How does the shortage of handwashing stations/sinks in hospitals affect infection rates?

Hospitals are continually searching for new and better ways to improve infection control and reduce the spread of harmful pathogens. In this effort, many healthcare specialists have championed the importance of maintaining good hand hygiene as an effective way to kill and remove harmful bacteria. Many more campaigns, such as The Gloves are Off and World hand hygiene, continue to promote and celebrate this importance, however, further research has exposed some key details surrounding handwashing stations/sinks that could threaten the improvements of IPC (infection prevention and control) in hospitals.

A double-edged sword: how sinks and handwashing stations can affect infection rates

There is a plethora of research demonstrating the effectiveness of handwashing against germs, illustrating the important role hand hygiene plays in reducing infection rates, however, there are more subtle problems beginning to emerge when it comes to the pragmatics of handwashing stations/sinks in a hospital environment. According to an article by STAT, there are two major issues when it comes to hospital sinks/handwashing stations:

The first issue concerns the water coming into the sinks/handwashing stations. Typically, municipal water treatment systems disinfect and filter water, removing unwanted constituents and producing water for industry and drinking. This neutralises the risk of contracting any harmful pathogen for most healthy people. This method of treatment, albeit an effective way of eliminating most harmful pathogens, does not completely sterilise the water. Because of this, there remains water-dwelling infections that can still cause potential harm to weakened patients. One such example could be found on any ICU (Intensive care unit), for someone whose immune system is suppressed, these typically harmless bugs found in this treated water could potentially be life threatening.

The second issue is that the installation, particularly the pipes that drain the sink/station, provide ideal places for bacteria to proliferate. This mass collection of bacteria form what is known as biofilms - bacteria that settle onto surfaces and begin to aggregate into large clumps surrounded by a protective coating of DNA, proteins, and polysaccharides. The implementation of p-traps (a U shaped bend in the piping) used to drain the content of a sink provides an ideal place for bacteria to get caught and biofilms to develop. In a recent discussion concerning IPC in relation to available facilities, Dr. Alex Kallen, a medical officer in the Center for Disease Control and Prevention division of healthcare quality promotion, asserts: “once you have the biofilms in there, short of ripping the sinks and the piping out, it’s impossible to get rid of”.

Dr. Michael Gardam, director of infection control at University Health Network, highlights a third and final problem in the manufacturing of handwashing stations/sinks. With first hand experience, Gardam investigated an outbreak after three dozen patients in an intensive care unit contracted a drug-resistant bacteria. Gardam noticed “they had gooseneck faucets that directed water straight down into the drain. The pressure created backsplash, 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’s experience brought attention to the necessary alterations that would need to be made to ensure IPC safety.

Implementing change: how the shortage of handwashing stations/sinks in hospitals affect infection rates

Understanding the issues surrounding handwashing stations/sinks allows for future developments to ensure the correct changes are made within the healthcare environment. These insights have ensured that healthcare facilities and equipment are now manufactured to best serve infection control. Both the World Health Organisation (WHO) and Centre for Disease Control and Prevention (CDC) have emphasised and encouraged that, when properly implemented, hand hygiene is the single most important, easiest and cost-effective means of reducing the ubiquity of healthcare associated-illness (HCAI) and the spread of antimicrobial resistances. Unfortunately, the problem that now persists is a spatial imbalance of equipment and facilities - a shortage of facilities fully equipped and available to use.

In 2016, a cross-section study on the impact of handwashing/sink locations on hand hygiene compliance after care of patients with Clostridium difficile infection showed that “poor access to handwashing/sinks is associated with decreased hand washing compliance. Improvement strategies are urgently needed”. Providing more accessible means for both patients and healthcare professionals to be able to wash their hands is one of the most important implementations that would help prevent and control the spread of illnesses. Reportedly, the study on hand hygiene compliance demonstrated that “in half of all occasions, healthcare workers needed to perform 2 or more 90° turns to reach the nearest handwashing facility with a maximum of 37.8 m to travel”. 

Understanding the high frequency with which healthcare workers clean their hands, the WHO has recommended “that an adequate number of appropriately positioned hygiene facilities should be readily available at the point of care”. Pragmatically, this would mean that hospitals would require both portable and nonportable variations of washing stations/sinks. Facilities should be available at every point of care, with portable facilities available for medical emergencies.

A brief summary 

Providing protection against infection is not as simple as it may seem - any old sink or station will not provide the appropriate protection against harmful pathogens. In fact, many handwashing stations/sinks that are manufactured today pose as a double edged sword, albeit hand hygiene is the single most important and easiest method of reducing infection rates, the actual facilities themselves have to support the environment in which it is located. As Dr. Michael Gardam, director of infection control at University Health Network, notes: “handwashing/sinks are the cornerstone of infection control policy. All of the [hospitals] guidelines in the developed world talk about having handwashing stations/sinks … and some of the stuff we’ve learned is: Don’t have a 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. And make sure that the stuff around each facility is waterproof.”

A clear understanding of the manufacturing and installation can aid in providing the best available protection against harmful bacteria. However, after all the changes are said and done, both healthcare workers and patients must have access to the correct facilities to be able to follow clinical guidance and lower infection rates.

Finally, perhaps the most important and unchanging truth, hand hygiene is important for everyone, not just healthcare professionals. Changing the culture of hand hygiene is to ensure each and everyone of us adhere to the seven key steps proposed by the NHS to keep ourselves safe.