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


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.




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.


Article Content

Inclusion criteria

Types of participants

This review will consider studies that include patients over the age of 18 with no upper age limit, regardless of ethnicity and gender, in all hospital wards. Patients with skin allergies, visible damage to their skin, a chronic skin condition (e.g., eczema, or dermatitis), sensitive skin, or pre-existing medical conditions known to affect the dermal vasculature (e.g., diabetes) will be excluded.


Types of intervention(s)

This review will consider studies that evaluate bed bath practices performed by healthcare staff, in particular nurses.




The intervention of interest is innovate bed bath practices, including all bag bath interventions, not limited to any specific type or brand. For the purpose of this systematic review, bag bath interventions include bathing patients with pre-packaged disposal washcloths by use of a different cloth to wash each part of the patient's body. The washcloths typically comprise rayon/polyester cloth pre-moistened with an evaporating no-rinse cleanser and emollients.4,7




The comparator is the traditional bed bath (towel bed bath) intervention, regardless of type and frequency. For the purposes of this systematic review, traditional bed bath refers to a practice using one new washcloth for each body part and the equipment includes a washbasin, water, towel, washcloths and soap.1,12


Types of outcomes

This review will consider studies that include the following outcome measures:


Primary outcome:


* Hospital-acquired infections defined as infections that becomes evident 48 hours after admission and are measured through surveillance of infection rates.22



Secondary outcome:


* Skin microbiology measured by pathogen microbial counts on skin.20,21


* Skin barrier function and skin integrity measured by skin flakes, skin dryness, water vapour pressure gradient and skin pH.15,18



Types of studies


This review will consider any experimental study design including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies for inclusion.


Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken, followed by analysis of the text words contained in the title and abstract and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies.


Studies published in English, Danish, Swedish and Norwegian will be considered for inclusion in this review. Databases will be searched from their inception to June 2014.


The databases to be searched include:


Pubmed, CINAHL, Scopus, Swemed, swepub, Turning Research into practice (TRIP), Pedro


Additional searching for published literature:


Hand searching reference lists and bibliographies of included articles and any relevant systematic reviews identified in the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports and Cochrane databases of systematic Reviews


The search for unpublished studies will include:


Conducting an online search of databases and websites including:


Mednar, National Institute of Health, Center of Disease Control and Prevention, forskningsdatabasen, Statens Serum Institut(SSI) public enterprise under the Danish ministry of Health, Sundhedstyrelsen(SST)The national Danish Health and Medicine Authority


Initial keywords to be used will be:


Bedbath, disposal wipes, wipes, soft towel, bath, towel, waterless, bathing, baths, intimate, intimacy, personal care, personal hygiene, care, penile, penile hygiene, genitalia, body, body care, basins, washing practices, soap, washbowls, bowls, single use, hygiene care, detergents, cleansers, skin care products, bag bath.




Alternative, versus, comparison, costs, efficiency, traditional




Counts on skin, HAI, microbial, prevention, nosocomial infection, cross infection, skin barrier function, skin flora, skin care, skin infection, skin integrity, skin flakes, nosocomial


Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.


Data collection

Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.


Data synthesis

Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratios (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the chi-square test of homogeneity. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.


Conflicts of interest

None identified







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11. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection(review). The Cochrane Library. 2012; (9): 1-49. [Context Link]


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18. Kron-Chalupa J, Benda T, Williams B. The basinless bath: A study on skin dryness and patient satisfaction. Iowa City Vetrans Affairs Medical Center. 2006. [Context Link]


19. Hodgkinson B, Nay R, Wilson J. A systematic review of topical skin care in aged facilities. Journal of Clinical Nursing. 2006; 129-136. [Context Link]


20. Larseon EL, Ciliberti T, Chantler C, Abraham J, Lazaro EM, Venturanza M, Pancholi P. Comparison of traditional and disposable bed baths in critically ill patients. Am J Crit Care. 2004; 13: 235-241. [Context Link]


21. Ronner AC, Berland CR, Runeman B, Kaijser B. The hygienic effectiveness of two different skin cleansing procedures. J Wound Ostomy Continence Nurs. 2010; 37(3): 260-264. [Context Link]


22. McGuckin M, shubin A, Hujcs M. Interventional patient hygiene model: Infection control and nursing share responsibility for patient safety. Am J Infect Control. 2008; 36: 59-62. [Context Link]

Appendix I: Appraisal instruments


MAStARI appraisal instrument[Context Link]

Appendix II: Data extraction instruments


MAStARI data extraction instrument[Context Link]


Keywords: bed bath; Bag bath; infections; microbial counts on skin