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Abstract |
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• Objective To compare the traditional basin bed bath with a prepackaged disposable bed bath in terms of 4 outcomes: time and quality of bath, microbial counts on the skin, nurses’ satisfaction, and costs.
• Methods Forty patients in surgical, medical, or cardiothoracic intensive care units received both types of bath on different days. Baths were observed, timed, and scored for quality. Cultures of the periumbilicus and groin were obtained before and after each bath. At the end of the study, nurses were interviewed about their preferences.
• Results Neither total quality scores nor microbial counts differed significantly between the 2 bath types. Significantly fewer products (P < .001) and less time were used, cost was lower, and nurses’ ratings were significantly better with the disposable bath.
• Conclusion The disposable bath is a desirable form of bathing for patients who are unable to bathe themselves in critical care and long-term care settings, and it may even be preferable to the traditional basin bath.
| Mechanical friction of bathing loosens skin cells that contain bacteria, increasing microbial counts.
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Methods |
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A sample size of 40 patients was sought in order to find a difference in microbial counts between the 2 types of baths of 0.5 log or greater with a power of 80% and an alpha less than .05.4
Procedure
The study was approved by the institutional review board, and written information on the study was provided to each patient and nurse in the study. Each observed nurse signed a written consent form. All data on patients were "de-identified," so the requirement for written consent from patients was waived by the institutional review board. Each day, for each of the 3 study units, either the traditional basin or the disposable bath was used; that is, all patients on day 1 received the traditional bath, on day 2 the disposable bath, and so on. Hence, all patients in the participating units received each type of bath on alternating days. Each participating patient was included in the study for 2 baths, 1 bath with each product. In a series of informal meetings with the study team, nursing staff from each study unit received an orientation to the study protocol. The disposable product (Comfort Bath, Sage Products Inc, Cary, Ill) consisted of a package containing 8 individual washcloths impregnated with an emollient-based skin cleanser that was heated in a microwave and used for 1 patient. The disposable system was used according to the manufacturer’s directions with 1 cloth used for each specific body part (eg, arms, back, chest, legs, groin). The units had no written procedure for the traditional bath, so staff members were instructed to perform the bath in their usual manner and to use the products provided in the units.
Time and Quality of Bath
Each study bath was observed and timed with a stopwatch by 1 of 2 trained research assistants using a bath observation tool. Data collected included the patient’s age, diagnosis, surgical procedure, time in hospital, and time receiving antibiotics before sampling. Bath data included number of washcloths and pairs of gloves used, number of bathers, names of products used, duration of procedure, and various aspects of quality. A score of 1 point was given for each of the 8 practices listed in Table 1
, so that each bath was given a score with a possible range of 0 to 8. The parameter "avoids recontamination" was defined as not reusing a cloth that has been used in groin area, perineum, or toes. Using the same cloth washcloth for the whole upper body or both legs was not considered recontamination. Appropriate waste disposal was defined as direct disposal of used materials in an appropriate receptacle. Dropping used materials on the floor or the bed, for example, was considered inappropriate waste disposal.
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Microbiological Sampling
For both methods of bathing, immediately before and after the bath, the research assistants obtained specimens from the skin of each patient for microbiological cultures. Two sites, one side of the groin and the area around the umbilicus, were sampled. These sites represent a dry, open skin surface with lower microbial counts (periumbilicus) and a moist surface with generally higher counts (groin).
In order to obtain the specimen, a sterile cotton swab was moistened with sterile buffered transport medium (0.075 M phosphate buffer, pH 7.9, 0.1% polysorbate 80), and a quarter-sized area was swabbed in a circular motion with approximately the pressure applied when using a pencil eraser. Each swab was placed in a vial containing 2.0 mL of the transport media and was transported to the clinical microbiology laboratory of the study institution. Samples were diluted 10-fold in the transport medium, up to 10–3, and were spread plated onto 5% sheep blood agar (BBL, Cockeysville, Md) as a general nutrient medium and MacConkey agar (BBL) for selective isolation of gram-negative bacteria.5 Total counts were obtained from the blood agar plate, and counts of gram-negative rods were made from the MacConkey plate.
Nurses’ Satisfaction
Because most patients were unconscious during one or both baths, information about patients’ satisfaction could not be obtained. At the end of the entire study, however, nurses working in the 3 study units were interviewed by the research assistants and were asked to respond to 6 questions about the nurses’ preferences between the baths (ease of use, time required, patients’ comfort, supplies required, which system the nurses thought cleaned and moisturized skin better, and overall preference). Respondents were also asked to estimate the time required to gather supplies to complete both types of baths.
Costs
The cost of the 2 bath procedures was estimated by adding the direct product charges and the cost of the nurses’ time. For the disposable product, the charge per bath was obtained from the nurse managers who purchased the product. For the traditional procedure, the costs of the bath basin and bar soap ($0.45 per basin, $0.05 per bar of soap) were included, but the costs of the other products were more difficult to calculate because the product use varied considerably between patients. Hence, we calculated a "mean" product charge as follows: the cost per container of 2 products used as adjuncts to the bathing (protective ointment and antibacterial skin cleanser) was divided by the proportion of patients for whom the products were used to obtain a mean cost per patient. The cost of nurses’ time was calculated as follows: the mean salary and fringe benefits across all 3 study units was calculated per second of a nurse’s time. This value was multiplied by the mean duration (in seconds) of the traditional or disposable bath.
Data on laundry costs were obtained from the director of laundry at the study institution. Costs of the laundry were $0.36/lb (0.45 kg). The mean wet weight for washcloths was 16 cloths per pound (0.45 kg), or $0.02 per cloth. The damp weight for each towel was 0.5 lb (0.23 kg). Calculated costs were based on the mean number of washcloths used and 1 towel per traditional bath multiplied by the cost per cloth or towel. The mean salary and fringe benefits for critical care nurses were obtained from the nurse managers. The total for annual salary and benefits was divided by the mean number of hours worked during a year (a mean of 48 work weeks at 36 hours per week = 1728 hours) to obtain an hourly rate and then divided by 360 to get a salary cost per second. The labor cost for each bath was calculated by multiplying the salary per second by the mean number of seconds for each type of bath by the mean number of staff members giving the traditional and disposable baths.
Data Analysis
The 
2 test and the Fisher exact test were used to compare quality indicators between traditional and disposable baths, and the paired t test was used to compare mean bath times. For each sample, the total number of colony-forming units was converted to a log10 count to normalize the data, and paired t tests were used to compare log counts before and after each type of bath and between the traditional and disposable baths. Nurses’ evaluation scores were tested for differences between the traditional and disposable bath by using the nonparametric Wilcoxon signed rank test. Analysis of variance was used to compare mean bathing time (in seconds) for the traditional bath between patients whose bath water was changed and patients whose bath water was not changed. Since not all observations were made of every bath, denominators vary (eg, n = 43 in Table 1
and n = 44 for products used in cost analysis).
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Results |
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Time and Quality of Bath
Total quality scores did not differ significantly between the traditional (mean score, 5.51) and disposable (mean score, 5.88) baths (P = .25). Mean bath times were 14.4 minutes for traditional baths and 12.8 minutes for disposable baths (P = .08), and mean number of bathing products used was 2.2 for traditional baths and 0.53 for disposable baths (P < .001; Table 1). In most instances (30/43, 69.8%) of the traditional bath, bath water was not changed. The mean time required for bathing, however, did not differ significantly for patients whose bath water was changed and patients whose bath water was not changed (analysis of variance, P = .11).
Skin Microbiology
Total counts from the umbilicus ranged from 1.30 to 6.92 log10 colony-forming units before the bath and 1.30 to 8.20 after the bath. Counts for the groin ranged from 1.30 to 8.43 before the bath and 1.78 to 8.69 after the bath. At the umbilical site, gram-negative bacteria were present before the bath in 18 (45%) of 40 patients and after the bath in 20 (50%) of 40 patients (P = .65 comparing prevalence before and after the bath); at the groin site in 28 (70%) of 40 patients before the bath and 35 (87.5%) of 40 patients after the bath (P = .06).
The total bacterial counts did not differ significantly between the 2 bath types at either the periumbilical or groin site or with the sequence of bathing (ie, whether traditional or disposable bath was first, P = .29). The number of pairs of umbilical samples that were positive for gram-negative bacteria before and after the traditional (n = 2 pairs) or disposable (n = 4 pairs) baths was not sufficient for statistical analysis. For the traditional bath, gram-negative bacterial counts in the groin area were significantly reduced after the bath (P = .04), and for the disposable bath, total counts in the umbilical area were significantly increased after the bath (P = .04). No other differences in counts before or after the bath were significant for either type of bath (Table 2).
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| Differences in skin microbiology for patients bathed with the 2 different methods were not clinically significant.
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Nurses’ Satisfaction
Forty nurses were interviewed about their preferences for bathing patients. They expressed a significant overall preference for the disposable bath and rated it preferable for all factors assessed but 1: they expressed no significant preference about which bath type was more likely to clean and moisturize the skin (Table 3). Estimated time for gathering bath supplies was significantly shorter with the disposable bath (4.05 vs 1.90 minutes, Wilcoxon signed ranks test, P<.001).
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| Nurses preferred the disposable bath.
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Costs
In 40.9% (18/44) of the traditional baths and 9.1% (4/44) of the disposable baths, a protective ointment was used. An antibacterial skin cleanser was used in 4.5% (2/44) of traditional baths and 9.1% (4/44) of disposable baths. Laundry costs were $0.06 per washcloth and $0.18 per towel, and the mean number of cloths used per traditional bath was 3.98. The mean numbers of bathers were 1.55 and 1.44, and the mean bath duration was 14.4 minutes (864 seconds) for the traditional bath and 12.8 minutes (768 seconds) for the disposable bath. The mean cost for nurses’ salary was $0.02 per second. On the basis of these numbers, the mean costs for the 2 types of baths are summarized in Table 4. Although the costs of the bathing products used were slightly higher for the disposable bath ($2.79 vs $2.59), the overall cost ($18.15 vs $19.87) was less for the disposable bath because of the savings in nurses’ time and salary.
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| When nurses’ time was considered, costs for traditional and disposable baths were comparable.
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Discussion |
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Others9 have reported significantly less agitated behavior with a disposable bath than with a tub bath in elderly patients, an issue that is also relevant in critical care settings where patients often have reduced mentation, but we did not assess agitation. Our study was designed to examine only immediate aspects of the bathing procedure because patients generally have short stays in the ICU. In several other studies10–12 in long-term care units, however, disposable baths also were associated with reduced skin dryness and skin tears.
Skin Microbiology
Although the general assumption is that bathing reduces microbial counts on the skin, such a reduction did not occur in a number of studies. The mechanical friction that accompanies bathing loosens skin squamous cells that contain viable bacteria13–15; hence, microbial counts of the skin are often increased after bathing, as noted in our study. Not surprisingly, basin bath water becomes heavily contaminated with skin flora during bathing,2 and if the water is not changed, it could serve as a reservoir for recontaminating the patient’s skin or moving flora from one area of the body to another. Thus, the effectiveness of a basin bath in terms of removal of potentially harmful microorganisms depends on the technique used by the bather. In our study, the 2 types of baths were quite similar in terms of removal of bacteria with 2 exceptions: the total bacteria counts for the umbilical area after the disposable bath were significantly greater than the counts before the bath, and the counts of gram-negative bacteria in the groin were significantly reduced after the traditional bath but not after the disposable bath. In both situations, however, the absolute difference in counts was less than half a log10 and therefore is unlikely to be clinically significant. In addition, the disposable bath offered fewer opportunities for recontamination of the skin.
Nurses’ Satisfaction
Several investigators10,16 have assessed satisfaction with disposable bath products among patients and nurses and have reported consistently positive responses. Although we could not assess patients’ satisfaction in this study, nurses expressed a clear and significant preference for the disposable bath.
Costs
Although the direct charge for each disposable bath was slightly higher than that of the traditional bath, one apparent advantage of the disposable bath was that nurses used fewer other products. When nurses’ time was considered, the costs of the 2 procedures were quite comparable. Others16 also reported savings with the disposable bath, primarily associated with reduced labor costs. This calculation is based on the assumption, however, that the disposable bath packets are fully used. If only 1 or 2 cloths from the packet were used to clean parts of the body between baths, the disposable bath would not be as cost-effective.
A limitation of the study is that the costs of water consumption, heating, and sewage were not included because site-specific data were not readily available. However, the cost of heating the water can be 21% to 32% of a hospital’s total energy consumption, depending on climate zone.17,18 Further, the disposable bath is a safe alternative if water service is interrupted (water-main breaks, construction/remodeling) or during severe water shortage (drought, energy brownouts, pressure unavailable). In the study institution, washcloths are replaced after an average of every 1.5 uses, and this factor was not included in the costs either. If these costs were included, the cost differential in favor of the disposable bath would be even greater.
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Conclusions |
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| The disposable bath is a desirable form for bathing critically ill patients.
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ACKNOWLEDGMENTS |
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REFERENCES |
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
