: Occupation of the patient: Occupation of the patient's partner: ., hereby declare that the information provided is complete and accurate. I fully understand that any false information can put the healthcare workers attending to me at a high risk of contracting COVID-19 disease. I fully agree to follow all the instructions regarding precautionary steps by Dr……………………………… and the staff at the clinic. I am visiting the clinic with full knowledge that we are going through a COVID-19 global pandemic. There is always a risk of contracting this virus when I am visiting a place during this pandemic. There is a possible risk of getting this virus by visiting any place during this pandemic. I have been fully explained the content of this declaration form in a language that I can understand. 

