With a move that flies contrary to conventional wisdom, NHS England staff have pulled the plug on handwashing as part of the fight against superbugs, reports The Telegraph.
Intensive care unit consultant Dr Karim Fouad Alber said he had a few questions when he and his colleagues were asked by his hospital to start washing their hands less.
The first one was pretty reasonable: whether not handwashing was going to be clean enough for the sterile procedures they were doing, he said. Understandably, he was tentative.
The guidance contradicts everything he had ever been trained to do, even though the replacement advice was to use repeated hand sanitiser instead of washing. “Initially, I was slightly slow to take it up – I used to wash my hands as I normally did,” he admitted. “Until the sinks were taped over.”
Taped over, and then removed.
To be exact, 23 sinks have been removed in his ICU at Slough’s Wexham Park Hospital, outside London, and 108 sinks have been removed from across the hospital as a whole over the past year. They have been taken from nine wards, including two elderly care wards and the Eden Day Unit oncology ward.
Eventually, it is possible that up to 80% of the hospital’s sinks will be removed across the whole site, which is part of the Frimley Health NHS Foundation Trust.
In the end, the only ones likely to be left will be those in toilet facilities. In its sister hospital, Frimley Park, work is even starting to remove sinks in the neonatal ward.
The move was spearheaded by Dr Manjula Meda, the consultant clinical microbiologist.
In a first for a UK hospital, after the introduction of similar practices in The Netherlands and Germany, the decision is actually part of a landmark “water-safe” initiative designed to protect patients against antimicrobial-resistant superbugs – bugs that are increasingly resistant to antibiotics.
Sinks, drains, waste pipes and, by extension, handwashing, when it is done badly – which, apparently, is 95% of the time – are the key harbourers and spreaders of this potentially fatal bacteria.
Few of us wash for the 20 seconds required to be effective.
Yet given the barrage of Covid hand-washing messaging, it is no wonder that questions are being asked.
“The notion of washing your hands being a bad thing was completely unheard of,” said Alber. Now, the hospital’s guidance is that hands should only be washed by staff, visitors and patients when they are visibly soiled, which includes after toilet use, or if staff have been caring for patients with vomiting, diarrhoea or gastrointestinal infection.
Instead, hand sanitiser should be used, copiously – for staff that means between every patient interaction. Regularly, staff say that this means soap and water are used fewer than a handful of times a day.
“Handwashing is what we are taught,” agreed ICU Matron Ruramai Chidzambwa. “
You would never guess a sink used to sit at the end of each ICU bed here. Waste bins, sanitiser and glove dispensers now take their place. Even the side kitchen is now sinkless, depending instead on a dishwasher and a uniquely-designed drainless and basinless “Frimley faucet”, as it is nicknamed, which protrudes from the wall, hanging in space.
There is a second tap in the ward – and not a sink in sight. Before the removals, rehearsal scenarios had to be played out. “We had to take every procedure where we used water and imagine not using water,” said Chidzambwa.
It has meant either using wipes to wash patients or rationed water collected from the “Frimley faucet”, which only dispenses one litre at a time. It has also meant brushing patients’ teeth without water, using gel and the same sort of suction device you would experience at the dentist’s.
Though she’s on board with the fewer-sinks approach, “it’s just quite challenging to keep walking around”, admitted staff nurse Margie Yambao, describing frequent trips to the “Frimley faucet”, which is positioned away from the beds near the door.
She now has to dispose of bowls safely and collect wipes from the dispenser where they are warmed (they would be too cold if kept by a patient’s bedside).
But Meda uses convincing language to explain the overhaul. You get the impression that she’s become accustomed to persuading doubters.
“Water and wastewater are reservoirs of bacteria… It’s an Amazon rainforest in drain systems,” she said. “We know that when people wash hands or go to the toilet, bugs are going… into drain systems. But until now, we’ve never appreciated the fact that they travel from drains to patients.”
A combination of warm temperature, foodstuffs thrown down plugholes (that quite literally feed the bugs) and the 90% of antibiotics that remain unchanged in patients’ urine (which increases the bugs’ resistance), make sinks potentially lethal hideaways close to vulnerable immune systems.
“These bugs are using drainage systems as a super highway,” added Meda.
A sink has a splash reach of two metres. Furthermore, when solid material goes down a drain, pressure is released upwards. “So you’re getting plumes of bacteria out of drain systems all the time,” Meda added.
Antimicrobial resistant superbugs have killed an estimated 1m people worldwide every year since 1990. Most concerning is the rise in carbapenemase-producing enterobacterales (CPEs), such as E. coli, a family of bacteria which can “colonise” the gut without causing problems, but which in other parts of the body or bloodstream can cause life- threatening infections.
Because they are resistant to the majority of antibiotics, they can cause devastating outbreaks. “CPEs have become the biggest threat to modern medicine,” said Meda. “The risk of dying if you get an infection… is anywhere from between 30% to more than 50%.”
Studies estimate that between 7% and 40% of CPE acquisitions by hospitalised patients are attributable to a sink. In France, half of sink drains across 73 ICUs were found to be contaminated with multidrug-resistant organisms.
A German study showed that patients in ICUs with sinks had a 30% higher risk of hospital-acquired infections than those without.
At Wexham, the trust was prompted to take water-safe action when the number of patients found to have acquired a CPE during their stay grew. The count was small because scanning was not widespread – eight cases in 2022-23 rising to 14 in 2023-24. Though a CPE “colonisation” may not have led to infection, up to 20% of cases do, says Meda.
But it was enough.
Now, every patient is scanned on admission and discharge, and there has been a drop in those revealing hospital-acquired CPEs: currently 40 for 2025-26 compared with 80 in 2024-25. In the Eden Day Unit, where four sinks have been removed and one remains, there has been just one case since the beginning of last year, compared with nine in 2023.
All infections, including pneumonia, have decreased in ICU by around half.
It has not helped that previous schools of thought have advocated for installing sinks “in every corner” to combat infections, especially of C. difficile, which affects the colon.
But Meda explains that “studies now show C. difficile can be present in sinks as well”.
And these numerous sinks cost. Frimley estimates to keep a hospital sink “safe” through cleaning and testing costs around £1 000 a year.
In Wexham’s ICU, three sinks remain, plus the two novel taps. They’re operated by a motion sensor, and a bowl needs to be held underneath them. Nurses must deposit the dirty bowl in a new utility area with designated “dirty” and “clean” sides, placing it in a washer-disinfector for nine minutes.
There is a sink here but it has been designed so that the plug hole is away from the tap, to reduce drain splash-back. Similarly, in the shower room, the shower head has been moved far from the plughole. (A regular sink remains in the staff room, for now…)
The nurses say spillages have always been dealt with using wipes, and insist that they have got used to the new system. “Handwashing is what we are taught (but) actually defining it as hand hygiene made a difference,” said Chidzambwa.
There is hand sanitiser everywhere. If hands are washed, it must be used afterwards.
“There are a few (patients and visitors) who say they really want to wash their hands and can’t find water, but it’s education,” Chidzambwa adds. Leaflets are distributed. Patients are not told not to hand-wash – but they’ll need to find a sink first…
Meda has hopes of waterless toilets next (think aeroplane style). She believes Wexham is a “blueprint” for the NHS. But she realises that people need time: “The trust has been on a big journey.”
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Hand washing reminder gets cold shoulder