Managing a Clinic Post COVID-19

By Dr Vincent Wong / 14 May 2020

Dr Vincent Wong shares practical suggestions for returning to clinical practice

Note: This article was written and submitted on May 8, prior to the JCCP guidelines being released

The COVID-19 pandemic has affected healthcare, social and financial systems. Not only will this leave a mark on history, but will also play an influential role in setting new working and social norms. In the field of medical aesthetics, new measures must be taken to ensure maximum protection to both practitioners and the general public when lockdown measures are eased, despite being a low risk form of medicine with regards to viral transmission. Without official guidance from the Government for the aesthetic industry (at the time of writing), we must gather what relatable guidance we do have, as well as the current recommendations from different countries, which can then be adapted according to advice from local government.

As well as the information I have collated in this article, you can also read guidance from the Joint Council of Cosmetic Practitioners by clicking here.

About COVID-19

COVID-19 is a new illness caused by a novel coronavirus (SARS-CoV-2). Many cases were reported in Wuhan in December 2019 and the disease has subsequently been declared as a pandemic by the World Health Organization (WHO) due to outbreaks globally, affecting more than 3.7 million people with at least 270,000 deaths.1 The virus can infect many animals and species, including bats, pigs, and humans. The virus cannot be effectively inactivated by chlorhexidine, but is sensitive to ultraviolet (UV) light and heat (56oC for 30 minutes), as well as certain chemical agents including 75% ethyl alcohol and 250mg/L chlorine disinfectant.1 The disease is transmitted through respiratory droplets and close contact with infected patients. According to WHO, the symptoms of COVID-19 include fever, dry cough, tiredness, aches and pains, sore throat, diarrhoea, conjunctivitis, headache, loss of taste or smell and a rash on skin, or discolouration of fingers or toes. In many cases, these symptoms progress to difficulty breathing, chest pain and loss of speech or movement.1 As asymptomatic infected people may also be a source of infection, this poses a great health risk to healthcare professionals (HCPs) in the aesthetics field and therefore calls for certain conditions with strict policies, procedures and protocols to be integrated into clinical practice.

Staff safety and preparedness

According to guidelines from the Aesthetic and Anti-Ageing Medicine Society of South Africa, as well as personal experiences of cosmetic doctors in China, considerations when planning clinic reopening should include phased opening (e.g. half capacity to start with), listing services that you will be able to perform safely within the clinic and supply chain for Personal Protective Equipment (PPE) and cleaning supplies.

Communication about COVID-19 with all members of staff is crucial when preparing for re-opening. This should include sharing current and relevant information about the disease, potential ‘second wave’, reopening strategy and any new employee policies or role changes. Other key points include training, shift patterns, health status, and uniform.

Training

  • Specific training for COVID-19 on hygiene and protection measures (including hand washing, updated sanitation, disinfection and cleaning guidelines) is necessary to protect staff members and patients. Such trainings are available on the WHO website, free of charge.2
  • All members of staff with direct patient contact should be trained on the correct ways to wear and dispose of medical protective face masks and/or PPE. Guidelines on this can be found on the WHO website.3
  • Depending on the size of the clinic, signage and posters should be placed in strategic areas to promote safe hygiene measures.
  • Ensure that all members of staff are aware that hand sanitisers should be readily available for patients and staff, and that they are encouraged to wash their hands regularly.
  • Training in managing deliveries must be provided as SARS-CoV-2 can remain viable on plastic and cardboard for up to four days.4 This includes protective measures such as wearing masks and gloves when receiving deliveries, signing using own pen, disinfecting all packages and washing hands immediately afterwards.

 Shift patterns

  • Governments of countries entering recovery phase of the pandemic have suggested staggered work shift patterns in order to meet safe social distancing requirements. Many cosmetic clinics in China are operating on skeleton staff.
  • Based on current suggestions, safe social distance must be respected amongst staff at all times. This varies between countries from one to two meters.

Health status5,6

  • A system to monitor and screen the health status of staff members daily should be implemented. This includes temperature measurement and symptoms check.
  • Returning staff must not have had a temperature above 37.3oC for 14 days prior to return or been exposed to a COVID-19 positive person in the past two weeks.
  • Vulnerable and high-risk employees must also be identified and advised to continue isolation and not return to work.

Uniform2

  • Uniform should only be worn upon entering the practice, and should be washed at a temperature over 60oC immediately after every use on arriving home.
  • Staff shoes should be sterilised before and after each shift, or covered with disposable shoe covers. Some members of staff may consider having a dedicated pair of shoes that remain in the practice.
  • Personal belongings that are used often (e.g. mobile phones) will require continual disinfection.
  • Avoid sharing pens and disinfect regularly.
  • Jewellery, watches and loose hair should be avoided.

Preparation before re-opening

The entire practice should be sterilised before re-opening. Special attention should be paid to soft furnishings, retail areas, bathrooms, reception and common areas and consultation rooms. 20ml of bleach in 1L of water is an inexpensive and effective disinfectant for common areas, floors, surfaces and door handles.4 Consultation rooms should be cleaned with appropriate viricidal/bactericidal products, such as 0.1% sodium hypochlorite and 75% ethyl alcohol.4 The entire practice should be thoroughly sterilised before opening and after closing every day.4

Pre-appointment preparation for patients

  • Patients should be made aware of the new measures and changes to reassure them that you are ensuring maximum safety.
  • Patients should ensure that they have not had a high temperature (above 37.3oC) for 14 days before their appointment or been exposed to a COVID-19 positive person in the past two weeks.5 This should be checked by a member of staff when booking or confirming an appointment.
  • Consultations should be carried out virtually before appointment and all forms should be digitalised and signed electronically prior to appointment. Practices should consider adding a COVID-19 Pandemic Disclosure and Consent Form, as suggested by the Aesthetic and Anti-Aging Medicine Society of South Africa (AAMSSA) – click here to download.4
  • Patients should also be advised that appointment time will be longer, but it is essential that they arrive on time.
  • Patients should arrive unaccompanied if possible and should be advised to wear a face mask when out in public at all times.6

Managing appointments6

  • Appointments must be staggered and spaced to ensure that only one patient is in the reception or waiting area at a time.
  • Absolute numbers of patients seen in a day should be reduced. The suggestion is 50% to start with. However, this depends on the duration the clinic is open, to ensure that there is enough time to sterilise etc. in between patients and to maintain a ‘one in, one out’ policy that clinics in Italy, China and Malaysia are using.
  • Follow up/review appointments should be carried out online or over the phone.
  • Cancellation policies should be reviewed and adjusted accordingly. In my clinic, I have suspended the 48-hour cancellation policy. Moving forward, I plan to communicate with patients the evening before or on the morning of their appointment to ensure that they are well and still able to attend. Those who need to reschedule would not have their deposit forfeited.

Patient reception

  • Patient temperature should be checked upon arrival.
  • Patients arriving early should wait in the car or outside until called for their appointment if social distancing of 2m cannot be maintained.
  • If patient arrives wearing gloves, they must be removed and discarded upon arrival.
  • Patients should wash their hands using hand sanitiser on arrival.
  • Tissues and pedal bins should be readily available for respiratory hygiene and cough/sneeze etiquette.
  • Disposable shoe covers should be considered for patients. Alternatively, practices can disinfect patients’ shoes on arrival.4
  • Coffee/tea/water/refreshment station and all magazines/leaflets should be temporarily removed to reduce patient’s contact with surfaces.
  • Face masks should be provided to the patient if they arrive without one.4
  • Reception and common areas should be disinfected regularly.

During appointment

It is highly recommended that ventilation of medical settings be improved.5 This can be easily achieved by opening windows at least two to three times a day for over three hours. Additionally, timely cleaning and disinfection of consultation room is also important.5 Table tops, work surfaces, treatment couch, door handles and other relevant surfaces should be cleaned at the start of the day, in between patients and after the last patient of the day. Frequently-used personal belongings of the practitioner (e.g. mobile phones and keys) should be disinfected regularly, and disposal of sharps and clinical waste should be managed effectively. Patients should be advised to keep their personal belongings in their pockets. Large items such as bags should be left at a designated area to avoid spread and contamination.

PPE

Wearing masks and protective eyewear when taking care of patients may reduce touching facial mucous membranes for both physician and staff.6

Quality control

Key points for Infection and Quality Control as currently recommended are summarised in the table below.6

Algorithms

In order for aesthetic practices to reopen and function is a safe environment for all, there is a strong need for triage and treatment algorithms. I have developed the following in-clinic algorithms developed based on current recommendations and WHO guidelines (Figure 2 & 3).8,9

After the appointment

Clinics should consider providing a pedal bin at the exit of the practice to allow patients to dispose of any disposable material such as tissues, gauzes etc. used during the appointment. Before leaving the practice, patients should be able to wash their hands once again with hand sanitiser. Clinics should also consider accepting payments through bank transfer to avoid handling cash. If card payments are accepted, the card reader should be disinfected after every use.

As included in the triage algorithm, HCPs should practice due diligence during the virtual/telephone follow-up appointment. Should the patient develop symptoms of COVID-19 or had contact with someone who tested positive for the disease (previously unknown prior to appointment), local guidance for contact tracing must be followed. As mentioned above, Public Health England is currently working on this.10

Summary

COVID-19 has a huge impact on the aesthetics industry, affecting both patients and HCPs. Although most aesthetic procedures are relatively straightforward and considered to be low risk in terms of contamination, the potential risk of transmitting COVID-19 is not negligible. Careful considerations should be made when planning for clinic reopening once lockdown measures are eased to ensure the safety of HCPs, staff members and patient. The algorithms described in this article may be adapted according to local guidelines to provide peace of mind for all and to ensure best practice as the world embraces the ‘new normal’.


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