New Guidance Targets Infection Hazards in Hospital Sinks
February 8, 2023— Update based on new evidence on ways that various pathogens can spread in healthcare settings.
New infection prevention guidelines, recently issued by several organizations, tackle fingernails, sinks, and cracked hands.
Among the recommendations for hospital sinks, published in Infection Control & Hospital Epidemiology, from the Society for Healthcare Epidemiology, the Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the American Hospital Association, and the Joint Commission are applicable to hospital sinks, drains and plumbing:
Recent evidence indicates sinks and other drains, such as toilets or hoppers, in healthcare facilities can become contaminated with multidrug-resistant organisms (MDROs). These pathogens can stick to the pipes to form biofilms, which allow the organisms to persist in drains for long periods of time and are often difficult to impossible to fully remove. Because different types of bacteria may contaminate the same drain, drains can serve as sites where antibiotic resistant genes are transferred between bacterial species.
Patients may be exposed to organisms in drains when water splashes from the drain. Splashes may occur when water flow hits the contaminated drain cover or when a toilet or hopper is flushed. Splashes can lead to dissemination of MDRO-containing droplets, which in turn may contaminate the local environment or the skin of nearby healthcare personnel and patients.
What is wrong with this picture? There is no separation between “Clean patient care supplies” and “Dirty, water splashing” on countertops. The contaminated water has been implicated in the probability of placing patients at risk of infection.
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Guidelines for health care facility design mandate that sinks be placed in acute care facilities to promote hand hygiene and protect patients from hospital-acquired infections. By virtue of the fact that these sinks need to be in close proximity to the point of care places them in the “patient hot zone.” That zone is often the most contaminated real estate in the patient’s room
The other problem is that sinks, particularly the pipes that drain them, are ideal places for bacteria to proliferate. The “bugs” form what are known as biofilms – colonies where they gang together and attach to a surface. These water-dwelling bacteria especially like p-traps, the U-shaped bend in pipes that drain the contents of a sink.
Getting rid of biofilms once they form is, well, pretty much impossible. There are cleaning tricks hospitals try, but even those generally only lower the bacterial count for a while until they rebound.
“Once you have the biofilms in there, short of ripping the sinks and the piping out, it’s impossible to get rid of. And in fact, even if you do that, it frequently comes back,” said Dr. Alex Kallen, a medical officer in the Center for Disease Control and Prevention’s division of health care quality promotion.
SINKS IN THE “PATIENT HOT ZONE”
“The thing about the sinks is that they’re the cornerstone of infection control policy. … All of the [hospital] guidelines in the developed world talk about having sinks — the ratio of sinks per beds and where they are and that sort of thing,” said Dr. Michael Gardam, director of infection control at University Health Network, an institution comprising four Toronto hospitals.
Gardam has firsthand experience with an outbreak caused by a sink. It was a bad one. Three dozen patients in intensive care contracted a drug-resistance bacteria; an investigation after the fact said five died because of the infection.
Figuring out how the patients were getting infected took sleuthing, but eventually suspicion fell on some sinks in the ICU. They had gooseneck faucets that directed water straight down into the drain. The pressure created back splash, with tiny droplets of bacteria-laced water spraying onto nearby porous surfaces where medical staff prepared tubing and other equipment used in patient care.
Gardam ordered staff to stop using the sinks, going so far as encasing them in garbage bags. There were no new cases after that.
The hospital subsequently made a number of changes, which have been adopted elsewhere as well, Gardam said.
“Some of the stuff we’ve learned … is: Don’t have the gooseneck (faucet) drain directly into the drain; have it drain off the side of the bowl. Don’t allow it to splash. Make sure it’s deep enough that it can’t splash on you and splash on your clothing. Make sure that the stuff around [the sinks] is waterproof.”
As more and more hospitals become aware of the potential for bacteria and “super bug” contamination from their plumbing systems, the industry is responding by developing new fixtures and systems that reduce or eliminate the potential of infection. These include implementing UV lights, low-splash sinks, and exhaust in fixtures, as well as automatic injection of sanitizing agents.
Of course, these more sophisticated fixtures’ planning, design and installation require infrastructure to support their associated strategies. Electrical and exhaust connections, along with new piping systems and other central systems, bolster the different strategies that are designed to reduce infection in the care environment. Reimagining an entire system from the ground up can drive up construction costs, but in the end reduce the overall costs of healthcare.
Existing drain disinfection chemistries and technologies are not effective at killing bacteria in drains and they depend on employees who actually perform the service. Efforts to disinfect drains have included complete replacement of the sink or its components, installing self-cleaning traps, disinfection with processed steam, enhanced manual cleaning, descaling of pipes, and disinfection with chlorine-based solutions or other liquid disinfectants. It’s important to note that liquid disinfectants do not come in contact with the surface of the drain long enough to meet the contact time needed to kill the bacteria.
CALL TO ACTION
Whether a hospital leader has a 20-year-old building, or is considering a new replacement hospital, you should consider engaging an experienced “healthcare” engineering design expert to assist with developing solutions that address risk of infection and contamination from plumbing fixtures. Implementing best practice design and engineering strategies in areas that cannot be sanitized can result in reduced exposure to infection across the entire hospital.