Recently, I spent 14 full days with a family member on critical care, stepdown, and acute care surgical units. During that time, not once did I see a clinician or any other hospital staff use the handwashing sink in the patient room. Instead, each person either used alcohol-based sanitizer (ABHS) and/or  donned disposable gloves.

In the critical care and stepdown rooms, the sink was located right inside the door; on the older surgical unit, it was across from the foot of the bed—both locations visible and accessible.

This got me thinking—have protocols changed, especially since COVID?  Should healthcare designers rethink the need for, or location of, a patient room handwashing sink?

History of handwashing stations

The 2001 edition of the FGI Healthcare Facility Guidelines was the first time the Facility Guidelines Institute included the requirement in new construction that a handwashing station be provided in the patient room in addition to a sink in the toilet room. The intention was that positioning a handwashing sink station near the entrance of the room would provide unobstructed access for use by healthcare personnel and others and encourage hand hygiene compliance, a top protocol for protecting patients and staff from potentially deadly germs. Subsequent research has indicated that patients preferred seeing staff wash their hands. Historically, hand washing compliance by staff between seeing patients was low at many institutions.

A year later, the Centers for Disease Control and Prevention (CDC) revised its collective hand hygiene guidelines to recognize the efficacy of ABHS products as a secondary sanitizing solution if soap and water were not available or if time saving was important. Afterwards, ABHS use proliferated at the entry to patient rooms and throughout the hospital.

During the COVID -19 pandemic, gloves were recommended when taking care of COVID-19 patients, though there was no direct evidence that the use of gloves increased protection when compared with proper hand hygiene. Hand washing or ABHS was still recommended by the CDC before and after each patient contact, either with or without gloves, and when gloves were removed.

Now it seems that many staff members have become comfortable with the added protection and are continuing to use gloves.

Unintended consequences of in-room sinks

Water coming into sinks contains bacteria that isn’t a risk to a healthy person but can be very dangerous to someone who is immune suppressed or otherwise weakened in an inpatient room.

Bacteria can proliferate in pipes as biofilms , a slimy matrix of microorganisms in which cells stick to each other and also to a surface. Biofilms are difficult to eradicate, requiring intensive disinfection at regular intervals.

This is especially an issue if the sink isn’t dedicated to handwashing alone and other bodily fluids are being dumped into them, causing infectious organisms to splash onto the counter or become aerosolized So, the question is whether a handwashing sink in such proximity to a patient is the best way to prevent hospital acquired infections or if its inadvertently causing them?

Evolving guidelines on sinks in healthcare facilities

In February 2023, The Society for Healthcare Epidemiology (SHEA) in collaboration with multiple associations published new guidelines to “highlight practical recommendations to assist acute-care hospitals in prioritization and implementation of strategies to prevent healthcare-associated infections through hand hygiene.”

In the list of essential practices, the guidelines’ focus on promoting staff’s healthy skin and nails that could become dry and cracked and lead to infection. The report emphasizes “the preferential use of ABHS in most clinical situations” because it has been shown to be superior to handwashing in preserving hand skin integrity.

The new guidelines recommend that ABHS dispensers be installed both inside and outside patient rooms and that hand moisturizer is readily available, too. Throughout the hospital, the organization suggests that certain sinks should be dedicated to handwashing alone. Additionally, medications or patient care supplies should not be kept on countertops or mobile surfaces within 3 feet of the sink.

The CDC has also stated that unless hands are visibly soiled an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. “Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands,” the organization states in its hand hygiene guidance.

Room for discussion

In general, it seems none of the expert organizations are dictating yet the removal of handwashing stations from patient rooms. Instead, they seem to suggest the best approach, if provided, is freestanding lavatories without countertops, located outside each patient room or in an entry alcove.

Anecdotally, colleagues have reported that some states, such as Pennsylvania, are now permitting variances for inpatient rooms without handwashing stations in new bed towers.

Looking ahead, the topic of whether handwashing stations should still be required in patient rooms, where they should be located, and how they should be appointed will be a worthy one for FGI to consider in its current review cycle for the 2026 publication of its Healthcare Facility Guidelines.

Sheila Cahnman, FAIA, FACHA, LEED AP, is president, JumpGarden Consulting LLC. She can be reached at