Authors

1. Veje, Pia RN, MSN
2. Larsen, Palle RN, MSN, PhD Candidate

Abstract

Review question/objective: The objective of this systematic review is to identify, appraise and synthesize the best available evidence on the effectiveness of bed bathing practices on skin integrity and hospital-acquired infection (HAI) among adult patients.

More specifically, the review question is:

What is the effectiveness of traditional towel bed bath practice compared to other innovate bed bath practices on maintaining skin integrity, skin barrier function and reduction of pathogen microbial counts on skin among adult patients in all settings?

Background: Bathing has long been regarded as a ritualistic pleasure, specifically since the Middle Ages; however, in recent times it has come to be most commonly used to improve an individual's personal hygiene and social acceptance.1

While the primary outcome of bathing is to maintain patient hygiene and leave patients refreshed and comfortable, there are other benefits including for both patient comfort and health outcomes.1,3 In addition to decreasing body odour and stimulating circulation, bathing assists in removing sweat, oil, dirt and micro-organisms from the skin and reducing the potential for infection. Other clinical goals which have been identified as benefits of bathing include the ability to induce comfort, relaxation, reduce pyrexia and provide an opportunity for skin integrity assessment.4

In a qualitative study of older persons' perspectives on bathing, researchers found that bathing was regarded as a means to cleanliness, related to notions of wellbeing and virtue, concerns about odour, the social expectation to bathe, as well as pleasure and relaxation.5

For both clinical and personal reasons, bathing, be it in a tub or bed, has long been regarded as a necessary and therapeutic nursing intervention. It is a basic and essential nursing task and is performed in nearly all hospital wards.

Bed bathing provides dependent patients who cannot leave their beds with an alternative way to stay clean and fresh. Traditionally and historically, wash bowls/basins, towels and soap have been well known and often used utensils. In recent times however, these items have been challenged by several innovative single-use products consisting of skin-cleansing towels/wet wipes that are warmed before and disposed of after use. The bag bath developed by Susan M. Skewes in 1994 is now well known in international nursing practices.2

The purpose of this review is to highlight the evidence for performing personal hygiene by traditional bed bath methods versus the more recent bag bath approach.

Cross-contamination

Bathing should improve patient hygiene, remove microbes and decrease the potential for infections.3 On the downside, bath basins have been cited as a reservoir for bacteria and may be a source for transmission of HAI.6-9 During bathing, mechanical friction releases skin flora into the basin and this can become a source of cross-contamination from one person to another. Studies have shown that basins are frequently contaminated with microbes and some have found that bacteria grew in up to 98% of the basins.6-8 One of the possible reasons for this could be that the washbasins are not adequately dried after use and then become contaminated with pathogen microbes and/or fungi.8,9

Nosocomial infections are a marked burden on the healthcare system and are linked to high mortality rates. It has been reported that each year, up to 10% of all patients admitted to Danish hospitals acquire nosocomial infections.10

In one systematic review, the authors concluded that there was no clear evidence that washing with chlorhexidin reduced surgical site infections when compared with other washing procedures. They recommend that focus should be on interventions where effects have been demonstrated.11

One such intervention has been reported to have many advantages including less cross-contamination.1,12 The bag bath is said to leave the patient's skin cleaner and better moisturized, thus minimizing the risk of the skin impairment. Due to the fact that only one washcloth is in contact with one body part, the practice also reduces cross infections from wash basins.1,14

Skin integrity and barrier function

Since they can harbor micro-organisms, it is necessary to remove body excess secretions, but without the cost of drying skin. Intact skin serves a vital role in maintaining the body's first line of defence against invading microbes. Dry skin is prone to cracking, which can in turn lead to an infection.12,15

Studies show that soap and water washing can have a direct impact on the epidermis by posing a number of threats to skin integrity and skin barrier function. Soap can remove the resident flora and the natural lipids, increase skin acidity, interfere with the water-holding capacity of the skin, thin the layers of the stratum corneum and decrease natural skin lubricants.12,15

A patient's skin can actually harbor more gram-negative organisms after the traditional soap and water bath than before.8,9 It has also been shown that washing with soap and water and towel drying has a disruptive effect on the skin barrier. There is also tentative evidence for skin damage increasing as frequency of bed baths increases.16

The combination of cleanser and emollient wipes used in bed bathing helps restore or improve and maintain the skin which is left feeling soft and supple.1,15 The cleansing product Bag bath can be used to reduce the dryness, flaking and scaling of skin.3,17,18

Findings of one systematic review concluded that the no rinse cleansing product Bag bath/Travel bath could be used to reduce overall dryness, flaking and scaling of skin over a period of least six months.19 It has also been shown that a disposable bath may be preferable for patients in critical care and long-term care settings.20

In a study designed to compare soap and water with no-rinse cleanser in terms of their ability to remove transient microbial flora from the skin, the investigators concluded that no-rinse cleansers could achieve a sufficiently low level of pathogenic microbes on the skin and provide an acceptable alternative to washing with soap and water.21 Both procedures in this study were free of all disinfection agents, but the authors did not discuss the potential for basins to be a reservoir for bacteria and therefore a possible source for transmission of HAI.

A major study compared the traditional and disposable bed bath in critically ill patients.20 The purpose was to compare these two practices in terms of four outcomes, including time and quality, microbial counts on skin, nurses satisfaction and costs. Although results revealed that there were no clinically significant differences in skin microbiology between the two methods, the authors concluded that because it offered fewer opportunities for recontamination on the skin, the disposable bath may be preferable to the traditional bed bath.

Conversely, a case study found that an increased urinary tract infection rate was reported after prepacked bath towel products were removed and traditional bed baths using water and soap reinstated. This HAI infection increased from 50% to over 95% during their mandatory state reporting of infections.22

An initial search of several databases including the PROSPERO register, CINAHL, JBI Database of Systematic Reviews and Implementation Reports, Pubmed and Cochrane Database of Systematic Reviews, showed that no systematic review on this topic exists or is currently underway.