2.1 Staff

• Consider personal circumstances, family circumstances and their social behaviours and how those might impact risk to patients.
• Reduce their own exposure and risks to patients as far as is possible.
• Individual circumstances will need to be assessed and taken into account when considering how and when to deploy.
• Should feel that the measures taken and roles allocated are appropriate and safe for them to undertake.
• Please alert Dr. Silva as soon as possible if you have an concerns or information that may risk the clinic staff and its patients.

2.2 Patients

• Will be screened patients over the telephone before the appointment, in addition to the usual medical, social and psychological history, specific risks for Covid-19 need to be identified.

In Addition

Some exclusion criteria are common sense, some Dr. Silva may decide upon himself. Some risks will be appropriately addressed with additional precautions.

Risk factors to be included in the screening questionnaire include;

2.3 Medical History

Patients who have been asked to shield or a deemed as high-risk may refused an appointment.

 Medical conditions include-

• System diseases such as cardiac disease, respiratory disease, liver disease or kidney disease
• Diabetes
• Immunodeficiency
• Currently being treated for cancer
• Obesity

Other factors include

• Age 65 or over
• Any patient that has been advised to shield at home
• Any seasonal allergies which cause spontaneous coughing or sneezing

Please note

• Ethnicity (black and asian) Please refer to the following guidance for additional information;
• Additional information can be found – https://www.medrxiv.org/content/10.1101/2020.05.06.20092999v1.full.pdf

2.4 Recent symptoms

• Fever
• Persistent cough

Additionally any symptoms that are not ‘normal’ such as (but not limited to);

• Fatigue
• Body aches
• Headache
• Sore throat
• Loss of smell or taste
• Nausea

2.5 Social factors

• Living with vulnerable family members (elderly or shielding).
• Recent contact (within 14 days) with someone diagnosed with Covid-19.
• Current employment and social distancing measures at work.
• Living with family who continue to work without adequate social distancing.
• Uses public transport to work.

Any staff  with symptoms must self -isolate and close contacts advised and act as per government guidelines.

Any patients with the symptoms above may not be given an appointment and therefore refused treatment

4.1 The appropriate PPE will be provided for staff

• Disposable gloves
• Disposable aprons and
• Fluid resistant surgical face masks
• Facial visors
• (accessed May 2020)

Fluid-resistant (Type IIR) surgical masks (FRSM) provide barrier protection against respiratory droplets reaching the mucosa of the mouth and nose. FRSMs are for single use or single session use and then must be discarded. The FRSM should be discarded and replaced and NOT be subject to continued use if they become soiled or damaged.

The protective effect of masks against severe acute respiratory syndrome (SARS) and other respiratory viral infections has been well established. There is no evidence that respirators add value over FRSMs for droplet protection when both are used with recommended wider PPE measures in clinical care, except in the context of AGPs.

4.2 Surgical masks should:

Cover both nose and mouth
Be worn once and then discarded – hand hygiene must be performed after disposal

Be changed when they become moist or damaged
Not be allowed to dangle around the neck after or between each use
Not be touched once put on

A single face mask can be worn for a single task or session where you are going to be within a metre of the patients face. A single session refers to ‘a period of time where a practitioner is undertaking duties in a specific care setting/exposure environment A session ends when the practitioner leaves the care setting/exposure environment’.

Sessional use should always be risk assessed. PPE should be disposed of after each session or earlier if damaged, soiled, or uncomfortable. It may not be necessary to change the mask between patients, providing you do not need to adjust it or remove it. If you need to take it off, remove it completely and dispose of it. Avoid touching it, or your face.

4.3 Eye protection or full-face visors

Eye and face protection provides protection against contamination to the eyes from respiratory droplets, aerosols arising from AGPs, from plume generating procedures and from splashing of secretions (including respiratory secretions), blood, body fluids or excretions.

Eye and face protection can be achieved by the use of any one of the following:

• Surgical mask with integrated visor
• Full-face shield or visor
• Polycarbonate safety spectacles or equivalent
• Regular corrective spectacles are not considered adequate eye protection.

4.4 Other points to note

• Since we are not treating confirmed, suspected cases or symptomatic patients (though we cannot know), such protection should be worn if there is a risk of splashing with blood, respiratory or bodily fluids or you are performing plume generating procedures which include laser and ablative plasma.
• Staff should be dispose of the PPE correctly and in the appropriate manner
• Wash hands after removing and disposing of PPE hand washing guidelines.
• Staff wearing PPE should take regular breaks and maintain hydration
• When requiring signatures, risk assess and use alternative methods.

For example;

• Paper records, the patient may sign with their own pen and place the record face down in a tray. These records can stored securely, for filing 72 hours later and not touched in the meantime.
• Pens/ stylus can be disinfected between use with alcohol wipes and used immediately following hand washing.

• No hugging, hand shaking, keep talking to a minimum and no laughing.
• Patients (and staff) with seasonal allergies who are prone to sneezing or coughing should take antihistamines and if symptoms are not managed, wear masks which may limit the treatment options. (This risk should be identified at pre appointment screening). It is important to minimise the dispersal of respiratory secretions, reduce both direct transmission risk and environmental contamination.
• If either a member of staff or a patient does need to cough or sneeze, then the ,’Catch it, bin it, kill it’ process must be applied.
• Disposable tissues must be available, used covering nose and mouth, then disposed of promptly in a lined, pedal operated bin and hands washed immediately.
• Patient’s skin should be disinfected with either hypochlorous products such as Clinisept+ or Natrasan or 70% alcohol.

4.5 Patient guidance

Consider how patients will access the clinic. Can you see them at the door? Is there a buzzer, if yes it should be decommissioned and a call or text message system put in place.

If for the patient, cash payment is necessary, then additional precautions should be taken; gloves worn, the cash bagged, and hands washed following the exchange.

Patients will be asked not to bring unnecessary belongings with them, essentials must be placed on a surface or in a container which can be disinfected or disposed of between patients.

Patients asked to attend their appointments wearing a face covering. The face covering to be worn at all times if possible.  

Some treatments present a higher degree of risk than others, either because of the site (close to the nose or mouth) or because they may generate aerosol, splash or plume.

Risk assess and determine which treatments require specific and additional measures and which treatments cannot be offered.

6.1 Injectables

Whilst injectables do not impact risk of contracting or recovery from any viral infection, there is some evidence to suggest viral or bacterial infections can trigger immunogenic reactions in the implants, which may be delayed. This risk is specifically addressed in your consent and documented. Should this complication arise, management may be challenging as steroids cannot be used, and should lock down recur, face to face treatment such as HyalaseTM (hyaluronidase) cannot be administered. The symptoms may be inconvenient, but will not be life threatening and may settle spontaneously.

6.2 Treatments requiring prolonged contact time

Subject to patient specific risk assessment, procedures are now planned to minimise contact time.

Multiple procedures should be avoided in.

Mouth washed may be provided if the treatment are is near the mouth.

6.4 Treatments requiring a staged course or more than one treatment at intervals

Circumstances may change rapidly.

Treatment may be deffered depending on the length and the number of treatments required.

6.5 Plume generating procedures (laser, ablative plasma or diathermy)

More information can be found at : https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/474136/Laser_guidance_Oct_2015.pdf

Generally, patients will be advised in advance and in writing that should a complication (any complication described in consent) arise and a lock down is enforced, face to face consultations will not be possible and any assessment, management and support can only be provided by telephone or video call, remotely. Corrective procedures will not be possible until lockdown is released. If this risk is unacceptable to the patient, they should not proceed. No refunds or financial compensation can be offered for circumstances beyond our control. By booking a treatment they are accepting these risks and terms.