Cost-consequence analysis of “washing without water” for nursing home residents: A cluster randomized trial☆
Introduction
Bathing serves body hygiene and skin integrity, which in turn is vital to the prevention of disease (Bulechek et al., 2013). Bathing assistance is a major task in nursing and the quality and efficiency of bathing can have a large impact on health and health care costs. Yet there are no guidelines for preserving skin integrity with optimal bathing regimens.
Traditional bed baths have been the standard in bathing of bedridden patients for a long time. Their relevance for body hygiene has gone without debate and they are acceptable for patients and care professionals. Yet, use of soap in combination with water and towel drying has been reported to raise skin pH, remove natural skin oil, lead to skin dryness and decrease resistance to microbial invasion (Gray et al., 2012, Grunewald et al., 1995, Korting and Braun-Falco, 1996). Furthermore, bed baths have been reported to be stressful and leading to resistance and agitation in patients, and as being labor-intensive and physically heavy for nurses’ backs and shoulders (De Bree, 2007, Sloane et al., 2004, Zweerts, 2004).
In the past decade, bed baths with disposable wash gloves or washcloths were increasingly introduced as an alternative for the traditional bed bath. These materials can be used with all patients who need bathing assistance, especially when taking a shower or sitting in a bath tub is not possible. Several pros and cons of disposable wash gloves are mentioned. On the positive side, disposable wash products are –most often – made of a mix of soft fibers and contain ingredients such as skin friendly cleaning and caring lotions that could optimize hygiene and skin integrity (Gray et al., 2012). Bed baths with disposable wash gloves supposedly cost less than traditional bed baths, increase patient satisfaction and improve professional ergonomic aspects (De Bree, 2007, Enzlin, 2001, Zweerts, 2004). On the negative, none of these claims can be related to evidence from well-performed studies. Also, counter opinions critique bed baths with disposable wash gloves as being impersonal, coming with less subjective cleanliness for patients and as being promoted for reasons of cost saving only (Jansen, 2008, Zweerts, 2004).
Despite the lack of evidence and the controversy surrounding bed baths with disposable wash gloves, they are rapidly being implemented in healthcare (Vilans, 2009).
Therefore, the current study aims to compare the traditional bed bath with a bed bath with prepackaged disposable wash gloves on effects on skin integrity, resistance during bed baths and costs. We also evaluated satisfaction in residents and nurses in the experimental group.
Section snippets
Study design
A cluster randomized trial (WASHING WITHOUT WATER) was conducted between April 2011 and November 2012. Randomization was performed prior to baseline data collection and at the level of nursing home wards (Altman et al., 2001, Campbell et al., 2004). Residents within the same ward were considered to be a cluster (Fig. 1). To ensure that all bed baths were performed according to randomization, we removed the washbowls from the rooms of the residents who were included and stocked their rooms with
Skin integrity
The primary outcome for this study was prevalence of skin damage, defined as clinical symptoms of intertrigo, (contact) dermatitis, or candidiasis (Fredriksson and Pettersson, 1978, Gray et al., 2007, Kennedy and Lutz, 1996, NVDVV et al., 2004).
We distinguished two levels of severity of skin damage.
Any skin abnormalities/lesions were considered present when at least one of the following symptoms were observed: bright red discoloration; erythema; white, green or yellow discoloration of the
Data collection
All data were collected by research nurses who were trained in skin assessment and not involved in care delivery.
Baseline characteristics of the resident, that is age, gender, BMI, cognitive state, and skin status at study entry, were collected at the start of the study.
Statistical analyses
The effect of the two bathing regimens on any skin abnormalities/lesions and significant skin lesions was evaluated on an intention to treat basis using a 3-level logistic model for repeated measurements for the effect of group (experimental vs control) on prevalence of skin damage in time. Random effects for wards were included to account for clustering of residents within wards and random effects for residents were included to account for repeated measurements. Time trends and difference in
Cost analysis
To assess costs in both groups, we observed relevant volumes of care (time and materials) prospectively. In the cost analysis we used real cost prices for the time of nurses and the use of materials for the bed baths in both the experimental group (disposable wash gloves, use of the microwave) and the control group (soap, wash gloves, towels, warm water) (Hakkaart-van Roijen et al., 2010). We used real cost prices for skin and wound care products used. Cost analysis was performed at resident
Ethical considerations
This study was carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki, 2013) for experiments involving humans.
The Medical Research Ethics Committee (MREC) of district Arnhem-Nijmegen assessed and approved of the study (2010/262; ABR nr NL32671.091.11).
Written informed consent was obtained from residents or their legal representatives.
Resident characteristics
We included 500 residents in the study, 290 in the experimental group and 210 in the control group. The mean age of residents was 82.4 years (sd 8.3), and 71% (n = 355) were female.
Almost two-thirds (61.6%) of the residents were mentally incapable due to dementia (Table 2). No Suspected Unexpected Serious Adverse Reactions occurred during the trial.
Any skin abnormalities/lesions
Prevalence of any skin abnormality/lesion was observed in residents at seven points in time (Table 3). There is a slight decrease in any skin
Residents
Ninety-eight of the 290 residents in the experimental group resided on a ward for somatic care. Fifty-five (56%) of these residents completed the questionnaire and gave washing without water a grade of 7.1 out of 10 (sd 2.0). Residents indicated washing without water was effective in cleaning the skin (94% sufficient or good), and they felt refreshed afterwards (83% sufficient or good). The scent of the product was neutral or pleasant according to 42% and 50% respectively. Fifteen percent
Discussion
This is the first randomized controlled trial into the effect of washing without water on skin integrity and costs. We showed that washing without water is a slightly more efficient intervention compared to washing with water and soap. The experimental condition does not differ from traditional bathing with respect to significant skin lesions, yet slightly protects from any skin damage. While it comes with no significant cost savings in nursing home residents, both residents and nurses are
Conclusion
Washing without water and traditional bed bathing have similar effects on significant skin lesions, yet washing without water mildly protects from any skin abnormality/lesion. As costs for preparing and performing bed baths were more or less similar for both bed baths we conclude that washing without water is favored to traditional bed bathing and generally the more efficient alternative.
Author's contributions
LS and TvA designed the study. LS, BvG and TvA participated in the acquisition, data management and analysis, drafting and preparing the manuscript for publication. EA, ST and CvdV contributed to the design of the study, data analysis and preparing the manuscript for publication. All authors approved the final version of the manuscript.
Acknowledgments
We thank ABENA in the Netherlands for providing the wash gloves (Verzorgend Wassen Premium) for the experimental nursing home wards during this study. ABENA did not have any role in the selection of the nursing homes, the collection, analysis and interpretation of the data, the writing of the report, or the decision to submit.
Conflict of interest: None declared.
Funding: The Netherlands Organization for Health Research and Development (ZonMw) funded and approved the design of this study [ID:
References (24)
- et al.
A critical review of the inter-relationship between skin vulnerability and urinary incontinence and related nursing intervention
Int. J. Nurs. Stud.
(2005) - et al.
The effect of detergents on skin pH and its consequences
Clin. Dermatol.
(1996) - et al.
The revised CONSORT statement for reporting randomized trials: explanation and elaboration
Ann. Intern. Med.
(2001) - et al.
CONSORT statement: extension to cluster randomised trials
Br. Med. J.
(2004) Person centered washing with disposables
Bijzijn
(2007)- Declaration of Helsinki, 2013. http://www.wma.net/en/30publications/10policies/b3/ (accessed...
Washing without water is comfortable,hygienic and saves times: the end of the washbowl
Verpleegkunde Nieuws
(2001)- et al.
Severe psoriasis – oral therapy with a new retinoid
Dermatologica
(1978) - et al.
Incontinence-associated dermatitis: a consensus
J. Wound. Ostomy Continence Nurs.
(2007)
Incontinence-associated dermatitis: a comprehensive review and update
J. Wound. Ostomy Continence Nurs.
Damage to the skin by repetitive washing
Contact Dermatitis
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Trial registration: ClinicalTrials.gov ID [NCT01187732].
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Shared first authors: these authors contributed equally to this work.