According to aesthetic nurse prescriber and NHS emergency department (ED) nurse Julia Mansell, there has been an increasing number of cosmetic complications presenting to her ED at King’s College Hospital London over the last year. The NHS does not currently collect data on complications that present due to aesthetic procedures, but in Mansell’s hospital the rise was enough to enlist the help of the Complications in Medical Aesthetics Collaborative (CMAC), which has since set out a plan to deliver educational presentations to emergency departments across the UK.
Mansell explains, “I was recently contacted by one of the emergency nurse practitioners because a patient had presented with periorbital cellulitis and hardening of filler, four weeks post tear trough treatment. The original injector was not able to manage the complication and referred the patient to their local emergency department, who weren’t aware of how to manage the complication. This was not the first complication I had been made aware of and it’s possible there may be many more as there are currently no audit requirements on this type of attendance.”
After alerting CMAC founding board member and prescribing pharmacist Gillian Murray, they decided to arrange teaching to doctors and nurse practitioners in the ED, starting at King’s. She adds that the talks are designed to raise the awareness of certain presentations and symptoms that will occur following an aesthetic complication, which will deteriorate if not addressed.
The rise in complications coming through emergency department doors is not limited to King’s, according to aesthetic practitioner Dr Alexander Parys, who has been holding his own complication educational sessions for emergency staff. He comments, “I left the NHS a few years back and at the time I was still working as an emergency department registrar. Back then, filler complications were relatively unheard of. Unfortunately, this has completely changed now and my colleagues still in the department all repeat year on year increases in cosmetic procedure complications, and it seems to be showing no sign of slowing down.”
With aesthetic complications becoming a growing concern, Aesthetics explores why practitioners believe it’s important for the specialty to be taking time to educate healthcare counterparts.
The problem
Chair of CMAC and aesthetic practitioner, Dr Lee Walker, believes the main issue which surrounds aesthetic patients presenting to emergency departments is the risk of misdiagnosis – and consequently mistreatment. He comments, “Local emergency departments are not best placed to recognise and manage complications caused by dermal fillers, as the aetiology, pathology and management form no part of medical undergraduate or postgraduate training. NHS pathways for non-urgent cosmetic wounds may take time to receive wound care, when these wounds should be more efficiently and effectively managed by the clinician who caused the injury (if they are a clinician).”
At the recent King’s College Hospital London CMAC presentation, the group presented a series of images to the attendees and invited thoughts on diagnosis, which reinforced this discrepancy. Dr Walker says, “It was acknowledged by the emergency staff that they may not recognise the specific signs of a vascular occlusion as the presentation is unique to the face and to vascular occlusions caused by dermal fillers. In addition, a recent history of dermal filler injections is not always disclosed by the patient and is not routinely asked when taking a history, so this is something we need to advise emergency department doctors to start doing.”
Dr Parys has noted similar concerns, stating that when he’s presented to emergency department doctors, they are often surprised at the range of complications that can occur from aesthetic procedures and how similarly they can present to other diagnosis. Dr Parys adds that another problem is that emergency departments are not usually equipped to properly deal with a serious aesthetic complication, such as a vascular occlusion. He comments, “Even if the medics working there have trained in aesthetics and are aware of how to manage certain complications, many EDs do not have hyaluronidase to hand, nor would they know where to locate some. This means they’re unable to effectively treat patients who present with these concerns, which is why I always recommend they have some in stock.”
Improving practice
The number of non-medically trained injectors in the UK is rising, which practitioners say is problematic. Dr Walker comments, “CMAC recognise that due to the lack of standards in education, and the absence of regulation, patients can either be sent to, or self-refer to, local emergency departments when complications arise. This is entirely inappropriate (with the exception of ocular symptoms)1 and can be avoided if clinicians are appropriately trained and competent in the diagnosis and management of their own complications. This can only be achieved if they are medically qualified. Medical practitioners also have a responsibility to seek complications prevention and management training.”
Dr Parys emphasises that practitioners should ensure they are fully prepared and have thorough support in place for patients post-procedure so they know exactly what to do should a complication arise. He says, “This should include things such as out of hours emergency contact details, perhaps teaming up with colleagues in the area to provide cross-cover support and maintaining our own education regarding complication recognition and management.” Dr Parys believes it’s also important for practitioners to reflect on any complications that arise, discover key learning points on how to prevent future occurrences, and share these with colleagues.
It’s also important that practitioners stay in touch with their community, inside and outside the NHS, according to Dr Parys. He comments, “We should remember that even though one is private, and one is public, we need to still act as one and collaborate and coordinate with colleagues. Should a patient end up at your clinic needing treatment after attending an emergency department, the treatment, outcome and final diagnosis should be fed back to them so they can reflect and learn from the episode. In addition, joining groups such as CMAC and ACE Group World can help provide you with support from other aesthetic practitioners, and therefore hopefully reduce the chances of patients presenting to emergency departments.”
Educating patients
Dr Walker comments that the lack of patient education around the importance of seeking a medical professional who can perform a medical diagnoses and treatment plan is a contributing factor to the problem. He says, “The patient who has made poor choices is left unsupported by unregulated and unaccountable providers who are unlikely to be using evidence-based products and working in a medical clinic setting, which can reduce patient safety.”
Dr Walker emphasises that the medical aesthetic specialty is key in helping to stop the rise in complications presenting to emergency departments by giving the patients the information they need. “Aesthetic patients (and practitioners) need to be educated to make safe decisions, respect the risks and to not rely on the NHS as a safety net. It is the responsibility of the speciality to raise awareness for our potential patients so that it’s clear to them that when they choose a provider, they should choose a healthcare professional who is accountable to their regulatory body,” he explains.
ED’s shouldn’t be your first option
Aside from the danger that this poses for the patient, Dr Walker comments that the strain this may put on NHS resources is another issue, especially in the pandemic world. While many are dedicated to the education of hospitals, the CMAC emphasises that this should not be considered as an initial viable option for aesthetic practitioners, with the exception of vision loss. Dr Walker says, “It is not appropriate for the NHS to pick up a complication and allocate precious resources and funds, when complications should be managed by the provider. The function of an emergency department is to triage and stabilise sick patients. Aesthetic complications, whilst catastrophic to the patient, are mostly cosmetic and will be prioritised as such.”
