By AmSpa & ByrdAdatto

Patient Protocol

Q: Do I need to require all patients to wear masks?

A: It is crucial that you follow state and local rules, so first review any requirements from your state and local governments, as well as any guidance from your medical and nursing boards, to determine whether your patients are required to wear masks. Always review CDC guidelines for guidance, as well. If masks are not required, each medical spa will need to make its own judgement call. Keep in mind that people infected with COVID-19 can be contagious for up to 14 days before experiencing symptoms and some are asymptomatic. So, while pre-screening and taking temperatures will reduce the chance of treating a contagious patient, it will not entirely remove it. Likewise, staff members may unknowingly be contagious. Therefore, it is prudent to ask that patients wear masks to the extent possible as long as they are in the facility.

Q: What are the basic protocols for patients entering your office (e.g. text them when you're ready to see them, give them a mask, etc.)?

A: Protocols need to be set in accordance with your own circumstances. Factors include your geographic area, the size of your space, the infection rate in your locality and others. In general, the time the patient spends in the facility and the number of people they interact with should be minimized, and all necessary steps should be taken to ensure a sanitized environment and as little interaction as possible. Following are some ideas for protocols.

• Contact patients 24 hours prior to their appointments to screen for exposure and symptoms.
• Have patients wait in their car, receive a text message from you and be met at the door for their appointment.
• Before permitting a patient to enter the facility, take their temperature and implement a screening process.
• Provide face coverings and hand sanitizer.
• Lead patients directly to a treatment room, as opposed to your waiting room.
• Prohibit guests or family from accompanying the patient.
• Take payment over the phone to avoid close contact.
• Ensure proper distancing during check-in and check-out.
• Space appointments to ensure adequate time for disinfection between patients.

Q: Are there specific things I should do to disinfect treatment rooms?

A: Use an EPA-approved disinfectant for cleaning all surfaces that come into contact with patients, including these areas, at a minimum:

• Beds and chairs;
• Doorknobs;
• Light switches;
• Railings;
• Tablets;
• Credit card machines;
• Bathroom fixtures;
• Counters;
• Handheld mirrors; and
• Pens.

Disinfection procedures should be implemented after every patient visit.

Q: Should I take every patient's temperature before they come into the office?

A: Protocols need to be set in accordance with your medical spa's circumstances. Factors include your geographic area, the size of your space, the infection rate in your locality and others. If you wish to take patients' temperatures, do so in accordance with a general wellness screening (including symptoms, contact with others, etc.). However, keep in mind that it is possible to have COVID-19 and not have a fever (or any other symptoms). Be sure to disinfect thermometer between uses.

Q: Should I require every patient to be tested before treatment?

A: Protocols need to be set in accordance with your medical spa's circumstances. Factors include your geographic area, the size of your space, the infection rate in your locality and others. While testing for COVID-19 may provide an extra level of verification, the tests that are currently available are not 100% accurate, take some time to return results, and may be in short supply. Additionally, the time between having the test and their appointment provides a window for infection. It is better to screen for obvious signs of infection and to treat all patients as potentially infectious.

Q: Should I test patients myself?

A: This is up to every medical practice individually, but AmSpa generally does not recommend that medical spas provide testing for its patients. In addition to the reasons above, providing the test yourself can potentially create a duty to treat the patient for COVID-19 if they test positive.

Q: If I decide to test my patients, where do I get tests?

A: Availability is changing rapidly—the types of tests are changing and FDA approval is changing. Your medical supplier should be able to provide them for you, given that they are available when you order.

Q: If I do test patients, how do I protect myself, given that some tests have false negatives/positives?

A: See above—this is one reason why administering testing is not advised.

Q: What should I tell my patients? I don't want to open myself up to liability, but I want them to feel comfortable.

A: Simply explain all the measures that you are actually taking to protect your staff and your patients. Don't make any promises—just list the facts. Don't say you're doing something you're not.

Q: What should be included in the COVID-19 consent? What other consents are needed?

A: AmSpa provides an example of a COVID-19 consent in its Re-opening Toolkit for Medical Spas. In general, the consent should cover known risks of contracting the virus, address possible outcomes of the illness, and acknowledge that, although you're making your best efforts to reduce the chance of infection, the chance of infection is not eliminated.

Q: Am I setting myself up for liability if I take protective action, but people get sick anyway?

A: You are more liable if you do not act within the accepted standard of care to avoid infection.

Q: Do all these protocols need to be in writing? If so, where do I get them?

A: Yes, all policies and protocols you implement in your facility should be in writing and reviewed and updated on a regular basis. In some cases, minutes from a staff meeting may suffice; in others, more detailed guidelines may be needed. Make sure that your actual practices match what your written practices say. AmSpa provides a number of protocol examples you can base yours on in its Re-opening Toolkit for Medical Spas.

Treatments

Q: What types of treatments should I offer under the circumstances?

A: Protocols need to be set in accordance with your medical spa's circumstances, including determining which treatments to offer and which treatments, if any, to withhold. Factors include your geographic area, the size of your space, the infection rate in your locality and others. As you do a phased re-opening, you may wish to temporarily limit your services to account for demand, staffing concerns, supply issues and cleaning requirements. In general, treat every patient as if they are positive for COVID-19 and make adjustments accordingly.

Q: Are there any treatments I should not offer—e.g. should I avoid lip fillers or treatments around the mouth, or water-based facials because they spray fluids everywhere?

A: AmSpa is not aware of any non-surgical medical procedures that increase the spread of COVID-19 more than others. It does not appear that COVID-19 can be spread solely from the skin. However, any virus that has landed on the skin may be transferred to other surfaces or become airborne if blown off. It is unknown if any treatments can do this, but it may be prudent to take precautions as if they do. The employee providing treatment should wear face-, eye- and splatter protection while performing the procedure. Note that certain invasive procedures do increase the risk of spread (intubating patients, surgery, etc.).

Q: What about laser treatments that produce a plume of gas/material? Are they dangerous?

A: There is no evidence that COVID-19 can be spread in this manner. However, any virus that has landed on the skin could be transferred to other surfaces or become airborne if blown off. It is unknown if the surgical smoke plume from laser treatments can do this, but it may be prudent to use a surgical smoke evacuator to filter the plume and for the employee to use face and eye protection while performing the procedure.

Q: How do I determine what treatments to offer? If patients are wearing masks, should I avoid certain treatments?

A: To the extent possible, the patient should keep their mask on. It should only be moved or removed for the minimum time needed to render treatment and then replaced.

Employees

Q: What types of PPE should I require my employees to wear?

A: Protocols need to be set in accordance with your own circumstances. Factors include your geographic area, the size of your space, the infection rate in your locality and others. Consider the following when making this decision:

• What does my state and/or licensing body mandate?
• What does my staff want to wear?
• What do I have access to?
• What does the CDC recommend?
• What's the status of the community I serve? Am I serving a hotspot, or are there minimal cases in my community?
• What do OSHA guidelines say?

Q: Do my staff members need to wear masks?

A: See above for additional considerations.  A face covering on each employee provides an additional level of protection to your staff and patients beyond cleaning and hygiene practices.

Q: Do I test my employees? How often?

A: Protocols need to be set in accordance with your medical spa's circumstances. Factors include your geographic area, the size of your space, the infection rate in your locality and others. In general, there is no requirement to test all your employees. However, if an employee has symptoms or a known exposure, you should refer them to their primary care physician or a local testing site. If they are positive, let your team know without disclosing the identity of the staff member.

Q: What if an employee doesn't want to return to work? What if they don't feel safe, even though the state has allowed medical spas to open and we have safety protocols in place?

A: You may want to have a conversation with the person to better understand their concerns and address the steps you have taken to see if a compromise can be reached. If they were laid off during the shutdown, they are under no obligation to return, and you are under no obligation to re-hire them. If they were furloughed or given temporary leave, you should consult with an attorney or a human resources professional to discuss the next steps that need to be taken. You will also need to determine if the American with Disabilities Act applies in your situation.

Q: Should we make our employees sign a consent form or put language in our handbook regarding COVID-19? 

A: It is a good practice to have employees acknowledge in writing that they have been informed of your policies and procedures and the training you provide.

Q: Should we make employees change out of scrubs before they leave and change whenever they come in?

A: This requirement would be more in line with hospital staff who are treating COVID-19 patients. This is likely not necessary in a medical spa setting, but discuss it with your employees to gauge their level of comfort.

Q: Can we require this scrubs policy in an employee contract or handbook?

A: New policies and procedures can be added to the employee handbook according to its amendment policy, but any employment contract changes must be mutually agreed on.

Q: Should I reconfigure my office to ensure employees and patients aren't within six feet of one another? 

A: Yes, you will want to organize your office and adjust your scheduling to minimize person-to-person contact and locations and surfaces the patient touches or goes near. Maintaining six feet of separation would be ideal, if it's feasible in your facility. Require that patients do not bring visitors with them to lessen crowding.

General Questions

Q: What do I do when state orders conflict with local orders?

A: This will depend on the specific language found in the state order. The state order can set either:

• The maximum level, and the local order cannot be more restrictive; or
• The minimum level where, between state and local, the most restrictive would apply.

Q: What resources are out there to find consent forms and protocols?

A: AmSpa provides resources for consents and protocols in its Re-opening Toolkit for Medical Spas. Additionally, both the CDC and OSHA maintain websites with multiple resources.

Q: If patients say they don't care about COVID-19 and want to be treated anyway, what do I do?

A: The patient's personal opinion should not affect your processes and does not affect your liability. The pre-appointment screening should still take place, infection mitigation and sterilization procedures should still be exercised, and the patient must still give informed consent. Ultimately, it is your option to accept them as a patient, and you may choose not to if you feel they would put your staff or other patients at undue risk.

Q: What postings should I have on my clinic's walls and website?

A: Communicate any changes to your processes and things patients need to know before they arrive, limits on your services, etc. People appreciate the communication. If you require anything of the patient, such as wearing a face mask, let them know prior to their visit—preferably when they are scheduling their appointment.