A new paper by Hopman and colleagues (Andreas is also another author but is being modest) has evaluated the effect of removing sinks from the ICU. The trigger for this intervention was an outbreak caused by an ESBL-Enterobacter that could be related to contaminated sinks. The study looked at what happens if you remove all water sources from the ICU, and all water-related activities were migrated to a tap water-free solution. This meant wipes were used for staff hands if soiled (followed by alcohol), wipes and shampoo caps were used for patient hygiene and bottled water for medications, drinks and oral hygiene. Despite already low colonisation rates due to the use of Selective Digestive Decontamination (SDD), the study reported a significant 18% reduction (P=0.02) in colonisation with Gram-negatives which was related to length of stay, with the biggest reduction in patients with a stay in over 14 days. I would have been very interested to see what the staff opinion of this intervention was. Would staff accept the removal of the sinks and what would they think about it? In the UK there has always been a perceived wisdom that hand hygiene with soap and water is the gold standard and I wonder how this would be received by staff. I would probably talk extensively with the staff to see how they feel about such an intervention prior to any potential implementation as I know from personal experience that many nurses still feel that patients should be washed in soap and water due to concerns that wipes would not be effective and would not affect residual bacteria on the skin (not true, as studies have shown).

Given other issues of what’s going on in a sink in terms of genetic transfer of resistance genes and problems with Pseudomonas, removing sinks may be a consideration for organisations facing major renovations and with residual biofilm issues. I’d now like to see the cost-effectiveness study as I could definitely see a perceived cost issue with the use of wipes and bottled water. Whether this could be offset by savings in terms of infection and other costs would be good to know.