Focus: Plumbing
Sink with low/no splash zone and multiple technologies to reduce or eliminate drain and p-trap microorganisms that could just patient and staff harm

Plumbing strategies to reduce HAIs

Bacteria lurking in the plumbing pipes and fixtures can contribute to HAIs

By Greg Koll / Special to Healthcare Facilities Today

Infection control impacts every hospitals’ bottom line and remains a top priority for good reasons. According to the U.S. Centers for Disease Control (CDC), one out of 25 patients in U.S. hospitals contracts a Healthcare Acquired Infection (HAI). HAIs are a significant source of complications across the continuum of care and contribute to delayed recovery times, increased costs, and in the most serious cases, death.  

In 2012, NBC Nightly News reported that of the approximately 1.7 million American patients who acquire a HAI annually, an estimated 99,000 will die based on 2012 CDC statistics. A 2009 report on the direct medical costs of HAIs in US hospitals stated that the cost of a single HAI case could range from just under $1,000 to nearly $50,000 depending upon the type of infection — with the direct cost of HAIs to hospitals estimated at between $28 billion and $45 billion. 

As a result, healthcare organizations have invested significant time and financial resources developing strategies to reduce infection rates by introducing care protocols for inserting PICC lines and urinary catheters. In addition to patient care protocols, implementing best practice design and engineering strategies can often provide a first line of defense in protecting patients from a wide range of HAIs related to their physical environment. Technology can also be implemented in the patient environment, creating additional barriers between the patient and areas or systems that can’t be sanitized in order to reduce or eliminate exposure.

What you can’t see can hurt you

Every member of the care team is responsible for preventing infections and Environmental Service Workers are frequently on the front line as they are responsible for sanitizing the hospital room after a patient is discharged by removing all linens and disinfecting the hard surfaces that are regularly touched and easily seen by the naked eye:  floors, beds, fixtures, restroom.  However, it is the bacteria lurking in the plumbing pipes and fixtures that can contribute to HAIs. 

Hospital wastewater plumbing systems are large, complex waterworks with low-flow areas that produce stagnation and biofilm formation. The water in a hospital is designed never to freeze, with average water temperatures in the 70s – and this labyrinth of pipes provides dark moist areas that are perfect breeding grounds for bacteria.  People assume that bacteria is washed away with cleaning products.  In reality, bacteria grows in the opposite direction of water flow.  Independent lab tests, performed on hospital sites, have proven that water and bacteria frequently get caught in the sink’s plumbing trap and becomes a primordial soup, or biofilm that facilitates the growth of more bacteria out of the trap itself.  

This was confirmed by an investigation undertaken by the National Institutes of Health into where germs live in hospitals after an outbreak of antibiotic-resistant infections killed 11 patients at the Clinical Center in 2011-2012. Published in 2013 in Clinical Infectious Diseases, the study revealed that bacteria and several forms of antibiotic resistant ‘super bugs’ were living in the plumbing and scrubbed out sink drains. And an independent team found, as reported by NBC News in 2017, that the bacteria can splash back out of sink drains.

Begin by raising awareness of the issue

There are many studies documenting the antibiotic properties of different types of room finishes:  paint, flooring, carpet, handrails and have taken rigorous measures to sanitize these surfaces.  Unfortunately, many hospitals have not invested the same amount of resources testing their plumbing systems.  They may suspect there is an issue, but may not know how to address the problem.  They may also fall victim to the ‘out of sight – out of mind” response.  Healthcare Mechanical Engineering Specialists (HMES) experts can be a valuable resource in helping to educate a facility staff on how to address potential infection and bacteria posed by plumbing fixtures.

Don’t underestimate the impact of proximity 

One of the easiest solutions to implement, according to a 2013 French study published in the Journal of Hospital Infection, is measuring the “splash” radius from each sink in the patient room and making sure nothing is in close proximity.  For example, assure that a patient’s toothbrush is not in the splash zone of the restroom.  Include a ledge on a perpendicular or opposite wall and instruct patients and their family members not to place their personal belonging near the sink.  Similarly, measure the “splash” radius of the caregiver’s hand washing sink and make sure the paper tower dispenser and glove boxes are not within three feet of the sink, well out of the water’s splash zone.  Specify paper towel dispensers that are completely enclosed and dispense towels with a wave of a hand to ensure no cross contamination.  Consider installing a standalone hand washing sink rather than a sink mounted in a countertop, as the countertop is frequently used as a staging area for sterile materials.  Creating a physical separation between the sink and counter will reduce any contamination from splashing water.

If you can’t change the room configuration, consider new care protocols

Perhaps a facility leader can’t change where a sink is located, but can alter what is done around the sink.  For example, consider giving patients a new hospital-supplied toothbrush each day that can be disposed of after one use.  That will reduce any infection or contamination from the sink or toilet.  Train caregivers not to use countertops adjacent to handwashing sinks as sterile prep areas.  Encourage them to use single use carts, making sure they do not “park” them next to the handwashing sink and make sure they are sterilized after each use.   Ask your patients and their families to keep the bathroom door closed while flushing and when not being used.

Helping to prevent infection through engineering and design

With advances in modern medicine, hospitals are able to treat and cure people that are sicker than ever before, which means they are more immunosuppressed than ever so they are more susceptible to infection.  Cancer patients are particularly vulnerable to even small amounts of bacteria.  As part of experienced HMES experts’ education process with hospitals, such project team experts review the engineering systems and design of their most intensive care environments and recommend suggestions to enhance infection control and reduce potential for cross contamination.  This review includes how the nursing staff uses the different surfaces and equipment in high risk environments.  Suggestions included changing sink types and moving the patient bed away from the hand washing zone.  In another instance, HMES project team experts observed that in some patient rooms, the hand washing sinks were connected back-to-back with the wrong trap arm fittings, providing a more direct path of contamination of sinks on the opposite side of the wall.  A simple and cost-effective intervention was to offset the traps which significantly reduced cross contamination between rooms.

Investigate new technologies and fixtures

As more and more hospitals become aware of the potential for bacteria and “super bug” contamination from their plumbing systems, the industry is responding by developing new fixtures and systems that reduce or eliminate the potential of infection.  These include implementing UV lights, low-splash sinks, and exhaust in fixtures, as well as automatic injection of sanitizing agents. 

Of course, these more sophisticated fixtures’ planning, design and installation require infrastructure to support their associated strategies. Electrical and exhaust connections, along with new piping systems and other central systems, bolster the different strategies that are designed to reduce infection in the care environment. Reimagining an entire system from the ground up can drive up construction costs, but in the end reduce the overall costs of healthcare.

Not taking action can be costly

With the rise in antibiotic resistant infections, hospitals are looking at all causes and strategies to reduce infection – both caregiver-based and facility-based.  The good news: the CDC’s 2016 and 2017 National and State Healthcare-Associated Infections Progress Reports showed decreases for HAIs and facility types included in the report. Whether a hospital leader has a 20-year old building, or is considering a new replacement hospital, consider engaging an experienced “healthcare” engineering design expert to assist with developing solutions that address risk of infection and contamination from plumbing fixtures.   Implementing best practice design and engineering strategies in areas that cannot be sanitized can result in reduced exposure to infection across the entire hospital. 

Greg Koll is Senior Mechanical Engineer with Specialized Engineering Solutions.  He can be reached at

April 14, 2020

Topic Area: Infection Control

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