By Brian Ward
A patient walks into your waiting room with a cough, a mild fever, and shortness of breath. Your waiting room is crowded, so she sits down next to other visitors. She left her phone in the car, so she flips through a magazine and plays with the TV remote. Her name is called, and someone takes her seat as soon as she stands. By the time you finish lecturing your patient about how she should have called ahead with these symptoms, several others have come and gone from your waiting room out into the community.
That patient had the flu. But she could have just as easily had any number of infections, from the common cold to the SARS-CoV-2 virus that causes COVID-19.
Cleaning and keeping a healthcare waiting room safe for patients is a difficult task, says Jennifer Cowel, RN, MHS, a former Joint Commission executive and CEO of Patton Healthcare Consulting. Many elements need to be considered: furniture, electrical outlets, sanitizer dispensers, toys, and high-touch objects. And unlike patient rooms, there’s no turnover time between people where the space can be cleaned or checked.
“Waiting rooms are challenging because you can’t control who is in there or what they touch,” she says. “You can have children, adults, or seniors. We are to clean high-touch surfaces, [and] if you have children in the room, every surface could be high touch!”
Accrediting organizations (AO) don’t have a specific standard on waiting room infection control, but there are still issues you can be called out on. In her many years as both a surveyor and healthcare consultant, Cowel has seen (and inspected) many waiting rooms. She’s shared some of the problems she’s seen most frequently, starting from the floor up.
“You’re going to have children in [waiting rooms, and many of those rooms] don’t have the protective covers over the electrical outlets. Those child safety outlets are recommended because little kids crawl under furniture and put things into electrical outlets,” Cowel says.
“There are child-safe outlets out there if you can replace your existing outlets,” she says. “The cheaper alternative is placing those little plastic caps over them so kids can’t jam things in there. The problem with those is that families take them off routinely so they can charge their electrical devices, phones, and such.
“I would recommend replacing [your outlets] with child-safe ones that the family can use to charge. I also suggest having enough charging spaces because you see that a lot, [people] moving furniture around to plug in their devices.”
“If you have a children’s area, you do want to have things the kids can use,” says Cowel. “But then they have to be cleaned right afterwards.”
If you can, take your cleanable toys after they’re used to a “dirty area” where they will be collected and cleaned before going back into the play room.
(See below for a sample toy cleaning policy.)
If your waiting room furniture is in good repair, you don’t have to replace it. However, if the cover on a chair or seat has cracked, the surface material has worn through, or the protective covering has been delaminated, that item would need to be repaired or replaced.
Some furniture surfaces are considered uncleanable and should never be used in a waiting room. An example would be furniture with a fabric cover or made entirely of fabric, as well as wall decorations, which are considered uncleanable by surveyors. It is possible to get a vinyl surface that mimics fabric and is cleanable, Cowel says.
Waiting rooms can have fabric curtains, but they should be cleaned often, and you should consider replacing them with a different material.
There are also rules for wooden furniture with a polyurethane laminate.
“Once [the laminate] is worn down, scratched, nicked, gouged and you see the inside surface, that can no longer be cleaned,” she says. “If you have a shiny original surface, that can be cleaned.”
There are some materials and items that will be touched often and simply can’t be disinfected. It’s for this reason that Cowel discourages the use of books or magazines in your waiting room. They’re uncleanable, high-touch items that present infection risks.
Cowel says that if you really wish to give out books or reading material, give it directly to visitors and tell them to take it with them when they leave.
In 2020, there are plenty of entertainment options for people that don’t involve high-touch items, such as TVs (with inaccessible remotes). And, of course, many visitors will bring in their own cellphones and tablets.
“That is entertainment enough,” she says.
With the novel coronavirus that causes COVID-19 spreading around the world, the best practice is to have patients call in with their symptoms before coming to the facility. The goal is to limit the number of visitors in your waiting room during an outbreak, be it COVID-19 or the common cold. However, this isn’t always possible, nor do patients always listen. When that happens, Cowel recommends adjusting your seating arrangements to allow for extra space between people.
“With COVID-19, the thing is having enough space between seating groups, trying to ensure [social] distancing,” she says. “That’s an idea you want to put into place now and is a good idea in the future.”
If possible, she recommends having two waiting areas—one for people with potential respiratory issues, and one for those without.
Out of soap, signs, and PPE
Check and double-check your hand sanitizer and soap dispensers to ensure they are full. Also work with your facility team to ensure that the bathrooms are being cleaned frequently and properly, and that they are sufficiently stocked with paper towels and other sanitary items.
“Then allow sufficient hand sanitizers in the waiting room so that people can clean their hands if they’ve touched a high-touch surface,” Cowel says.
Also make sure your waiting room is stocked with PPE for patients who need it. Put up signs so that new arrivals know to self-identify respiratory illness symptoms so they can get PPE.
“Have signage to tell people if they’ve got a cold or a cough or something like that, they’re supposed to self-identify up front,” Cowel says. “Because then you’re going to be giving them a mask to wear throughout their visit or how long your infection control policy says.”
Cowel explains that during the COVID-19 outbreak, the CDC expects more frequent cleaning of high-touch surfaces using a hospital-approved disinfectant.
“Your infection preventionists should weigh in using the most recent recommendations from CDC to guide your decision,” she says.
With all cleaning and disinfecting products, always check the expiration date and follow manufacturer instructions for use—concentration, application method, contact time, and so on.
With COVID-19, Cowel says, “you’re supposed to use a cleaner EPA-approved for emerging viral pathogens, and the CDC does have a list of those.”
In response to the COVID-19 outbreak, the CDC has put out recommendations for how one can clean and disinfect their home for the virus. The lessons from those recommendations also work for a healthcare waiting room setting.
The CDC’s posted recommendations are summarized below:
Wear disposable gloves when cleaning and disinfecting surfaces and dispose of the gloves after each cleaning.
If reusable gloves are used, those gloves should be dedicated for cleaning and disinfection of surfaces for COVID-19 and should not be used for other purposes.
Consult the manufacturer’s instructions for cleaning and disinfection products used.
Clean hands immediately after gloves are removed.
If surfaces are dirty, they should be cleaned using a detergent or soap and water prior to disinfection.
For disinfection, using EPA-registered disinfectants should be effective.
Diluted household bleach solutions can be used if appropriate for the surface. Follow manufacturer’s instructions for application and proper ventilation.
Check to ensure the product is not past its expiration date.
Never mix household bleach with ammonia or any other cleanser.
Unexpired household bleach will be effective against coronaviruses when properly diluted.
University of Utah Hospitals and Clinics policy:
Cleaning of toys
Use this policy, shared courtesy of Lynda Bailey, RN, BSN, CSHA, accreditation specialist for quality and patient safety at the University of Utah Hospitals and Clinics, as a starting place to review your own toy cleaning practices and procedures. (Originally published in Inside the Joint Commission.)
Set an organizational standard for cleaning toys used in playrooms, play areas of waiting rooms, exam rooms, etc.
Immersible toys: toys that have no moving parts, no hollow spaces, and a non-porous surface. They will not soak up water into closed cracks or spaces (e.g., Lego toys, stacking cups).
Non-immersible toys: toys that have inside spaces, small openings, or hinges (e.g., dolls, cars) or are too large to be immersed (e.g., castles, slides).
Uncleanable toys: toys that soak up water and are damaged by immersion (e.g., games, books, puzzles, activity books, crayons, stuffed animals).
The overall responsibility for infection control surveillance in the [INSERT FACILITY NAME] resides with the Infection Prevention and Control Department. All of the clinical service managers have a responsibility for infection prevention and control in their specified areas. Infection prevention and control is overseen by the hospital epidemiologist (MD).
- Frequency of Cleaning
- Toys will be cleaned on a routine basis, according to sections described in the guideline, and whenever soiled, to ensure that the toys will not become fomites for infectious microorganisms.
- Toys that cannot be cleaned will be “one time use” items and either sent home with the child or discarded.
- Cleaning Process
- Unit/area staff and environmental services staff share the cleaning responsibilities for playrooms and large toys (e.g., slides, castles, gym mats, wall-mounted toys). Small toys are cleaned by unit/area staff.
- Immersible toys are either: (a) immersed and cleaned thoroughly in an instrument soap, dish soap, or green soap and water; removed; rinsed and then allowed to dry; or (b) wiped thoroughly with a SaniCloth and allowed to dry (note: the toy should be wet enough from the SaniCloth that it takes more than a minute to dry).
- Non-immersible toys are wiped thoroughly with a SaniCloth and allowed to dry. The toy should be wet enough from the SaniCloth that it takes more than a minute to dry.
- Uncleanable toys are discarded or sent home with the child/family.
- Playrooms may be used only by children who do not have airborne or severe respiratory communicable diseases (e.g., measles, mumps, rubella, pertussis, RSV, chickenpox, influenza, TB).
- Children with less severe illnesses may use playrooms if their secretions/excretions are “controlled” (e.g., they do not soil the general environment of the room with stool, nasal drainage, etc., or have an uncontrolled cough/sneeze, etc.)
- Playrooms are cleaned daily and as needed when visibly soiled.
Centers for Disease Control and Prevention: Guidelines for Environmental Infection Control in Health Care, June 6, 2003/52(RR10);1–42.
Brian Ward is editor of Medical Environment Update.