What is the ideal location for a sink in an Intensive Care Unit (ICU)?

Optimal Sink Placement in Intensive Care Units

Sinks should be completely removed from patient care areas in ICUs to reduce transmission of multidrug-resistant gram-negative bacteria. 1

Evidence for Sink Removal

• Contaminated handwashing sinks have been identified as significant reservoirs for multidrug-resistant gram-negative bacteria (MDR GNB) in ICUs, promoting outbreaks and endemic infections 1
• Current evidence shows that removal of handwashing sinks may reduce the risk of transmission and infection of drug-resistant bacteria in ICU, although the quality of evidence is low 2
• A 6-year longitudinal study 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 3
• Sink removal significantly decreased non-fermenting gram-negative bacilli in bronchoaspirate samples from ventilated patients 1
• A systematic review of water-free interventions in ICUs found that 71.4% of studies reported outbreak cessation after implementing sink removal and other water-free measures 4

Implementation Recommendations

If complete sink removal is not feasible, follow these alternative approaches:

1. Optimal sink placement if removal is not possible:

   • Place handwashing facilities outside patient care areas (e.g., corridors, staff working areas) 1
   • Relocate sinks as far as possible from patient bedsides 1
   • Install baffles to prevent water splashing 1

2. Alternative hand hygiene solutions:

   • Install alcohol-based hand rub dispensers strategically throughout the ICU 1
   • Create dedicated handwashing areas outside patient care zones 1
   • Implement "water-free patient care" protocols 1

Risk Factors for Sink Contamination

• Using sinks for both handwashing and disposal of body fluids significantly increases contamination risk 5
• Splash risk was identified in 36% of ICU sinks in one study, with 34% of these contaminated by ESBLE (Extended-Spectrum Beta-Lactamase-producing Enterobacteriaceae) 5
• Sink design and hospital wastewater systems that promote biofilm formation contribute to outbreaks 6

Effective Mitigation Strategies

• Restricting sink use to handwashing only (not for disposal of fluids) significantly reduces contamination rates 5
• Daily sink disinfection using bleach is associated with lower contamination rates 5
• Complete removal of sinks from patient rooms combined with water-free patient care shows the most significant reduction in MDR GNB transmission 3

Caveats and Considerations

• Despite the low quality of evidence supporting sink removal, guideline development groups believe the benefits outweigh potential harms 2
• Implementation may face challenges including feasibility variations across healthcare facilities, additional costs for renovation, and the need for staff education on new workflows 1
• Simply providing convenient sinks without proper education may not increase handwashing compliance, as one study showed handwashing occurring at only 24% of expected opportunities even with accessible sinks 7
• When planning ICU design, consider that services in patient areas should prioritize access to the patient, with all outlets arranged to minimize interference with nursing care 2