Should there be a sink in the Intensive Care Unit (ICU)?

Sinks Should Be Removed from ICU Patient Care Areas

Sinks should be removed from areas directly related to patient treatment in ICUs to reduce the risk of transmission and infection of carbapenem-resistant gram-negative bacteria (CRGNB). 1

Evidence for Sink Removal in ICUs

• Contaminated sinks have been identified as significant reservoirs for multidrug-resistant gram-negative bacteria (MDR GNB) in ICUs, promoting outbreaks and endemic infections 1, 2
• A 6-year longitudinal observational study in Spain demonstrated that removing sinks from an ICU, along with implementing water-safe policies, reduced MDR GNB infection rates from 9.15 to 2.20 per 1000 patient-days 1, 2
• A before-and-after controlled study showed that removing sinks and implementing "water-free patient care" significantly reduced GNB colonization rates from 26.3 to 21.6 per 1000 ICU patient-days (RR = 0.82,95% CI 0.67-0.95) 1
• The reduction in GNB colonization became more pronounced with longer ICU stays, reaching a 3.6-fold reduction for patients staying 14 days or longer (P < 0.001) 1
• A quasi-experimental study found that sink removal significantly decreased non-fermenting gram-negative bacilli in bronchoaspirate samples from 11.28/1000 to 1.91/1000 ventilated days (5.90 times decrease, 95% CI: 1.49-51.05, P=0.003) 1
• A 2023 retrospective analysis of 552 ICUs found that ICUs with sinks in patient rooms had higher incidence of hospital-acquired infections (3.97 vs 3.2 per 1000 patient-days) compared to ICUs without sinks 3

Implementation Recommendations

For New or Renovating ICUs:

• Completely remove handwashing sinks from areas directly related to patient treatment 1
• Place handwashing facilities outside patient care areas (e.g., corridors, staff working areas) 1

For Existing ICUs with Sinks:

• If resources permit, remove sinks from patient care areas, particularly in high-risk wards (ICUs, neonatal, hematology, burns) 1
• If removal is not feasible, relocate sinks as far as possible from patient bedsides 1
• Install baffles made of smooth, disinfectant-resistant, moisture-proof materials to prevent water splashing 1

Risk Factors and Mechanisms of Transmission

• Sink drains serve as reservoirs for MDR GNB, including carbapenem-resistant Klebsiella pneumoniae carrying NDM-5 carbapenemase genes 4
• Non-handwashing activities at sinks contribute to bacterial colonization and transmission:
  • Medical care activities (37.4% of observed sink usage) 5
  • Disposal of nutrients and body fluids that promote microbial growth 5
  • Environmental care activities (5.0% of observed sink usage) 5
• Actual handwashing represented only 4% of total behaviors observed at ICU sinks 5

Caveats and Considerations

• The quality of evidence supporting sink removal is considered low, indicating some uncertainty in the observed effects 1
• Despite this limitation, guideline development groups believe the benefits of removing handwashing sinks outweigh potential harms 1
• Implementation may face challenges:
  • Feasibility varies across healthcare facilities 1
  • Additional costs for renovation and alternative hand hygiene solutions 1
  • Need for staff education on new workflows 1
• If sinks must remain, strict protocols should be enforced:
  • Use sinks exclusively for hand hygiene 1
  • Never dispose of body fluids, excreta, or use for cleaning equipment 1
  • Implement daily disinfection with chlorine 4

Alternative Hand Hygiene Solutions

• Alcohol-based hand rub dispensers strategically placed throughout the ICU 1
• Dedicated handwashing areas outside patient care zones 1
• Implementation of "water-free patient care" protocols 1

The evidence strongly suggests that removing sinks from ICU patient care areas can significantly reduce the risk of CRGNB and other MDR GNB infections, ultimately improving patient outcomes by reducing morbidity and mortality associated with these difficult-to-treat infections 1, 3.