PATIENT ROOM SINKS HAVE BEEN SUSPECT IN MANY OUTBREAKS
Handwashing sinks have been a target for infection control improvement in the healthcare environment because the nature of their design brings potentially high concentrations of healthcare pathogens such as the nontuberculous mycobacteria, Pseudomonas aeruginosa, and other Gram-negative bacteria into close proximity to patients, HCP, and fomites.
In a study that analyzed the number of different activities performed at or near handwashing sinks in patient rooms, handwashing only accounted for 4% of sink activities. Other activities performed were associated with medical care, placing items near the sink, patient nutrition, or environmental cleaning.
What is a “Splash Zone” and What is the CMS Guidance Associated With It?
A splash zone is an area around a sink in which contamination could occur to objects within that space becomes wet due to handwashing or other activity being done in the sink. Splashing can occur up to about three (3) feet from the sink. A more rigorous hand wash could potentially distribute droplets farther, but for purposes of surveying healthcare facilities, CMS (Centers for Medicare and Medicaid Services) uses 3 feet as their guide.
The survey form from CMS holds the following direction:
Medications should not be prepared near areas of splashing water (e.g., within 3 feet of a sink). Alternately when space is limited, a (vertical) splash guard can be mounted beside the sink.
There have been outbreaks associated with preparation of medication close to sinks. One such outbreak was reported in the following publication, Outbreak of Mycobacterium mucogenicum Bloodstream Infections Among Patients with Sickle Cell Disease in an Outpatient Setting.
Tap water from two sinks were implicated in the outbreak; a nurse in the clinic had prepared intravenous port flushes on the sink counter, using a saline bag that was hanging over the sink, throughout the shift instead of using prefilled saline flushes. The same sink was being used for hand washing.
Splash near sinks plays a part in contaminating nearby medical supplies, a patient’s toothbrush or equipment used by nursing staff. Therefore, CMS recommends not to store anything within the splash zone.
What is the Source of the Contaminated Splash?
Sink drain covers can become contaminated by patient or HCP (Healthcare Personnel) input or by pathogen-containing biofilms that can grow from the p-trap to the drain cover, highlighting the importance that biofilm growth mode plays in the dissemination of organisms in premise plumbing systems.
Sinks have been recognized as important reservoirs for pathogens in healthcare settings, but the distribution of pathogens within sinks and between HCP and patient room sinks has not been previously studied. In one study, individual samples from within the same sink varied in the level of target organism contamination.
Because the sinks are cleaned regularly, the sink surfaces and drain covers were not as heavily contaminated as the pipe and p-trap surfaces. One limitation of this study is the time at which sinks were cleaned relative to when the sinks were sampled is unknown.
The variation in drain cover contamination between samplings suggests that the drain cover can become contaminated between cleanings and therefore may be an important locale in which to focus infection prevention practices.
Previous findings suggests that bacteria must be present on the sink bowl surface or drain cover in order for dispersion to occur. It was unclear in this study whether the source of drain cover contamination is from the biofilm in the plumbing below, or from patient, HCP, or visitor inputs during sink usage.
Based on the findings of Kotay et al. demonstrating green fluorescent protein-labeled-E. coli growing from p-trap water to the drain cover in a span of seven days (eight-inch distance), contamination of the drain cover by the biofilm growing in the plumbing between daily cleanings is plausible.
Don’t Underestimate The Impact Of Proximity
One of the easiest solutions to implement, according to a 2013 French study published in the Journal of Hospital Infection, is measuring the “splash” radius from each sink in the patient room and making sure nothing is in close proximity. For example, assure that a patient’s toothbrush is not in the splash zone of the restroom.
Include a ledge on a perpendicular or opposite wall and instruct patients and their family members not to place their personal belonging near the sink. Similarly, measure the “splash” radius of the caregiver’s hand washing sink and make sure the paper tower dispenser and glove boxes are not within three feet of the sink, well out of the water’s splash zone. Specify paper towel dispensers that are completely enclosed and dispense towels with a wave of a hand to ensure no cross contamination.
Consider installing a standalone hand washing sink rather than a sink mounted in a countertop, as the countertop is frequently used as a staging area for sterile materials. Creating a physical separation between the sink and counter will reduce any contamination from splashing water.
If You Can’t Change The Room Configuration, Consider New Care Protocols
Perhaps a facility leader can’t change where a sink is located but can alter what is done around the sink. For example, consider giving patients a new hospital-supplied toothbrush each day that can be disposed of after one use. That will reduce any infection or contamination from the sink or toilet. Train caregivers not to use countertops adjacent to handwashing sinks as sterile prep areas. Encourage them to use single use carts, making sure they do not “park” them next to the handwashing sink and make sure they are disinfected after each use. Ask your patients and their families to keep the bathroom door closed while flushing and when not being used.
Helping To Prevent Infection Through Engineering And Design Investigate New Technologies And Fixtures
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.
CALL TO ACTION - NOT ACTING CAN BE COSTLY
Now that you have a grasp of the issues surrounding sinks in hospitals, you need to take the next step to discover the only patented complete solution that addresses the splash zone and biofilm.
The ReSet265 sink has a CURVED SURFACE-For the first time the sink has implemented a curved surface to reduce splash by coordinating and matching the exact location of the surface with the discharge location of the faucet.
ADA COMPLIANT-For the first time the design of the sink naturally incorporates slopes such that the sink naturally meets ADA Requirements while allowing a deeper basin than current ADA Compliant Sinks.
Let me challenge you to:
1. Do your own Infection Prevention Risk Assessment
2. Complete the CONTACT FORM for more information
3. Buy a sink, install it, and
4. Follow the SHS roadmap for your own 4-week study.
If your in-house convinces the facility stakeholders that the ReSet265 sink will prevent sinks from being the source of HAIs in your hospital, Tom Hicks will help you with a 2-3 year replacement program as you install ReSet265 sinks in your critical care units and where your most vulnerable patients receive care (eg. Emergency Department, Oncology Unit, Transplant Unit, Burn Unit, Scrub sinks in the OR, etc.).
