Bed bathing in adult critical care patients

INTRODUCTION

Intensive care units (ICUs) play a crucial role in delivering critical care to patients facing potentially life-threatening conditions, providing continuous treatment and monitoring to sustain vital bodily functions.(1) Among nursing professionals, the quality of care administered plays a pivotal role in the recovery and well-being of critically ill patients.(2) However, the limited autonomy for personal care in ICUs often leaves patients feeling helpless when it comes to meeting their basic needs.(3)

One of the interventions aimed at addressing these fundamental needs is bed bathing or in-bed hygiene of the patient. This intervention not only seeks to offer comfort and well-being but also serves as a preventive measure against infections. Bathing is recognized as a significant practice because it offers a holistic assessment of the patient and their environment, taking into account various factors such as dependency, neurological stability, mobility, skin condition, and pain experiences, among others. Furthermore, bathing also aims to safeguard the patient from risks and threats during healthcare assistance.

Critically ill patients, however, are exposed to various risks, including skin colonization and infections stemming from comorbidities, immunodeficiency, antibiotic administration, and impairments in skin integrity associated with invasive medical devices.(4,5) In order to optimize hygiene, comfort, and healthcare outcomes, profoundly ill patients frequently undergo daily in-bed bathing.

Despite the significance of patient hygiene within the field of nursing, the practice of bed bathing has been a topic of contention. Certain studies have documented adverse events linked to this intervention, including instances of intracranial hypertension and cardiac arrest.(5) This apprehension has prompted inquiries into the suitability of this procedure for critically ill patients, emphasizing the necessity for specialized nursing personnel equipped with comprehensive expertise and a solid foundation in bed bathing care to reduce morbidity and mortality rates among critically ill patients.

Extended hospital stays in ICUs and critical care units can lead to detrimental consequences, encompassing muscle weakness, pressure ulcers, and sleep disturbances, ultimately yielding an unfavorable prognosis throughout their hospitalization.(6) In this context, bath therapy emerges as a supplementary intervention capable of mitigating some of these challenges and augmenting the quality of care delivered by nursing personnel.

The primary aim of this review article is to assess and consolidate existing research, comparing the efficacy of bed bathing to conventional hygiene care in adult patients facing critical illness. Consequently, we present the following query: "What is the relative effectiveness of bed bathing in comparison to conventional hygiene care among critically ill adult patients, according to published research?" Employing a systematic review approach (adhering to the PRISMA methodology)(7), we aspire to offer a contemporary outlook on the effectiveness and advantages of bed bathing. Our objective is to inform clinical decision-making and advocate for the implementation of optimal hygiene practices for critically ill patients.

Hence, this article seeks to make a substantial contribution to the progression of knowledge within the field of critical care, carrying direct implications for enhancing the care and overall well-being of critically ill patients. Through the provision of an extensive perspective on existing evidence, we anticipate that this article will serve as a valuable resource for healthcare professionals in the process of clinical decision-making. Additionally, it is expected to inspire further research initiatives and the adoption of innovative approaches in the care of critically ill patients.

METHODS

A comprehensive literature review was conducted utilizing the Scopus and Scielo databases, utilizing the DeCS-MeSH descriptors in their English form: "baths" and "critical care". These descriptors were combined using the boolean operator "and", which showed 60 scientific articles during the search across both databases. The inclusion criteria encompassed studies directly pertinent to the central topic, addressing care and procedures related to bed bathing for patients in critical condition who were incapable of performing this task independently. Moreover, only publications in English and Spanish from the years 2018 to 2023 were considered, and that they were accessible either freely or through a subscription. Conversely, duplicate articles, those focusing on pediatric and neonatal care, those related to non-critical care, those lacking relevance to the research topic, and those inaccessible were excluded. Consequently, a total of 22 scientific articles were acquired after applying the review criteria (refer to Figure 1).

The main objective of this article is to evaluate and consolidate the published evidence comparing bed bathing with conventional hygiene care in critically ill adult patients. The review was conducted in accordance with the PRISMA methodology.(8)

RESULTS AND DISCUSSION

Figure 1 illustrates the workflow conducted in accordance with the proposed methodology.

In Table 1 (Annex), we present the main findings from the included articles for their respective review and analysis. The table comprises information about the author, country of origin, year of publication, study type, research sample, and the main outcomes.

The current review has examined 22 studies that compare the efficacy of bed bathing with standard care for the hygiene of adult patients in critical condition.

In terms of the efficacy of Chlorhexidine Gluconate (CHG) bathing, several studies underscore its effectiveness in reducing bacterial colonization, respiratory infections, and the occurrence of bloodstream infections in critical care patients.(11,12,15,16,21,22,23) Some studies also note that achieving compliance and adherence to CHG bathing can pose challenges for certain patients and healthcare professionals.(18,24,27) Addressing this challenge is vital to ensure the intervention's effectiveness, as research indicates that CHG bathing can be as effective as, or even more effective than conventional care in preventing infections in critical patients.(3,11,16,20,21) However, Bui et al. reported no significant differences in the incidence of Clostridium difficile infection between the two approaches.(24)

Similarly, the concentration of Chlorhexidine Gluconate (CHG) and the bathing method's application technique are highlighted as crucial factors for achieving greater effectiveness in reducing bacterial colonization.(24,27) Concerning patient preferences and comfort, it's worth noting that CHG disposable wipe baths were favored by nursing staff due to their convenience and efficiency.(5) Nevertheless, it is acknowledged that individual patient preferences may vary, and it's essential to consider their specific needs. Consequently, there is an emphasis on the necessity for further research to obtain more robust evidence, establish the optimal bathing method, and determine the suitable frequency and duration of CHG treatment.(13,27)

Conversely, a comparative study contrasting traditional bed baths with dry bed baths, as reported by Toledo et al.(12) did not reveal significant differences in median tympanic temperatures between the two approaches. Nonetheless, a noteworthy reduction in axillary temperature was observed following the completion of the baths, with a 0,2ºC variance noted between the traditional and dry bath methods. However, the dry bed bath was deemed more efficient and less invasive for the patients when compared to the traditional method and it was also favored by nursing staff due to its perceived comfort and time-saving advantages. Regarding temperature management, one study demonstrated the effectiveness of a warm sponge bath as an intervention for fever reduction in ICU patients.(11)

Additional factors, such as the bacterial contamination of nursing uniforms, were examined in a meta-analysis, which revealed that bed baths were linked to a heightened probability of contamination with pathogenic bacteria.(25)

The research conducted by Jacq et al. concluded that the inclusion of music during bed baths for mechanically ventilated patients led to a notable reduction in both the intensity and duration of pain experienced by these patients. The article posits that music could serve as a beneficial means of pain relief during bed baths. Nevertheless, additional studies are required to corroborate these findings.(23)

In terms of patients' perception and compliance with the use of Chlorhexidine Gluconate (CHG) soap during bed baths, one study revealed that some patients declined to use CHG due to a limited perception of susceptibility to infections and a lack of awareness regarding the advantages of CHG treatment. However, it was noted that patient education regarding the benefits of CHG bathing could eliminate this refusal.(21)

Certain studies acknowledge risks associated with CHG bathing, including the development of antimicrobial resistance and skin irritation. Nevertheless, the overall benefits of CHG bathing persist and outweigh these drawbacks.(10,23)

CONCLUSIONS

The analyzed studies emphasize the efficacy of Chlorhexidine Gluconate (CHG) bathing in mitigating bacterial colonization, respiratory infections, and the incidence of bloodstream infections among critical patients. These findings suggest that the incorporation of CHG in bed bathing protocols may constitute a valuable intervention for enhancing clinical outcomes within this population.

Conversely, certain studies highlight that achieving compliance and adherence to CHG bathing can present challenges for both patients and healthcare professionals. Addressing this concern is of paramount importance to guarantee the efficacy of the intervention and to foster the correct implementation of CHG bathing as an integral component of hygiene protocols in intensive care units.

Finally, despite the favorable outcomes regarding the efficacy of Chlorhexidine Gluconate (CHG) bathing, further research is imperative to acquire more robust evidence and establish precise guidelines. Conducting additional studies with larger sample sizes and providing comprehensive insights into the methods of CHG application are essential steps toward achieving heightened effectiveness in the reduction of bacterial colonization. Furthermore, there is a pressing need to define the optimal bathing protocol and ascertain the suitable frequency and duration of CHG treatment to maximize its advantages for critically ill patients.

References

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