By Dr Kayleigh Cox-Nowak, Technical Support Manager, schülke UK
It is indisputable that effective infection prevention and control strategies in hospitals are essential. Particularly as up to 15% of patients acquire an infection during their stay, which was not present on admission [Hacque, 2018]. Hospital-acquired infections (HCAIs) can exacerbate illnesses, delay recovery and reduce quality of life [NICE, 2017]. It’s not only the impact on patients that is of concern, but also the additional burden HCAIs place on an already stretched NHS. They’re estimated to cost £2.7 billion and add 7.1 million hospital bed days every year in England alone [Guest, 2020]. Therefore any approaches which can be taken to decrease the number of hospital acquired infections are worthy of careful consideration.
One area which is increasingly being examined is the concept of water-free patient washing, which includes the removal of sinks from patient rooms. Reports of sinks as sources of contamination and infection go back to the 1970s [Teres, 1973]. More recently Johnson et al. [2009] reported in their study that patients’ wash basins should be considered as a reservoir for bacteria and a potential source of infection particularly for high-risk patients, such as those on ICU. They evaluated 92 wash basins from three ICUs in acute care hospitals and found bacteria in 98% of basins [Johnson, 2009].
In another multicentre study, samples were taken from basins in 88 hospitals. 62.2% of the 1,103 basins sampled were contaminated with common hospital-associated pathogens. [Marchaim, 2012]
Other publications have highlighted the role of sinks as a source of outbreaks and transmission of multidrug-resistant gram-negative bacilli (MDR-GNB) in intensive care units, including paediatric and neonatal ICUs [Hopman, 2017]
Despite the increasing body of evidence linking sinks in patient rooms with HCAIs, their removal may be challenging. Sinks are present in virtually all hospital wards and patient rooms. They have played an integral part in traditional hospital hand hygiene strategy.
Yet the move to water-free hand hygiene with a hand disinfectant has been both widely accepted and widely embraced. This has been demonstrated in significantly improved compliance levels amongst hospital staff [Bischoff, 2000]. Therefore a move towards waterless patient washing could also be embraced if the benefits are well communicated and underpinned by evidence.
The move towards water-free patient washing appears to be gathering momentum in ICUs. A recent two-year study evaluated the effect of removing sinks from ICU patient rooms and introducing ‘water-free’ patient care, on gram-negative bacilli (GNB) colonisation rates [Hopman, 2017]. This intervention was followed by a statistically significant immediate reduction in GNB colonisation. The reduction rate became even more pronounced in patients with longer stays in ICU [Hopman, 2017]. Researchers concluded that the removal of sinks from patient rooms and introduction of ‘water-free’ patient care is associated with a significant reduction of patient colonisation with GNB’ [Hopman, 2017].
Further research shows both staff and patients are generally positive about washing without water [Schoonhoven, 2015]. Nurses graded washing without water with a 7.5 out of 10 (sd 1.2) and they also reported a decrease in their workload. Sixty-one percent preferred water- free washing to standard bed baths and it was viewed as a more efficient alternative [Schoonhoven, 2015].
A 12-month evaluation of water free patient washing with octenidine-based wash mitts compared to bucket washing, found a real reduction in the prescription of antibiotics for wound infections, a reduction in unwarranted infections and improvements in the quality of care delivered. Patients and healthcare staff both preferred waterless wash mitts to more traditional water-based cleansing methods [Dhoonmoon, 2020].
If a move towards the removal of patient sinks and the adoption of water-free patient washing becomes part of hospital routine, wash mitts could play a key role.
References
Bischoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP. Handwashing compliance by health care workers: The impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med. 2000 Apr 10;160(7):1017-21.
Dhoonmoon L, Dyer M. Improving leg ulcer care in the community. Journal of Community Nursing, vol. 34, no. 6, Dec. 2020, pp. 40+
Guest JF, Keating T, Gould D, et al Modelling the annual NHS costs and outcomes attributable to healthcare-associated infections in England BMJ Open 2020;10: e033367. doi: 10.1136/bmjopen-2019-033367
Haque M, Sartelli M, McKimm J, Abu Bakar M. Health care-associated infections – an overview. Infect Drug Resist. 2018; 11:2321-2333.
Hopman J, Tostmann A, Wertheim H, et al. Reduced rate of intensive care unit acquired gram-negative bacilli after removal of sinks and introduction of ‘water-free’ patient care. Antimicrob Resist Infect Control. 2017; 6:59. Published 2017 Jun 10.
Johnson D, Lineweaver L, Maze LM. Patients’ bath basins as potential sources of infection: a multicenter sampling study. Am J Crit Care. 2009 Jan;18(1):31-8, 41; discussion 39-40
Marchaim D, Taylor AR, Hayakawa K, Bheemreddy S, Sunkara B, Moshos J, Chopra T, Abreu-Lanfranco O, Martin ET, Pogue JM, Lephart PR, Panda S, Dhar S, Kaye KS. Hospital bath basins are frequently contaminated with multidrug-resistant human pathogens. Am J Infect Control. 2012 Aug;40(6):562-4.
National Institute for Health and Care Excellence (NICE). Healthcare associated infections: prevention and control in primary and community care, Clinical guideline [CG139], 2017. https://www.nice.org.uk/guidance/cg139
Schoonhoven L, van Gaal BG, Teerenstra S, Adang E, van der Vleuten C, van Achterberg T. Cost-consequence analysis of “washing without water” for nursing home residents: a cluster randomized trial. Int J Nurs Stud. 2015;52(1):112-120.
Teres D. Pseudomonas in sinks, not taps. Lancet. 1973 May 5;1(7810):1001. doi: 10.1016/s0140-6736(73)91642-5.
