A Path to Resume Aesthetic Care: Executive Summary of Project AesCert Guidance Supplement-Practical Considerations for Aesthetic Medicine Professionals Supporting Clinic Preparedness in Response to the SARS-CoV-2 Outbreak.

Abstract

Facial Plastic Surgery & Aesthetic MedicineVol. 22, No. 3 Special Communication: COVID-19—Guidance SupplementOpen AccessCreative Commons licenseA Path to Resume Aesthetic Care: Executive Summary of Project AesCert Guidance Supplement—Practical Considerations for Aesthetic Medicine Professionals Supporting Clinic Preparedness in Response to the SARS-CoV-2 OutbreakJeffrey S. Dover, Mary Lynn Moran, Jose F. Figueroa, Heather Furnas, Jatin M. Vyas, Lory D. Wiviott, and Adolf W. KarchmerJeffrey S. Dover*Address correspondence to: Jeffrey S. Dover, MD, SkinCare Physicians, 1244 Boylston Street, Chestnut Hill, Boston, MA 02467, USA, E-mail Address: jdover@skincarephysicians.netSkinCare Physicians, Chestnut Hill, Massachusetts, USA.Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut, USA.Brown Medical School, Providence, Rhode Island, USA.Search for more papers by this author, Mary Lynn MoranDepartment of Otolaryngology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.Search for more papers by this author, Jose F. FigueroaDepartment of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA.Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.Search for more papers by this author, Heather FurnasDepartment of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California, USA.Search for more papers by this author, Jatin M. VyasDivision of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA.Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.Search for more papers by this author, Lory D. WiviottDepartment of Medicine, California Pacific Medical Center, San Francisco, California, USA.Search for more papers by this author, and Adolf W. KarchmerHarvard Medical School, Boston, Massachusetts, USA.Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.Search for more papers by this authorPublished Online:15 May 2020https://doi.org/10.1089/fpsam.2020.0239AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Executive Summary of Project AesCert™ Guidance SupplementThis Project AesCert Guidance Supplement (“Guidance Supplement”) was developed in partnership with a multidisciplinary panel of board-certified physician and doctoral experts in the fields of infectious disease, immunology, public-health policy, dermatology, facial plastic surgery, and plastic surgery. The Guidance Supplement is intended to provide aesthetic medicine physicians and their staff with a practical guide to safety considerations to support clinic preparedness for patients seeking nonsurgical aesthetic treatments and procedures following the return-to-work phase of the coronavirus disease 2019 (COVID-19) pandemic, once such activity is permitted by applicable law. Many federal, state, and local governmental authorities, public-health agencies, and professional medical societies have promulgated COVID-19 orders and advisories applicable to health-care practitioners. The Guidance Supplement is meant to provide aesthetic physicians and their staff with an additional set of practical considerations for delivering aesthetic care safely and generally conducting business responsibly in the new world of COVID-19. The Guidance Supplement is published as an Appendix to this article and can be read in full online at www.liebertpub.com/fpsamAesthetic providers will face new and unique challenges as government stay-at-home orders and related commercial limitations are eased, the U.S. economy reopens, and health-care systems transition from providing only urgent and other essential treatment to resuming routine care and elective procedures and services. Medical aesthetic specialties will therefore wish to resume practice in order to ensure high-quality expert care is available and, importantly, to help promote patients' positive self-image and sense of well-being following a lengthy and stressful period of quarantine. In a number of areas, this Guidance Supplement exceeds traditional aesthetic office safety precautions, recognizing reduced tolerance in an elective treatment environment for any risk associated with COVID-19's highly variable presentation and unpredictable course. The disease has placed a disturbing number of young, otherwise healthy patients in extremis with severe respiratory and renal failure, stroke, pericarditis, neurologic deficits, and other suddenly life-threatening complications, in addition to its pernicious effects on those with pre-existing morbidities and advanced age. Accordingly, the Guidance Supplement seeks to establish an elevated safety profile for providing patient care while reducing, to the greatest extent reasonably possible, the risk of infectious processes to both patients and providers.While the Guidance Supplement cannot foreclose the risk of infection or serve to establish or modify any standards of care, it does offer actionable risk-mitigation considerations for general office comportment and for certain nonsurgical procedures typically performed in aesthetic medical settings. It is axiomatic that all such considerations are necessarily subject to the ultimate judgment of each individual health-care professional based on patient situation, procedure details, office environment, staffing constraints, equipment and testing availability, and local legal status and public-health conditions.Federal, state, and local government legal pronouncements and public-health conditions will inform the gating decisions of when permissible and prudent to reopen practices and re-engage with patients, and whether to limit certain procedures that may present greater contagion risk. While such gating decisions are not the focus of this Guidance Supplement, it is advisable that practices should consider, at a minimum, whether in their local communities: (1) new COVID-19 cases are declining sequentially to eliminate or at least substantially control community spread; (2) testing is available at a meaningful scale to validate perceived prevalence reductions; and (3) adequate protocols and resources are in place in conjunction with local health departments to conduct effective contact tracing where necessary in response to COVID-19 incidents. Without robust testing, the ability to identify individuals with COVID-19, do appropriate contact tracing, and isolate and treat the infected is substantially reduced. Therefore, in the absence of these enumerated local conditions, practices must factor cautiously the attendant increased risk of transmission into their reopening calculus.Significantly, the principal variables within the control of the practicing aesthetic medicine physician are office and staff preparation, and communication and transparency with patients. The Guidance Supplement is focused heavily on these subjects, offering consensus guidance from authors representing relevant scientific and clinical disciplines.The Project AesCert Guidance Supplement provides specific recommendations and considerations for preparing to reopen a medical aesthetic office and begin to deliver aesthetic patient care in a COVID-19 environment, including: Patient communication—establishing appropriate expectations for office visits and attendant risks;Clinic schedule management—considerations for schedule modification to convert non-treatment interactions to telehealth consultations, separate patients from one another in the office and avoid unnecessary staff contact;Facility management—physical modification of office common areas and treatment rooms, as well as check-in and check-out procedures, to promote safe practices and physical distancing;Cleaning procedures—discussion of disinfection methods and practices in each office area, ranging from medical instruments and treatment rooms to administrative items and reception areas;Personal Protective Equipment (PPE) for providers, staff and patients—recommendations for PPE types and use depending upon procedure-based risk assessment, and recognizing current global equipment shortages;Employee health screening and training—procedures and methods for identifying staff members who may be unwell before, during, and after work, and training of staff to identify potential COVID-19 presentation in coworkers, patients, and other office visitors; risks associated with exposure to known or suspected COVID-19-positive individuals are also discussed;Patient health and screening—procedures and methods for symptom recognition in patients before, during, and after office visits, with follow-up monitoring where appropriate;Remedial measures following onsite symptom presentation—a framework for addressing isolation of symptomatic individuals, office containment and disinfection, and contact tracing;Treatment room setup—preparing and securing treatment rooms for patient entry to contain office contamination and reduce overall potential COVID-19 exposure; andAesthetic treatment considerations—pretreatment preparation and precautions, and other suggestions for minimizing risk of transmission in performing the most common types of office-based aesthetic procedures, such as neurotoxin and dermal filler injections, noninvasive body contouring, lasers and other similar energy-emitting devices, and a range of medical skin care treatments.The Project AesCert Guidance Supplement also contains summary charts and checklists designed in collaboration by both infectious disease and aesthetic experts, which can be utilized immediately to assist office staff in understanding and modeling sound safety practices.ConclusionAesthetic medicine practices must navigate a daunting series of medical and business challenges occasioned by the COVID-19 pandemic. Most offices have been closed by operation of both common sense and legal requirement, as the public health community labors to comprehend both the magnitude and complexity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its sequelae. This crisis has created significant safety concerns and occasioned severe financial hardship for aesthetic physicians, staff, and patients alike. However, the authors posit that application of sound safety measures identified and considered in the Guidance Supplement will serve to assist aesthetic medicine specialties in returning to the delivery of patient care with reasonable risk-minimization strategies. It is critical that all disciplines of medicine, aesthetic and otherwise, share available information and work together to evolve effective approaches to practicing in a dramatically changed environment.AcknowledgmentsThe authors wish to acknowledge the scientific and clinical staff of The SkinBetter Science Institute™ for its contributions to the development of this Project AesCert Guidance Supplement. Special thanks to staff members Diane Nelson, RN, MPH; Mitchell Wortzman, PhD; Lily Phillips, BS; Seth Rodner, JD; and Jonah Shacknai, JD. Special thanks also to project medical advisors Howard Luber, MD; Jody Comstock, MD; and David McDaniel, MD.The AesCert™ mark designation embodies a multi-specialty consensus view of aesthetic safety considerations to promote patient health in reopening aesthetic offices during the COVID-19 outbreak.Author Disclosure StatementNo competing financial interests exist.Funding InformationThe development of the Project AesCert Guidance Supplement has been supported by an educational grant from The SkinBetter Science Institute as a service to the medical aesthetics provider and patient community.AppendixA PATH TO RESUME AESTHETIC CARE: Project AesCert Guidance—Practical Considerations for Aesthetic Medicine Professionals Supporting Clinic Preparedness in Response to the SARS-CoV-2 OutbreakCopyright © 2020 The Skinbetter Science Institute™. All rights reserved.Table of ContentsI. Statement of Purpose ............................................................ 128II. Introduction ............................................................ 128III. Medical Office Preparedness ............................................................ 129Patient Communication and Transparency ............................................................ 129 Managing the Office Environment - General Guidance ............................................................ 130Capsule Summary: Office Environment Considerations ............................................................ 131 Cleaning & Disinfecting Practices ............................................................ 132 Personal Protective Equipment and Medical Supplies ............................................................ 133Capsule Summary: PPE and Medical Supply Considerations ............................................................ 135IV. Employee and Patient Health ............................................................ 135 Employee Health and Training ............................................................ 135 Recognition of Symptoms ............................................................ 136 Symptomatic Patients and Employees ............................................................ 137Capsule Summary: Employee and Patient Health Considerations ............................................................ 138V. Patient Management Procedures ............................................................ 138 Pre-Screening Patients ............................................................ 138 Office Arrival, Check-In and Check-Out ............................................................ 138Capsule Summary: Patient Management Considerations ............................................................ 139VI. Clinical and Non-Surgical Treatments ............................................................ 140 Treatment Room Set-Up ............................................................ 140 Anesthesia and Analgesia ............................................................ 140 Injectables ............................................................ 141 Non-Invasive Body Contouring ............................................................ 141 Energy-Based Procedures of the Face and Neck ............................................................ 142 Skin Treatment Procedures ............................................................ 143Capsule Summary: Non-Surgical Treatment Considerations ............................................................ 143VII. Conclusions ............................................................ 145VIII. References ............................................................ 145IX. Appendix Figures ............................................................ 147 Figure 1: Daily Treatment Room Disinfectant Checklist ............................................................ 147 Figure 2: Common Area Disinfectant Checklist ............................................................ 148 Figure 3: Wellness Screening Checklist ............................................................ 149 Figure 4: Patient Screening Flowchart ............................................................ 150 Figure 5: Post-Appointment Screening ............................................................ 151I. Statement of PurposeThis Project AesCert Guidance manuscript (“Guidance”) was developed in partnership with a multi-disciplinary panel of board-certified physician and doctoral experts in the fields of Infectious Disease, Immunology, Public Health Policy, Dermatology, Plastic Surgery and Facial Plastic Surgery. This Guidance is intended to provide aesthetic medicine physicians and their staffs with a practical guide to safety considerations to support clinic preparedness for patients seeking non-surgical aesthetic treatments and procedures following the return-to-work phase of the COVID-19 pandemic arising out of the novel coronavirus SARS-CoV-2, once such activity is permitted by applicable law.Many federal, state and local governmental authorities, public health agencies and professional medical societies have promulgated COVID-19 orders and advisories applicable to health care practitioners, largely focused on the threshold determination of whether and when to reopen for business. These standards should be seriously considered, and where required by law or otherwise applicable or prudent, followed thoughtfully. This Guidance is not intended to contravene any such other mandates, which supersede this Guidance in the event of any conflict, but rather, to provide aesthetic physicians and their staffs with an additional set of practical considerations for delivering aesthetics care safely and generally conducting business responsibly in the new world of COVID-19.II. IntroductionAesthetic physicians and their staff will face new and unique challenges as government stay-at-home orders and related commercial limitations are eased, and the U.S. economy reopens and healthcare systems transition from providing only urgent and other essential care to resuming routine care, elective procedures and services. Debate will continue about the wisdom, pace and scope of such reopening, but in the meantime patient demand for aesthetic treatments will return. The medical aesthetics specialties will therefore wish to resume practice in order to ensure high quality, expert care is available, and importantly to help promote patients' positive self-image and sense of well-being following a lengthy and stressful period of quarantine. In reopening aesthetic practices during the ongoing pendency of the COVID-19 outbreak, delivery of care must be accompanied by necessary precautions to safeguard the health and welfare of not only the patients and providers within the context of the office environment, but also the community at large with whom they interact immediately beyond the office walls.There is widespread perception that, while aesthetic procedures are self-esteem and self-image enhancing, they are generally considered elective, with notable exceptions that may be deemed medically necessary (e.g., cases of congenital anomaly or traumatic injury). Because of their elective nature, extraordinary care must be taken to protect patients and healthcare professionals from COVID-19. While physician practice guidance is available from many sources, the AesCert Guidance has been developed specifically for aesthetic medicine settings. In a number of areas, this Guidance exceeds traditional aesthetic office safety precautions, recognizing reduced tolerance in an elective treatment environment for any risk associated with COVID-19's highly variable presentation and unpredictable course. The disease has placed a disturbing number of young, otherwise healthy patients in extremis with severe respiratory and renal failure, stroke, pericarditis, neurologic deficits and other suddenly life-threatening complications, in addition to its pernicious effects on those with pre-existing morbidities and advanced age. Accordingly, the Guidance seeks to establish an elevated safety profile for providing patient care while reducing, to the greatest extent reasonably possible, the risk of infectious processes to both patients and providers.While the Guidance categorically cannot foreclose the risk of infection, nor serve to establish or modify any standards of care, it does offer actionable risk-mitigation considerations for general office comportment and for certain non-surgical procedures typically performed in aesthetic medical settings. This Guidance is purely advisory in nature and should be regarded as a set of baseline precautions that should be considered; however, it is not an exhaustive list of everything required to operate safely. It is axiomatic that all such considerations are necessarily subject to the ultimate judgment of each individual healthcare professional based on patient situation, procedure details, office environment, staffing constraints, equipment and testing availability, and local legal status and public health conditions.Importantly, this Guidance is also subject to present limitations on medical and scientific understanding of COVID-19, and any future changes in such understanding will need to be evaluated by providers in determining its continuing utility. Additionally, this Guidance has been prepared in a nationwide environment marked by limited diagnostic resources for both active disease and possible immune response, and an absence of validated pharmaceutical treatments or vaccines. As point of care testing becomes more widely available, affordable and reliable, and once therapeutic or preventive protocols are in place, such developments may permit certain modulation of the Guidance.In the interim, federal, state and local government legal pronouncements and public health conditions will inform the gating decisions of when it is permissible and prudent to reopen practices and re-engage with patients, and whether to limit certain procedures which may present greater contagion risk. Given the multiplicity of such circumstances across the country, these are necessarily highly localized and indeed individualized assessments. While such gating decisions are not the focus of this Guidance, it seems clear that practices should consider, at a minimum, whether in their local communities: (1) new COVID-19 cases are declining sequentially to eliminate or at least substantially control community spread, (2) testing is available at meaningful scale to validate perceived prevalence reductions, and (3) adequate protocols and resources are in place in conjunction with local health departments to conduct effective contact tracing where necessary in response to COVID-19 incidents. Without robust testing, the ability to effectively identify individuals with COVID-19, do appropriate tracing, and isolate and treat the infected is substantially reduced. Therefore, in the absence of these enumerated local conditions, practices must cautiously factor the attendant increased risk of transmission into their reopening calculus.Further, subsequent to the threshold decision to reopen, it is possible that future COVID-19 prevalence in a particular community, along with limits on testing and treatment availability, could periodically require limitations in scope of practice or even temporary office closure to reduce risk of harm. Again, this Guidance takes no position on these contingencies, and seeks only to provide information and best practices for operational implementation where it is otherwise legally permissible and medically responsible to interact with patients in the office setting for delivery of medical aesthetics care. More broadly, in this highly dynamic pandemic environment, this Guidance is necessarily based on, and its applicability confined to, the public health environment and related government pronouncements in effect as of the date of publication. Subsequent evolution in transmission prevalence, testing and tracing capacity, and treatment as well as vaccine availability could warrant either further restriction or expansion of aesthetic practice from this Guidance, depending on the direction of such evolution.In the meantime, based on the current public health landscape and the medical and scientific information now available, the Guidance next proceeds to outline a series of practical considerations associated with practice reopening, ranging from preparing the medical office environment, staff training, and patient and staff health screening, to treatment room set-up, selection of Personal Protective Equipment (PPE), and precautions for common office aesthetic procedures, such as neurotoxin and dermal filler injections, energy-emitting devices, body contouring and medical skin care treatments.III. Medical Office PreparednessPatient communication and transparencyWhile effective patient communication and transparency are always a hallmark of any well-functioning medical practice, they are particularly critical during the return-to-work phase of this COVID-19 outbreak. Accordingly, it is important for practices not only to implement and follow high safety standards as a substantive matter of public health, but also to clearly convey these steps to their patients to foster a sense of awareness and confidence. Therefore, as an overarching theme to this entire Guidance, measures and changes undertaken by practice in response to the COVID-19 outbreak should be proactively signaled to patients to heighten confidence. Utilizing established means to communicate to patients, such as the practice's website and notifying patients via digital and direct personal communication, is an important first step in conveying the practice's commitment to the health and safety of patients and the public, while maintaining high-quality patient care.Communicating new policies and protocols throughout the clinic with visible reminders such as display posters and other signage will assist staff in remaining vigilant, in addition to conveying a practice's emphasis on safety for patients and others. It is advisable to display such materials throughout the clinic, including common areas, reception areas, waiting room, treatment rooms and bathrooms, reminding patients and staff of symptoms related to COVID-19, healthy hygiene and prevention etiquette. Examples of display posters are provided in the following links, although it should be noted with respect to the symptoms poster that this is not an exhaustive list, and additional symptoms are increasingly recognized, such as severe fatigue, nausea and diarrhea, chills, repeated shaking with chills, myalgia, headache, sore throat, new loss of taste or smell, and unexplained anorexia: symptoms of COVID-19 – sample poster/flyer, preventing the spread of COVID-19 – sample poster/flyer, and handwashing and respiratory hygiene – sample poster/flyer.Additionally, in the same spirit of patient transparency and disclosure, given that there remains inherent, ineliminable risk of an infectious process or other complication arising from any sort of medical procedure during an ongoing global pandemic, even after respecting the considerations set forth in this Guidance and elsewhere, practices may wish to append a COVID-19 disclosure to their standard patient consent form. An example consent form developed by the American Society of Plastic Surgeons (ASPS) may be found using the provided link.16 Further, in the case of patients at higher risk of COVID-19 complications, such as those who are of advanced age, immunocompromised, or otherwise afflicted with cardiac or respiratory conditions or other comorbidities such as diabetes, hypertension or obesity, consideration should be given to possibly delaying aesthetics intervention, if patient risk factors are deemed too high.19Managing the office environment – general guidanceIt is clear that during this pandemic, social distancing (hereinafter referred to as “physical distancing” in order to emphasize the intended minimum physical separation of six-feet between individuals, and limits on congregating in large groups) is as important to the safe operation of a medical aesthetics practice as to any other business, household or community. And it will remain so for the foreseeable future. Accordingly, as a second overarching theme running through this Guidance, physical distancing principles should be incorporated throughout the practice, from the moment of initial patient scheduling through post-procedure check-out, and all office workflows from staff's arrival in the morning until the doors are locked at night. Put simply, limiting the number of individuals in a particular setting and space at a given time is fundamental to minimizing transmission.Utilizing telemedicine and leveraging remote videoconferencing technology for patient consultations and non-procedure visits will aid in minimizing office traffic while allowing for the development of a treatment plan (both short- and long-term), building rapport with patients and reducing in-office contact time.2,16,17,20 The efficiency and value of this approach can be enhanced by sending patients a pre-consultation form in advance of a scheduled telehealth interaction to learn more about patient's primary concerns and the type of information or treatment they are seeking. Capturing this information in a more formal manner will help facilitate and guide discussion between the patient and clinician in a manner that timely surfaces various opportunities to divert in-person visits to safer, more efficient interactions. Various enabling developments have occurred in this regard, ranging from the proliferation of telehealth and other video technology platforms, to certain applicable standards surrounding the privacy and reimbursement of distance versus in-person provider interactions (N.B. - legal requirements vary by jurisdiction).20With respect to treatment-related visits or other necessary in-person office visits, consider spacing or staggering appointments to reduce the number of patients in the office at one time and to allow for proper disinfection between patients. Mindful of office size and staffing constraints, consider limiting overall patient volume per day, or extending office hours to spread patients out over a longer time horizon throughout the day.Remind patients of the need to arrive to their appointment promptly and alone, and that individuals accompanying patients will be required to wait in their vehicle or outside of the office for the duration of the appointment.2,16 Special arrangements may be made in advance for minors, elderly patients or persons with disabilities. Visitors spending any time in the office should be screened in the sam